Vision 2030 for the optimal approach to cancer research and care in Europe: A mission or a network of networks?

Introduction: A mission-oriented approach to cancer care in Europe was proposed by Julio Celis and Dainius Pavalkis in 2017. The major proposed objective is to achieve long-term survival of 3 out of 4 cancer patients by 2030. Background: The authors are president or president-elect of Organization of European Cancer Institutes (OECI) EU Life or European Cancer Community Organization (ECCO). Results: The goal is laudable and ambitious. However, it can only be successful if it is coordinated with active involvement of all stakeholders and interacts with an already well-organized, recognized, and certified European Accreditation and Designation quality approach to identify and select the potential candidates to participate in such a virtual network. Conclusions: The building of a virtual European Cancer Institute based on coordinated networks should refer to unquestioned criteria using a solid and proven methodology operated by an independent arbitration body. The cancer community must share a fundamental responsibility to act collectively and in today’s era of the World Wide Web, it is time to think out of the box and consider the possibility of establishing networks of networks.


Introduction
A mission-oriented approach to cancer care in Europe was proposed by Julio Celis and Dainius Pavalkis in 2017. 1 The major proposed objective is to achieve long-term survival of 3 out of 4 cancer patients by 2030.
This goal is laudable and ambitious. Given the importance of the task, it may only be reached if the overall cancer community will be able to apply better the existing instruments to provide high-quality cancer care, offering to a higher percentage of cancer patients the possibility to benefit from the best available treatments. It should also be complemented by developing a capacity of early intervention to prevent the disease before it manifests. Therefore, if we want to reach the survival goal and prevent a disastrous disease outbreak in the future, important issues should first be debated at the European level: • • How do we facilitate interactions among and improve quality within the highest-volume cancer centers?
• • How do we support the access to innovation and the growth of centers that have not yet reached a level enabling them to offer the best available treatments for a wide range of patients with cancer?
The cancer community must share a fundamental responsibility to act collectively, and in today's era of the World Wide Web, it is time to think outside the box and consider the possibility of establishing networks of networks.
Vision 2030 for the optimal approach to cancer research and care in Europe: A mission or a network of networks?

The Challenge
A landmark resolution on cancer prevention and control was adopted by member states at the World Health Assembly 2017, noting that "risk reduction has the potential to prevent around half of cancers" and urging "to promote cancer research to improve the evidence base for cancer prevention and control." Cancer prevention is the most important challenge. 2 Subsequently, screening and early diagnosis of cancer greatly increase the chance for successful treatment. Screening programs should be undertaken only when their effectiveness has been demonstrated, 3 when resources are sufficient to cover the target group, and when facilities exist for confirming diagnosis and proceeding to treatment and follow-up. Based on the existing evidence, screening by population programs can be advocated only for breast cancer, cervical cancer, and colon cancer. 4 More recently, targeted screening programs have been identified for well-specified populations at risk. Moreover, recognizing possible warning signs of cancer and taking prompt action lead to early diagnosis and in such a case surgery with or without radiation therapy is often sufficient to cure a majority of patients.
Early diagnosis and screening are the second major challenge to achieve long-term survival in Europe for patients with cancer.
Recent progress in the field of immunotherapy showed that we need to better understand the underlying mechanisms before using this new avenue of treatment for a broader group of patients. 5 Fundamental research is the major way forward to structurally improve cancer survival in a non empirical way. The scientific outcome of fundamental research had helped us develop each individual tumor's specific genomic and molecular portrait as one of the ways towards precision medicine. 6 Resolving spatial cellular heterogeneity, capturing cellular change in time, and establishing computational frameworks as parts of our understanding of the cause and biology of malignant diseases will further enhance our knowledge and thereby be a major step in the fight against cancer. 7 Fundamental research is a third (but one of the most important in a long-term vision) contribution to approach the 2030 challenge of cancer in Europe.
Translational research is not only to work with industry in early clinical trials. It also includes the proof of concept that a laboratory discovery may be translated to applications in clinical practice, for which animal models remain of utmost importance.
Translational research should be hypothesis-driven and should support bench to beds studies. Early phase 0 and I studies are an important chapter but phase II and III and also phase IV studies in real life are part of this important challenge. 8 Translational research, to transfer research discoveries from bench to bed and vice versa, is a fourth major challenge to achieve the targeted long-term survival of 3 out of 4 cancer patients by 2030. Furthermore, reverse translation is equally important, since feeding back the most fundamental research based on data arising from studies with the patients is a necessary final means to the most effective iterative process to progress at all levels without working on each aspect separately.

A Network of Networks: A Forwardlooking Approach to Define a Missionoriented Approach to a Virtual pan-European e-Cancer Institute Project
The ongoing proposal concerning a Virtual European Cancer Institute has the potential to be promising. 1 However, this can only be successful if it is coordinated with active involvement of all stakeholders and interacts with an already well-organized, recognized, and certified European Accreditation and Designation quality approach to identify and select the potential candidates to participate in such a virtual network.
A possibility, as briefly described below, is to set up coordination between currently existing networks that have the potential to evolve over time.
1. The main challenge is at the level of primary prevention, which could reduce the number of cancers by 30% to 40%. Virtual networks already exist, mainly around Cancer Prevention Europe (Table 1), the European Network of Cancer Registries, the European Cancer Leagues, and a certain number of  (Figure 1), which brings together both cancer special-ists and patients, is entirely legitimate to establish a second network focused on the issues related to cancer care from screening over diagnosis, bridging hospital care with primary care levels (eccoorg.eu). 3. The third level is fundamental research to nurture our knowledge. The EU-LIFE alliance (Figure 2), for instance, represents an interesting model in    Being also a legal entity, Cancer Core Europe may serve as a hub and an engine to coordinate and optimize joint translational cancer research efforts across Europe. "Cancer Core Europe was exclusive at the start to become inclusive in the long term as a strong pillar was necessary to build and ensure the long-term success of the initiative." 1 particularly strong position to contribute to the development of novel real-life approaches, raising the question of the price of innovative treatments.
In addition to university hospitals and cancer centers/ institutes, many general hospitals and private clinics are treating cancer without an established link with cancer research. As our efforts are patient-centered, we have to think about how these peripheral actors may interact with CCCs at a regional level and find their place as part of a network.
All the above levels are needed and should positively interact and collaborate owing to a solid though flexible and creative coordinating network. The head (the virtual European Cancer Institute) should be composed of a team of 20 to a maximum of 40 officers acting as conductors and facilitating the creativity and expression of the individual networks with a bottom-up approach representing the overall community.

Selecting members of the networks: A major issue
As far as translational research and clinical research is concerned, we need to select the CCCs in a first phase (cancer center or cancer centers within a university hospital) and focus on their capacity to join a network for translational research. This is one of the issues OECI/Cancer Core Europe and several European Joint Actions are currently addressing. Indeed, the European Networks on Rare Cancers (rare solid cancers of adults, pediatric tumors, and rare hematologic malignancies) have proved to play a major role to ensure the same high level of quality of care for all patients with these rare malignancies.
The whole cancer community, together with the representatives of our patients, effectively linked to all domains of research, should communicate effectively in order to discuss and design the way Europe should act to guarantee a sustainable future for cancer research and care.
To achieve an open, multidisciplinary, democratic, and transparent approach including all the necessary talents, we have an existing model that fulfils the requirements: a model of integration and combination that translates differently depending on contexts, which may differ in terms of funding schemes and organization from one country to another, or organizational environments; for example, a cancer center compared to a university hospital. These models should not be exclusive, but on the contrary they should be united and complementary. Among the European cancer centers, members of OECI, currently 20, are defined by OECI as CCCs within a university or with a link with the university. Designation as a CCC by OECI may be the first step to become part of a network for translational research.
In due course, therefore, other European CCCs are expected to join a putative mission based on their capacity to demonstrate scientific excellence. (EU-Life in particular will bring early translational research tools to such a network.) Cancer Core Europe in collaboration with EACS has developed quality criteria and methodologies for the designation of CCCs of excellence, defining in particular the level of integrative research to develop clinical applications. 1 The method was already tested in practice during autumn 2014 and has been in use since the beginning of 2017.
Thereby, the designation of excellence for translational research may be a second step to select the members of the translational network. Centers in EU-Life are also players in the translational research field and connection among OECI, Cancer Core Europe and EU-Life may improve the process. OECI aims to create a critical mass of expertise and competences contributing to the production and dissemination of knowledge, so as to reduce fragmentation and increase competitiveness. These goals are being achieved by promoting and strengthening the concept of comprehensiveness and supporting quality in both cancer research and care, including a well-structured internal organization of these cancer centers. The final goal that should be obtained is to accelerate the production and implementation of personalized care approaches to ensure better treatments to all cancer patients, to produce more comprehensive care, and to improve patient quality of life through evidence-based medicine. The Accreditation and Designation Programme is the OECI core business and aims to improve quality in cancer care and research, including the capacity to promote innovation. The OECI quality approach is ISQua certified as the only existing European process (with the German system) specifically designed to monitor the quality for cancer centers, while providing a significant impact on the organization of cancer care.

Conclusion
The building of a virtual European Cancer Institute based on coordinated networks should refer to unquestioned criteria using a solid and proven methodology operated by an independent arbitration body. Quality and meritocratic criteria are the foundation on which to build such an initiative.
National networks already exist in many of the European countries. They must be involved in the process. This can only be achieved through the support of the concerned ministries and the needed cofounding to a project that cannot exclude risking the reflection by the main political actors of this historic challenge for the members' state.
Our organizations OECI, EU-Life, and ECCO are enthusiastic to be part of such a vision to build a real network including all European citizens to increase duration and quality of life everywhere in our community.