Opportunities and strategies for effective cancer prevention

1. Opportunities and strategies for effective cancer prevention David Hill, President UICC Shanghai, May 2010

2. Global burden of cancer The burden of cancer is huge and growing Cancer accounted for 7.9 million deaths in 2007, about 80% in low- and middle-income countries. (WHO, Fact Sheet, July 2008) Cancer A development issue An equity issue

3. The looming disaster in developing countries Sum of: Mainly poverty-related tumours (cervical, oesophagus, liver) Tumours linked to Western style of life (breast, lung, prostate, colorectal) Lack of primary and secondary prevention Lack of resources for treatment Only about 5% of global resources for cancer are spent in developing countries.

4. UICC - 342 members, 108 countries Membership map

5. UICC - What we do UICC is the custodian of the World Cancer Declaration and promotes it through: UICC’s mission is to ‘connect, mobilize and support organizations, leading experts, key stakeholders and volunteers in a dynamic community working together to eliminate cancer as a life- threatening disease for future generations’. • World Cancer Day • World Cancer Campaign • World Cancer Congress • UICC Community • GLOBALink • Global Access to Pain Relief Initiative (GAPRI) • Cervical Cancer Initiative • “My Childhood Matters” • Cancer Capacity-Building Fund • International Cancer Fellowships • UICC Publications

6. World Cancer Declaration (2008) ‘A global call to action to help substantially reduce the global cancer burden by 2020 and increase cancer's visibility on the international political agenda.’ Priority actions at local and national levels. 11 targets and a priority action plan to stop and reverse current trends. Aimed towards significant improvements in the measurement of the global cancer burden and in cancer survival rates in all countries around the world. Please help us by signing online: www.uicc.org/wcd

7. World Cancer Declaration • Ensure effective delivery systems in all countries • Significantly improve measurement of the cancer burden • Decrease global tobacco, alcohol consumption and obesity • Ensure universal coverage of the HBV/HPV vaccine • Dispel damaging myths and misconceptions • More cancers diagnosed via screening and early detection • Improve access to diagnosis, treatment, rehabilitation and palliative care • Universal availability of effective pain control • Improve training opportunities for cancer control professionals • Reduce emigration of healthcare workers specialized in cancer • Major improvements in global cancer survival rates

8. World Cancer Declaration: 11 Targets PREVENTIVE Tobacco, obesity, alcohol Vaccination THERAPEUTIC Early detection- screening, public and professional awareness Access - diagnosis, first-line treatment, support, rehabilitation, palliation Pain control • ENABLING • Delivery systems – national and international • Measurement – size of problem, targets, progress • Public attitudes • Training • Workforce retention • OUTCOMES • Incidence, survival, mortality

9. Primary prevention targets • Ensure effective delivery systems in all countries • Significantly improve measurement of the cancer burden • Decrease global tobacco, alcohol consumption and obesity • Ensure universal coverage of the HBV/HPV vaccine • Dispel damaging myths and misconceptions • More cancers diagnosed via screening and early detection • Improve access to diagnosis, treatment, rehabilitation and palliative care • Universal availability of effective pain control • Improve training opportunities for cancer control professionals • Reduce emigration of healthcare workers specialized in cancer • Major improvements in global cancer survival rates

10. Percent cancer preventable by lifestyle changes and vaccinations* *Based on Colditz and Biers 2010

11. Factors thought to cause and prevent cancer* China incidence rate F/M, Age Standardized Global rates, per 100,000 (Globocan/ IARC) Arsenic in water Domestic air pollution Red Meats Alcohol Infections Body fatness Processed Meats Solar UV Tobacco Aflatoxins Lactation Exercise • X Melanoma & Skin Cancer → Melanoma • X • X • Lung • ? • Stomach • X • X • X • X • X • X • Colon & Rectum • X • X • X • Mouth & Pharynx • Nasopharynx • X • X • X • Liver • X • Cervix • X *Based on World Cancer Research Fund analysis & other evidence • X • X • X • Oesophagus • X • Bladder • ? • X • X • Pancreas • X • X • Larynx • ? • X • Endometrium • X • ? • X • (X) • Breast • Pre & (Post) menopause  risk  risk 0 5 10 15 20 25 30 35 40

12. It is difficult to prove cancer prevention interventions “work” because: • Interventions need to be strong enough to reduce exposure to carcinogen • Carcinogenic process occurs over many years • Difficulty of sustaining behaviour change over a long time

13. Cancer prevention opportunities: environment and occupational exposures • Asbestos, arsenic in drinking water, food contaminants (eg aflatoxins, pesticides) radiation • Indoor domestic air pollution (estimated 420,000 premature deaths in China)* *Zhang et al Environmental Health Perspectives 2007 115:500-513

14. Cancer prevention opportunities: diet and dietary supplementation • Work in progress! • Clear guidelines for action not available

15. Cancer prevention opportunities: medications • Causation • Combined oestrogen plus progestin – breast • Prevention • Oral contraceptives -endometrium • Aspirin -colon * • Selective oestrogen receptor modulators - breast** • (eg Tamoxifen, Raloxifene) • *note negative cardiovascular and other effects • **reduction in breast cancer risk outweighs increased risk of uterine cancer

16. Cancer prevention opportunities: infection control • Chronic infection due to- • Helicobacter pylori (stomach, lymphoma) • Human papilloma virus (cervix, mouth, pharynx) • Hepatitis B, C (liver) • Epstein-Barr virus (nasopharynx, Hodgkin, Burkitt) • HIV (Kaposi, Non-Hodgkin lymphoma) • Human herpes virus 8 (Kaposi, Non-Hodgkin lymphoma, schistosoma haematobium) • Proportion of cancer due to infections • Developing world = 26% • Developed world = 8%

17. Cancer prevention opportunities: behavioural risk factors (1) • Smoking • Cancer of lung, mouth, oesophagus, larynx, bladder, pancreas, stomach, cervix, AML. • Alcohol • Cancer of mouth, pharynx, larynx, oesophagus, liver, breast, colon, rectum. • Physical inactivity • Colon (“convincing”), • post-menopausal breast, endometrium (“probable”), • lung, pancreas, pre-menopausal breast (“suggestive”)

18. Cancer prevention opportunities: behavioural risk factors (2) • Weight control • Oesophagus, colon, rectum, endometrium, kidney, post-menopausal breast* • Sun exposure • Melanoma, basal and squamous carcinoma of skin * Evidence of intervention effect on cancer rate Eliassen et al JAMA 2006 296:193-210

19. Tobacco control: do we focus on prevention or cessation? • Preventing uptake – 20+ year lag in impact on disease rates • Cessation – disease impacts seen within 5 years • Uptake rates dependent adult smoking prevalence • Therefore, cessation strategies essential

20. Continuing cigarette smoking Stopped age 60 Stopped age 50 Stopped age 40 Stopped age 30 Lifelong non-smokers Peto et al. 2000 (93)

21. Cancer risk begins falling within 5 years of quitting Continuing smokers Nurses Health Study 1980-2004; Kenfield, S. A. et al. JAMA 2008;299:2037-2047.

22. If more adults smoke, then more adolescents smoke Each dot represents a state of the U.S.A.

23. Male smoking prevalence and lung cancer mortality in Australia

24. Projected male lung cancer mortality in Australia if no decrease in smoking prevalence Lives saved

25. W.H.O. MPOWER Strategy for tobacco control • Monitor tobacco use and prevention policies • Protect people from tobacco smoke • Offer help to quit tobacco use • Warn about dangers of tobacco • Enforce bans on tobacco advertising, promotion and sponsorship • Raise taxes on tobacco

26. Australia: Plain packaging from 1 July 2012

27. Melbourne Collaborative Cohort Study • 41,000 Victorians (17,000 men and 24,000 women) followed for 17 years • At baseline (1990-1994) we measured: • Height • Weight • Waist and hip circumference • 47% of men and 46% of women had waist measurements that put them in the overweight/obese category • Identified cancers from the Cancer Registry

28. Waist measurement versus Body Mass Index (BMI) • Waist circumference was a better indicator than BMI of risk of several cancers • Waist is easier for people to measure than BMI

29. What we found: relative risk for diagnosis of cancer for 10cm difference in waist circumference

30. How to measure your waist

31. Recommendation: Men waist less than 100cm Women waist less than 85

32. Chapter 3 Achieving behavioural changes in individuals and populations David Hill, Helen Dixon In: Elwood JM, Sutcliffe SB (Eds). Cancer Control, Oxford: Oxford University Press, Chapter 3, 2010, pp 43-61

33. The Big Five principles of behaviour change • Repeated and habitual behaviour is determined by extent to which a person: • wants to do it, • sees others doing it, • has the capacity to do it, • remembers to do it, • is rewarded for doing it, • or suffers for not doing it. conscious motivation modelling resources, self-efficacy memory and prompting reinforcement - positive or negative *Hill D, Dixon H, Achieving behavioural changes in individuals and populations; in 'Cancer Control' edited J. M. Elwood, S. B. Sutcliffe, Oxford Univ. Press, Oxford 2009.

34. Motivation NEARLY ALWAYS USED, BUT A RELATIVELY WEAK PRINCIPLE WHEN USED ALONE

35. Motivation Child measures father’s waist circumference to find he is at increased risk of cancer

36. Modelling

38. (Objective) Capacity

39. Source: Dobbinson et al, BMJ, 2009

40. (Subjective) Capacity

42. Remembering

43. Can mobile phone text messaging increase quitting in Smokers? • Randomized controlled trial • 1705 smokers over 15 in New Zealand • 4 weeks of free, tailored text messages about quitting • Educational content as well as prompts Source: Rodgers et al, Tobacco Control, 2005

44. Reinforcement: positive and negative VERY STRONG PRINCIPLE, CAN BE HARD TO IMPLEMENT

45. Australia: Tobacco tax increase April 2010

46. The Big Five principles of behaviour change • Repeated and habitual behaviour is determined by extent to which a person: • wants to do it, • sees others doing it, • has the capacity to do it, • remembers to do it, • is rewarded for doing it, • or suffers for not doing it. conscious motivation modelling resources, self-efficacy memory and prompting reinforcement - positive or negative *Hill D, Dixon H, Achieving behavioural changes in individuals and populations; in 'Cancer Control' edited J. M. Elwood, S. B. Sutcliffe, Oxford Univ. Press, Oxford 2009.

47. Conclusion • There are established principles of behaviour change to guide us • Cancer-related population behaviour CAN be changed • Multiple, co-ordinated, sustained strategies are needed • In time, behaviour change will be reflected in changed cancer rates • Commitment, patience, persistence (and probably politics!) essential

48. UICC’s Global survey Interviews with over 40,000 adults in general population of 42 countries Overall, one quarter agreed with the statement: “Once a person has cancer not much can be done to cure it” Global survey supported by Pfizer, and Roy Morgan Research Company, Gallup International

49. Pessimism/fatalism: “Once a person has cancer, not much can be done to cure it” * * * *Countries in World Bank income categories

50. China: Prevalence of cancer risk behaviour