POLITICS OF CANCER

1. POLITICS OF CANCER • position cancer as a case study: trends in prevalence and approaches • outline current theories about cancer: causes and responses • ‘conventional’ personal risk factors • ‘radical’ structural and environmental factors • ‘pyschosocial’ perspectives • policy implications

2. EXTRA READING • the Guardian and The Observer website has several articles: http://www.guardianunlimited.co.uk • Truths and myths: the cancer report, parts one and two 50 things you need to know about the Big C. Peter Silverton, Sun Oct 15th, 2000 • eg George Monbiot: Are man-made chemicals turning against us? Jan 11th 2001, plus letters • Department of Health website for National Cancer Plan; Saving Lives: our Healthier Nation • articles BMJ and JECH • many websites

3. WHAT IS CANCER? • group of diseases affecting different part of body • uncontrolled reproduction of cells’: • CARCINOMA(85-90%) from cells of tissues that cover internal and external surfaces of the body • SARCOMA (2% of cancers) originate in muscles, bones, fat and lymphatic vessels • TUMOURS (neoplasms) can be: • MALIGNANT invade normal tissue; cancerous cells separate, travel via blood stream to other parts of body, can form new growths (secondaries or metasteses) • BENIGN ‘stay in place’; less dangerous but can block blood vessels, nerves, or grow in confined spaces • feared: ability to spread generates anxiety - ever ‘cured?’; metaphorical power ‘being eaten away’

4. CANCER: CURRENT TRENDS • leading cause mortality, 1 in 4 deaths in UK - 130,000/yr; not only because ageing population? • not ‘disease of affluence’ but of the poorest (not breast cancer);  in poorer ‘South’ countries too • 4 in 10 people will be diagnosed with cancer some time in their life • risk of developing disease  ->200,000 new cases annually • much of increase since WWII was lung cancer (now  men  women); breast, colon and cervix remained stable? stomach declined •  death rates but survival rates poor compared other European countries; ++ variation in UK

5. Females Lung Rising ? Breast Rising Cervix/ovary Stable* Stomach Falling Skin Rising * rates rising among younger age groups Males Lung Fallling Prostate/ testicle* Rising Stomach Falling Colon/rectum Stable Skin Rising * rates rising among younger age groups CANCER MORTALITY RATES 1971 onwards (Social Trends)

6. MOST COMMON ‘KILLERS’ (Saving Lives; Our Healthier Nation) • lung cancer • one fifth all diagnosed cancers; ¼ cancer deaths in men; survival rate 5 yrs= 6/100; cost £130 million • breast cancer (women) • one third diagnosed cancers women; one fifth all cancer deaths; survival rate=66/100; cost £150 million • prostate cancer (men) • 1 in 7 all diagnosed cancers men; one eighth all cancer deaths in men; survival rate=40/100; cost £100 million • colorectal cancer • 1 in 7 all diagnosed cancers; one ninth all cancer deaths; survival rate=40/100; cost £250 million

7. CANCER: ROLE OF BIOLOGY • age - accounts for some of increased rates; • 70% all cancers deaths in those >65yrs; • rates also <65s, only 5% male, 9% female <45s • 0.6% in <15s (1/3 leukaemia of whom 50% survive) • general ageing process in cells • heredity - • identical twins only 10% chance same cancer (prostate most heritable), ie heritability low • screening ‘risky’ individuals - treat/prevent/insure? • infectious agents • some role - stomach, cervical, liver • biological factors account for ~20% variation

8. SOCIAL PATTERNING CANCERS • social or environmental causes ~80% variation; rates strongly patterned by class, gender, ‘race’: • deaths lung cancer unskilled men 5x professionals • deaths stomach cancer unskilled 3x professionals • death rates lung and cervical cancer 20% higher north England than national average • women born in Caribbean 25% less likely to die from breast cancer than other women living in UK • women more likely than men to contract skin cancer but less likely to die from it • differences in incidence and in experience

9. CAUSES: DIFFERENT VIEWS • ‘establishment’ view: individualist, behaviour Doll, Peto OHN (McVie, Nurse) • tobacco: smoking is linked to 35% cancers, specifically lungs, major cause for mouth, larynx, pancreas, bladder; part in kidney, oesophagus, stomach and leukaemia; 120,000 die in UK/year • diet: linked to 30% cancers;  fruit/veg intake linked to  risk lung, stomach, colon; saturated fat intake associated higher risks colon, prostate, breast (not causative?); selenium, fibre protective? • excessive alcohol consumption linked to  cancer mouth, oesophagus, larynx, liver • reproductive and sexual behaviour: early age inter-course and promiscuity linked to cervical

10. CAUSES: DIFFERENT VIEWS • ‘radical view’ environmental lobby, Trades Unions Doyal, Epstein • exposure to chemicals/toxic substances at work and at home • pollutants in the environment, including components diesel engines, organo-chloride residues, radioactive discharges • neither denies importance of any of these risk factors; argument is over proportion - establishment puts work/industrial hazards/pollution risks at 4-5%; radical view estimates 20-40%

11. CAUSES - ‘ESTABLISHMENT’ CAUSE % deaths Diet 35 Tobacco 30 Infection 10?? Rep. & Sex. Behav. 7 Occupation 4 (2 - 8%) Alcohol 3 Geophysical Factors 3 Pollution 2 Food additives 1 Chemical Industries Association ‘best estimates’; based on Doll & Peto, The Causes of Cancer

12. EVIDENCE: OCCUPATIONS, WORK • coal miners 2.5 x more likely to get cancer pancreas than general population • woodworkers 2x more likely to get nasal cancer • agricultural workers 5x more likely cancer of the lip • plasterers 1.5x more likely cancers of lung, trachea, bronchus • BUT, few official carcinogenic links made for many occupations, though specific chemicals known • symptoms take many years to develop • carcinogenic substances also released into air, water; working classes live in most polluted areas • workers bring toxic substances home with them

13. CHALLENGES IN POSITIONS • ‘establishment’ view rejects environmental views because lack of epidemiological evidence • smoking and dietary causes account for >70% cancers and major causes death • argue environmentalists exaggerating risks, and indifferent to costs • treat smoking and diet as individualist/ ‘lifestyle’ risks, seldom as structural? (recent shifts?) • tobacco industry big employer, generates tax, sponsors sport and culture; political ‘clout’ • industry regulation controversial? difficult to do technically and politically

14. PSYCHOSOCIAL INFLUENCES • evidence linking cancer incidence and outcomes to stress is mixed (mostly studies of ‘life events’) • psychosocial, emotional factors do play some role • Wilkinson: inequalities in income lead to power-lessness, internalized anger, poor social cohesion - ‘chronic strain’ - differential health experiences • ?Type C personalities? similar to Type A but emotionally inexpressive; ‘repressive coping styles’ (Greer in Heller et al) • structural factors on ‘lifestyles’: women smoke to ‘cope’ with poverty (Graham); men and women smoke to cope with boring work (Theorell, Marmot)

15. POLICY IMPLICATIONS • ‘establishment’ view: screening for early detection, encourage lifestyle changes; partnership individual and government to enable structural support • ‘radical’ view: remove carcinogenic substances from environment, prevent new ones entering it; crucial role of government in monitoring and enforcing legislation; industrial response • ‘psychosocial view’: action to reduce social and economic influences that affect ‘quality of life’ and shape lifestyles; learning new behaviour to deal with negative ‘coping’

16. NHS CANCER PLAN DOH 2000 • existing Smoking Kills targets:  28%-24% adults smoking by 2010 • national targets on  smoking gap socio-economic groups: manual  32%-26% by 2010 • explicit local targets for 20 Health Authorities with highest smoking rates • new targets to  waiting times diagnosis, referral, treatment - aim is one month max: • already true: acute leukaemia, children, testicular • milestones for other cancers • extra £50 million NHS funding for palliative care