Opportunities and
strategies for effective
cancer prevention
David Hill, President UICC
Shanghai, May 2010
international union
against cancer
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
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.
UICC - 342 members, 108 countries
Membership map
UICC - What we do
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 lifethreatening disease for future generations’.
UICC is the custodian of the World Cancer Declaration
and promotes it through:
•
•
•
•
•
•
World Cancer Day
World Cancer Campaign
World Cancer Congress
UICC Community
GLOBALink
Global Access to Pain
Relief Initiative (GAPRI)
•
•
•
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Cervical Cancer Initiative
“My Childhood Matters”
Cancer Capacity-Building Fund
International Cancer
Fellowships
• UICC Publications
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
World Cancer Declaration
1.
2.
3.
4.
5.
6.
7.
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
8. Universal availability of effective pain control
9. Improve training opportunities for cancer control professionals
10. Reduce emigration of healthcare workers specialized in cancer
11. Major improvements in global cancer survival rates
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
Primary prevention targets
1.
2.
3.
4.
5.
6.
7.
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
8. Universal availability of effective pain control
9. Improve training opportunities for cancer control professionals
10. Reduce emigration of healthcare workers specialized in cancer
11. Major improvements in global cancer survival rates
Percent cancer preventable by
lifestyle changes and vaccinations*
Lifestyle
Smoking
Alcohol
Overweight/obesity
Physical inactivity
Diet:low fruit &
vegetable
Sun exposure
Vaccines
HPV/Hepatitis B
*Based on Colditz and Biers 2010
High income
countries
Worldwide
29%
4%
3%
2%
3%
21%
5%
2%
2%
5%
2%
1%
Minor impact
8-16%
Factors thought to cause and prevent cancer*
China incidence rate F/M, Age
Standardized Global rates, per
100,000 (Globocan/ IARC)
*Based on World Cancer Research Fund analysis & other evidence
X
?
X
Melanoma & Skin Melanoma
Cancer →
X
Lung
X
X
X X
Stomach
X X
X X
X
X
Nasopharynx
X
Liver
X
Cervix
X X X
Oesophagus
X
Bladder
X X
Pancreas
X
Larynx
?
X
?
 risk
Mouth & Pharynx
X
X
X ?
Colon & Rectum
X
Endometrium
Breast
Pre & (Post) menopause
X (X)
 risk
0
5
10
15
20
25
30
35
40
It is difficult to prove cancer
prevention interventions “work”
because:
1. Interventions need to be strong enough to
reduce exposure to carcinogen
2. Carcinogenic process occurs over many
years
3. Difficulty of sustaining behaviour change over
a long time
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
Cancer prevention opportunities:
diet and dietary supplementation
Work in progress!
Clear guidelines for action not available
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
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%
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”)
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
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
Continuing cigarette smoking
Stopped age 60
Stopped age 50
Stopped age 40
Stopped age 30
Lifelong non-smokers
Peto et al. 2000 (93)
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.
If more adults smoke, then more
adolescents smoke
% Frequent Smokers
(US Adolescents)
30
25
20
15
10
5
0
10
15
20
25
30
% Current Smokers (US Adults)
Each dot represents a state of the U.S.A.
35
19
4
19 5
50
19
5
19 5
6
19 0
6
19 5
7
19 0
7
19 5
8
19 0
8
19 5
9
19 0
9
20 5
0
20 0
05
Lung cancer mortality (Standardised rate
per 100,000 Australians)
70
80
60
70
50
40
30
20
60
50
40
30
20
10
10
0
0
Smoking prevalence (%)
Male smoking prevalence and lung
cancer mortality in Australia
Mortality
Prevalence
19
4
19 5
50
19
5
19 5
6
19 0
6
19 5
7
19 0
7
19 5
8
19 0
8
19 5
9
19 0
9
20 5
0
20 0
05
Lung cancer mortality (Standardised rate
per 100,000 Australians)
70
80
60
70
50
Lives saved
40
30
20
60
50
40
30
20
10
10
0
0
Smoking prevalence (%)
Projected male lung cancer
mortality in Australia if no decrease
in smoking prevalence
Mortality
Prevalence
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
Australia: Plain packaging from
1 July 2012
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
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
What we found: relative risk for
diagnosis of cancer for 10cm
difference in waist circumference
Adenocardinoma of the
oesophagus
Colon
Myeloid leukaemia
Aggressive prostate
Uterus
Kidney
Postmenopausal breast
Rectum
Women
1.46
Men
1.46
1.14
1.35
1.27
1.17
1.13
1.12
1.37
1.35
1.29
1.17
1.12
How to measure your waist
Recommendation: Men waist less than 100cm
Women waist less than 85
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
The Big Five principles of
behaviour change
Repeated and habitual behaviour is determined by extent to
which a person:
conscious motivation
• wants to do it,
modelling
• sees others doing it,
resources, self-efficacy
• has the capacity to do it,
memory and prompting
• remembers to do it,
reinforcement - positive or
• is rewarded for doing it,
negative
or suffers for not doing it.
*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.
Motivation
Principle
Example
Behaviour is planned on the
basis of reasoning in order to
satisfy personal needs and
goals
Using argument and visual
evidence to change the belief
that a suntan enhances
physical appearance
The more positively valued
outcomes & the more social
approval expected from
engaging in a particular
behaviour, the more likely is
that behaviour to occur
Mass media campaigns
NEARLY ALWAYS USED, BUT A RELATIVELY WEAK
PRINCIPLE WHEN USED ALONE
Motivation
Child measures
father’s waist
circumference to
find he is at
increased risk of
cancer
Modelling
Principle
Example
Some behaviours can be
learned by observation
Swimming pool lifeguards
wore hats, sunscreen and
protective clothing while on
duty
Behaviour more likely to be
copied if seen in liked /
admired other person or if
seen to produce a desired
outcome
Many elements of Australian
SunSmart campaigns
(Objective) Capacity
Principle
Example
Behaviour can only occur if
resources are available
Providing shade structures
in school playgrounds
Source: Dobbinson et al, BMJ, 2009
(Subjective) Capacity
Principle
Example
Self-efficacy beliefs help
determine behaviour and
these can be changed by
training
Belief in one’s ability to take
action (self-efficacy) can be
changed by training, e.g.
training people to prepare
suitable meals
Remembering
Principle
Example
Intended behaviours can be
- forgotten
- put off
Reminders serve to bring
intended behaviour to
- top of mind
- “today’s agenda” for
action
Any mass media campaign
SMS on smoking cessation
to prompt quitting
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
Reinforcement: positive and negative
Principle
Example
Probability of an action being
repeated is increased if it is
followed by a desirable
(positive) experience
Rapid, pro-active notification of
“good news” to those who get
the all-clear in screening
programs
Life insurance discounts for
smokers who quit
Probability of an action being
repeated is decreased if it is not
Raising the cost of smoking
followed by a desirable
experience or if it is followed by through taxation
an undesirable (negative)
experience
VERY STRONG PRINCIPLE, CAN BE HARD TO IMPLEMENT
Australia: Tobacco tax increase
April 2010
The Big Five principles of
behaviour change
Repeated and habitual behaviour is determined by extent to
which a person:
conscious motivation
• wants to do it,
modelling
• sees others doing it,
resources, self-efficacy
• has the capacity to do it,
memory and prompting
• remembers to do it,
reinforcement - positive or
• is rewarded for doing it,
negative
or suffers for not doing it.
*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.
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
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
Pessimism/fatalism: “Once a
person has cancer, not much can
be done to cure it”
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
43%
33%
31%
14%
Low income *
countries
Middle income *
countries
High income *
countries
China
*Countries in World Bank income categories
China: Prevalence of cancer risk
behaviour
50%
42%
40%
30%
21%
20%
23%
7%
10%
3%
1%
0%
Tobacco use
Alcohol
Sunburnt (last
Physical
(freq./mod.)
12 mths)
activity most
days (work)
Physical
activity most
days (home)
Physical
activity most
days
(gym/sport)
Sm
ok
ing
Ch
ew Alc
ing oho
tob l
ac
co
S
Fa tres
tty s
fo o
Inf ds
ec
Ov tion
erw s
Air eigh
po t
Su llut
n e ion
xp
os
u
Re re
No Mo d m
t e bile ea
t
a ti
ng pho
ve nes
La get
a
ck
of bles
e
No xer
c
No t ea ise
t e ting
a ti
ng fruit
ce
rea
T a ls
pw
ate
r
China: Perceived cancer risks
100%
80%
60%
40%
20%
82%
72%
50%
45%
81%
51%
63%
52%
36%
22% 26%
33%
43%
23% 22%
11%
0%
China: Perceived cancer risks and
level of evidence for actual risk
4.8
High
Level of evidence for cancer risk
Sun overexposure
Infections
Alcohol
Lack of exercise
Being overweight
Chewing tobacco
Eating red meat
Not eating fruit
Not eating veg. Eating fatty foods
Smoking
? Domestic air
pollution
Lack of cereals
Outdoor air
pollution
Mobile phones
0.5
Low
Tap water
10%
Being stressed
100%
Low
High
Perceived cancer risk
(as reflected by % of population who believe each factor is a cancer risk)
UICC World Cancer Congress
2010, Shenzhen, China
Why Asia? Why China?
•The burden of cancer is shifting to Asia
•Milestone in history of UICC to organise
Congress in China
•Hosted by:
–Chinese Anti-Cancer Association
–Chinese Medical Association
Join us at the
2010 World Cancer Congress
18-21 August 2010 – Shenzhen, China
Preventing the preventable
Treating the treatable
Systems to make it happen
In parallel – World Leadership Summit
on Cancer. ‘Its everybody’s business’
www.worldcancercongress.org
Join us at the
2010 World Cancer Congress
18-21 August 2010 – Shenzhen, China
For more information:
www.worldcancercongress.org
Thank you for inviting me to Shanghai !