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Portugal
1 – General Information
The cancer mortality rate in Portugal is among the lowest in Europe, even though this
disease is the second most common cause of death in the country. In 2002, 6,008
women were admitted to hospital suffering from breast cancer, 8,050 from colon
cancer, and 1,058 from cervical cancer (see Appendix no. 1). This led to the
institutionalization of public hospitals. Regulatory Decree no. 6/2001 of 5 May
contains the list and the index of occupational diseases (Decreto Regulamentar
n°6/2001: aprova a lista das doenças profissionais e o respetivo índice codificado).
According to it, diseases classed as “occupational” occur as a result of a work
activity, resulting in a disability or the worker’s death (an ad-hoc list of these diseases
is provided).
2 – National List of Disabilities caused by industrial injuries and occupational
diseases (Tabela Nacional de Incapacidade por Acidentes de Trabalho e Doenças
Profissionais)
The list was included in Decree no. 341 of 30 September 1993. Chapter XVI explains
that the identification of occupational diseases (and, more specifically, cancer) is
based on the strong relationship between occupational hazards and the working
environment (a cause and effect relationship).
The diagnosis of cancer should be made considering the individual’s medical and
professional background, and confirmed by additional examinations, such as smear
tests, histology, and immunology.
The identification of carcinogenic agents is made taking into account statistics and
epidemiological data. The list of the factors that are likely to cause cancer should also
include additional information, such as physiopathology.
From a medico-legal point of view, the agents classified as “carcinogenic” are those
appearing in the above-mentioned list. As we have seen, the diagnosis of cancer is
made considering the individual’s medical and professional background, and
confirmed by additional examinations, such as smear test, histology, and
immunology. For this reason, in Portugal, people with cancer resulting from the
exposure to agents classed as carcinogenic by law, are required to prove that the
disease was caused by this exposure. Only in this case is it possible to speak of
“occupational cancer”.
Carcinogenic substances are included in the following decrees:
- Decree no. 479/85 of 13 November;
- Decree no. 273/89 of 12 August;
- Decree no. 284/89 of 24 August;
- Decree no. 348/89 of 12 October.
In part 3 of Chapter XVI, num. 9, entitled “Guidelines for a medical evaluation”
(Guião para exame pericial), breast, cervical, and ovarian cancer (points h, g, and i,
respectively), are classed as diseases caused by the working activity, but not
necessarily as occupational diseases. In fact, in this last case, the cause and effect
relationship has to be proven, in order to classify people with this condition on the
basis of Provision no. 2127 (chapter XXV, no. 2).
Part 4 of the same chapter contains the table of disabilities (Tabela de
incapacidades), and explains that each case is evaluated on the basis of general
criteria and levels of severity, also considering carcinogenic and co-carcinogenic
factors.
In this connection, general directives are provided, for example:
1) in the event of a benign tumour, the side effects of the treatment have to be
evaluated, as well as the lesion to part of the body concerned. It is important in this
case to consult the ad hoc section of the table, where several levels of severity are
reported;
2) in the event of chronic illnesses (e.g. malignant tumour), it is the same as for point
1;
3) in the event of malignant tumours or metastasis seriously affecting the patients’
quality of life, the degree of disability can be increased to 60%;
4) the degree of disability for people with a malignant tumour with low life
expectancy (due to the failure of medical treatment) ranges from 80 and 100 percent;
5) the degree of disability, in the event of cancer reactivation with generalized
metastasis, and malignant tumours with low life expectancy, is always 100%;
6) the degree of disability will be multiplied by 1.5 if, in the event of point five, the
patient is not self-sufficient and the disease affects his/her life seriously.
Regulation on legal protection for workers who are exposed to carcinogens or
mutagens at the workplace
(Regula a protecção dos trabalhadores contra os riscos ligados à exposição a
agentes cancerígenos ou mutagénicos durante o trabalho)
This provision is included in Decree no. 301/2000 of 18 November, and it
implements Directive 90/394/CEE, amended by 97/42/CEE and 99/38/CE. They deal
with the extension of the list of mutagens, also adopting limit value for occupational
exposure to a number of chemicals (e.g. benzene and hardwood). In this connection,
the definition of “carcinogens” has also been modified, including new substances that
are dangerous for workers’ health, in case of prolonged exposure.
The decree does not provide special protection for women, nor for women workers
with cancer (whether caused by prolonged exposure to chemicals or not). It only
provides that it is mandatory for the employer to reduce as much as possible the use
of carcinogens and mutagens, replacing them with safer substances, in order to
improve the health and safety of workers at the workplace.
National Health Plan 2004 – 2010
The National Health Plan includes a set of principles regulating the activity of the
institutions within the Ministry of Health, as well as that of private facilities which
deal with public health issues. It aims at promoting the prevention of the diseases in
the period 2004 - 2010.
The plan also provides important statistics. It points out, for instance, that in Portugal,
in the period 2000 - 2001, life expectancy for both sexes was 76.9 years (which is
lower than the EU average of 78.2 years). More specifically, male life expectancy
was 73.5 (EU average 75.2), while the corresponding figure for women was 80.3
years (EU average 81.2).
With regard to 2001, circulatory diseases and malignant tumours were the leading
causes of death in the country, especially among young people. Cancer-related death
rates are higher among men than women.
Comparing national statistics with those of EU countries with the lowest cancer
mortality, it might be possible to reduce untimely death rates by 38% for men, and by
10% for women. Breast cancer is the most common cause of death among women
(see Appendices 2 and 3). It should be noted, however, that in Portugal mortality has
decreased lately (13.5 cases per 100,000 inhabitants in 1998).
Colon cancer is the third most common cause of death among men and the second
among women, and mortality for this pathology has increased.
With regard to cervical cancer, death rates have fallen, especially among young
women, thanks to the promotion of smear tests.
According to the National Health Plan projections, by 2010, 60% of national cancer
cases will be detected, cancer death rates among people under the age of 65 will
decrease by 30%, and survival rates for cancer patients will comply with the EU
average (10 years).
As for working conditions, increasing attention is paid to the adoption and promotion
of effective measures relating to health issues. In this connection, a Health Promotion
and Protection National Program has been set up, consisting of five basic intervention
strategies. The program aims at putting into practice the principles contained in the
National Prevention Plan on health and safety at work, working conditions and
industrial injuries, as established by 2001 Economic and Social Council.
According to the Ministry of Health, the national screening program will focus on
breast, cervical, and colon cancer.
NB IT IS IMPORTANT TO AVOID SPLITTING A SENTENCE WITH A TABLE
IN BETWEEN THE TWO PARTS OF THE SENTENCE
A determined effort will be also made to establish a set of rules regulating scientific
research and the provision of medical treatment, in order to promote a rational
approach to the disease.
In this connection, public health has to be safeguarded, providing practical
information on the issue, and also promoting a healthy lifestyle.
This is the reason why the government set up the National Program for Integrated
Intervention in Health Determinants Related to Lifestyles, which deals with
transmittable and non-transmittable disease, such as AIDS, tuberculosis, arterial
hypertension, ischemic heart diseases, and several types of cancer (lung, breast,
stomach, colon, and cervical cancer).
Appendix
1 – Breast cancer cases (GDH: 174): Admissions to hospital), in the region of Salud
in 1998 and 2002, broken down by city and average cost of hospitalization (in Euros).
2 – Number of deaths and breast cancer death rate in 2001 among women (ICD9:113), broken down by age and sex (out a total of 100,000 inhabitants)
Statistics:
Analysis of the processed 2006 Eurostat data. Mortality for cancer (standardized
data considering 1.000.000 cases)
Portugal
%
1995
1996
1997
1998
1999
2000
2001
1707
1650
1636
1627
1604
1613
1617
0,171%
0,165% 0,164% 0,163% 0,160% 0,161% 0,162%
-0,006% -0,001% -0,001% -0,002% 0,001% 0,000%
2002
2003
2004
2005
2006
1616
1615
1556
1560
0,162% 0,162% 0,156% 0,156%
0,000% 0,000% -0,006% 0,000%
2006 Eurostat data progress chart. Mortality for cancer (standardized data
considering 1.000.000 cases)