This chapter provides an overview of current screening programmes for various types of cancer, including their governance, operationalisation and recent developments. It reviews the relevance of evidence‑based cancer screening programmes to tackle the burden of cancer among EU countries. The chapter also delves into the policies and innovations aimed at enhancing awareness of, access to and quality of early diagnosis and cancer screening, with a focus on vulnerable populations. The overarching objectives are to share evidence‑based guidance and good practices, to highlight promising innovations being tested across countries to improve cancer care screening and early diagnosis, and to close inequalities across and within EU countries.
Beating Cancer Inequalities in the EU
Spotlight on Cancer Prevention and Early Detection
OECD Health Policy Studies
4. Improving early diagnosis and screening programmes
Abstract
Key findings
In December 2022, a new EU Council Recommendation on Cancer Screening was adopted. It replaces and extends the scope of the previous Council Recommendation 2003/878/EC adopted in 2003, which encompassed recommendations for breast, colorectal and cervical cancer screening. The new Recommendation aims to ensure that 90% of the EU population who qualify for breast, cervical and colorectal cancer screening are offered these by 2025. It furthermore calls for extending screening programmes for prostate, lung and – under certain circumstances – gastric cancer, in a stepwise approach and based on further research.
For breast cancer screening, the Recommendation recommends mammography for women aged 50‑69, and suggests it for women aged 45‑74; for cervical cancer screening, it recommends testing for human papillomavirus (HPV) as the preferred tool for women aged 30‑65, with an interval of five years or more; for colorectal cancer screening, it recommends quantitative faecal immunochemical testing as the preferred screening method before referring individuals aged 50‑74 for follow-up colonoscopy.
Most EU+2 countries (the 27 European Union Member States, Iceland and Norway) have implemented population-based screening programmes at the national or regional level for breast, colorectal and cervical cancers. These programmes were introduced at different times, and exhibit varied governance, implementation models and coverage. Some countries have yet to establish national population-based screening programmes.
Breast cancer screening is implemented in 26 of the 29 EU+2 countries, with slight variations in age ranges and screening intervals. Personalised risk approaches to breast cancer screening are a major area of research in Europe, with results from large trials expected in the coming years.
A population-based colorectal cancer screening programme is in place, organised at the national or regional level, in 22 EU+2 countries. These programmes also vary in terms of target age and invitation practices. Half of EU+2 countries offer the option of self-sampling at home.
Cervical cancer screening is implemented in 21 EU+2 countries, organised at the national or regional level, with wide variation in target age ranges. EU+2 countries are increasingly shifting from cervical smear tests to high-risk HPV testing. Self-sampling is offered in only 7 EU+2 countries and only a few utilise risk-tailored strategies.
There is wide variation in participation in cancer screening among EU+2 countries. For example, the proportion of women aged 50‑69 who had a mammography examination varies nine‑fold across countries, with the highest participation rate in Denmark (83%) and the lowest in Romania (9%). Implementation of population-based screening programmes, access to preventive services, awareness of the eligible population, level of social protection and the degree of out-of-pocket payments are all relevant factors to explain such disparities.
People with low education levels are less likely to participate in screening activities than those with high education levels. In breast cancer screening for example, the likelihood of having received a mammogram is 54% among women aged 50‑74 with low education levels, which is 15% lower than that among highly educated women. Similarly, for colorectal cancer screening, only 31% of people with low education levels reported having received preventive tests compared to 38% of people with high education levels.
Cancer awareness influences access to early diagnosis and screening programmes. Factors such as socio‑economic status, education level, ethnicity and age can affect cancer awareness. Lower socio‑economic groups in Spain and France have been found to have lower cancer awareness and delayed help-seeking behaviour, for example. Of the 29 EU+2 countries, 21 reported having initiatives to raise public awareness of screening and early detection of cancer, and more than half (18 countries) have initiatives to reach vulnerable populations.
Many countries are developing migrant-sensitive health services – for example, by providing information in multiple languages to improve health literacy and access to screening services (e.g. Belgium, Finland, Germany, Ireland and Slovenia).
Primary healthcare has a key role to play in early detection of cancer. General practitioners (GPs) are best placed to clarify questions and remind eligible populations about screening programmes, and to refer symptomatic patients to specialist care following a positive result or for suspected cancer. Only half of EU+2 countries reported considerable reliance on primary healthcare providers to deliver cancer screening activities for colorectal (12 countries) and cervical (15 countries) cancers.
Delivery of screening close to home or at the community level is also increasing, with common use of mobile screening units for breast cancer (in Croatia, Cyprus, Estonia, France, Iceland, Ireland, Norway, Slovenia and Sweden) and increased use of self-sampling tests for colorectal and cervical cancer screening, sent by post or delivered in local pharmacies or by GPs.
To reduce the time between cancer suspicion and diagnosis, fast-track pathways or fast-track referral mechanisms are a positive development implemented in a few countries (in Denmark, Ireland, Latvia, Lithuanian, Poland, Slovenia, Spain and Sweden).
Use of screening data to inform quality improvement cycles and develop targeted actions could be further encouraged to reduce inequalities. Collection of and linking screening data with socio‑economic data is reported by Denmark, France, Germany, Italy, the Netherlands, Slovenia and Sweden.
There are several promising innovations in the field of early cancer detection, although many are still in the research phase:
Research on risk-stratified screening is expected to yield results in the coming years; it has the potential to personalise screening programmes, thereby improving their cost – effectiveness and benefit – harm ratios.
Biomarkers represent another area of research. Despite the lack of solid evidence for their use in population-based cancer screening at present, European countries are participating in various ongoing research and pilot projects.
Artificial intelligence (AI) is being investigated for multiple applications in early cancer detection. Several European countries are participating in clinical trials involving AI, with a focus on enhancing prevention and cancer care. This includes creation of imaging repositories and improvement of non-invasive testing options for colorectal cancer screening.
4.1. Cancer screening and early diagnosis are essential components of an effective cancer control strategy
Primary prevention aims at avoiding the manifestation of diseases; it is connected to health improvement and preventive services such as vaccination (WHO, 2023[1]). Secondary prevention involves early detection and treatment of diseases; this includes preventive measures taken during the initial stages of disease and timely medical intervention, which can lead to improved outcomes. Screening and early diagnosis are two crucial components of secondary prevention, and are key to an effective comprehensive cancer control strategy (WHO, 2017[2]), which is highly relevant to tackling the high burden of cancer in EU+2 countries (the 27 European Union Member States, Iceland and Norway).
Early detection of cancer comprises two key aspects: screening that focuses on testing asymptomatic and apparently healthy individuals to identify a precursor or early-stage cancer lesion in people without symptoms, and early diagnosis that focuses on detecting symptomatic people as early as possible. Screening involves systematic testing of the at-risk population to “sort out apparently well persons who probably have a disease from those who probably do not” (Wilson and Jungner, 1968[3]), enabling detection of the disease at an early stage. Early diagnosis involves awareness among citizens of symptoms potentially related to cancer, as well as timely access to medical care for diagnosis, identification of the stage of disease, and treatment directed to cancer and related symptoms (WHO, 2017[2]).
Early diagnosis of cancer contributes to ensuring better survival rates, fewer complications and better quality of life (Hawkes, 2019[4]; Neal et al., 2015[5]). It also supports the financial sustainability of healthcare systems, since cancer treatment is generally less complex and expensive when diagnosed at early stages (Cancer Research UK, 2014[6]; McGarvey et al., 2022[7]). Many cancers are diagnosed at advanced stages, and therefore present poor prognosis. Potential causes of delays in the diagnosis and treatment of cancer are related to poor cancer awareness by people, late referral and sub-optimal health system performance related to diagnosis, and waiting lists or sub-optimal resources delaying access to the treatment phase. Financial, logistical and psychosocial barriers can also prevent people from seeking care rapidly (WHO, 2010[8]).
Scientific evidence indicates that screening is a relevant tool to increase the likelihood of successful treatment, particularly when cancer is identified at an early stage. Meta‑analyses of randomised controlled trials have shown reductions in mortality rates related to cancer screening. For example, screening with guaiac-based faecal occult blood testing reduced colorectal cancer-specific mortality by 21% (Zheng et al., 2023[9]), and mammography screening reduced breast cancer-specific mortality to 12% among screening attenders versus 58% among non-attenders (Zielonke et al., 2020[10]). A systematic review measured the effect of screening on cervical cancer mortality in Europe: ten observational studies reported a mortality reduction among screening attenders versus non-attenders ranging from 41% to 92% (Jansen et al., 2020[11]). Furthermore, higher survival rates were reported for people with colorectal cancer detected through screening (83.4%) than for those diagnosed through other routes (57.5%) (Cardoso et al., 2022[12]).
Breast cancer screening rates based on programme data demonstrate that countries that had higher participation rates among the eligible population in 2015 had better cancer outcomes in 2020, such as a lower ratio of breast cancer mortality to incidence rate (Figure 4.1). Among the 25 countries with available data, 8 had lower participation rates in breast cancer screening and a higher ratio of mortality to incidence (top left quadrant). A further 12 countries had higher participation rates in breast cancer screening and a lower ratio of mortality to incidence (bottom right quadrant).
Figure 4.1. Higher coverage rates for breast cancer screening programmes are associated with lower ratios of breast cancer mortality to incidence
Notes: The quadrant chart shows the association between breast cancer screening rates (2015) and cancer outcomes as measured by a breast cancer mortality to incidence rate ratio. Age‑standardised breast cancer mortality data are from 2020; age‑standardised breast cancer incidence rates are 2020 estimates from the Joint Research Centre; and breast cancer screening rates are based on programme data from 2015 (or nearest year). The centre of the quadrant chart is the EU average.
Source: OECD Health Statistics (2023[13]), https://doi.org/10.1787/health-data-en; Eurostat (2023[14]), Causes of Death – Deaths by Country of Residence and Occurrence, https://ec.europa.eu/eurostat/databrowser/view/HLTH_CD_ARO__custom_6537139/default/table; ECIS (2023[15]), European Cancer Information System, https://ecis.jrc.ec.europa.eu.
In 2023, a meta‑analysis compared a lifetime with access to cancer screening versus a lifetime without (Breekveldt et al., 2023[16]). The findings suggest that common cancer screening tests do not extend lifetime when considering all-cause mortality. In fact, cancer screening programmes focus on preventing and improving survival from cancer and enhancing quality of life of people experiencing cancer, but they do not change the risk of people developing other potentially fatal diseases during their lifetime. Indeed, risk factors for developing cancer were also related to the risk of developing other non-communicable diseases (e.g. coronary heart disease or diabetes mellitus), for which different prevention and early detection strategies have also proved effective.
Potential harms of screening are the risk of detecting an abnormality that, after additional investigation, is concluded not to be a disease (false positive) (Brodersen et al., 2018[17]) and the risk of detecting a disease where treatment will not provide benefit and may cause harm (overdiagnosis) (Brodersen, Schwartz and Woloshin, 2014[18]), such as an early-stage cancer where diagnosis and treatment will not translate into morbidity or survival gains. In both situations, people will experience unnecessary follow-up exams and procedures, with associated psychological distress and potential financial burden. For instance, in South Korea, after the introduction of national screening programmes in 1999, many hospitals included thyroid cancer screening with ultrasonography in “health check-up” programmes (Ahn, Kim and Welch, 2014[19]). This led providers to offer thyroid cancer screening frequently as an add-on to other screening programmes. Consequently, incidence of thyroid cancer increased over six‑fold in South Korea from 1999 to 2008 (Park et al., 2016[20]). However, the mortality rate from this disease remained stable over the same period (Ahn, Kim and Welch, 2014[19]).
Since knowledge about each cancer’s biology, clinical behaviour and treatment options is rapidly evolving, it is highly relevant to re‑evaluate the trade‑offs between harms and benefits regularly when considering implementation of screening programmes. Benefits should outweigh risks, and cost – effectiveness analysis should inform decision making about implementation of screening programmes, considering context-specific features, such as population demographics, socio‑economic factors and culture, and health service models of care and capacity.
4.2. Implementation of population-based screening programmes is converging across EU+2 countries, but marked differences remain
The principles proposed by Wilson and Jungner in 1968 (Wilson and Jungner, 1968[3]) and by the Council of Europe in 1994 (European Commision, 2003[21]), further developed by other leading experts (Andermann et al., 2008[22]; Harris et al., 2011[23]; Dobrow et al., 2018[24]), are key to informing policy making related to cancer screening. These principles consider disease aspects, such as its epidemiology and natural history, as well as principles related to the relevant tests, such as performance and post-screening test options (Programmes principles are summarised in Box 4.1).
Alongside the existence of a national policy supporting screening programmes, how screening is delivered within a country has influence on the outcomes of the programme. Population-based screening means that, from the whole population, a group of people defined by sex and age is identified as the target to screen for a certain type of cancer (SAPEA, 2022[25]). A screening programme is called “organised” when it fulfils certain requirements: 1) the screening test is part of a care pathway and not performed in isolation; 2) the eligible population is defined following appropriate scientific evidence concerning risk-benefit ratios; 3) the screening test is offered in a systematic way to the eligible population; 4) the screening pathway is governed by evidence‑based protocols or guidelines; 5) evidence‑based quality standards are followed by screening providers; and 6) the screening programme is supported by an information system, ideally linked to population registries (WHO, 2020[26]). These requirements are key to ensuring that all citizens have an equal opportunity to participate in screening and receive adequate follow-up care in the case of a positive result (IARC, 2016[27]). As such, they contribute to the effectiveness of screening programmes in achieving the greatest benefit with the least harm at the population level.
Box 4.1. Consolidated principles for screening programmes based on a systematic review and consensus process
1. Screening programme infrastructure: there should be adequate existing infrastructure or a clear plan to develop adequate infrastructure, to allow for timely access to all components of the screening programme.
2. Screening programme co‑ordination and integration: all components of the screening programme should be co‑ordinated and, where possible, integrated with the broader healthcare system.
3. Screening programme acceptability and ethics: all components of the screening programme should be clinically, socially and ethically acceptable to screening participants, health professionals and society, and there should be effective methods for providing screening participants with informed choice, promoting their autonomy and protecting their rights.
4. Screening programme benefits and harms: the expected range and magnitude of benefits (e.g. decreased cause‑specific mortality) and harms (e.g. overdiagnosis and overtreatment) for screening participants and society should be clearly defined and acceptable, and supported by existing high-quality scientific evidence that indicates that the overall benefit of the screening programme outweighs its potential harms.
5. Economic evaluation of screening programme: an economic evaluation of the screening programme using a health system or societal perspective should be conducted (or there should be a clear plan to do so); the evaluation should assess the full costs and effects of implementing, operating and sustaining the screening programme while considering the opportunity costs and effect of allocating resources to other potential non-screening alternatives for managing the disease or condition.
6. Screening programme quality and performance management: the screening programme should have clear goals or objectives that are explicitly linked to programme planning, monitoring, evaluating and reporting activities, with dedicated information systems and funding.
Source: Adapted from Dobrow, M. et al. (2018[24]), “Consolidated principles for screening based on a systematic review and consensus process”,, https://doi.org/10.1503/cmaj.171154. This systematic review comprises 41 articles, including one outlining the Wilson and Jungner principles (1968[3]), Principles and Practice of Screening for Disease, https://iris.who.int/bitstream/handle/10665/37650/WHO_PHP_34.pdf.
Europe’s Beating Cancer Plan includes specific goals on cancer screening (European Commission, 2021[28]). One goal is to support EU Member States in ensuring that 90% of the target population receives invitations for cancer screenings for breast, cervical and colorectal cancers by 2025. In 2003, the first EU Council Recommendation on Cancer Screening encouraged Member States to implement three population-based and quality-assured cancer screening programmes for cervical, breast and colorectal cancers (European Commision, 2003[21]). In December 2022, a new EU Council Recommendation underscored the importance of strengthening prevention through early detection for breast, cervical, colorectal, lung, prostate and gastric cancers (European Commission, 2022[29]) (Box 4.2).
Box 4.2. The 2022 EU Council Recommendation on Cancer Screening emphasised the importance of enhancing prevention through early detection across different types of cancers
Breast cancer: Screening for women aged 50‑69 with mammography is recommended. Lowering the age limit for screening to 45 and increasing the upper age limit to 74 is suggested. Furthermore, use of digital breast tomosynthesis or digital mammography is suggested. Magnetic resonance imaging should be considered when clinically appropriate.
Colorectal cancer: The preferred screening test is the quantitative faecal immunochemical testing for people aged 50‑74. Further research is suggested to develop risk-tailored strategies, such as thresholds defined by sex, age and previous test results. Endoscopy is suggested as a relevant tool to implement combined strategies.
Cervical cancer: The preferred screening test is human papillomavirus testing, using only clinically validated assays for women aged 30‑65, with an interval of five years or more. Risk-tailored strategies could be considered by adapting the age range and intervals based on individual human papillomavirus vaccination history, as well as the possibility of offering kits for self-sampling (particularly relevant among non-responders).
Lung cancer: In light of the preliminary evidence regarding lung cancer screening with low-dose computed tomography, countries should: 1) focus on primary and secondary prevention approaches, primarily directed to individuals at high risk for lung cancer such as current or past heavy smokers; 2) investigate the feasibility and effectiveness of screening with the use of low-dose computed tomography targeting individuals at high risk; 3) perform further research regarding optimal ways to reach and invite the eligible population, including identifying and targeting other profiles at high risk.
Prostate cancer: Taking into consideration the preliminary evidence and the substantial amount of opportunistic screening, countries should consider a stepwise approach to evaluate the feasibility and effectiveness of organised prostate cancer screening programmes. The test suggested is prostate‑specific antigen testing, combined with additional magnetic resonance imaging as a follow-up test.
Gastric cancer: Implementation studies and screen-and-treat strategies for Helicobacter pylori should be considered in countries/regions with high gastric cancer incidence and death rates. People with pre‑cancerous gastric lesions unrelated to Helicobacter pylori infections should be addressed by screening strategies.
Notes: A recommendation can be strong (when it is “recommended”) or conditional (when it is “suggested”). A strong recommendation means that policy makers can adopt it as policy in most circumstances, while a conditional recommendation means that policy makers’ decisions should be dependent on the involvement of various stakeholders (European Commission, 2023[30]).
Source: European Commission (2022[29]), Council Recommendation on Strengthening Prevention Through Early Detection: A new EU approach on cancer screening replacing Council Recommendation (2003/878/EC), https://data.consilium.europa.eu/doc/document/ST-14770-2022-INIT/en/pdf.
4.2.1. Governance, operationalisation and developments in current screening programmes differ across countries
Population-based breast cancer screening is implemented in 26 EU+2 countries
Embedded in the European Commission Initiative on Breast Cancer (ECIBC), European screening and diagnosis guidelines were launched in 2021 (European Commission, 2023[31]), together with a quality assurance scheme to support improvement of quality and continuity of care in the context of population-based breast cancer screening (European Commission, 2021[32]; Muratov et al., 2020[33]). For women without symptoms of breast cancer who are considered to have average risk, the ECIBC’s Guideline Development Group recommends a population-based screening programme with mammography, suggesting use of either a digital breast tomosynthesis (DBT)1 or digital mammography (DM) (see Box 4.2). Furthermore, the ECIBC’s guidelines recommend that screening intervals differ according to a woman’s age (every two or three years for women aged 45‑49; every two years for women aged 50‑69; every three years for women aged 70‑74) (European Commission, 2023[31]).
Aside from Bulgaria, Lithuania and Romania, all other EU+2 countries have population-based screening programmes in place for breast cancer (Table 4.1). Most screening programmes are organised at the national level, except for those in Belgium, Italy and Sweden, which are organised at the regional level. In January 2023, Bulgaria adopted a National Cancer Plan, yet the organisation of screening activities is not performed under this plan. Breast cancer screening in Lithuania follows a nationwide non-population-based approach, while in Romania a pilot is under way, and the first results are expected in early 2024.
Table 4.1. Characteristics of breast cancer screening vary among EU+2 countries
Sources: EU Country Cancer Profiles (OECD, 2023[34]) and 2023 OECD Policy Survey on Cancer Care Performance.
Most of the breast screening programmes among EU+2 countries include mammography every two years for women aged 50‑69 (Figure 4.2). Nevertheless, there is some variation in Austria, Cyprus, Czechia, France, Hungary, Iceland, the Netherlands and Sweden, which screen women within a broader age range.
Among the 26 EU+2 countries responding to the 2023 OECD Policy Survey on Cancer Care Performance,2 8 have identified changes in breast cancer screening (Cyprus, Estonia, Germany, Iceland, Ireland, Latvia, the Netherlands and Poland). Consistent with the EU Council Recommendation, the changes to breast cancer screening are mostly related to extending the age limits of the target population. For instance, in Malta, there are plans to extend screening to women aged 45 instead of 50; in Spain, the possibility of extending the age range to 45‑75 is being evaluated; and in Poland, a legislative process is under way to introduce changes to breast cancer screening.
In Cyprus, the age range of the target population for breast cancer screening has recently been expanded to women aged 45‑74 (from 30 September 2023). In Estonia, a legislative process is under way for 2024 to expand the breast cancer target group to ages 50‑74. In Germany, a recent guideline, which is not yet in force, raised the upper age limit of breast cancer screening from 69 to 75 (Gemeinsamer Bundesausschuss, 2023[35]). This follows a scientific assessment by the Bundesamt für Strahlenschutz (BfS) – the Federal Office for Radiation Protection – in December 2022 in favour of quality-assured breast cancer screening for women up to age 75 (BfS, 2022[36]). In addition, the Institute for Quality and Efficiency in Health Care has determined that the benefits of screening women between the ages of 45 and 49 outweigh the harms, but that informed decision making is important given the marginal benefit. Implementation of the lower screening age will be possible after a positive evaluation from the BfS. It is expected that eligible women will be able to register for screening tests under this new guideline from July 2024.
Figure 4.2. Target age range of population-based breast cancer screening programmes differs among EU+2 countries
Sources: OECD (2023[34]), EU Country Cancer Profiles, www.oecd.org/health/eu-cancer-profiles.htm and 2023 OECD Policy Survey on Cancer Care Performance.
Population-based colorectal cancer screening programmes are implemented in 22 EU+2 countries
The new EU Council Recommendation on screening updated the preferred test for population-based colorectal cancer screening to faecal immunochemical testing (FIT) instead of guaiac-based faecal occult blood testing (gFOBT) (see Box 4.2). European colorectal cancer screening guidelines are expected to be announced by the end of 2024, as well as a quality assurance scheme for colorectal cancer screening and care services.
Among the 29 EU+2 countries, 22 have population-based colorectal cancer screening in place, organised at the national or regional level (Table 4.2). In Bulgaria, Cyprus and Iceland, a population-based colorectal cancer screening programme is planned but not yet implemented (in Cyprus, it will be implemented in the first trimester of 2024 using FIT). In Austria, implementation of population-based screening was recently advised by the National Screening Committee on Cancer. In addition, among 26 EU+2 countries responding to the 2023 OECD Policy Survey on Cancer Care Performance, 8 identified recent changes in their colorectal cancer screening programme (Austria, Cyprus, Czechia, Estonia, Germany, Latvia, the Netherlands and Norway).
Table 4.2. Characteristics of colorectal cancer screening vary among EU+2 countries
Note: NA stands for information not available.
Source: OECD (2023[34]), EU Country Cancer Profiles, https://www.oecd.org/health/eu-cancer-profiles.htm, and OECD Policy Survey on Cancer Care Performance.
While recommendations suggest performing FIT among people aged 50‑74, the age ranges vary substantially among EU+2 countries (Figure 4.3), and only 10 countries include the age range 50‑74. With the exception of Austria, which will target people aged 45‑75 when the recent recommendations are implemented, the other countries include narrower age intervals, such as 60‑68 in Estonia, 59‑69 in Ireland and 55‑65 in Norway.
Figure 4.3. Target age of population-based colorectal cancer screening programmes differs among EU+2 countries
Note: In Czechia, the upper age limit is determined on an individual basis.
Source: OECD (2023[34]), EU Country Cancer Profiles, www.oecd.org/health/eu-cancer-profiles.htm and 2023 OECD Policy Survey on Cancer Care Performance.
Most countries provide FIT to perform screening, in accordance with current recommendations. Compared to gFOBT, FIT offers various advantages, including the need for one sample instead of three. FIT is also not affected by diet or medications, and allows the cut-off for a positive test to be adjusted according to cost – effectiveness considerations in each country/region. In Ireland, the cut-off value for FIT in the colorectal cancer screening programme is 45 μg Hb/g faeces – similar to the value in the Netherlands (47 μg Hb/g faeces; 235 ng Hb/mL), although it depends on the specific FIT test. In Denmark, a positive result is defined as greater than 100 ng Hb/mL (Petersen et al., 2020[37]). In Poland, discussions are ongoing about introducing FIT for colorectal screening. In Cyprus, colorectal screening with FIT will be implemented in the first trimester of 2024. In 2021, Latvia changed the frequency of FIT in colorectal cancer screening from every year to every two years.
In Norway, colorectal cancer screening started recently, and all 55‑year‑olds will be invited for screening through FIT every two years for ten years (Kreft Registeret, 2023[38]). The first invitations were sent out in May 2022, and rollout continued in 2023. The Cancer Registry of Norway has been given responsibility for operating the new screening programme, and it co‑operates closely with the regional health authorities to ensure the best possible service. Austria’s National Screening Committee on Cancer recommended implementation of population-based colorectal screening for people aged 45‑75 in 2022: it recommended a colonoscopy every ten years or FIT every two years (Federal Ministry of Social Affairs, Health, Care and Consumer Protection, 2022[39]), but this has not yet been implemented. In Germany, a nationwide quality-assured colorectal cancer screening programme was introduced in 2019, based on the Cancer Screening and Registry Act of 2013. The former gFOBT was replaced by a quantitative immunological faecal occult blood test (FIT) in April 2017.
The Danish randomised controlled trial CareForColon2015 is examining the use of a colon capsule endoscopy (CCE) applied to colorectal cancer screening (imaging-based screening) (Deding et al., 2021[40]). The control group comprises individuals who undergo regular colorectal cancer screening (FIT followed by colonoscopy when FIT is positive); they are compared with individuals who choose between the colonoscopy or the CCE following positive FIT. The published interim analyses (2021) reported safety and efficiency of CCE and high participation rates, while the proportion of suspected cancers retrieved was lower than expected. The CCE procedure was reviewed, and the trial is under way until 2024.
Different invitation strategies are used across EU+2 countries (Table 4.3). Of the 22 countries with population-based colorectal screening, 19 send invitation letters by post to the eligible population, accompanied by background material for informed decision making. Some countries, such as Estonia and Poland, also send personal electronic notifications. In Ireland, test kits are sent to participants only after their consent is provided to the first round of screening by phone; in subsequent rounds, the test is sent without further phone calls.
Among the countries sending personal invitations, 14 provide citizens with the option to self-test at home and send their sample to a laboratory for analysis. The test kit is attached with the invitation letter in some countries, such as Belgium, Denmark and the Netherlands. Other countries offer the option to obtain a self-test kit in pharmacies, via a GP consultation (e.g. Italy), or sometimes combined with the option to order a test online to receive it at home (e.g. Hungary). France is currently revising the invitation process (deployment in January 2024), with the health insurance fund taking charge of invitations. Citizens will be invited to consult a GP to access the test kit, and will also have the option to access screening tests via pharmacies or online.
Table 4.3. Invitation letters for colorectal cancer screening are used in many EU+2 countries
Note: NA stands for not available.
Source: OECD (2023[34]), EU Country Cancer Profiles, www.oecd.org/health/eu-cancer-profiles.htm and 2023 OECD Policy Survey on Cancer Care Performance.
A systematic review considered 34 studies when assessing the effectiveness of invitation practices in colorectal cancer screening in 11 countries (Gruner et al., 2021[41]). The findings show that any invitation scheme is more effective in increasing screening participation compared to no invitation. The highest increase in test uptake was found when multiple components of invitations were used (increased test usage ranging from 3.2% to 24.7%). Sending an invitation with an attached screening test led to higher uptake of the screening test (ranging from 4% to 19.7%) than other strategies. Reminders delivered by letter or email were more effective (ranging from 8.5 to 15.8%) than those using phone call or text message (ranging from 0.6% to 6.5%). Notably, advance notification, mailing of the screening test and providing reminders were practices demonstrating important, complementary roles in increasing the uptake of the gFOBT in colorectal cancer screening.
Population-based cervical cancer screening is implemented in 21 EU+2 countries
In recent decades, remarkable advances have been made in the availability of effective primary and secondary prevention tools to tackle cervical cancer – namely, vaccination against the most oncogenic human papillomavirus (HPV) types (Chapter 3) and screening with HPV-based testing. Europe’s Beating Cancer Plan establishes the goal of eliminating cervical cancer by largely focusing on these preventive strategies (European Commission, 2021[28]).
Of the 29 EU+2 countries, 21 have population-based cervical cancer screening in place, organised at the national or regional level (Table 4.4), and 11 have identified changes to cervical cancer screening programmes (Cyprus, Czechia, Estonia, Germany, Latvia, Lithuania, the Netherlands, Spain, Sweden, Iceland and Norway). In Germany, a nationwide organised quality-assured cervical cancer screening programme was introduced on 1 January 2020. Since then, women aged 35 and over are entitled to a combined examination comprising a cervical smear (cytology) and HPV testing every three years. In Sweden, in 2022, the National Board of Health and Welfare revised the recommendations on cervical screening. Rollout of the new recommendation on primary HPV testing differs across regions; the plan is to have it fully implemented by 2024. In 2018, the Spanish Ministry of Health ordered all autonomous communities and cities (regions) to shift from non-population-based cervical cancer screening to a population-based programme. In April 2019, population-based cervical cancer screening was incorporated into the national health system’s portfolio, and regions were given five years to implement the new approach, which is currently in progress across the country.
Table 4.4. Characteristics of cervical cancer screening vary among EU+2 countries
Notes: NA stands for information not available.
Source: OECD (2023[34]), EU Country Cancer Profiles, www.oecd.org/health/eu-cancer-profiles.htm and 2023 OECD Policy Survey on Cancer Care Performance.
There is wide variation in age ranges of the population eligible for screening in EU+2 countries (Figure 4.4). Consistent with the new EU Council Recommendation, Estonia, Finland and France target women aged 30‑65. Some countries include lower age limits, such as Germany and Slovenia (age 20), and some include women until ages 69 (Norway) and 70 (Czechia, Latvia and Sweden). In Norway, where the cervical screening programme is run by the Cancer Registry, the age for HPV testing was lowered to 30 in January 2023, and then again to 25 in July 2023. Thus, all women aged 25‑69 years are eligible for cervical screening. In Denmark, where HPV-based screening is in place for women aged 23‑64, a study is under way to compare screening of women aged 30‑54 with HPV testing (every five years) or cytology (every three years).
Figure 4.4. The target age of population-based cervical cancer screening programmes differs among EU+2 countries
Sources: OECD (2023[34]), EU Country Cancer Profiles, www.oecd.org/health/eu-cancer-profiles.htm and 2023 OECD Policy Survey on Cancer Care Performance.
Alongside the variability in age range, there is also heterogeneity regarding testing methods (see Table 4.4). Screening tests for cervical cancer include conventional cytology, where cervical cells are collected and analysed to identify pre‑cancerous lesions (which can be treated to prevent progression to a more invasive disease) or early-stage cancer (allowing for earlier cancer treatment). However, cervical cytology has certain limitations. It is relatively insensitive in detecting pre‑cancerous lesions and cancer; it needs to be conducted frequently to achieve programme efficacy; and interpretation of results is subject to a high degree of subjectivity (Kitchener, Castle and Cox, 2006[42]). Thus, in recent decades, since persistent infection with high-risk HPV is strongly associated with cervical cancer, tests to detect DNA of high-risk HPV virus in cervical cells have been developed as an alternative to cytology-based screening.
Scientific evidence shows that HPV-based screening is an effective method, offering better protection than cytology-based screening, including lower incidence of pre‑cancerous lesions and cervical cancer compared to women undergoing cytology (Hamers, Poullié and Arbyn, 2022[43]). An additional benefit is the possibility of using HPV testing on samples collected by individuals themselves. Self-samples based on polymerase chain reaction are as sensitive as samples taken by clinicians (Arbyn et al., 2014[44]; Arbyn et al., 2018[45]), which provides a potential additional tool to reach non-respondents or populations with restricted access to healthcare. International guidelines recommend avoiding co-testing with cytology and HPV at any age (von Karsa et al., 2015[46]). As part of the European Commission Initiative on Cervical Cancer, launched in 2023, the European guidelines on cervical cancer are being updated, and a quality assurance scheme is being developed (European Commission, 2023[47]).
Most of the 29 EU+2 countries offer either high-risk HPV-based testing or a combination of cytology and HPV (mostly defined according to age). Of the 22 countries organising population-based screening, 7 have only HPV-based screening in place (Denmark, Finland, Portugal, the Netherlands and Ireland since 2020, Estonia since 2021, and Norway since 2023). Further, 9 use age‑dependent screening methods, where a cytology screening test is recommended for younger women and HPV-based screening for older women, with some variability concerning the age range (France, Germany, Iceland, Latvia and Spain).
Screening intervals are determined based on the test used. Randomised controlled trials assessing HPV-based screening used intervals between three and five years (Kitchener et al., 2009[48]; Rijkaart et al., 2012[49]). Intervals of at least five years with HPV-based screening showed greater protection against invasive cervical carcinomas, when compared to the smear test (Ronco et al., 2014[50]). Another important factor to consider in HPV-based screening is the age at which screening should begin, given that the HPV infection and its clinical progression are dependent on age. HPV infection without symptoms is very common among young women, and it frequently clears spontaneously without further consequences (Schiffman et al., 2007[51]). As such, HPV testing in younger women can lead to considerable overdiagnosis, since only a minority will develop invasive cancer over time (peak at-risk age is about 35‑55). The new EU Council Recommendation on Cancer Screening suggests HPV-based testing for women aged 30‑65, with an interval of five years or more. It also suggests that countries should consider risk-tailored strategies and self-sampling to increase participation rates.
Some countries without population-based programmes are working to introduce HPV-based testing. In Cyprus, a cervical screening programme is expected to be implemented in 2024. In Bulgaria, the National Cancer Plan adopted in early 2023 includes a population-based screening programme for cervical cancer. At present, cervical cancer screening is accessible to insured women aged 30‑40: it is carried out during routine check-ups through cytology tests provided by gynaecologists or GPs. In Croatia, a population-based programme is being piloted in one county, combining both cytology and HPV-based testing. In Sweden, since 2022, HPV testing is available to women aged 23, and intervals have been expanded: every five years for women aged 23‑49, and every seven years for women aged 50‑70 (Socialstyrelsen, 2022[52]). This new recommendation updates the previous one from 2015 in four key aspects: 1) HPV testing is recommended for all age groups eligible for the screening programme, including participants aged 23‑29; 2) the time intervals for testing are extended to women with negative HPV test results; 3) supplementary analysis (i.e. double testing of both cytology and HPV) is no longer recommended; and 4) self-sampling can be offered as an alternative to sampling by a healthcare provider.
A few countries use risk-tailored strategies in cervical cancer screening, where the approach is adjusted based on HPV vaccination history. In the Netherlands, since January 2022, previous HPV results have been factored into screening invitations. Referral policies have also been modified based on HPV genotype risk stratification, although any changes to the screening strategy based on vaccination status are not expected before 2028. Meanwhile, the Slovak Republic adjusts the intervals between screenings based on the results of the previous cytology.
In the new EU Council Recommendation, the possibility of self-sampling is suggested, considering its potential role to reach non-responders, as this allows the test to be sent to eligible women and performed at home. Mailing the eligible population self-sampling devices has also been shown to increase uptake (for both cervical and colorectal cancer screening) (Camilloni et al., 2013[53]). Of the 29 EU+2 countries, 7 provide the option of self-sampling for HPV testing: Czechia, France, the Netherlands, Estonia, Norway Sweden and Spain (in some regions) (Table 4.5). In Denmark, women who do not respond to cervical cancer screening invitations are offered HPV self-sampling tests in the second reminder letter. A pilot programme took place in Czechia, where self-sampling HPV tests were sent to women aged 50‑65 from vulnerable groups – such as those at risk of poverty and social exclusion in deprived areas. In Estonia, an HPV self-sampling feasibility and pilot study was conducted in 2020 and 2021, followed by an implementation project (2022‑24). Since August 2022, women who did not participate in cervical cancer screening in the first half of the year will be able to choose between being provided with a test in a clinic or conducting self-sampling at home. The self-sampling kits can be ordered through an online platform. Additionally, a pilot project was carried out in the north-eastern region of Estonia in 2022, providing self-sampling kits in pharmacies. As of October 2023, the kits are available in pharmacies in five regions. From 2024, the HPV self-sampling option will be available to the target population throughout the year (Tervise Arengu Institut, 2023[54]). In Ireland, a study is being planned to understand attitudes to self-sampling in the population, complemented by a study of attitudes of sample takers.
Table 4.5. Invitation practices and delivery models for cervical cancer screening are heterogeneous across EU+2 countries
Notes: NA stands for information not available.
Source: OECD Country Cancer Profiles (OECD, 2023[34]) and 2023 OECD Policy Survey on Cancer Care Performance.
4.2.2. New cancer screening programmes are under way
Alongside breast, cervical and colorectal cancer screening programmes, 15 of the 26 EU+2 countries that responded to the 2023 OECD Policy Survey identified ongoing pilot projects in place for lung, prostate and gastric cancers.
An increasing number of countries have pilot programmes for lung cancer screening
Lung cancer screening is ongoing or planned across several EU+2 countries, while other countries are considering pilot projects. Croatia is the only country with a non-population-based lung cancer screening programme targeting people aged 50‑75 who are active smokers or have at least a 15‑year history of smoking, without regard to other comorbidities or medical history.
Pilots are under way in Belgium, Czechia, Italy, Norway, Slovenia, Spain and Sweden. In Belgium, pilot projects are ongoing in Flanders to assess the effectiveness of lung cancer screening, particularly for at-risk individuals. In Czechia, the Early Detection Programme for Lung Cancer has been running since January 2022. This aims to identify people at risk of developing lung cancer. The target population comprises individuals aged 55‑74 who are either current or former smokers (minimum of 20 pack years3) (Májek et al., 2022[55]). This group will be referred by their GP to a pulmonary specialist for a lung examination and will receive a low-dose computed tomography (CT) scan. In Italy, the pilot programme is conducted across 18 regions for men aged 55‑75 who are either current smokers or quit smoking less than 15 years ago (30 pack years). In Norway, an ongoing pilot has invited 125 000 individuals aged 60‑79 to participate in lung cancer screening. It aims to determine an effective selection process for identifying the at-risk population who should be offered screening. Participants in the study will undergo a CT scan. If no lung findings or signs of injury are detected, they will be included in a subgroup randomly assigned to receive a CT scan either annually or every two years. If lung findings are present, participants will receive annual CT scans. Based on this study, it will be possible to have results on the feasibility of a national screening programme, including its costs and benefits, within two years. Slovenia and Spain are evaluating the feasibility and cost – effectiveness of introducing a programme for lung cancer screening through pilot programmes that are under way. In Sweden, an ongoing lung cancer screening pilot started in 2020, organised by the Regional Cancer Centre Stockholm Gotland. One of its aims is to understand the cost – effectiveness of a targeted approach to lung cancer screening. Linked to this project, in 2022, 15 000 women were invited to answer a survey about smoking history; the at-risk population received subsequent follow-up with a low-dose CT scan and smoking cessation support via the Stop Smoking support line.
Denmark is in the process of planning a three‑year implementation study on lung cancer screening, which is planned to start in 2024. In Estonia, a feasibility study was conducted 2021 in three family doctor practices in Tartu, targeting individuals aged 55‑74 (Kallavus et al., 2023[56]). The findings show that systematic enrolment of people by family doctors resulted in high screening uptake (around 87%) and provided important input to the organisation of the ongoing regional lung cancer screening pilot, in which 73 practices are participating. In Germany, preparation for early detection of lung cancer with low-dose CT scans among adults aged 50‑75 with a history of smoking is under way, following a positive scientific evaluation by the BfS (2021[57]), based on 38 publications of randomised controlled studies. The meta‑analysis showed evidence of a benefit of the early detection procedure for heavy smokers. From early summer 2021 until summer 2023, the HANSE prevention programme offered free lung exams for former and active smokers in northern Germany. Three lung cancer centres in the region invited people aged 55‑79 who were at an increased risk of lung tumours as either smokers or ex-smokers to a free lung exam. The programme, which travels between three cities via a mobile study truck, anticipated that up to 5 000 participants would receive a free low-dose CT examination. It is co‑ordinated by a multiprofessional team and is intended to provide evidence through a pilot study that a comprehensive and effective lung cancer early detection programme can be implemented in Germany.
Two European trials will inform health policy concerning lung cancer screening in the coming years. The SOLACE Project was launched in April 2023 under Europe’s Beating Cancer Plan, with funding from EU4Health. It aims to facilitate implementation of and reduce inequalities in lung cancer screening programmes across Europe (SOLACE, 2023[58]). The study plans to develop, test and disseminate individualised approaches for lung cancer screening at national and regional levels to help overcome challenges and address well-known inequalities in European countries. The first pilot programmes will be run in 10 EU countries. The other trial is 4‑In-The‑Lung-Run (2023[59]), which aims to include 26 000 participants at high risk of lung cancer in screening sites in the Netherlands, Germany, Spain, Italy and France. The study will inform the creation of risk-based screening strategies demonstrated to be effective, affordable, acceptable to the people, cost-effective and suitable for implementation.
There are few ongoing pilots for prostate cancer screening
Prostate cancer screening with prostate‑specific antigen (PSA) is associated with a high number of false positive test results. Previous studies showed that around 70‑80% of prostate biopsies following a positive PSA screening are negative (Schröder et al., 2009[60]). In addition, non-population-based screening programmes have shown higher rates of overdiagnosis and a small survival benefit compared with population-based screening. Thus, the standard practice has been active surveillance of low-grade disease. The development of risk-tailored approaches to screening – adding non-invasive exams such as magnetic resonance imaging (MRI) and/or biomarkers used in reflex strategies (following a positive PSA result), combined with well-defined criteria for active surveillance – may contribute to reducing the harms of prostate cancer screening and drive implementation of cost-effective programmes (Heijnsdijk and de Koning, 2022[61]). The recent EU Council Recommendation on Cancer Screening urges Member States to pursue further research on the effectiveness and feasibility of population-based prostate cancer screening using PSA testing combined with a follow-up MRI (see Box 4.2).
While some EU+2 countries already have well-established non-population-based screening initiatives for prostate cancer (e.g. as implemented in Germany since the 1970s), others are now considering introducing prostate cancer screening. Most EU27 countries provide PSA testing in a non-population-based model, or on request. In some countries, pilot population-based prostate cancer screening programmes are under discussion (Croatia, Czechia, Estonia, Finland, Ireland, Malta, Romania and Sweden). PRAISE‑U is a project co-funded by the EU involving 12 countries (launched in April 2023), which aims to develop national cost-effective algorithms for early detection of prostate cancer (European Association of Urology, 2023[62]). Pilot studies within PRAISE‑U will take place in Poland, Lithuania, Ireland and Spain (European Association of Urology, 2023[63]).
In Germany, the PROBASE study is prospectively evaluating risk-adapted PSA screening according to a baseline PSA level, after the country decided against general prostate screening in 2020, considering the potential harms related to overdiagnosis (Deutsches Krebsforschungszentrum, 2020[64]). The primary objective of this clinical trial is to establish the superiority of delayed risk-adapted PSA screening starting at age 50, in comparison to risk-adapted PSA screening starting at age 45, with respect to the specificity of the screening. In Sweden, the National Board of Health and Welfare recommends against a national population-based screening programme, but pilots for prostate cancer testing at the regional level are ongoing, co‑ordinated by a national working group with representatives from each health region. The first pilot started in 2020. A health economics analysis found that evolving the prostate cancer screening from unorganised PSA testing across the regions to an organised screening with PSA testing would increase quality-adjusted life‑years in the population and would be cost-saving from a societal perspective in the long term (Confederation of Regional Cancer Centres, 2023[65]). In Slovenia, non-population-based screening for prostate cancer is available, but further steps have been taken to evolve the current design into an organised population-based screening programme. In Cyprus, a prostate screening programme is expected to be implemented during 2024.
Pan-European projects aim to provide recommendations on implementation of gastric cancer screening
In Europe, incidence rates of gastric cancer are considerably lower than in Asia (Japan and Korea), which is related to distinct Helicobacter pylori (H. pylori) strains and infection rates among the population, as well as diet factors, smoking and alcohol consumption. For instance, Japan has over a two‑fold higher incidence rate of gastric cancer among men than Lithuania (Morgan et al., 2022[66]). The effectiveness of gastric cancer screening among people aged 40 and over was evaluated in Korea in a nested case‑control study (Jun et al., 2017[67]). Mortality from gastric cancer was less likely in screened subjects than non-screened patients (the odds ratio for dying from gastric cancer among screened subjects was 0.79). Gastric cancer frequently presents at late stages, and its prognosis is generally poor, which underscores the relevance of prevention and early diagnosis. Considering these factors, as well as improvements in diagnostic testing, some countries are making efforts to understand the extent to which implementation of a screening programme for gastric cancer is beneficial.
TOGAS, launched in March 2023, is the first pan-European project to evaluate strategies to reduce deaths from gastric cancer (European Cancer Organisation, 2023[68]). It is led by the Institute of Clinical and Preventive Medicine of the University of Latvia, with partners from 14 European countries. The EU-funded project is set to operate for three years; it aims to provide recommendations on implementation of gastric cancer screening in EU countries. It plans to carry out three large‑scale pilot studies pertaining to different features of gastric cancer screening, such as focusing on screening in young adults, strategies for combined screening for upper and lower gastrointestinal cancer, and the adverse effects of H. pylori eradication in middle‑aged population. TOGAS will build on and scale up another EU-funded project, EUROHELICAN, which was launched in November 2022. This focuses on: 1) implementation of a population-based H. pylori test-and-treat programme in Slovenia targeting young adults to assess its processes, feasibility and acceptability; 2) evaluation of long-term effects of the strategy in middle‑aged Latvians participating in the GISTAR study (a multicentric randomised study focusing on H. pylori eradication and pepsinogen testing for prevention of mortality related to gastric cancer); and 3) development of implementation guidelines for a population-based H. pylori test-and-treat strategy via expert working group meetings held by the International Agency for Research on Cancer (IARC) and WHO (European Commission, 2023[69]). In Slovenia, efforts to improve gastric cancer prevention are being supported by these two EU4Health projects. In Croatia, several strategies are under investigation. These include a screening programme for gastric cancer using endoscopy or fluoroscopy, screening for pre‑cancerous lesions and screening for H. pylori.
4.3. Improving access to cancer screening and early diagnosis, and strengthening awareness are needed
4.3.1. The impact of the COVID‑19 pandemic on screening rates for breast, cervical and colorectal cancers has been substantial
Preventive and diagnostic services suffered from substantial disruptions during the COVID‑19 pandemic worldwide, as urgent care was prioritised. In the initial phase of the pandemic, 12 of the 15 EU countries examined halted screening (OECD/European Union, 2022[70]), in addition to which, people were hesitant to seek out healthcare due to fear of COVID‑19 infection or of burdening the health system. Few countries were able to increase screening capacity after this first phase (Fujisawa, 2022[71]). A reduction was also observed in the number of diagnostic procedures for and diagnoses of cancer (Chapter 2).
The Joint Research Centre conducted a survey among the cancer registries of 16 EU Member States, plus Norway and Iceland, to understand how the first wave of the COVID‑19 pandemic (March to May 2020) affected cancer screening, diagnoses and care (EU Science Hub, 2023[72]). Almost 90% of the respondents reported an interruption or slowdown of organised population-based cancer screening for breast, cervical and colorectal cancers. At least four national cancer registries reported a significant decrease in cancer diagnosis (referring to all cancer diagnoses, not only those targeted by cancer screening): Belgium, Denmark, the Netherlands and Slovenia. In Denmark, a 20% reduction in cancer diagnoses was reported. In Belgium, a 6% reduction in the number of diagnosed cancers was reported in 2020, which corresponds to an estimated 4 000 cancers not diagnosed in 2020 compared to 2019 (Peacock et al., 2021[73]). The OECD/EU 2022 edition of Health at a Glance reports that breast and cervical cancer screening rates decreased in most EU countries in 2020, with an average reduction of 6% across countries with available data (OECD/European Union, 2022[70]). For colorectal cancer screening, almost all countries had lower participation rates in 2020 than in 2019.
4.3.2. There is scope to improve participation in cancer screening programmes in many EU+2 countries
In 2021, there were wide disparities in the proportion of women aged 50‑69 who had had a mammogram in the preceding two years. Breast cancer screening varies nine‑fold across countries (Figure 4.5). For instance, in Romania only 9% of eligible women had been screened in 2019, while the EU27 average reached 54% of eligible women. In Romania, despite a small-scale pilot programme for breast cancer screening in 2017, no population-based screening programme has been implemented yet. Furthermore, women in Romania frequently incur out-of-pocket costs for healthcare, limiting access to screening and early diagnosis activities (Furtunescu et al., 2021[74]).
Figure 4.5. In 11 EU+2 countries, participation in breast cancer screening is lower than 50% of women aged 50‑69
Notes: Mammography screening in women aged 50‑69 within the past two years. 1. Programme data. 2. Survey data. While programme data are collected from national/regional cancer databases/registries, survey data are obtained from international surveys, limiting the international comparability.
Source: OECD Health Statistics 2023, https://doi.org/10.1787/health-data-en.
Disparities in cervical cancer screening uptake among EU+2 countries are also noticeable (Figure 4.6), although not as marked as in breast or colorectal screening programmes. The proportions of women aged 20‑69 who had been screened for cervical cancer within the preceding three years varies seven‑fold across countries. The proportions were 12% in Poland and 24% in Malta in 2021, while Sweden was able to screen 79% of eligible women that year. Factors such as access to healthcare and level of social protection in Sweden could partly explain such differences beyond differences in the nature of the data reported (De Prez et al., 2021[75]). Furthermore, population-based screening was implemented in Sweden in the mid‑1960s, while in Malta the national programme was launched only in 2016. This could also explain low levels of awareness of preventive services, knowledge of risk factors and risk perception among the target population (Deguara, Calleja and England, 2020[76]). Also, after the COVID‑19 pandemic and the halting of screening for three months, Sweden changed its approach to cervical cancer screening, sending self-sampling kits to all eligible women, leading to a substantial increase in uptake of cervical cancer screening. For instance, screening uptake in the Stockholm region increased by 10 percentage points to 85% in just over one year (WHO, 2022[77]).
Figure 4.6. In 9 EU+2 countries, participation in cervical cancer screening is lower than 50% of women aged 20‑69
Notes: Women aged 20‑69 screened within the past three years. 1. Programme data. 2. Survey data. While programme data are collected from national/regional cancer databases/registries, survey data are obtained from international surveys, limiting the international comparability.
Source: OECD Health Statistics 2023, https://doi.org/10.1787/health-data-en.
Compared to breast and cervical cancer screening programmes, participation rates in colorectal cancer screening programmes are lower on average, at 36% in the EU27, and variation in uptake across countries is wide (Figure 4.7). Of the 29 EU+2 countries, 13 have colorectal cancer screening rates of 30% or less. While in Finland the participation rate was close to 80% of the eligible population, Cyprus, Hungary and Romania had participation rates of about 3% in 2021 (or latest year). In Cyprus, in general, citizens face challenges to universal access to public health systems, aggravated by a high share of out-of-pocket expenses (OECD/European Observatory on Health Systems and Policies, 2017[78]). These factors contribute to low levels of participation in colorectal cancer screening. Implementation of a population-based screening programme is planned for the first trimester of 2024.
According to 2019 data from the European Health Interview Survey (EHIS), disparities in uptake of colorectal screening by sex among the population aged 50‑74 are not large. For example, the average percentage of women (33.6%) and men (33%) reporting uptake of colorectal cancer screening within the past two years was similar. The highest gaps by sex were observed in Belgium (11%), Austria (10%), Germany (8%) and Romania (7%). In these countries, women reported screening more frequently than men. In some countries where the difference between men and women was not substantial, such as Finland (4.4%) and Poland (4.3%), men had a higher percentage of reported screening than women.
Figure 4.7. Two-thirds of EU+2 countries have participation rates in colorectal cancer screening programmes lower than 50%
1. Programme data are based on national programmes that may vary in terms of age group and frequency. 2. Survey data based on EHIS, referring to people aged 50‑74 screened over the past two years. While programme data are collected from national/regional cancer databases/registries, survey data are obtained from international surveys, limiting the international comparability.
Source: OECD Health Statistics 2023, https://doi.org/10.1787/health-data-en.
4.3.3. Uptake of cancer screening varies according to individual socio‑economic characteristics including education, income and citizenship
The Survey of Health, Ageing and Retirement in Europe wave 8 (2021/22), which asks whether people have received breast and colon cancer screening, indicates that across EU+2 countries with available data, people with lower socio‑economic characteristics have a lower probability on average of attending screening for the two types of cancer. For breast cancer screening, the likelihood of having received a mammogram is 54% among women with lower education levels compared to 64% among women with higher education levels. Inequalities in favour of better educated people are observed in 19 countries (Figure 4.8). The largest inequalities are found in Austria, the Netherlands, Poland, Estonia and the Slovak Republic, with gaps of between 12 and 19 percentage points between education groups. Only in Spain, Lithuania, Finland and Malta is uptake of breast cancer screening higher among people with lower education levels. A comparable pattern of inequality is found when comparing the richest and the poorest income quartiles. In 19 EU+2 countries, the likelihood of receiving breast cancer screening is higher among the highest income quartile (63%) than the lowest (52%). This is consistent with previous research on income and education-related inequalities in cancer screening using EHIS data (OECD, 2019[79]).
Figure 4.8. Women with low education levels are less likely to receive a mammogram in 19 EU+2 countries
Indirectly age‑standardised probability of having had a mammogram, by country and education level
Notes: Analysis based on 16 035 observations of women aged 50‑74 living in a private household in 23 countries. Probabilities are based on indirect age standardisation. Education level is built according to the International Standard Classification of Education (ISCED), with ISCED 0‑2 for low level of education and ISCED 4‑6 for high level of education.
Source: Survey of Health, Ageing and Retirement in Europe wave 8 (2021/22).
For colorectal cancer screening, only 31% of people with lower education levels reported having received preventive tests compared to 38% of people with higher education levels. Inequalities in favour of people with higher education levels are observed in 18 countries. The largest inequalities are found in Austria, Poland and Spain, with differences of between 10 and 13 percentage points between education groups. Only in Czechia, Finland, Italy, Romania and Slovenia is uptake of colorectal cancer screening similar across education groups or higher among people with lower education levels. Comparable patterns of inequality are found when comparing the highest and the lowest income quartiles. In 20 EU+2 countries, the likelihood of receiving colon cancer screening is higher among the highest income quartile (37%) than the lowest (31%).
Controlling for all core individual characteristics (demographics and socio‑economic characteristics) and country-specific effects, analysis largely confirms the association between income and education with cancer screening participation (Table 4.6). It also points to the importance of citizenship and living areas to explain screening participation rates. Across EU countries, people with migration backgrounds have a lower likelihood of accessing breast cancer screening, but the relationship is entirely explained by a lower education and income. People living in rural areas also have a significantly lower likelihood of receiving breast and colon cancer screening than those living in urban areas. As shown in Table 4.6, the association remains statistically significant after controlling for all individual characteristics for both cancer screening services.
Table 4.6. Income and education are significant predictors of cancer screening participation in EU+2 countries
Notes: Level of significance: NS: non-significant, * p <0.10, ** p <0.05, *** p <0.01, **** p <0.001. An up arrow indicates positive marginal effects, and a down arrow indicates negative marginal effects (for example, people in the highest income quartile and with the highest education level have a higher likelihood of reporting access to breast cancer screening than those in the lowest income quartile and with low levels of education).
Source: The Survey of Health, Ageing and Retirement in Europe, wave 8 (2021/22).
These results align with previous studies in several EU and OECD countries. A recent study on cancer test utilisation in Europe revealed that people with lower household incomes were generally less likely to undergo mammography (odds ratio (OR) = 0.55), cervical smear tests (OR = 0.60) and colorectal testing (OR = 0.82) compared to those with higher incomes. Additionally, individuals born outside the EU, those with lower educational levels, and unemployed or retired people were also less likely to get tested. The income‑related gap in access to breast and colorectal testing was most pronounced in Southern Europe; for cervical smears, it was most significant in Central and Eastern Europe (Bozhar et al., 2022[80]). In the Netherlands, within the National Colorectal Cancer Screening Programme, the participation rate in FIT screening was notably lower for individuals in the lowest socio‑economic quintile (67%) in contrast to those in the higher quintiles (ranging from 73% to 75%). Similarly, there was a significant difference in uptake of colonoscopy following a positive FIT result among these socio‑economic groups (van der Meulen et al., 2022[81]). A recent French cross-sectional study, based on census data from the health insurance information system, also revealed stark disparities in screening participation rates by socio‑economic position and place of residence. Looking at mammography and cervical smear testing, the study shows higher participation rates in large urban areas than rural areas, with a stronger social gradient in large urban areas than other areas (Ouanhnon et al., 2022[82]).
In Germany, significant variations were found in cancer testing utilisation among people with a migration background. Specifically, migrants from EU countries (adjusted OR = 0.73) and non-EU countries (OR = 0.39) were less inclined to opt for gFOBT than non-migrants (Wahidie, Yilmaz-Aslan and Brzoska, 2022[83]). Non-EU (50.1%) and EU migrant women (52.7%) consistently reported lower utilisation rates of cervical cancer screening than non-migrant women (57.2%). These disparities persisted even after accounting for predisposing, enabling and need factors, highlighting the continued differences in screening uptake (Brzoska, Aksakal and Yilmaz-Aslan, 2020[84]). The main barriers to cervical cancer screening for migrant groups included a lack of information, an absence of female healthcare providers, limited proficiency in the local language, and emotional responses to the test – with fear, embarrassment and discomfort being prominent concerns. EHIS data also confirmed that migrant populations have a lower likelihood of being up to date with cancer testing including mammography, cervical smear test and colorectal test (Bozhar et al., 2022[80]).
Inequalities in access to screening programmes have also been highlighted for lesbian, gay, bisexual and transgender (LGBT+) communities, mainly because sexual minority populations are subject to stigma and trauma experiences, leading to health inequalities in cancer care (Kaster et al., 2019[85]). Previous studies have shown that the LGBT+ community have lower access to cancer screening programmes than their heterosexual counterparts due to discrimination, limited access to healthcare providers and lower health literacy (Polek and Hardie, 2020[86]).
4.3.4. Several policy actions are being explored to improve the reach of screening programmes and early diagnosis
Several factors influence both uptake of cancer screening programmes and early diagnosis of symptomatic cancer. Beyond disease factors (such as tumour biology and history of the disease), demand-side factors (such as knowledge and awareness of cancer, and health literacy) and supply-side factors (such as health provider knowledge of the signs and symptoms of disease, and referral pathways) are important drivers of cancer screening and early diagnosis that could be better targeted to promote early detection.
Building cancer awareness is one important policy option, particularly among socially vulnerable populations
Disparities in access to screening and early diagnosis are partly explained by differences in cancer awareness around both screening programmes and recognising symptoms and help-seeking behaviour. Poorer cancer awareness can delay diagnosis, which can lead to lower survival rates. Poor awareness of screening programmes, cancer symptoms or barriers to help-seeking care have been associated with delays in cancer diagnoses in several countries. Large heterogeneity of cancer awareness has also been found across several countries including Australia, Canada, Denmark, Norway, Sweden and the United Kingdom. Overall, Nordic countries (Denmark, Norway and Sweden) have higher levels of cancer awareness than the others (Forbes et al., 2013[87]).
A systematic review and meta‑analysis of the European evidence on medical help-seeking for breast cancer suggests that higher levels of breast cancer knowledge, positive beliefs in the benefits of screening and previous screening history were associated with a higher level of screening attendance and prompter help-seeking behaviour (Grimley, Kato and Grunfeld, 2019[88]). Low cancer awareness has been reported to be more prevalent among groups with low socio‑economic status, low education levels, ethnic minority backgrounds and older ages (Green, Lloyd and Smith, 2023[89]). In Spain, for example, responses to the Awareness and Beliefs about Cancer Questionnaire showed that respondents from lower socio‑economic backgrounds recognised fewer cancer symptoms and were more delayed in help-seeking (Petrova et al., 2023[90]). In France, an empirical analysis based on administrative data showed that women with low socio‑economic status have a two‑fold risk of having late‑stage breast cancer, mainly due to less regular follow-up and poor awareness of breast cancer (Orsini et al., 2016[91]).
Important policy actions to reduce inequalities in cancer awareness include informing people through individual counselling about identifying cancer symptoms, and addressing barriers and beliefs associated with delays in help-seeking. In a literature review assessing the impact of interventions among lower socio‑economic groups, individual counselling on screening activities was found to be more effective than either one call or a letter accompanied by one call (Spadea et al., 2010[92]). Interventions to improve cancer awareness have been developed in 21 of the 26 countries responding to the 2023 OECD Policy Survey, among which 18 reported having specific initiatives to reach vulnerable or remote populations (Figure 4.9). At the EU level, the Cancer Screening Campaign webpage provides multi-language information, direct access to websites related to national screening programmes and media kits to raise awareness of cancer screening among European citizens, including a focus on vulnerable populations (European Commission, 2023[93]).
Figure 4.9. Several EU+2 countries have public awareness campaigns and initiatives to reach vulnerable populations
Note: Information for Belgium and Portugal is not available.
Source: 2023 OECD Policy Survey on Cancer Care Performance.
In Ireland, for example, equity is defined as a key priority in the Strategic Plan for the National Screening Service 2023‑27 (Health Service Executive, 2023[94]). Various research projects are being conducted, such as development of a strategic framework to improve equity in screening, and research related to behavioural interventions to improve screening uptake among vulnerable populations. Tailored awareness and information campaigns directed to the indigenous minority of Irish Travellers are also being developed, focusing on the cancers that most affect these populations (Marie Keating Foundation, 2023[95]). Workshops, online information materials and other tailored educational resources are helping to reach these marginalised communities. In France, easy-to-read and -understand tools are available for people with low literacy. In Belgium, pilot projects on self-testing for women with disabilities are ongoing in Flanders. In Finland, invitation letters are available in minority languages on request, while in Germany and Belgium, information about the cancer screening programmes is available in various languages (see Box 4.3 for other country examples). In the Netherlands, changes were introduced to support access to cancer screening programmes among refugees from the war in Ukraine. In addition, funds are allocated to reach groups with lower socio‑economic status, and additional funds were made available by the Dutch Cancer Society to focus on implementation of cancer prevention projects at the local level to support a healthy lifestyle and living environment (Chapter 3).
Box 4.3. Policy actions are in place to increase cancer awareness
Policies to raise cancer awareness, increase engagement with vulnerable populations and increase screening participation
Media campaigns and information leaflets to increase awareness among the population are available (Bulgaria, Estonia, Italy, Luxembourg, Norway, Poland, Slovenia).
Peer-to-peer helpers inform people in their networks about screening and early detection (Slovenia, Sweden); in some programmes, this includes piloting a quick-response (QR) code on the invitation to translate the information to the language set on the cell phone (Sweden).
A “hesitation hotline” that can be called about colorectal cancer is provided by medical students, supported by physicians (Netherlands).
Easy-to-read and -understand tools are available for people with low literacy (France); information leaflets about the colorectal cancer screening programme are available in simple language (Germany).
Policies to reach disabled, migrant and other vulnerable or minority populations
Slovenia communicates with non-governmental organisations working with people with disabilities. Community health nurses can visit people at home if they need help to carry out screening programme procedures.
Health professionals from various countries have created informative video messages for migrant communities. These videos are available in 25 languages and cover important health topics. Online guides to cancer screening are available in English, Irish, Ukrainian and Russian (Ireland).
Invitation letters are available in minority languages on request (Finland); information about the breast cancer screening programme is available in 12 languages (Germany); online information about screening programmes is available in 10 languages (Belgium, Flanders).
Leaflets, infographics and videos about all screening programmes are available in English, Turkish, Arabic, Ukrainian and Russian, with letters and leaflets updated annually (Netherlands).
Breast and cervical cancer screening are made accessible for transgender and intersex people to whom screening is relevant (Netherlands).
LGBT+ awareness training takes place for professionals involved in cervical cancer screening, dedicated points of contact for the LGBT+ community and representatives of the LGBT+ community in the Patient and Public Partnership of the National Screening Service (Ireland).
A few countries have implemented interventions to target LGBT+ communities specifically. The Irish targeted intervention for the LGBT+ communities is an example of good practice across EU+2 countries to reduce inequalities in cervical screening. The intervention, which is part of the Cervical Check Programme, includes a specific training programme for health professionals and dedicated points of contact for the LGBT+ community. The overarching objectives are to increase training for sample takers, to include and communicate with the LGBT+ community in cervical screening, to develop more targeted messaging and campaigns for the LGBT+ community, and to do further research. Similar programmes exist in Canada, the United States and the United Kingdom. In Canada, for example, the Canadian Cancer Society developed awareness programmes for the LGBT+ community on breast, cervical and colorectal cancer screening. Members of LGBT+ communities share their experience with screening to improve screening awareness and encourage each other to get screened.
Mobile units and an increased role for pharmacists help to reduce socio‑economic and geographical disparities in access to screening programmes
In the area of cancer screening, new delivery models have been adopted to reach socially vulnerable populations, including rural and underserved communities. As highlighted by previous research, people on lower incomes and those living in rural areas can experience poor access to screening services because of financial or geographical barriers. Mobile cancer screening programmes have a key role in bringing cancer screening to people in the communities where they live and work. Mobile breast cancer screening programmes have been implemented in a few countries (Croatia, Cyprus, Estonia, France, Iceland, Ireland, Norway, Slovenia and Sweden). For example, in Estonia, three mobile mammogram buses drive around the country and stop in multiple cities and towns in all counties to make sure that everyone has easy access to breast cancer screening. In Ireland, 24 mobile breast cancer screening units are used for vulnerable and remote populations. In Germany, approximately 70 mobile screening facilities (screening buses) are in service for the mammography screening programme; they are particularly used in rural areas. In France, mobile mammography units travel to isolated populations far from radiology centres and to marginalised urban areas. In other OECD countries, such as in the United States, mobile lung buses bring low-dose CT lung screening to areas where at-risk individuals may have limited access to screening services, and breast, cervical and colorectal mobile screening are also in place in some states.
Among the scarce available evidence, a cost – effectiveness analysis in France suggested that mobile mammography units increase participation in breast cancer screening and reduce geographical and social inequalities. The study shows that a mobile mammography unit is more cost-effective than a radiologist office in remote and in deprived areas (De Mil et al., 2019[96]). Earlier studies also found 15% higher participation rates for mobiles units compared to fixed sites, particularly for women in the lowest household income quintile. Women who receive mammography in mobile units are more likely to belong to low socio‑economic backgrounds and live in rural areas, and less likely to have contact with the healthcare system; thus, the units help to reduce socio‑economic and geographical inequalities (Reuben et al., 2002[97]).
Some countries are also extending the role of pharmacists in cancer screening activities to facilitate early detection of diseases. Community pharmacists remain among the most accessible healthcare providers, along with GPs, and have close communication with patients. Evidence suggests that inclusion of pharmacies in screening programmes has resulted in higher coverage for detection of colorectal cancer because of pharmacies’ opening hours, accessibility and familiarity with their users. In France and Spain, community pharmacists are allowed to distribute gFOBT or FIT for sample collection; they provide information to users about the correct method of collection and delivery of the sample. In Catalonia (Spain) the number of kits delivered has increased four‑fold since 2013, resulting in positive experiences among the public. In Ireland, community pharmacists have recently been involved in a pilot project for colorectal cancer screening in County Kerry. Evaluation of the pilot demonstrated that colorectal screening kit return rates were 74% after the intervention compared to the 38% national return rate (Flaherty, Flaherty and Farrelly, 2019[98]). In Norway, community pharmacists offer dermatological cancer screening services. Pharmacies assess moles and pigmented lesions and send the images to a trained dermatology specialist for interpretation (PGEU, 2020[99]).
General practitioners, supported by training and decision tools, facilitate participation in screening activities and in identifying cancer at earlier stages
Primary healthcare providers – as the first point of contact with the healthcare system and having both individual-level data and close relationships with communities – have a key role to play in facilitating participation in screening activities and early diagnosis. One notable role is to clarify questions and remind eligible populations about screening programmes. Another is to refer symptomatic users to specialist care following a positive result or for suspected cancer.
Among the 26 countries responding to the 2023 OECD Policy Survey, half reported relying considerably on primary healthcare providers (or GPs) to deliver cancer screening activities for colorectal (12 countries) and cervical (15 countries) cancers (Figure 4.10). Cervical cancer screening is often performed at the primary healthcare level by GPs, GP assistants, practice nurses (as in Ireland) or gynaecologists (as in Germany), who sometimes work at the primary care level (as in Slovenia). In some countries, however, cervical cancer screening is partly carried out in hospitals – as in Spain, where screening is carried out in a co‑ordinated manner between primary care and hospitals, and Italy. For colorectal cancer screening, local health services have a role in delivering the tests (as in Italy) while in some countries colorectal cancer screening is partly carried out in hospitals (as in Denmark and Spain). In Germany, both GPs and specialists are involved in cancer screening: GPs, gynaecologists and urologists hand out FIT kits, and colonoscopies are performed by gastroenterologists. For breast cancer screening, in some countries GPs are responsible for inviting the eligible population (as in Lithuania). Nonetheless, most countries have a process for inviting people to screening co‑ordinated at the national or regional level. In Bulgaria, the three most common cancer screening types (colorectal, breast and cervical) are performed by specialist medical doctors following a referral by a GP. In Cyprus, it is anticipated that primary healthcare providers will have a greater role in cancer screening activities, with the aim of boosting participation rates. In 2022, France implemented a nationwide effort to improve health information and education via three free comprehensive GP visits that take place at 25 (vaccines, physical activity, addictions, entry to work life), 45 (physical and mental health assessments and screenings for cardiovascular diseases and cancers) and 65 years of age (maintenance of independence, screening for cancer and preventable diseases, and psychological preparation for retirement) (Government of France, 2022[100]).
At the international level, research shows evidence of higher patient participation in breast, cervical and colorectal screening programmes when eligible populations are reminded by primary healthcare providers, or after a primary healthcare recommendation. Postal invitations and reminders, phone calls and providing a scheduled appointment instead of an open appointment were also found to be effective approaches to increase uptake of organised screening (Duffy et al., 2017[101]; Mandrik et al., 2021[102]; Wender and Wolf, 2020[103]). Primary healthcare can thus help to engage and encourage people who are under-screened, or who have never been screened. Recommendations and reminders sent by primary care providers should be a priority intervention to enhance screening participation.
Figure 4.10. Primary healthcare has a key role in delivering cancer screening activities in up to half of EU+2 countries
Countries that reported primary healthcare as the principal provider of cancer screening activities, by type of cancer
Note: Information for Belgium and Portugal is not available.
Source: 2023 OECD Policy Survey on Cancer Care Performance.
Beyond participation in screening activities, the role of primary healthcare in early diagnosis is also of relevance – particularly in raising awareness about relevant symptoms, as well as identifying and referring people with concerning symptoms for further assessment when necessary. Primary healthcare needs to be well equipped with educational interventions (such as training programmes and continuous medical education), decision-support tools and risk scores to assist in recognising and referring symptomatic people with suspected cancer. Optimising primary healthcare recognition and interpretation of symptoms is an important way to improve earlier diagnosis of cancer. Primary healthcare providers need to be appropriately trained to evaluate the risk of cancer and consider the need for investigation. The impact of GP-targeted cancer awareness campaigns, training and continuous medical education about referral guidelines is well documented. It has been found to improve knowledge of cancer among GPs and to improve selection of patients for urgent cancer referral (Toftegaard et al., 2016[104]; Saab et al., 2022[105]). In Denmark, for example, a continuous medical education programme in earlier cancer diagnosis was introduced as part of the National Cancer Plan. The overarching objective was to support GP decision-making strategies for referral. The programme focused on diagnostic processes in general practice, symptom risk assessment tools, risk of false negatives and gynaecological examinations. Similar continuous medical education programmes in cancer diagnosis are in place in other OECD countries, including the United Kingdom and Australia.
In addition, a systematic review analysing the impact of decision-support tools suggested that electronic clinical decision-support tools improve GP decision making in cancer diagnosis, reducing delays in diagnosis for cancer with non-specific symptoms (Chima et al., 2019[106]). Such tools should be made available and be used by primary healthcare providers. In the United Kingdom, for example, primary healthcare providers have access to computer-based algorithm tools, incorporated into GP software systems, to calculate the risk of a patient having an undiagnosed cancer during consultations. They are called Risk Assessment Tools and Cancer, and are available for 18 cancer sites, using symptoms, test results and the individual’s characteristics to estimate the risk of cancer. However, according to a cross-sectional survey of primary care providers, cancer decision-support tools are an underused resource in the United Kingdom: they were available and used by only 17% of primary care practices (Price et al., 2019[107]).
Fast-track pathways help to address delays in cancer diagnosis
Once primary healthcare has identified underlying cancer, there is a need to confirm the diagnosis in a timely manner. Fast-track pathways or fast-track referral mechanisms are a policy option to help reduce the time between cancer suspicion, cancer diagnosis and start of initial treatment to affect cancer prognosis. They have been developed in a few countries, including Denmark, Ireland, Latvia, Lithuania, Poland, Slovenia, Sweden and some regions in Spain (OECD, 2020[108]).
In Ireland, the National Cancer Control Programme developed a system of rapid access clinics to reduce time to cancer diagnosis and improve patient outcomes. Patients can typically secure an appointment at a breast or lung rapid access clinic within two weeks, and at a prostate rapid access clinic within a month of being referred by a clinician. The clinics take on much of the country’s diagnostic work for these tumours (OECD, 2023[109]). Recent available evidence demonstrated that a dedicated rapid access lung cancer clinic resulted in a higher percentage of early-stage lung cancers being identified compared to the most recent figures from the National Cancer Registry of Ireland (Dunican et al., 2023[110]). The rates of stage I and stage II cancers were more than double those in the Cancer Registry, suggesting that earlier disease is being detected, resulting in better opportunities for intervention.
In Denmark, fast-track cancer pathways were introduced in 2007 by the Danish Health and Medicine Authority to improve the prognosis of people with cancer. The pathways are supported by national guidelines, according to which GPs ensure collection of a pre‑defined minimum panel of blood and urine tests, and assesses the results of a CT scan of the thorax, abdomen and pelvis prior to further evaluation and diagnostics at hospitals (Bislev et al., 2015[111]). Based on data from the Danish Cancer in Primary Care Cohort, the cancer pathways significantly improved relative survival rates. For all cancer patients, three‑year relative survival increased from 45% to 54% after implementation of the cancer pathways (Jensen, Torring and Vedsted, 2017[112]).
Poland introduced the Rapid Oncology Therapy Package in 2015: if suspected cancer is confirmed, a primary care or outpatient specialist doctor issues a cancer diagnosis and treatment card. This ensures delivery of services covered by the Oncology Package within the guaranteed maximum waiting time limits: 28 days from visiting the primary care doctor to basic diagnostics; 21 days from specialist consultation to in-depth diagnostics; and 14 days from multidisciplinary team meeting to the start of treatment. The introduction of the fast diagnostic pathway resulted in marginal improvements in waiting times for services covered by the Oncology Package, while waiting times for services not covered and follow-up cancer care increased. The National Cancer Strategy 2015‑24 developed a framework for reorganising cancer care delivery through the National Oncology Network.
In 2016, Latvia introduced fast-track access for people with cancer (called the green corridor), paid in full by state budgets, to streamline diagnosis and treatment decisions for suspected cancer cases. This requires specialist consultation and diagnostic examination within ten working days of the date of referral. Fast-track access for people with recurrent cancer (called the yellow corridor) was also established to ensure timely access to care. Access to cancer care improved, and the proportion of people diagnosed at early stages increased from 50% in 2015 to 55% in 2017 (OECD, 2023[113]).
In Lithuania, the green corridor cancer care pathway has been institutionalised to manage the care pathway effectively, from diagnosis to follow-up or end-of-life care. Every cancer centre has adopted this approach, which ensures quicker provision of diagnostic and treatment services for people with cancer that is within national waiting time targets (a total of 42 days from suspicion of cancer to treatment) (Ministry of Health, 2023[114]).
4.3.5. Use of cancer screening data in quality assurance mechanisms could be improved to monitor inequalities and improve quality
Screening data management is key to ensuring identification and invitation of eligible citizens, to maintaining information about screening tests performed and their results, and to implementing quality assurance mechanisms. Compiled data on population-based cancer screening programmes across the EU are available at IARC’s CanScreen5 Project (IARC, 2023[115]) – a global data repository that enables comparisons among countries through standardised methods and definitions to estimate performance indicators. The EU4Health-funded project CanScreen-ECIS intends to develop a data system for collection, management and dissemination of performance data related to cancer screening programmes in Europe (European Commission, 2023[116]). The project will be embedded in the European Cancer Information System (ECIS) and aims to improve opportunities to compare screening programmes and monitor inequalities. Data are also key to identifying and engaging with vulnerable groups, allowing tailored policy actions to increase awareness and uptake of screening among non-participants from disadvantaged groups (Spadea et al., 2010[92]).
Of the 29 EU+2 countries, 13 gather information from both population-based and non-population-based screening in existing cancer screening databases (Figure 4.11). Use of screening data to inform quality improvement cycles could also be further encouraged. Among the 26 responding countries, 16 (62%) acknowledged using screening data in quality improvement cycles.
Figure 4.11. Cancer screening information is used in quality improvement cycles in 16 EU+2 countries
Note: Information for Portugal is not available.
Source: 2023 OECD Policy Survey on Cancer Care Performance.
In the Netherlands, screening data are translated into performance measures and embedded in quality improvement cycles for colorectal, breast and cervical cancers. Such performance measures provide uniform quality assurance for screening programmes; allowing population screening to be monitored at the local, regional and national levels. The National Reference Centre for Population Screening periodically conducts medical assessments of screening organisations. In Luxembourg, a set of performance indicators has been developed for the breast cancer screening programme to monitor and improve care quality for breast cancer patients on an ongoing and systematic basis. The Swedish National Breast Cancer Register comprises diagnostic and therapeutic data, as well as outcomes for all in situ and primary invasive breast cancers, along three sections: notification (with information on the cancer staging at diagnosis), adjuvant therapy and follow-up. A validation study conducted on Register data showed high completeness, comparability and agreement of data. One area identified for improvement was the timeliness of reporting (Löfgren et al., 2019[117]). Czechia has maintained its National Oncological Registry since 1977; it is compulsory by law to provide data to the Registry. Its official website provides epidemiological statistics, incidence per region and clinical stages of diagnosed cancers. In Lithuania, the National Council for Monitoring the Implementation of the Cancer Control Programme, established in 2014, performs evaluations of oncological care (structure, process and outcomes data) and programme implementation annually.
Among populations eligible for cancer screening, age, sex and geography seem to be common variables collected across EU+2 countries to keep track of inequalities in participation rates (Figure 4.12). Collection and linking of socio‑economic data are not common among EU+2 countries, performed by only six countries (France, Germany, Italy, the Netherlands, Slovenia and Sweden). Denmark, Italy and Sweden report collecting data about education.
Figure 4.12. Age, sex and geography are the most common variables used by countries to monitor inequalities in cancer screening participation rates
Note: Information for Portugal is not available.
Source: 2023 OECD Policy Survey on Cancer Care Performance.
Spain is working on a cancer information system to measure uptake of screening and assess inequalities. In the Netherlands, screening databases include information about migration status and geographical location. An evaluation report on the screening programmes, studying non-respondents to screening across geographical locations, is being prepared by the National Institute of Public Health. Previous studies have used Dutch postal codes as measure of socio‑economic status (van der Meulen et al., 2022[81]). Italy collects screening data assessing socio-demographic characteristics, such as citizenship, household information, socio‑economic status and education, facilitating evaluation of disparities in access within vulnerable populations (National Screening Observatory, 2023[118]). In Germany, since 2008, the Robert Koch Institute has been conducting a nationwide cross-sectional survey of the resident population on behalf of the Federal Ministry of Health, called the German Health Update. This provides information about utilisation of and inequalities in cancer screening based on sex, age and education level. In Slovenia, certain categories are not measured in all screening programmes (socio‑economic status, geography, and migration status). Occasionally, screening programmes perform analysis on sub-groups of the population by linking screening data with data available from the Statistical Office. In France, territorial and social inequalities may be the subject of studies by regional cancer screening co‑ordination centres and are the subject of occasional national studies on participation in screening according to the territory and deprivation level. In Ireland, in 2022 a proof-of-concept BowelScreen Patient Experience Survey was launched to assess the experience of colorectal cancer screening participants by gathering real-time feedback (Health Service Executive, 2023[94]). Given the success of the Survey, implementation of the programme for breast cancer screening is being planned. Beyond EU+2 countries, Australia has a very comprehensive Breast Cancer Registry, where data on inequalities are particularly rich. Its database includes participation rates for breast cancer screening aggregated by age, state and territory, level of remoteness, socio‑economic area, and culturally and linguistically diverse populations, including indigenous populations.
4.4. While some innovations in early detection of cancer are promising, many are still in the research phase
4.4.1. Risk-stratified screening is a growing field of research, but policy makers need to consider implementation and ethical challenges
Breast cancer includes diseases with very heterogeneous biological behaviours – from indolent to very aggressive. Most current screening approaches do not consider the variety of breast cancer subtypes or the heterogeneity in risk profiles among women. A stratified risk approach can support personalisation of screening decisions according to individual risk profile (Pashayan et al., 2020[119]). This approach would allow the intensity of screening among women at lower risk of breast cancer to be reduced, while concentrating on those at higher risk through customised surveillance. This could support early detection of more aggressive breast cancer forms and implementation of preventive treatments. Individualised breast cancer risk prediction models allow stratification of women according to risk, by incorporating various factors such as family history, hormonal and reproductive aspects, mammographic breast density and common genetic variants.
Polygenic risk scores (PRS) can be derived from saliva samples and provide information on the combined effect of genetic variants. A personalised breast cancer risk assessment combines PRS with other genetic and non-genetic risk factors. Such models are not yet used routinely in organised screening programmes, partly because further research is needed (Louro et al., 2019[120]). Various international studies are investigating the personalised risk-stratified breast cancer screening approach compared to standard age‑guided screening approaches, as well as aspects related to its implementation. These include PROCAS (United Kingdom) (Evans et al., 2016[121]), WISDOM (United States) (Esserman and WISDOM Study and Athena Investigators, 2017[122]), MyPeBS (Belgium, France, Israel, Italy and the United Kingdom) (Roux et al., 2022[123]), and the Canadian PERSPECTIVE I&I (Brooks et al., 2021[124]). The MyPeBS study, funded by the EU, primarily intends to show non-inferiority of the risk-stratified screening approach regarding incidence of breast cancer stage II or higher compared to the standard screening strategy for women aged 40‑70. This approach requires collection of each woman’s genetic and non-genetic data, calculating her risk profile using risk prediction models and tailoring screening accordingly, as well as potentially applying risk reduction approaches – such as prophylactic bilateral mastectomy – to high-risk women (Lapointe et al., 2022[125]).
In addition, MRI for women with dense breasts is a screening strategy that could be considered according to each country’s context. Breast density decreases the sensitivity of mammography, which makes these women more prone to being underdiagnosed in regular screening programmes. Consequently, the likelihood of a delayed diagnosis of breast cancer is higher among women with dense breasts (48% of women). In addition, women with dense breasts are at higher risk of developing breast cancer, thus providing an example where tailored screening programmes may consider individual risk factors. Recent studies – such as the DENSE trial (Bakker et al., 2019[126]), the EA1141 trial (Comstock et al., 2020[127]) and a modelling study that used results from the DENSE trial (Geuzinge et al., 2021[128]) – have provided evidence on the cost – effectiveness of MRI screening for women with dense breasts. This last study showed that incidence of interval cancers4 was significantly lower in the group of women receiving an MRI (rate of 2.5 interval cancers per 1 000 screenings) compared to the group of women receiving mammogram only (rate of 5 interval cancers per 1 000 screenings). In 2021, the ECIBC suggested using a DBT or DM for asymptomatic women with high mammographic breast density detected in previous screening exams, in the context of population-based screening programmes (a conditional recommendation due to uncertainty of the supporting evidence) (European Commission, 2023[31]).
Personalised screening strategies for colorectal cancer are also being researched. The possibility of sex-specific and age‑specific cut-off values for FIT, and of tailoring screening intervals according to the results of prior FIT (specifically, the measured faecal haemoglobin in participants with a negative FIT), instead of considering only a single threshold, are both under consideration. For instance, the PERFECT-FIT study in the Netherlands is studying the effectiveness of screening intervals adjusted based on prior faecal haemoglobin concentration in a FIT-based screening programme (Breekveldt et al., 2023[16]). Such strategies to tailor colorectal cancer screening to individual risk are not yet being piloted or implemented in the EU27.
Implementation of such stratified risk approaches faces implementation challenges, such as resource considerations, health literacy and support for informed decision making by individuals (Toes-Zoutendijk et al., 2023[129]), as well as workforce training (Taylor et al., 2023[130]), and perception of acceptability among healthcare professionals and the general population (Cairns J.M., 2022[131]). For instance, low familiarity with the concept of PRS by healthcare providers not trained in genetics, such as GPs and oncologists, was reported in a previous study in Canada (Lapointe et al., 2022[125]). Social and ethical issues related to stratified risk approaches should also be considered and should be subject to further research to inform policy making. These include data security, logistical challenges related to informed consent (Hall et al., 2014[132]), and policies to ensure equitable access and protect the high-risk population from discrimination (Pashayan et al., 2020[119]). There is also a need for legal and regulatory frameworks related to incidental findings that can be obtained from genetic information.
In Estonia, the National Health Insurance Fund, which co‑ordinates breast cancer screening, started accepting PRS information to provide breast cancer screening to women younger than 50 on an opportunistic basis (e-Estonia, 2022[133]; Estonia Research Council, 2023[134]). In 2021, over 10 000 PRS tests were performed, and 42% of the women tested were advised to start screening earlier than the national screening programme target age. The EU-funded BRIGHT Project will conduct three pilot studies in Estonia, Sweden and Portugal to evaluate precision breast screening approaches, targeting screening based on genetic risk. The Estonian health-technology company performing PRS for breast cancer also tests the genetic risk of prostate cancer, colorectal cancer and melanoma. Centres for familial breast and ovarian cancer and centres for familial colorectal cancer have been established in Germany (German Consortium for Familial Breast and Ovarian Cancer, 2023[135]; German Familial Colorectal Cancer Consortium, 2023[136]). These provide counselling, genetic testing and prevention/intensified early detection to populations at risk (such as women with hereditary breast and ovarian cancers). In France, personalisation of screening or follow-up approaches is one of the objectives of the ten‑year Cancer Control Strategy.
Self-sampling tests for cervical cancer screening targeting women at higher risk are being developed. Genefirst (2023[137]) is developing a new self-sampling screening test (HPV OncoPredict), aiming to screen and triage women at higher risk of developing cervical cancer by including a triage assay for positive high-risk HPV samples that can distinguish relevant from clinically irrelevant HPV infections leading to cancer. Ultimately, this tool may be able to increase uptake and effectiveness of cervical cancer screening.
4.4.2. Biomarkers are another field of research, although there is no solid evidence yet for their use in population-based cancer screening
Cancer cells release DNA into the patient’s blood, and detection of the circulating tumour DNA in the blood constitutes the base of a “liquid biopsy” (Crowley et al., 2013[138]), a biomarker with several clinical applications. While its value in monitoring disease progression and treatment response and as a prognostic tool has been evidenced in various studies, its application as a tool in early diagnosis of cancer is a subject of research. Currently, there is not enough evidence on the effectiveness and safety of these tests as diagnostic tools – particularly in asymptomatic populations (Bradley and Barclay, 2021[139]).
A multicancer early detection blood test is the subject of current research, with a total of eight studies planned in the coming years. These are intended to validate the test in screening for different cancer types, evaluate its performance in eligible screening populations, and assess outcomes in real-world settings (Klein, Beer and Seiden, 2022[140]). As this test’s ability to detect cancers increases with the cancer stage, it has a lower ability to detect early-stage cancers (Klein et al., 2021[141]).
Of the 26 EU+2 countries that responded to the 2023 OECD Policy Survey, 11 reported having regulation of biomarker screening and genetic testing in place. For instance, Sweden has legislation on genetic integrity to regulate the use of biomarker data such as genetic testing. Germany has already determined reimbursement for some biomarkers for screening and genetic testing procedures. In addition, the Federal Government has assigned an evaluation committee of the nationwide reimbursement system to implement a process to determine reimbursement levels for new screening and testing procedures in outpatient settings. In Israel, in 2020 the Ministry of Health started funding wide BRCA1/BRCA2 gene testing for women with full or partial Ashkenazi Jewish origin (Greenberg et al., 2023[142]), who present higher risk for BRCA gene mutations, and thus have an increased risk of developing breast and ovarian cancers. The results of this policy can inform the effectiveness of BRCA1/BRCA2 carrier screening in other settings.
4.4.3. Machine learning is being explored for several applications in the field of early detection of cancer
Machine learning (ML) learns patterns from data to solve tasks, allowing a system to learn automatically and improve from experience, updating the internal parameters of the model through extensive contact with input data and the resulting outputs (Swanson et al., 2023[143]). Possible uses of ML in the field of screening and diagnosis are: 1) to triage people who should get enhanced screening by analysing characteristics of the population (risk prediction and risk-stratified screening); 2) to assist in the diagnosis of cancer by assessing images and results from medical exams (image‑based risk stratification and cancer detection); 3) to mine information for triage purposes from longitudinal records (e.g. in breast cancer) and identify people who should be diagnosed; and 4) to evaluate the treatment provided to patients with a specific diagnosis to determine whether it is consistent with up-to-date evidence‑based practices.
The first EU regulatory framework for artificial intelligence (AI) and a co‑ordinated plan for AI were proposed in April 2021 by the European Commission (2021[144]). In June 2023, the AI Act was adopted in the European Parliament (2023[145]) and in December 2023 (2023[146]) a political agreement was reached between the European Parliament and the Council. This Act is the first comprehensive EU legislation to regulate AI, and negotiations are ongoing to finalise the new law.
One of the flagship initiatives of Europe’s Beating Cancer Plan is the European Cancer Imaging Initiative, launched in December 2022. This aims to improve the precision, access and timeliness of screening, diagnosis and treatment by linking up databases to build an open infrastructure of cancer images for stakeholders. The AI for Health Imaging Network includes five EU-funded projects working on detection of cancer from imaging through development of AI algorithms, and on establishing federated repositories for cancer images (European Comission, 2023[147]). The EU-funded project EUCAIM (EUropean Federation for CAncer IMages), which is key to the European Cancer Imaging Initiative, started in January 2023 involving 12 European countries and building on the results of the AI for Health Imaging Network. By 29 September 2023, the Cancer Image Europe platform was linking 36 datasets of images of nine cancer types (including image series of about 20 000 individuals) (European Commission, 2023[148]). The EU4Health project eCAN – Joint Action on strengthening eHealth including telemedicine and remote monitoring for healthcare systems for cancer prevention and care (launched in September 2022) aims to provide recommendations on the use of telemedicine and remote monitoring of cancer patients – notably those from rural and remote areas (European Commission, 2023[149]).
ML can also facilitate extraction of clinical data from electronic health records. A study comparing manual extraction of clinical data with automated data extraction showed high accuracy and concordance in a swift manner (Gauthier et al., 2022[150]). This could be a valuable tool to conduct studies with real-world data at a larger scale, providing potentially useful insights for clinical practice and policy making. Another study outlined how the combination of data warehousing and processing text clinical documentation with natural language processing (a branch of AI where computers are enabled to process human language) facilitates creation of a prospective and up-to-date database that enables learning health systems in oncology (Petch et al., 2023[151]).
A contribution to advance personalised screening: risk stratification and risk prediction information are two areas being developed in the field of machine learning
Image‑based risk stratification is related to predicting characteristics associated with cancer risk, and to identifying individuals with higher cancer risk, based on medical imaging. Image‑based risk prediction using ML to predict the likelihood of breast, lung and prostate cancers from assessment of mammograms, X-rays and MRIs, respectively, has been studied (Swanson et al., 2023[143]). The ECIBC’s Guideline Development Group suggests use of double reading supported by AI for reading of mammograms using DM or a DBT in population-based screening programmes.
Cancer pathology slides also offer information that can be used by deep learning algorithms to predict clinically relevant biomarkers (Niehues et al., 2023[152]). The first ML algorithm for risk prediction was recently approved by the EU (Owkin’s automated Mismatch Repair Deficiency (dMMR)/Microsatellite Instability (MSI) screening). This facilitates prediction of a highly relevant biomarker in colorectal cancer diagnosis. It also uses pathology slides to predict the risk of relapse in breast cancer patients (Owkin, 2023[153]). Various challenges need to be addressed to advance the deployment of these algorithms, such as their generalisability, interpretability and potential application to other biomarkers.
A contribution to advance non-invasive screening tests: artificial intelligence as a potential tool to improve uptake of screening
Non-invasive screening tests combined with AI could improve coverage of colorectal cancer screening in Europe but are dependent on further research (Shaukat and Levin, 2022[154]). Tests based on imaging technology, such as CT colon capsule combined with AI/ML, may potentially allow performance of the test at home, with results assessed remotely. Such innovations require further evidence, and their implementation will depend on a trained workforce to assess benefits and limitations, and to engage in informed and shared decision making.
While only a few EU+2 countries already use artificial intelligence for cancer screening, some are engaging in discussions or pilot projects
Among respondents to the 2023 OECD Policy Survey, only Norway and Germany reported having already implemented policies on use of AI applications as part of their screening programmes. AI systems are being tested in some EU+2 countries to improve breast cancer detection in screening, but further evidence is needed (Dileep and Gianchandani Gyani, 2022[155]; Marinovich et al., 2023[156]; Larsen et al., 2022[157]). Recent research using mammography screening data from four sites showed that AI-supported mammography screening resulted in a similar cancer detection rate to standard double reading and reduced the mammogram reading workload of doctors almost by half (Lång et al., 2023[158]).
Some European countries are already testing this approach, such as the United Kingdom (Scotland) (pilot testing in six sites), Finland and Hungary. The sustainability of implementation of such practice should include cost – effectiveness considerations. A simulation model comparing two readers of the same exam with a single reader plus an AI technology in breast cancer screening in the United Kingdom showed that the AI technology had the potential to be cost-effective and feasible (Vargas-Palacios, Sharma and Sagoo, 2023[159]). In Germany, use of AI is also planned in cancer registries. Six collaborative research projects are in place, funded by the Federal Ministry of Health, which aim both to prepare cancer registry data for innovative uses of AI and to use AI to analyse the data. As part of the funding priority “Digital innovations for patient-centred healthcare”, the Federal Ministry of Health is also funding a project called SCP2 – Skin Classification Project, which uses AI algorithms to support diagnosis of melanoma. In the Netherlands, discussions are under way regarding how AI can support screening activities to make them more cost-effective. In Luxembourg, a project is ongoing about use of AI to support decision making on the level of prioritisation of mammography reading within the screening programme. Cyprus is also in the process of introducing use of AI as part of the breast cancer screening programme.
A project developed in a partnership between Estonia, Latvia, Lithuania and Norway aims to create personalised cervical cancer screening methods focusing on the cost – effectiveness of specific AI tools for prevention in cervical cancer (Stankunas et al., 2022[160]). The Implementation of Personalised Medicine in Estonia Project (2019‑23) aims to foster use of genetic data – notably in the area of breast cancer prevention and early detection. The PIONEER Big Data Platform offers a central and federated state‑of-the‑art Big Data analytic platform for prostate cancer at an EU level (PIONEER, 2023[161]). It aims to improve patient stratification and identification of low- and high-risk patients, including which patients are more likely to respond to a specific treatment.
Artificial intelligence for cancer screening and early diagnosis can exacerbate inequalities if projects are only implemented at the local scale
Implementation of AI technology in healthcare is in its early stages, and further research focused on regulatory, legal, ethical, clinical and economic aspects is needed. Many EU+2 countries have some small-scale projects in place. This is largely due to a lack of interoperability, fragmented technology and lack of harmonising policy. Unless addressed, these issues risk exacerbating cancer inequalities, as wealthier parts of the system may be able to conduct pilot projects and implement them at the local level, while others may be left without access to the innovation. Concerning the ethical challenges posed by AI in the medical field (Dennison, Usher-Smith and John, 2023[162]), the United Nations Educational, Scientific and Cultural Organization Recommendation on the Ethics of Artificial Intelligence acknowledges these challenges, such as aspects related to the risk of unequal access, and the need for an adequate digital infrastructure and regulatory frameworks (UNESCO, 2021[163]).
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Notes
← 1. A DBT is an imaging technique that provides quasi-three‑dimensional information on the breast, compared to the two‑dimensional image obtained with DM (Chong et al., 2019[164]).
← 2. Austria, Belgium, Bulgaria, Croatia, Cyprus, Czechia, Denmark, Estonia, France, Germany, Greece, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, the Slovak Republic, Slovenia, Spain and Sweden responded to the 2023 OECD Policy Survey on Cancer Care Performance.
← 3. A pack year is a unit representing the number of packs of cigarettes smoked per day multiplied by the number of years the person has smoked. One pack year is 20 cigarettes smoked/day for one year.
← 4. An interval cancer is a cancer that is diagnosed between screening tests. Interval cancers are an inevitable component of breast screening programmes (Public Health England, 2021[165]).