As president of the French League Against Cancer, Dr Daniel Nizri highlights the organization's 106-year legacy of fighting cancer through research funding, health promotion, patient support, and advocacy. He discusses the National Cancer Plan 2030's ambitious goals amidst the realities of healthcare system inequalities, the impact of the COVID-19 pandemic, the importance of prevention, and the challenge of medical deserts. Reflecting on President Macron's announcement to increase France's national production of medicines, Dr Nizri also underscores the critical importance of local manufacturing for drug supply and sovereignty.
Could you introduce yourself and then delve into the history and mission of the National League Against Cancer for our audience?
I have been serving as the President of the National League Against Cancer for nearly three years. Additionally, I’ve held the position of President of the league’s departmental committee in Seine-Saint-Denis, a department north of Paris, for almost seven years.
The National League Against Cancer, a volunteer-driven association, has been making a meaningful impact for 106 years. Present across all French departments, including mainland France, Corsica, and the overseas territories, we operate through approximately 15,000 dedicated volunteers who recruit employees to assist in running our 103 departmental committees. These committees, independent associative structures, comprise 103 local associations along with the national headquarters, totaling 104 associations.
Our shared ambition is to contribute to the fight against cancer, realized through four missions. The most recognized mission is supporting research, where we stand as the top private associative funder of cancer research. Upon assuming my role in 2021, our annual investment was 39 million euros, and as of 2023, we anticipate reaching around 44 or 45 million euros, reflecting a substantial increase.
In addition to research support, our other missions include promoting health and screenings, offering support to cancer patients and their families, and engaging in advocacy efforts. Notably, our national-level fourth mission, advocacy, is increasingly supported by our departmental committees. This involves active engagement with ministries, central administrative bodies, and parliamentary representatives, as exemplified in our recent involvement in discussions on the Social Security Finance Bill for 2023.
Lastly, I want to emphasize a crucial point: our association, recognized as a public utility, is authorized to represent healthcare system users. This is facilitated by our independence, as 95 to 97 percent of our funding comes from the generosity of the public. As a result, we maintain a fully independent voice, free from significant dependencies on public authorities.
The National Cancer Plan 2030 for France, initiated in February 2021, aims to reduce preventable cancer deaths to 50,000 through early diagnosis and prevention, improving the quality of life. What impact has it had so far, and what challenges lie ahead?
This ten-year strategy follows three previous cancer plans. The first plan, in 2003, emerged from the presidential initiative of then-President Jacques Chirac. It was formulated collaboratively by various stakeholders, building on insights from the National League’s general states of cancer patients in 1998—a significant accomplishment for us. These discussions led to a white paper, influencing the subsequent cancer plan. The League actively contributed to drafting not only the first plan but also the two that followed, driving actions at both national and departmental levels. Evaluations by structures like ministries and social affairs inspectorate may not entirely align with our perspective, as ours is shaped by the experiences of patients and their caregivers, introducing some divergence.
One crucial observation is that individuals who encountered cancer before these plans, whether as caregivers or patients, affirm substantial positive changes across various aspects. However, these changes are somewhat uneven nationally, contributing to inequalities in accessing prevention, screening, diagnosis, treatment paths, and overall reintegration into various life aspects. The significant event of 2020, the COVID pandemic, aggravated these access inequalities. Moreover, it exposed vulnerabilities in the French healthcare system, attributable, in part, to insufficient healthcare professionals, not limited to medical doctors but inclusive of all healthcare roles.
Deteriorating medical accessibility, termed medical deserts, presents a challenge. Developing and diagnosing cancer in metropolitan areas with proximity to hospital centers, universities, or cancer centers yields better outcomes than in so-called medical deserts. Addressing your question, the ten year strategy has commendable ambitions, particularly in promoting screenings, prevention, and reducing inequalities. However, we encounter difficulties matching these ambitions with the means available.
Take prevention, for instance. Over twenty years, public health strategies have consistently initiated with two goals: repositioning prevention as a priority and reducing inequalities. Despite acknowledging advancements, especially for those who witnessed cancer before the plans, we recognize persistent disparities in territories and affected populations. In 2021, an unforeseen challenge arose—the COVID pandemic. It significantly worsened these access inequalities, particularly for specific demographics, emphasizing the fragility of the French healthcare system. Issues like insufficient healthcare professionals played a substantial role in this fragility.
An example that highlights the challenges, 40 percent of cancers are preventable. While I won’t go as far as to claim this translates to 40 percent avoidable deaths, it’s noteworthy that these preventable cancers, from a societal perspective, predominantly affect individuals in vulnerable situations. These individuals have additional risk factors and face challenges in accessing both diagnostic and treatment services. It may not be 40 percent of deaths, but it’s still a substantial number, simplifying it, far too many deaths. Now, these 40 percent of preventable cancers are linked to tobacco, alcohol, nutrition, and the environment.
We have been emphasizing tobacco-related prevention for over 40 years, and progress has been made in decreasing smoking rates. Yet, achieving the Ten Year strategy’s goal of a tobacco-free generation by 2030 remains uncertain. Similarly, alcohol-related issues persist, with cultural and economic factors contributing to its prevalence. Despite a decrease in alcohol consumption since World War II, current consumption patterns, especially rapid and intense alcoholism among young people, pose challenges. Our proposals aim for responsible alcohol consumption, combining information, youth education, and support for change through pricing that penalizes highly alcoholic beverages. For instance, among these campaigns is Dry January. This campaign was initiated five years ago and has been gaining momentum in France. Partly funded by Santé Publique France (the French Public Health Agency), was abruptly halted at the request of the Head of State. We considered this to be a very strong signal, not just regarding alcohol-related issues but also underscoring the influence of lobbying from the agri-food industry.
Discussing nutrition, food industry lobbies hinder regulatory efforts, as seen in challenges to the Nutriscore system and regulations on salt, sugar, and fat in processed products. This suggests achieving significant results within the ten year strategy’s timeline will be challenging. The recent protests by farmers highlight complexities in balancing regulations to protect the population from potentially harmful substances used in agriculture.
Is there still a funding shortfall in the implementation of the European cancer plan, despite its alignment with overall priorities in the European cancer fight and the provision of a EUR 1.7 billion budget over 5 years, representing a 20 percent increase compared to the previous plan? Where are the remaining gaps in funding?
Concerning the deficits in funding, it is crucial to note that, within the framework of the ten-year strategy in France, the allocated funds to different ministries are substantial and have not decreased compared to previous plans. However, questions revolve more around how these funds are utilized and the concrete implementation of measures on the ground.
At the European level, there is significant heterogeneity among countries regarding the fight against disease. A concrete example involves the promotion of a health-friendly diet, where substantial rifts emerge, especially regarding support for the Nutri-Score. Some countries, such as Italy, oppose the Nutri-Score, proposing alternative tools to help the population make healthier dietary choices.
Another example illustrating these disparities concerns tobacco. In France, tobacco smuggling and cross-border movement of consumers to neighboring countries, like Belgium, where prices differ, pose challenges. Price differences sometimes encourage consumers to cross the border for their purchases.
the discussions at the European level, especially during negotiations on the Common Agricultural Policy, can be intricate due to differing expectations among member countries. Some countries, like Poland, may have different priorities than France. It is noted that, despite complexities and differences, actions are taken at both the national and European levels, but predicting the outcomes of these negotiations is challenging.
Ultimately, while actions are being taken both nationally and at the European level, health may not be a major priority in certain discussions, especially during arbitrations on issues like the Common Agricultural Policy.
What impact do you think French oncology research, for example, through initiatives like the Cancer Campus Biocluster at the Gustave-Roussy Institute, has on global cancer outcomes? Where does France stand in terms of cancer clinical trials, for example?
Firstly, it’s important to clarify that the Ligue is not a research structure but rather an organization that funds research projects. The emphasis is on funding projects of excellence, as determined by a national scientific committee and regional scientific committees that rigorously assess project quality.
Collaboration with the National Cancer Institute on various peer programs is a key aspect of our work. Collaborations with other associations, like the Arc Foundation, are also established to support projects in tandem with the National Cancer Institute. Research is deemed indispensable, particularly from the perspective of a patient advocacy group. When individuals learn of their cancer diagnosis, the immediate concern revolves around the prospects of recovery.
The Ligue, recognizing the importance of ongoing advancements in treatment, has established a Strategic Orientation Commission. This commission is instrumental in channeling the generosity of public donations to support major research projects. The funding, approved by the national board of directors, will be directed towards significant immunotherapeutic treatment projects, building upon the success of previous support for messenger RNA (mRNA) research.
France boasts a substantial number of researchers who work extensively in universities and specialized institutions such as cancer centers. The Ligue collaborates with Unicancer, the federation of cancer centers, and is in the process of signing an agreement with the French Hospital Federation, housing numerous university researchers. However, one notable challenge is the subsequent phase after successful research, specifically in terms of production, commercialization, cost considerations, and supply chain management. This phase often occurs outside France, and this trend has been evident for the past ten to 15 years.
An illustrative example is the COVID vaccine development, where initial French anticancer mRNA research pivoted to COVID research during the pandemic. The production aspects, however, were handled by laboratories with global operations, leading to some researchers relocating to other countries. This highlights a gap in France’s capacity to transition from research to patient care and production.
Despite France’s strong research capabilities, there is a lack of control over the production, cost, and shortages of crucial medical products. This issue is particularly concerning in the context of France’s healthcare system, which covers 100 percent of cancer treatment costs for patients. However, there are nuances, such as non-specific treatments not covered at 100 percent, leading to some out-of-pocket expenses. And the fact that there are certain out-of-pocket costs, which for some are not very significant and are manageable without impacting personal life. However, for vulnerable individuals, as mentioned earlier, these costs can lead to forgoing necessary treatments. We lack the means to negotiate or request negotiations on these prices, as we negotiate with actors over whom we have no control. It’s a complex situation, as it influences the survival of our social protection system, adhering to the French principle where everyone contributes according to their means and consumes according to their needs. It is virtuous, but for it to work, the cost of care must not be excessive.
Additionally, there is the issue of shortages, with some even suggesting that it is sometimes organized. We often witness shortages of specific antibiotics or pain relievers, I never thought this would be possible in France in 2024.
In summary, we have high-quality researchers engaged in the perpetual restructuring of research, seeking optimal performance with our resources. The research yields significant results. The question then arises: How can we ensure widespread access to these research products and innovations without exacerbating existing inequalities
Last year, President Macron announced that France would increase its national production of medicines with 50 new drugs, including six anticancer drugs. In your opinion, how important is local manufacturing for ensuring the drug supply, aside from addressing shortages?
Local manufacturing is fundamental. The more we enhance national production, the more control we have over flows, costs, and can safeguard against shortages. The notion of sovereignty, as seen in the restructured ministerial titles, is crucial for ensuring autonomy in agriculture, industry, and the digital realm. Sovereignty enhances our ability to guarantee supply chains and manage costs effectively.
Let me delve into the proposal brought forth by the National League Against Cancer, which is centered on a significant initiative. Many cancer medications, crucial for treating tumors and managing side effects, have transitioned into the public domain. We are inspired by the United States, where collaborative efforts among large hospital structures have successfully assembled medications and made them available at cost. The proposal advocates for establishing similar manufacturing structures in France, aiming to produce and distribute drugs without the burden of research-related expenses, allowing them to be sold at cost.
The success of comparable models in the United States, where drugs are provided at cost around specific structures, serves as a compelling reference. I, along with fellow administrators of the Ligue, am actively engaged in advocating for the adoption of such a model in France. The goal is to showcase that achieving more with fewer resources is indeed possible, fostering a positive cycle in the pharmaceutical sector.
Now, turning to the broader context, I want to emphasize the second crucial aspect. When a health strategy is championed at the highest political level, there is a legitimate expectation of adherence to the planned timeline.
Acknowledging the economic challenges we face, it is essential to generate direct and indirect taxation through the functioning of the state to support our social protection system. Striking a balance between economic considerations and health priorities, it’s crucial to be reasonable and understand the priorities at hand. For me and other associations representing patients, our priority is well-being — not just for those in good health but also for those already dealing with illnesses. It’s about adopting a holistic approach that considers the well-being of consumers, producers, and everyone involved in the various chains. Indeed, there is a social security fund dedicated to the agricultural community known as the MSA. Approximately two years ago, the MSA officially recognized prostate cancer among farmers as an occupational disease, attributing it to the exposure to products they use to enhance productivity. It underscores our commitment to also address the health concerns of farmers and highlights the complex interplay between agricultural practices and health outcomes.
As a closing message for our international audience, do you have any final thoughts?
I shared a significant initiative with the League and our numerous supporters, totalling 700,000 people. Our motto is simple yet ambitious—everything for everyone, everywhere. I wish for peace, health, and reflection on our shared humanity in these challenging times.
The key message is that together, we are stronger when we recognize who we are, who we’re here for, and why. While not an economics expert, current events, such as the high cost of war, make me dream of ways to provide urgent assistance to affected populations.
In France, 20 million people face fragility due to factors like job loss or illness, highlighting the need for leaders to address these issues collectively. Our commitment is clear—we stand ready to collaborate with all stakeholders to find solutions to these inequalities.
