 member of the board of IAEA and I'm very pleased to welcome you to this IAEA webinar which is co-organized and sponsored by Janssen which is the pharmaceutical division of Janssen and Janssen. I'm going to start just giving a little background to the IAEA itself because we have some people joining us today who may not be familiar with us. So IAEA is the Institute of International and European Affairs. It's Ireland's leading international affairs think tank and an independent not-for-profit organization. Our aim is to provide a forum for all those interested in EU and international affairs to engage in debate and discussion and to evaluate and share policy options. So in line with that mission this afternoon session addresses the important area of cancer care and policy. Every year 3.5 million people in the EU are diagnosed with cancer and unfortunately we lose 1.3 million people every year to cancer across the union and we also know that 40% of cancer cases are preventable. So in that context we're going to be talking about Europe's beating cancer plan that was launched in February 2021 and is the EU's response to growing challenges and developments in cancer control. This plan forms part of the EU Commission's proposal for a strong European health union with a view to ensuring a more secure better prepared and more resilient EU. So we're delighted that our expert panel today will give us policy, clinical, patient and industry perspectives on Europe's beating cancer plan and discuss how we can shape the future of national cancer care and policy in Ireland. The panel will also compare Ireland's performance without its European counterparts in terms of cancer care outcomes and the lessons to be learned to improve cancer care for patients in Ireland. So the our expert panel has to be very generous of the time and truth Attaya Schuppe who is project leader for the cancer task force with DJ Santé in the European Commission, Anouk de Pouret, the senior director of government affairs and policy with Johnson & Johnson, Professor John Crown is professor and consultant medical oncologist with St. Vincent's University Hospital and racial moral executive director of advocacy and external relations with the Irish Cancer Society. So we'll just tell you what's going to happen in the next hour and a half. Our panelists will each speak to us for about seven minutes and then we go to the Q&A with our audience. The panel's opening remarks there will take about 30 minutes and then we move on to the Q&A part and that'll allow us to continue the discussion up to when we'll draw proceedings to a close no later than 2.30pm. You'll be able to join the discussion using the Q&A function on Zoom which I hope you're all familiar with and you should see in your screen. Please feel free to send in your questions throughout the session as they occur to you and we'll come to them once the panelists have finished the remarks. I'd ask you in your question to identify yourself in your affiliation with anyone asking your question and you might let us know if you want to direct your question on the individual panelists or to all the panel. You might let us know that. A reminder that today's presentation and webinar and the Q&A are both on the record and as ever feel free to join the discussion on Twitter and we ask you to use the handle at IIEA. As this event is public we're also live streaming this afternoon's discussion so a very warm welcome to all of you tuning in via YouTube. I'm now going to introduce each of our speakers in turn so our first speaker will be Matthias Schupper. Matthias is the project leader of the cancer task force in DG Sante at the European Commission. Matthias has over eight years experience in policy and project management at the commission. Previously he worked for the European Public Health Alliance and the European Health Forum Gaston. He holds an MSc in health services and systems research from the London School of Hygiene and Tropical Medicine at the University of London. Matthias, we're delighted to have you and over to you. Thank you and good afternoon. I will share my screen for the presentation. Here we go. Okay, thank you. So next slide please. So the plan has 10 flagships and 32 other actions that cover each key stage of the disease and incorporates also the lessons learned from the pandemic so far and I will explain that a little bit later and has a dedicated budget of four billion euro coming from several different EU funding instruments. Next slide please. Looking at the plan in more detail and it will not go into all these 32 actions. I will focus on the flagships. We have a flagship on the Knowledge Center on Cancer that was already established as part of the joint research centers of the commission and was launched in June 2021 with the focus of facilitating synergies between the different EU level actions that are part of the plan. We will also launch next year European Cancer Imaging Initiative which I will explain a little bit more in detail when we get to that particular pillar. Next slide please. Now looking at prevention we have a flagship initiative of eliminating cervical cancer through action on HPV vaccination for both boys and girls. This is in line with the WHO targets to reach a 90% vaccination rate for girls and for boys we want to increase substantially the vaccination rates that exist at the moment. In the prevention area the plan takes the similar or same holistic approach as through the cancer continuum covering actions that focus on very different risk factors. On tobacco for instance alcohol consumption, healthy diets, physical activity but also air quality and exposure to of workers to hazardous substances. This is complemented by the European Court Against Cancer which will be updated and should help individual citizens to understand their cancer risk and try to reduce their cancer risk. Next slide please. In terms of early detection the plan has a flagship of establishing a new cancer screening scheme which builds on several elements. The first one is an update of the 2003 Council recommendation on cancer screening which at the moment recommends breast cervical and colorectal cancer screening and to explore and assess the scientific evidence to potentially expand this coverage to other types of cancers. Secondly the implementation and rollout of guidelines and quality assurance schemes covering breast colorectal and cervical cancer. The guidelines and the quality assurance scheme for breast cancer has already been launched and we are now implementing that through the EU Health Program whereas the the schemes for colorectal and cervical cancer will be developed in the coming years. And then the European Cancer Imaging Initiative with a focus to provide an ecosystem to test new tools for instance using artificial intelligence to improve imaging methodology. Next slide please. In terms of diagnosis and treatment three key flagship actions. The first supporting EU member states in creating national comprehensive cancer centers or infrastructures and networking these at EU level. Secondly through the cancer diagnostic and treatment for all initiatives trying to make the most advanced diagnostics and treatments available to more EU citizens and as part of the mission on cancer that is launched under the Horizon Europe Program and was adopted on the 29th of September an action to better understand cancer in the sense that we want to understand how it develops how it spreads in the human body. Other areas focus then on training measures as well on new European reference networks on specific cancer types and also on radionuclear medicine. Next slide please. Coming to the last pillar we want to also improve the life of cancer patients, survivors and the carers through initiatives establishing a cancer survivor smart card and the European Patient Digital Center which again is an action of the Horizon Europe mission on cancer and also explore a solution to ensure fair access for cancer survivors to financial services such as mortgage insurance for instance. Link to that is also an implementation of the directive on work-life balance for parents and carers. Next slide. Reducing inequalities we are establishing a cancer inequality registry that should monitor the trends in member states on key cancer indicators and also provide analysis in which areas further investment will be needed both at the EU and at national level. Other actions for instance to support the rollout of telemedicine, virtual consultation models of the existing ERN networks should help to improve member states preparedness in terms of pandemics and is a response to what we have learned during the COVID-19 crisis. Next slide please. And then the last pillar perhaps or the last cross-cutting action of the plan, the childhood cancer focus on establishing a new EU network of youth cancer survivors as the survivors card and also action under the mission on cancer to address childhood cancer. Next slide please. Now for the plan excuse me we have set up three different groups to improve or facilitate the running and implementation of the plan. The first one is a member state group and here under the existing steering group on health promotion and disease prevention a subgroup on cancer was established that brings together member state representatives from the ministries of health and research to focus both on the implementation of the cancer plan and the cancer mission. Secondly and this is at commission level we have established an implementation group this is basically to bring together all different commission departments that are responsible for implementing actions of the plan to collaborate and synergize better and this group is also preparing an implementation roadmap that will outline in more detail key deliverables and times timelines for the action of the plan. And last but not least a stakeholder contact group for engagement with civil society at large for which we are now in the process of establishing also thematic working groups that would follow the different pillars of the plan as I have outlined them before. Next slide. Now implementation one key funding instrument of the plan is the youth for health program and under the work plan 2021 we have already launched a significant number of calls. The first wave was launched in July and has already closed on the 15th of September focusing on the quality and safety of radiation technology in cancer diagnosis and treatment an update of the European cancer information system to include a new system of monitoring cancer screening programs the training component for instance but also the network of youth cancer survivors. A second wave has been launched this month on the 14th of October being open until the 25th of January focusing on HPV vaccination, dissemination of the European Code against cancer, actions to address liver and gastric cancers caused by infections, the healthy lifestyle for oral initiative that was launched by the Commission on the 23rd of September. The quality assurance schemes that I mentioned already the access to advanced cancer diagnostics and treatment as mentioned drug repurposing and the cancer survivor smart card. There was also launched for joint actions with member states to prepare work on the comprehensive cancer infrastructures the networks of expertise as well as HPV vaccination and the rollout of e-health and tele-monitoring services. Next slide. This is just for information if you want to follow up on the projects here you have the link. Next slide. Also to note that in Ireland you have a national focal point that can help you if you're interested in applying for these programs. This is the information on these colleagues. Next slide please. Similar. You also have it for a rise in Europe and there's also a newsletter. Next slide. And next slide which brings me to the end of my presentation. If you want to have general information you can also have a look at the Europa website, DGSanti, DGRTT and the joint research centers website and perhaps to flag also the final conference of the IPAC joint action which will take place on the 13th and 14th of December. Thank you. Thank you very much Mathias and just to let everybody know that this session has been recorded and will be available on the IA website. I know Mathias went through some of the slides and the links pretty quickly but they'll all be available to you after the session to go back and look and link in when you time. I'm delighted now to introduce our second speaker. Our second speaker is from Janssen which is the pharmaceutical end of Johnson & Johnson, Anouk de Pirey. Anouk is currently leading the EMEA government affairs and policy team for Janssen Pharmaceuticals. Anouk is responsible for managing the implementation of advanced purchase agreements in EMEA of Janssen's COVID-19 vaccine. She's involved in several industry platforms to support a strong climate of biopharmaceutical innovation. Throughout her 22 year career in the pharmaceutical industry, Ms. Ray has been involved in initiatives to accelerate European market authorization procedures both at the EU Commission and with the European Federation of the pharmaceutical industry. Anouk, we're delighted that you're with us this afternoon and over to you. Thank you Terence. Thank you very much and let me maybe start with the quote that you made Terence, 3.5 million newly diagnosed cases of cancer per year in Europe. I mean that is just too much right? We really need to work towards bringing that down and we have made progress already I would say in the last 25 years because even if incidents for cancer has went up we have been able to bring down mortality and we can really say that innovation in diagnostics, screening and treatment is what has resulted in better patient outcomes. So there's definitely hope for cancer patients and for all of us because one out of three of us will at some point we be confronted unfortunately with cancer. However, you know we will not stop also as a pharmaceutical industry until we find cures for cancer and that is really the vision that we all need to have. We need to bring the cancer to an end intercepted early because at early stage the disease is less complex, less resistant to therapy, patients are healthier and therefore the benefits will also be higher. We need to get the right treatment at the right time to the patients. Of course we need to keep sustainability of healthcare systems also into account and find the right solutions for that. Now bringing it a bit closer to the topic here with the European eating cancer plan I think we will now start a period where for the first time also European policy will have a bigger impact and on how national governments organize their care and in this case their cancer care. Mathias you referred to it already that the pandemic has learned us that European collaboration can make us stronger and more connected and I've been involved indeed in our vaccine discussions so I've been experiencing that firsthand and I think without European collaboration we would not have been in Europe with vaccinations where we are today so we really need to learn from that. So we will see these European policies from both the European cancer plan but also the European pharmaceutical strategy really reaching national government policies and this is really an opportunity because it can help to drive towards better patient outcomes on one hand. On the other hand we need to make sure that we strengthen Europe as an innovation hub for healthcare also going forward. So I would say that the European eating cancer plan will be successful if the policies are also leading to action and implementation in the member states but also if it can help to bring expertise and resources across the union and in particular also to areas that might be with less capacity today. Now let me zoom in for a moment into Ireland and I understand from my colleagues based in Ireland that Ireland has done a lot when it comes down to cancer care. The national strategy, the cancer program from 2006, these are really best practices within the European Union. Ireland also lets the EU smoking sensation plan. You were the first one to ban indoor smoking which I think we're all very happy with and it has had an impact that the five-year survival rates have improved for most cancers also in Ireland. Two out of three diagnosed with cancer will survive at least five years. Furthermore Ireland is still also a tiger when it comes into global biopharmaceutical hub, being a biopharmaceutical hub. A lot of companies manufacture in Ireland life-saving biologicals including for cancer and my company in Cork is also developing there one of our most complex biological treatments for cancer. So I would say Ireland has the foundation to lead the way and really help Europe to implement this cancer plan quickly and fast. So these are all positive signals I would say but I mean I would also want to give a perspective on some of the challenges that are still ahead and that are holding us back in making progress and on cancer care in Ireland. I would like to highlight three areas in particular. First of all I understand that there is still a quite lack of good quality usable data for cancer care which is one of the pillars as Matias described in the plan so really an opportunity to work on that. Secondly it is also a reality that in Ireland there is lower access to the newest treatments for cancer than in other countries and again I think we need to collectively work on improving that. And lastly there is relatively low activity in research and clinical trials for cancer in Ireland. So these three areas can definitely be improved if the European beating cancer plan is rapidly implemented. And maybe let me zoom in in three particular areas of the plan and that link actually with these and Matias already gave us a nice description of them but really you know the building of data infrastructure and looking at how we can share data across borders looking at interoperability helping to build the European health data space will be critical. Investment into screening diagnostics and biomarker testing there's a big opportunity here also leveraging some of the European recovery funds that the different countries will be getting because this is really in scope of improving health care across the region. And then the last example and again Matias referred to it the cancer registry on inequalities again will help to give more visibility and benchmark data on where the different member states stand in comparison to each other with access to treatment and treatment care so that we can drive towards the best possible outcome and excellence in access across borders. So I think to conclude to make the plan successful we have to partner and we might look at it from different angles and we need to be aware about that but at the end of the day industry government and the cancer care community we all have a benefit in making sure that we can rapidly build and implement the initiatives in the cancer plan and really bring this policy recommendations into practice. So that's you what I would like to bring as an introductory remark and I look forward to further discussing these points in the debate. Thank you Anouk that was great. We'll move on to our third speaker John Crown is a professor and consultant medical oncologist at St. Vincent's University Hospital. John received his medical training at University College Dublin and the State University of New York and completed his fellowship training in oncology at the Mount Sinai Medical Center and an hematology oncology at Memorial Sloan Kettering Cancer Center before joining St. Vincent's Hospital in 1993. We'll also remember John as a passionate member of our upper house the Senate but John joins us today to talk about cancer and oncology and we're very glad to see you John over to you. You're on mute John. Very sorry about that. Thank you very much Terence and I'd like to thank the Institute for the opportunity to address this important seminar. It's no secret that I'm a very committed and long-standing Euro file and specific supporter of the EU and a great believer that has been an organization that has been powerfully, powerfully positive in helping our country to develop. The EU's beating cancer document I think is full, replete with excellent goals. I think it is a very well stated summary of what the status of the problem is at the moment and how we can address it in the future. It is as is the nature of these documents and I say this not critically a little aspirational and it's hard sometimes to go into a lot of the specifics when you're talking about a number of different jurisdictions but I think it will give us a good framework for developing a lot of these specifics and you know aspiration is good in the words of attributed to two different Irishmen, one George Bernard Shaw and one Irish American Robert Kennedy. Some people see things as they are and say why, others dream of things that never were and say why not. So we should look at things that never were and say why not, why can't Europe have a much better cancer treatment prevention early diagnosis and support system than it has at the moment. I really believe that the flagship of public policy going forward needs to be prevention and I'm delighted to see that the document is very eloquently outlined by Matthias put such an emphasis on this. If you look at it the single biggest thing that made the biggest difference to cancer in general was the recognition that cutting down tobacco consumption would decrease the incidence of what is now the leading cause of cancer death worldwide lung cancer. This was an extraordinary advance. We do see sad cases where lung cancer occurs and people who have never smoked but in general if we were going to do just one thing, just one thing to save the greatest number of lives from cancer we would eliminate tobacco smoking. That's why the document has an appropriate emphasis on tightening regulation on the industry and also on education. It is my sincere doubt that we need to say this openly. We have one ambition for the tobacco industry and that's bankruptcy. It's the only thing we wish them to do is to go out of business. This is an evil industry. This is an industry whose business model is based on a very simple strategy which is addict children to carcinogens. We should have nothing to do with them but our park is in any area of public policy and it should be a goal that we would aim towards criminalizing any commerce and tobacco I believe within an appropriate timeframe perhaps 10 to 15 years. There is simply no way that if this product was discovered tomorrow it would be legal. It would never be approved. Alcohol will present a challenge. There is clear evidence that abuse of alcohol and excess alcohol consumption is bad in terms of increasing cancer risks and as a society we in Ireland will have certain challenges doing this both in terms of our culture and also due to the strength of the alcohol industry. The one that has me particularly intrigued is the goal to try and move more towards a plant-based diet. Understanding as we all do the power that the agricultural industry has had on EU policy over the years and if you pardon the awful pun it'll be interesting to see them locking horns with the cattle industry in the years to come to see how we will actually try to move more towards a plant-based diet but these are all very worthy goals and honestly this is where the biggest bank for the buck I believe at public policy level will come in prevention. Early diagnosis is critically important and it's very uneven across Europe and it's not particularly good in Ireland. We all think it really diagnoses as being screening and for some cancer screening is critically important. For some other cancers it's well established but has a little less impact and for some cancers it has little if any impact and there simply is no good proven screening technology for some cancers. To summarize what we've done with screening screening for pre-cancerous changes in the cervix has been an extraordinarily successful human undertaking. In countries that have widespread screening strategies the chance of dying of cervical cancer has dropped very very dramatically and it has to be said after a few years of very bad press about the Irish system most of which was wholly unjustified. Cervical screening in Ireland is very good. The actual metrics the outcome the error rates all of these things rank amongst the best in the world. We have a screening system that we should be proud of and has saved many lives. We need to take our hats off to those visionaries who brought it into place. Breast screening is harder because the technology isn't quite as good even in the very best one screening systems and ours truly is one of the best. It's past incredible international audits and at a very high level the impact of breast screening is somewhat lower but we have to remember that early diagnosis is not just screening. What do we have in place for the patient who develops a troubling symptom for the person who has a problem who presents to their GP it's desperately slow in Ireland. We have put a number of high-profile rapid access clinics in place but I can tell you for a variety of reasons on occasion to review a lot of cases there is a lot of late diagnosis of cancer in Ireland often not because anyone made a mistake but because the system is so slow so sclerotic so understaffed and so badly resourced. We have a very very small number of radiologists a very small number of scanner scanning machines as a result we have extraordinary weights for these things. There's a very interesting and I think understandable modern approach to new technology to start with and I'd like to compliment Matthias and his colleagues for this. We'll focus on two areas in particular new diagnostic technology there is no doubt that we are seeing a revolution in diagnostic technology which is not necessarily good news for the career structure of some of the doctors who choose to make futures for themselves in radiology and pathology because there is incredible capacity for technology and for automation in these in these areas. We will always need skilled people to take responsibility for the results but we will see incredible standardization I believe of radiology and pathology services in the future. I just hope that in Ireland we'll be in a good position to capitalize on them because we have not done well in terms of deploying the older technologies which are having such great impact on other countries and of course the whole area of information technology and it is a very laudable goal of the document to try and bring in compatible systems across Europe for smooth transfer of patient information, research information, safety information etc and I think it will be apparent to any of the the Irish participants in this meeting have been following the newspapers this year that the information systems in our own house systems were found to be very very very deficient indeed as outlined by the the cyber attack. What about access to care? This has been a real problem the document stresses the need for a European network of comprehensive cancer centres. Now I can tell you when I came back to Ireland in 1993 I started pushing hard for this I reckon that we needed to develop a small number of comprehensive cancer centres in Ireland. I'm afraid that argument did not win and instead we got the somewhat improved but still it has to be said somewhat bizarre patchwork of structures that emerged from the national cancer strategies of the first decade of this century where the idea in the end was rather than trying to tackle the big hospital big medical school politics which would have allowed the development of a small number of rational cancer centres instead what happened was a decision was made to make Dublin Inc as one comprehensive cancer centre with its resources deployed across five or six different sites. This was not a good idea I believe it's a it's a a nettle which should have been grasped at the time and it'll be hard to fix at this stage and paradoxically I shouldn't say paradoxically it may work better in places like Cork and Galway where I think you will find a concentration of cancer treatment prevention medical nursing radiation support supportive care psychiatry resources under roof which is under one roof which is really what we need. I'm glad to hear and surprisingly the industry pointing out that there's a problem with access to new drugs there isn't a problem with access to new drugs. Ireland has become one of the more restrictive environments for the approval and reimbursement of new drugs and for the benefit of the uninitiated the approval of new drugs takes place at European level individual decisions about whether the drugs will be made available are made by health technology assessments by health economists in the constituent countries and in Ireland we've developed an additional step but even if a drug passed the health technology assessment which is run by the National Center for Pharmacy Economics the HSC then has a veto right over whether it can decide it will afford it or not I for one have been very disappointed for the first time for the first time in my career in Ireland in the last few years we've seen a widening gap between the availability of drugs for public and private patients because the insurers and I'm glad that I don't use the word private insurance the VHI is not a private insurer the VHI is actually social insurance the VHI is somewhat similar to what the Canadians have only they don't call it private insurance they call it social insurance it's somewhat similar to what the Germans have with their social insurance the VHI have to their credit approved for reimbursement the number of drugs and the number of indications or about the public system and the other private insurers have said no and we need to fix that and there is a substantial problem with clinical trials I tried to address it many years ago and I found that the Irish cooperative oncology research group but if I may blow my own trumpet for a second there was a time more than a decade ago when Ireland actually was really punching way above its weight and we were there was one year when we were putting a higher percentage of Irish breast cancer patients on trials than any other country in Europe was doing and I'm just a little bit sad to see how that that whole thing is unraveled to an extent in recent years but hopefully there have been some new moves by the archery which hopefully will readdress it finally they say obviously finally the talk it gives the audience hope but finally I think Brexit gives us an intellectual opportunity I think we need to as we wave goodbye to our departing British colleagues and friends who've made I believe a historic mistake I believe we also need to say goodbye to the notion which has taken a deep grip on certain aspects of the Irish political sphere that we should try and emulate the 1947-1948 health service which was designed by an RN Dougan the British NHS and that's what is was being attempted with Shlontacare I believe Shlontacare will enshrine to take care I believe it addresses none of the core problems of the Irish health system which are inefficiency, inequality and generally mediocre quality and I'm sorry to say mediocre quality I know it sounds provocative it's not that the nurses and doctors aren't good but if you have to wait six months to see them it doesn't matter how good they are that's rotten care so thank you to the EU for your support over the years thank you for lighting the way which I hope will shine a bit of a light to deficiencies in our health system I do hope we have some visionary people domestically who will look at these understand the problems we have and try and fix some of the problems thank you very much thank you John and now last but not least our fourth speaker is Rachel Morrell Rachel is director of advocacy and external relation of the Irish health society since April 2020 and previously served as the head of advocacy department from 18 to 2020 she's an experienced campaigner with extensive advocacy and policy experience that have worked in New Roctus with large budget nationals in public affairs consultancy and the nonprofit sector for more than 15 years and we're very glad to see you Rachel and over to you thank you thank you chair and hello to everyone who's joined the discussion today I'm delighted to have been asked to participate and extend like my colleagues and particularly thanks the IEA for organizing and to Johnson for sponsoring such an important conversation about cancer care to begin and I want to start with the most important aspect of cancer care and that of course is patients and for those of you who are in Ireland and reading the newspapers today we're reeling off eye watering numbers and waiting lists and we speak of time bombs and tidal waves and it's important to reflect I think that aggregating the many challenges facing patients into headlines designed to motivate political action ignores the tragedy that it is our families and our friends our neighbors and our colleagues people who are loved and who are needed who are experiencing the day-to-day realities that having cancer brings and these day-to-day realities they're manifested in waiting times and other barriers to care that John spoke about they're being borne by patients over many years and certainly COVID has had a profound effect on health services ability to deliver cancer care but in our case in Ireland there were system level vulnerabilities that had been allowed to grow with inadequate investment in sufficient capacity to few health care professionals and limited resources so when the pandemic hit it was layered on top of a system that couldn't cope with existing predictable demand and the the scale of the challenge grew and grew and thankfully the eating cancer plan was already a key priority of the funder laying commission before COVID although it's publicated the population was delayed while the impact of the pandemic grew but alongside these delays the need for the pan-european plan was becoming more and more urgent given the severe disruption and cancer tests cancer screening and cancer treatment right across the EU and as our national government struggled to cope with the significant pressures of the health service the the pre-COVID cracks that I described there they became chasms and in Ireland we estimate that there were approximately 10% fewer cancers picked up in 2020 compared to 2019 although the official figures haven't been published yet and across Europe around 100 millions cancer screenings did not take place so in June the Irish Cancer Society told the Iraqi Health Committee that now is the time to revolutionise the way cancer care is delivered in Ireland because these delays the uncertainties and the cancellations and interruptions again in the news again today they've all had a really serious effect on cancer patients and their families not just because of the the clinical implications but on mental health patients they're calling our support line every day of the week they're feeling significant anxiety increased distress and the impact of that will be felt for many years to come and the impact of COVID on medical teams as well to deliver non-COVID care I know MEP's her testimony from an Irish oncologist earlier this year that during the pandemic he had stood beside someone's bed and prayed for a negative COVID swap so that a patient could die with unrestricted family visiting he'd told a patient that she was dying when he was dressed in full PPE and she had no family present and he called patients to delay life-saving treatment because of COVID issues and that is happening today and that is the trauma caused by COVID and it's that environment into which the the beating cancer plan was published and it's why it's even more important than ever before because not only has the pandemic negatively affected the delivery and access to cancer services and medical care which are in the competency of the national governments but it also caused like John said significant challenges with critical research, innovation, disease prevention, the digital transformation I mean the cyber attack in the middle of this is incredible and the sustainability of health systems themselves which are areas that the EU can complement national policies and I think there's many reasons to be optimistic and the beating cancer plan leverages like a fundamental observation that all of us will have had over the last 19 months and that's that COVID doesn't respect borders and of course cancer doesn't either and that's why we as Europeans must work together and implement this visionary policy so that it's felt by cancer patients in every member state because although COVID is a disease that kept us all apart we need to now come together and we need to build back a better response to cancer than was in place before. That's going to be challenging and John's touched on some of the challenges and so is Anuk but member states we're all starting off on different points in terms of our own national health strategies and it's at that national health service level that medical care defined and delivered but there's a lot that the beating cancer plan can do to complement our national health systems and the beating cancer plan is very aligned to our own national cancer plan and it has a significantly bigger budget and which is good and that it's already advancing and like Mateus said initiatives across all the pillars of the plan already and some of those are going to happen in 2021 are the Knowledge Centre on Cancer initiatives to improve the early detection and treatment of cancer and through the European Cancer Imaging Initiative and improving e-health and among other things but again John touched on cyber attack and I think that anybody who has observed health service delivery over the last number of years will know that Ireland and we're not exactly a leader in e-health solutions and in fact a report that was published at the end of last year was very tantalizingly called deploying data-driven intelligence to measure the impact of COVID-19 on cancer care and cancer patients and concluded more disappointingly than the title revealed that there were considerable data constraints in preparing that report and it pointed out that Ireland does not currently have a connected health data intelligence system that without innovative e-health solutions there's no access to high quality data and that the e-health strategy for Ireland which was published I think in 2013 needs to be fully implemented and that's just an example and but there are some elements of the beating cancer plan that may face some practical barriers when it reaches the point implementation at member-state level and another example is the Commission will soon set in motion an inter-speciality cancer training program and the hope is that it's going to be an effective way to deliver more skilled and mobile cancer workforce through cross-border training and information sharing but how do we ensure that more fundamentally we recruit and retain highly skilled cancer clinicians in Ireland when one in five consultant posts are unfilled and for reasons relating to working conditions and pay and lastly and it's mentioned before as well is the the the comprehensive cancer centres and despite some progress being made by individual cancer hospitals and their linked universities and we were looking at the implementation plan for the National Cancer Strategy and by the end of 2020 the Department of Health and the National Cancer Control Programme had only got to the stage of considering the steps required towards the establishment of the comprehensive cancer centre and yet before the end of the year the Commission will work to set up a network of comprehensive cancer centres which it says and is going to be a flagship that will make a significant difference to the quality of care and addressing equality so if we don't have the comprehensive cancer centre does that mean that our patients and clinicians are going to miss out because this aspect of the cancer strategy has not yet been advanced. I'm going to finish on the positive and because there there are so many when considering this this first step which has been described as a true European health union and there's so much motivation and belief commitment and energy surrounding the beating cancer plan and talking to to people in preparation for this discussion like I could feel it and it's it's electric and it's very motivating and I imagine we're on the start of a very long journey and but the the messages that we're moving and the next step like everyone has said is implementation and and that will be that will be the tricky part so we need strong APIs we need clear targets and lots of experts and financial support and with the committed and resilient leadership at EU and member state level I believe we can do it and I believe we must do it thank you. Thank you very much Rachel and now just remind people again that you want to have questions of the panel or any individual members of the panel please use the Q and A function on zoom might start in the whole area just of the how the the plan is will impact what you think how it how will it impact cancerous services in Ireland and we know we've dealt with that issue as well so you might just start off by asking this especially Rachel asked some questions there whether that whether Anuka or John or Mathias wants to address some of the questions of how the plan can be can best affect Ireland and help us propel forward what are the easy wins here what are the more difficult areas and what can we do about those so either with Amias Anuka or John maybe Anuka might start with you just on that issue of just what you've heard today any other further reflections. Yeah no short thanks thanks Terence for that well yeah I think I highlighted top line already a couple of things but I think one that we really should win on is getting to better data for cancer care I think again the pandemic has shown the power of real-time data generation and but also its limitations and and you know interoperability and and standardizing data is something for as long as I have been in European policy has been around as something we have to fix I think now with this plan but also with the European health data space initiative and legislative proposal that will be put forward by the European Commission we have the opportunity to really make this happen and I hear from my colleagues in Ireland that in Ireland you don't have European electronic health records yet but plan to build some so I think if if Ireland builds this now you should really take this cross-border sharing and interoperability into account during the conception phase it's maybe an advantage that nothing is built yet because you can build it in the right way and maybe also look at how other countries have done this I mean I know that in Finland there is a fantastic example but also in France so those best practice sharing could really help to build better data for cancer care and then maybe if I may second area I would want to highlight that we touched upon during our introductory speeches all of us is the early screening and diagnostics I mean what the EU did I can't remember when that the council recommendations on breast cervical and colorectal cancer were putting place but this was already an amazing step forward I mean all of us in most countries do get access to this and I know you want to bring it up to 90 percent of the population that should be eligible to get access and that's really a clear target so let's work to that but also adding other cancers and the work to generate evidence that it makes sense to add more cancers such as lung cancer gastric cancer pancreas cancer we need the data and the evidence that it makes sense but I think we should really prioritize that as well and then maybe lastly the innovative aspects of biomarker tests and getting towards tests and screenings that can cover more cancers in one go through to blood testing that their investment of the funds into public private collaborations to achieve that would be very important so maybe I'll you know might be other things but I'll stop there to give time to the others I'm going to go to John next but Matthias got quite a few questions used I'm not leaving you out but I'll just go to John next for his his uh uh any reflection about the duration the duration is finding out from the front line you're on mute John sorry in terms of what we think it will do to achieve change in Ireland I mean I'm I'm kind of I must admit I've kind of made a separate piece at this stage I devoted a big chunk of my youth in middle age to really aggressive attempts to reform the Irish health system up to including running and advocating in the shanty for it I've kind of given up at this stage so I think we should aim for what's doable with this I think what will approximately 40 million what can we do with Ireland and what lessons can we learn I don't think we'll get comprehensive cancer centers from it hopefully it will at least recreate the debate around the need for comprehensive cancer centers I don't think it'll fix the health service I would have thought that the big bang for the buck in this would be in the IT both in the new diagnostic IT and also in the as has been outlined a few moments ago but in the medical records I think there's a real opportunity that kind of money I think could make a difference in that regard and it's very primitive at the moment and it will there'll be a multiplier effect making investment in it now will enable us to make better value and to take advantage of other new technologies that will come in the future but if you don't have the platforms right in the first place we won't be able to do it and I think we should really really bone up our efforts on prevention I think we really need to tackle you know being obese is now unfortunately becoming nearly as big a risk factor that a bigger risk factor for cancer that smoking is a smoking decline so obesity is becoming a major problem in Ireland and we really have to tackle that problem too because it would be one thing which we could do which would greatly reduce the incidence of cancers thank you John Mathias then just going to with some of the specific issues in the in the plan that people are asking about I mean Hickey who's a patient giving a cancer ask two questions one can you just explain further about the cancer survivor smart card and its use and then also maybe say whether there's any proposed cancer patient involvement in the plan as well so those two questions yes well perhaps with the smart card there have been already EU projects preparing or considering a smart card setup and the idea behind the smart card is essentially that patients have access to their data can make this data available for research for instance it can be used for the follow-up care after after treatment etc so that this information patient information is portable patients have direct access to it can take it to other treatment centers to other professionals to get a second opinion etc so this is one of the ideas for the smart card that's linking also to the patient digital center with the view that patients of course voluntarily can make available their data can pull it and this can be used then also for research purposes for instance the second involvement of patients in the in the cancer plan first of all we had a very wide public consultation in the preparation of the plan on which we got 2400 responses including from patient organizations secondly we had the patient clearly in mind and our commissioner who herself is a cancer survivor made sure that this is the case when drafting the plan and thirdly as part of the stakeholder contact group this is also a way for us to engage with patients of course with all stakeholders but a special place we have there for patients thank you guys I might just follow on the question which I'll direct first to you with my breast for panel making as well and this is from Liz Yates who's the CEO of the Murray Keating Foundation and she asked can you advise what other cancer types are being considered for the extended cancer screening scheme so what are the cancers should we be trying to screen as an earlier stage very absolutely outstanding one is lung cancer there are incredible data have emerged over the last two years for screening for lung cancer screening women with a smoking history for lung cancer will save far more lives of women than screening all women in the appropriate age groups with mammography for breast cancer the impact is very very large and boy will it be difficult to do in Ireland we have such a I mean I'm sorry after studying like a broken record but I mean we now have a waiting list to get on the waiting list for scans and some of our hospitals we have just appalling waiting times for CT scans and screening for lung cancer involves a series of CT scans delivered over a number of years but this is incredibly powerful in terms of its potential for reducing mortality the data for that are very very strong yeah I was just going to echo what Fressa Crane said there around lung cancer screening and I think that it's really important that Ireland takes a leadership position there are trials and pilots that have taken place and over in the UK and they've been proved to be very successful and I know that the Irish MEP Georgia Cleen has put down an amendment to the beating cancer plan that includes lung cancer screening and I think we should all get behind that it's Rachel I don't know Matias do you anything to say on the cancer types between screening yes perhaps just to mention that we are already working on that so there is a strategic or scientific advice mechanism at the level so there's a group of chief scientific advisors that report directly to the president and they have a mandate to actually look into this matter and they have already organized a couple of workshops and they will present their opinion by the end of February secondly also in preparation of the proposal to update the council recommendation we will soon be launching a call for evidence so this is another public consultation by the commission where we invite also feedback now to concerning the question in the cancer plan we have explicitly mentioned three cancer types prostate lung and gastric cancer where we certainly will review the evidence whether this is sufficient to suggest population based screening but the mandate for this scientific advice mechanism is broader than that so they will also look at other cancer types that could be potentially considered and look anything on them screening from your perspective well I would also agree that it's important to look at other cancers and lung cancer in particular but also find screening techniques that can detect maybe the diseases at an earlier stage before it's already at a stage where maybe therapeutic intervention is more complicated yeah thank you again the question Matias as is from Haridu with the public policy manager with Merck she's asking are there any work streams or funding opportunities that Ireland can access under the plan to support efforts to improve how we collect and use cancer data so work streams are funding opportunities to help us improve the data collection that we all been talking about data but are any specific things that we can leverage from the from the EU initiatives well I think one of the core initiatives has already been mentioned the European health status base and the proposal that's currently under preparation perhaps also to flag that we are now working very closely with the joint research centers which provide the secretariat to the European network of cancer registries and we also intend to make additional support available to the registries to ensure that we can have better data coverage and more timely data coverage there is no call in 2021 but and I cannot pre-judge what comes out in 2022 but it's clearly our intention to support this element because it has been very clearly identified as a key issue to be addressed at the EU level okay might move on to another question then and then we also come to that and Thorsten Giesige who is the general manager of Janssen and Ireland says COVID-19 has told us that huge challenges can be solved by partnering collaboration in order to initiate a comprehensive collaboration to beat cancer in Ireland what other partners or stakeholders need to be included in that so the partnership and collaboration who else do we need to involve in this battle John or Rachel is going to start with that I'd say in terms that everybody needs a seat at the table when it comes to the beating cancer plan and the kind of the national level health systems as well I think that in this cancer strategy there is a patient panel that's part of the Department of Health and I think that that's contributed greatly to the input of patients into the kind of the policy level work that's being done and I also think that there's a role for and I think it was an equally mentioned kind of the public-private partnerships as well I think that that can accelerate progress and I think we need to look more deeply at that John anything on other people we need a question partner with just brief I would just say that I think we need to have a fundamental reeducation of the people who actually run the health service in the Department of Health in the HSE but the problems on the ground I just think that I think they're you know fighting the wrong war right now and they're fighting a war against the professionals working in their system and not actually seeing the need to actually fix the system and that the actual correction of the deficiencies in the system may involve some diminution in the power people in central office have I really believe that and that can only happen politically so I guess you understand why I'm not optimistic about big improvements certainly in healthcare reform the thing which would make the biggest difference to fix in cancer care in Ireland is fixing the health service maybe Terence just if I can add one perspective from my side I mean I think during the pandemic we saw bubbles of innovation of partnerships and I mean just looking at one examples of Italy where my colleagues in Italy were directly involved they set up a telemedicine get your medicine Janssen medicine at home project in collaboration with the medical society and with the government in the matter of weeks and and you know those type of innovations that we were able to do during the pandemic because there was a crisis and a need that trust that that we've built we should try to keep that going forward and I don't know one ID could be that you know in the member states we have little teams that look at the implementation of the plan with the different partners involved and and but make it very concrete so that it doesn't become you know just talking to each other and nothing happens but where we can really look at the initiatives and see okay how can we build these together each from our angle and I really hope that you know the kind of collaborations that were spurred during the pandemic can continue because that would be at least something positive coming out of covid okay and Matthias I think the rent in terms of other people to be drawn into partnership collaboration space um yes perhaps two points first um just just to be clear that the stakeholder contact group is open to all stakeholders so not not only to patients but also to health professionals to to industry etc so we want to be as inclusive and collaborative as possible um and then perhaps to referring to what Anook said um the teams to help or look at the implementation at national level um perhaps just to flag that in Belgium they are now setting up a mirror group basically um of what's happening at EU level at national level so they try to bring together all the stakeholders all the relevant political players departments as one group to replicate basically what we have at EU level in terms of governance and see how they can best implement the europe's beating cancer plan at national level and this could perhaps be a blueprint for other countries to follow to ensure that implementation does happen and that it's collaboratively as much as possible thank you Matthias uh it was a question that just was sparked by a couple of comments from Anook and Mayu et al on the impact of covid and the on the whole area of cancer and treatment um you talked about the difficulties that just the huge frustrations that brought as well to the whole area and Anook talked about some innovations that good practices there are any good practices we've seen during covid that we want to try and capture and and better structure into the into the treatment here Rachel or John um I I'm sorry now if I'm sounding like Banco's girl strip but I I I wasn't quite as impressed with how things went with covid I think there were really really heroic efforts by incredibly brave young nurses mostly young doctors thankfully people my age group went into frontland they did a huge job and I mean we really saw the motivation and the selflessness which was in the system but to me the big lesson is the deficiencies which were there to start over that how easily they were unmasked now thank god tragedies with covid awful lives lost lives cut short bereavements terrible it could have been so much worse this was the disease which had two closely related diseases SARS and MERS which each had a much higher mortality imagine if we had had a disease with a 10 percent mortality hit Ireland with our number of intensive care units we heard these frightening figures today that one third of the intensive care unit beds in Ireland are occupied by covid patients that is worrying and it's troubling troubling up for two reasons number one that we're still sick covid patients but troubling that we have so few ICU beds still that run the bottom of the scale what why do we have to prop up the bottom of the scale of every resource every mad person power resource and every actual physical resource in the OECD what why is it that we're always at the bottom of those scales and I really it has to be remembered that the reason we coped with covid and covid was distressed at the best health systems of the world would creek under the Germans did very well early on with covid and they creaked when they got a bigger surge later this was an unprecedented event in modern medicine so I wouldn't judge a system harshly for not doing well with it but the reason we cope well is we close pretty much everything else down that's the reason why we did it wasn't that we were so wonderful it's that all kinds of other areas just cease to exist for months at a time while we dealt with covid so I think the main lesson from covid is we weren't ready let's be ready the next time let's have resilience let's say we do need a little redundancy in the health system you know the idea that everything works at 105% may make the health economists really happy that you know we really have things down to a huge level of efficiency but it's not a humane way to run a health system the supply chain also needs a bit of redundancy as well as we're also finding out just go to Ration and then back to Nuka Matias Ration anything else from covid yeah I yeah I I would agree with John that you know there were challenges there before before covid and but I think that the fact that the elective care essentially stopped and has you know has had that huge emotional toll on people as well like those people who have got phone calls over the last week so very very recently to tell them that life-saving treatment isn't going ahead or it's being postponed because of these pressures that John's describing on ICU and that that you know the healthcare professionals have I echo totally what he's saying they've done an absolutely amazing job over the last period of time this isn't their fault it's the system that's actually blocking people from getting the care they need and one of our nurses was speaking to somebody who's diagnosed with bowel cancer over the last number of weeks and he was meant to be getting regular colonoscopies because he has a family history of bowel cancer and when he became symptomatic he went to his GP and he his his colonoscopy was was accelerated and he was diagnosed with bowel cancer and he he will never know whether he could have had treatment earlier and that could actually have been a much more positive outcome for him and these are the kind of you know these are real people these are people who we all know and and it's just it's a tragedy and and I hope that the recovery over the next period of time is swift and people get the care they need. So McLeod from your end the observing the impact of cancer or COVID on the on the health system any other lessons for your plan that have been affected by COVID in terms of learnings or our implications. Well I think there are a number of implications first of all it's it's true that we don't have real-time data so many member states could not basically assess what the impact of COVID on cancer care was I mean there of course there are now some research projects but that would be an element where we think collaboration across the EU could help get member states better data and more timely data. Secondly I think and this is unfortunately only anecdotal evidence there is a wealth of good practice examples how and Anuq referred to that how silos were broken down how how new collaborations sprung up and this is indeed that we will consider at the EU level how we can basically gather this wealth of evidence and make it lasting and and actually share it also across member states. I think this if something comes out of this of this pandemic it might be that we have new practices perhaps that we can roll out and support also with our mechanisms for instance on best practice implementation. Terence you're on mute but I think I'm on mute. Anuq just to say from your end you didn't give us an example of mislead anything any other issues that you see rise from COVID and implication? Maybe another example that you saw that impacted us directly that also clinical trials were suspended or slowing down and and that has also you know direct impact on on innovation and the speed of future innovation so also there I mean telemedicine also in clinical trials can also can also provide solutions but yeah we have to think about all these things going forward but other than that I would say that you know in my own country Belgium cancer diagnosis went down 30 to 40 percent and we have data that half of the patients their treatment was disrupted so this will have an impact on on their outcome and and I would say as a in key lesson well it's maybe not a lesson but I hope maybe let's hope that healthcare budgets are not cut because as professor crown was saying as well we we stopped all the other interventions and that's why we were able to minimize maybe to some extent the drama but we should really invest more in healthcare and austerity will not be the solution and specifically for cancer treatment and then bringing it to Ireland given access to the best possible treatment in Ireland is sub optimal there we need to really bring up the healthcare budgets to a level that would allow for better access to these treatments okay I want the next question and that's going to be what's at further that and this is from Muriel Auburn and Muriel makes the observation that the results of the EFPIA WAIT survey are deeply worrying with about Ireland's rate of availability oncology therapies being less than countries such as Bulgaria, Sevilleia and the Czech Republic she says considering our GDP as a country this seems shameful and she asks does the panel of any ideas that we can tackle this so new innovations can ultimately reach patients and I might leave you to last John because I think you've probably given us your initial views on this anyway so Ireland again views John's earlier words not high on the table and anything Ireland can do to make sure that new innovations get here quickly Anouk Britsun Well I'm happy to go first it is indeed I mean I know that data very well and directly involved with my team in an FPI in helping to regularly update that and we've seen since 2012 that indeed Ireland has been lagging behind again compared to my own country's patients in Ireland with three times longer than in Belgium or four and a half times longer than in Denmark which is a country with similar population and similar national income so I think well having more data on this and what are the consequences there I think the European eating cancer plan and the register that Matthias was referring to will give us data there are disparities in EU survival data EU five-year survival data as well and there is evidence that that is linked to uptake of cancer medicines so these two are connected but how can we improve uptake of cancer medicines I think as I said I mean we need to invest in cancer care financially also and bring up the budget and and then also measure outcome for cancer patients based on what matters to them and then calculate the cost based on that outcome I think I understand in many countries today the healthcare system rewards providers based on the number of patients that they treat not necessarily the outcome that these patients are having and that is a big shift which I don't know if the society is prepared to take but I think that would be one that could help drive to making better decisions on which treatment should which patient get at which point in time yeah I'd agree with those comments and I think that patients are the ones who are ultimately paying the price when they're when a you know their clinician doesn't have access to a drug that a patient in another country does and I think that that's very inevitable and I think that it's an area that the European Union and has great potential and that we as Europeans work collaboratively to ensure that patients in every member state and has the same level of access and we know that the clinicians in Ireland are greatly frustrated and certainly over recent years and where the budget for new drugs and has has been either low or non-existent and I think in the budget for 2022 I think a number I think 13 million was given to new drugs but that's probably only going to clear the backlog rather than to fund the new the new drugs that are needed by patients in Ireland. The price issue for Ireland and what innovations we should be tackling to to get up the league. Can I just say something briefly on that I mean we I think the main lesson from COVID was the magic money lesson when suddenly we really needed a whole lot of money to pay people to keep their keep businesses alive to keep people from starving because they couldn't go to work to you know to buy masks and buy drugs and buy vaccines for some reason the magic the money appeared like magic now I don't quite understand macro macro macro economics but systems that were told a few years ago that they couldn't spend 7 million to vaccinate every young girl in the country with a vaccine that would stop them dying of cancer suddenly we're able to pull tens of billions out of the ether to cope with the structure so somebody an economist will have to teach me what that lesson is how you find magic money because we could certainly do something for the cancer services. The other issue that we really have is that we're why is our drug access so poor it's because about 15 years ago we set up a system to emulate the way the British were approving cancer drugs the British had the most restrictive cancer drug approval process in the developed world they had a thing called NICE the National Institute for Clinical Excellence which was really tremendously or well you name because the effect was anything but nice and it meant that all kinds of lifesaving drugs just were routinely denied to British people disproportionately British women with breast cancer so the British have moved past that they now have new structures in place for providing drugs so they're now way ahead of us we're now at the bottom of the room we're down somewhere near New Zealand in terms of poor access to cancer drugs so why can't we have you know as I said earlier on I'm a very enthusiastic European I'm not beyond criticizing the EU and I sometimes grit my teeth when I hear harmonization as a goal all of its own the only problem that harmonization fixes is a lack of harmonization but there's one thing that really should be harmonized why don't we just make a rule if the drug is reimbursed in Germany we do it if we want to be like the Europeans if we want to be you know we're nearly as rich as they are now in terms of GDP per head of population if you know if it's approved in Belgium if it's improved in other and in other peer countries we should just approve it why do we have to go through a separate process of doing it here and what's more say we'll pay for it at the rate that they've negotiated why don't we have a European wide if I'm not sure if cartelling is if I'm breaking the law by suggesting a cartel but why don't the EU countries get together and say this is what the EU countries will pay and if if it's approved and if it's reimbursed we will guarantee it will be made available equally and fairly in every country and finally just a little editorial point on something that Lucas said there about paying providers to do things in Ireland we pay them not to do things we pay our hospital providers to keep people on waiting lists that's the way you stay under budget because there is no additional money if you're more efficient and you get people off the waiting list in Ireland the amount of money is the same if you have a waiting list of one or a waiting list of 10 million or a waiting time of a week or a waiting time of a year that's the problem we have in Ireland and we need to link activity efficiency and reimbursement and shalom to care ain't going to do that thank you John I'm a thighs again just coming to you in terms of things that Ireland can do from your perspective best practices of the countries anything that we should be thinking about it early on well I think with the cancer plan you have now the possibility for let's say large-scale EU collaboration in many areas that concern cancer and I think one of the specific added values of EU collaboration is that you can learn from each other and of course you have to be ready to let's say implement then also best practices that come from other member states I think a good sign and I mentioned in my presentation four joint actions that are launched with member states I think a positive sign is that out of those four for three Ireland has expressed interest to collaborate so I think this is already a very good sign I cannot provide further information because this is also still under development but Ireland is collaborating at the EU level and I think that's that's that's very good on the issue perhaps of access to drugs this this is difficult part because obviously this is under the mandate of the member states and they they can decide that and it's quite sensitive as has been shown by let's say the long time that was needed to get final agreement on the commission's proposal for health technology assessment so it is difficult and I think there's also something where let's say certain advocacy needs to be done at national level because I think at EU level we can offer these opportunities but we cannot force member states to take them. Thank you Matthias. We can we can force them we force them to do other things we just need to make a decision that we're willing to do it you know European law has precedence over national law we've heard this very eloquently outlined in the constitutional crisis in Poland we can do it if we make it a decision that we will do it. Thank you. So we're moving the last 10 or 15 minutes so these are going to be probably smaller questions or we won't get to all the questions unfortunately so I apologize to people who've asked questions we'll get to them but maybe get quick answers to these and it's a very specific one given the comments on tobacco what does Professor Crown recommend when it comes to reduced risk products like e-cigarettes and helping people move away from combustible tobacco so any views on e-cigarettes John? E-cigarettes are clearly far less harmful than cigarettes and they're a very useful smoking cessation tool and we should use them and as we're trying to get smokers to break their nicotine habit however it keeps the nicotine habit alive the real worry is that many of the forces that are pushing e-cigarettes are not necessarily good actor society a lot of them are either the drug sorry the tobacco companies themselves are their surrogates and they're pushing these because they want to increase the pool of people that will be addicted to nicotine because there is a fairly high rate of transfer from the e-cigarettes to tobacco so yes we should definitely use them to help people get off cigarettes they're far less harmful we're better to get them off nicotine altogether but we need to regulate them within an inch of their life in terms of letting children take them up as a new habit. Any other comments from panel members on that? I think that if they were to be used to say cessation tool then they'd need to be regulated as such and the fact that I don't think any e-cigarettes companies have actually applied to be regulated as a medicinal product just indicates I suppose it reinforces some HRB research which found that e-cigarettes weren't any more efficacious than the nicotine replacement therapy which is on the market and which is which is regulated and so I think that we need just to be mindful what John was saying they're about the people in back e-cigarettes they're owned by the big tobacco industry and that they do link to when children smoke e-cigarettes there is a link to them taking up tobacco and leisure life so I'd be treating them with extreme caution. This is from Bernard Malay who's the Irish Pharmaceutical Health Care Association he asks does the panel believe if there are risks to the development of new cancer treatments with potential changes in the way to the IP the intellectual property and census framework in Europe? Do you want to start with that one considering this I'm sure? Yes thank you Terence. So well absolutely IP and intellectual property and having the right incentives in place will drive innovations to certain areas I mean we have seen that if you look at at antimicrobials and antimicrobial resistance there's no more incentives for commercial organizations or they were I should say no more incentives for commercial organizations to enter into the development of these and that is needed to bring corporations together to do that so I going forward I mean I don't see that happening to cancer because there's also still a huge unmet medical need and that's also where we want to drive our innovations to but definitely for that innovation to happen in Europe it needs to continue to have a very strong intellectual property and incentives framework in place so that's key priority. Matthias, I don't know if you can make any observations on this? Well perhaps to refer to the pharmaceutical strategy that was also published recently and in which the commission is reviewing and perhaps innovating the existing legal frameworks for developing innovative products. Both we looked at and Rachel or John anything on that? Okay question from Kay Curtin Melanoma Support Ireland and again back to something at top we haven't come across today yet. As a result of COVID cancer patients were finding already finding it difficult to require travel insurance would find travel even more difficult. This is a particular problem in Ireland due to the costs involved so Kay asked what can the beating cancer plan do to remove financial barriers like this for patients so people who can find it hard to acquire and pay for travel insurance while they're a country patient. This is one of the elements that I mentioned in my presentation that we're looking into the issue of fair access to financial services and that includes also insurance different types of insurances but we are aware that cancer patients or cancer survivors have difficulties in accessing certain types of products. In the cancer plan we have said that we will work with the relevant players and the industry to develop a code of conduct and we will also look how in the more long run we can find solutions to these issues. Rachel? Yeah and I really feel for Kay and I know that there's many cancer patients cancer survivors who are suffering what Kay is at the moment. I obviously understand what Mateus is saying about code of conduct I'm not sure code of conduct is what's needed I would suggest that legislation is needed. I think that there is some amendments done from the Becca committee that would mean that an adult cancer survivor wouldn't be financially penalized for 10 years post diagnosis and a child provider's post diagnosis and it seems so unfair that people are being financially punished for actually surviving cancer by the financial services and we hope that legislation will be brought in in Ireland maybe we can show I know there's three countries in Europe already have legislation in place but maybe Ireland can be the next country which takes leadership in this area. We should have a bit of rights for cancer patients and cancer survivors we really should I mean this is Kay's pointing out an important area which is the tip of a bigger iceberg related even to things like getting mortgage insurance being able to apply to adopt a child. There is a wide range of irrational discriminations imposed on cancer patients which I think need to be addressed legally and the best way to do it would be some kind of a well-informed cancer patients full of rights. I'm not sure if you have anything you want to say on this one. You know another question here from Ewan McKinney who's in Ireland that makes the observation I've given the level of amendments 15,000 or so placed before the European Parliament's packet committee. Does Matthias have any concerns that the strands of prevention proposed will be watered down and weakened? So it's a big volume of amendments being placed already so I don't know if you have any observations of that Matthias. Well I think we have well let's let's put it that way we have studied these amendments and many of them are let's say going in the same direction so not necessarily they're all different in terms of nature. Of course there is a potential that the draft may be weakened and this has already been imminent when we when the parliament discussed the initial amendments in its recent meeting. On the other side I think there are also amendments and the report itself has several elements that goes beyond the existing european cancer plan perhaps providing also a bit of leverage for the commission to reconsider its approach if it has the backing of the parliament. We also want to tip in on that okay I want to have one of our last questions now this is from Niko Bryan as a student in UCD very specific question. She wants to know if there have been any developments in relation to pancreatic cancer screening or treatment? So anything recent developments in pancreatic screening or treatment? The treatment has improved a little bit I would have to say there's still considerable scope for improvement I think the treatment for earlier stages of pancreas cancer has improved quite a bit the treatment for advanced diseases has improved a bit too maybe in a different form if I get my colleague professor Ray McDermott who's a world authority on this to speak on it but it is it is a big it is a big stubborn challenge right now pancreas cancer we haven't made as much progress with it as we have in other areas. And Niko Rachel want to take with us? I think it just illustrates the the difference like to go back to inequity like even between cancers there's such an equity in terms of survival and there's so much work still to do in making sure that more people survive cancer and yeah like I really hope that you find you find the answer to your question. And well maybe one thing and again I'm not a specialist in this area but I think it's also important that we move towards more tumor agnostic treatments and screening so that you know then we will be able to cover a broader range of cancers together so so that's maybe just one area also where collaboration and investment would be beneficial. And we need a proper career structure for our researchers we have a desperate career structure for mid-level laboratory researchers in this country we have basically very little between the few people who become actual tenured professors and those who are postdoctoral researchers so many of them living year by year on soft money grants we need to fix that and we also need to fundamentally address the issue of our medical schools not having enough full-time faculty who have large amounts of protected time and designated as part of their job description doing research those of us who do it have had to pretty much always do it on a family time. If I saw anything and pancreatic cancers come across your desk recently. Well in the cancer plan we have focused some of the project to give priority to cancers with poor prognosis so not explicitly to pancreatic cancer exclusively but there are several several actions where we will focus also in terms of creating new EU networks for expertise but also in looking at the repurposing of existing medicines which should with priority look at pediatric cancers and also cancers with poor prognosis. Okay thank you that last one last question which can report a question. Prasila van der Leyen in her state of the union address she talked about proposals to develop a European health union in the coming years obviously at this stage health is still a mostly a national issue rather than a european-wide issue but the proposals on the table for European health union so what areas you think a european health union would help most in cancer policy across the EU? Mattias maybe just might give us your perspective on that one. Well I mean it's my president who said that so no I think COVID has given let's say new impetus to to address health also at the EU level and the commission president has clearly seized that opportunity I think we need to keep up that momentum that we can proceed and really make a difference in terms of EU funding in terms of EU collaboration and I think we should not lose that opportunity and a focus or a key issue in this is the cancer plan which has the full backing of our commission and also the president of the commission. Any other observations from your panelists on the european health union? Tom? I think you know again practicalities the specifics the deliverables I think if it did harmonize access to drugs and treatments it would be wonderful I think if it showed up the deficiencies in our diagnostic service it would be wonderful and if we had freer movement more greater more lubricated transfer of senior specialists between EU countries I think greater and more flexible degree an automatic degree of recognition of the training of colleagues who trained in other peer EU countries and have received senior training you know not making jump too many hoops to apply for a job in Ireland might be one way of you know encouraging people to try and fix the extraordinary extraordinary personal shortage we have. Any last quick words Rachel or Luke? From my side I really you know looked also at the developments under the European health union with a lot of enthusiasm and I really hope it will help to improve patient outcomes and still allow Europe to drive towards innovation and then the third piece is a setup of the pandemic preparedness strategy and the agency which I also hope will really operate based on the learnings from the COVID pandemic and really that you know hopefully not in our lifetime but if there is a next pandemic that we are ready more quickly to collaborate and work together towards getting treatments and vaccines to patients to people quickly. Thank you Anouk and I'll come at the end so I just want to say on behalf of everybody who participated today a big huge thank you to our panelists to Matthias, to Anouk, to John and to Rachel you I mean I'm conscious in an hour and a half and yet we only scratch the surface of many complex issues but I think people here today they heard a lot of challenges but they also heard a lot of new ideas and new frameworks coming along which can really help so hopefully we've helped develop a few issues today that'll be taken forward so really just thank our panelists again very much for your participation today and thank you all for participating and that's it goodbye from my AA this afternoon thank you