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

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Presentation on theme: "International union against cancer Opportunities and strategies for effective cancer prevention David Hill, President UICC Shanghai, May 2010."— Presentation transcript:

1 international union against cancer 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 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’. Cervical Cancer Initiative “My Childhood Matters” Cancer Capacity-Building Fund International Cancer Fellowships UICC Publications World Cancer Day World Cancer Campaign World Cancer Congress UICC Community GLOBALink Global Access to Pain Relief Initiative (GAPRI)

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:

7 World Cancer Declaration 1.Ensure effective delivery systems in all countries 2.Significantly improve measurement of the cancer burden 3.Decrease global tobacco, alcohol consumption and obesity 4.Ensure universal coverage of the HBV/HPV vaccine 5.Dispel damaging myths and misconceptions 6.More cancers diagnosed via screening and early detection 7.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

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 1.Ensure effective delivery systems in all countries 2.Significantly improve measurement of the cancer burden 3.Decrease global tobacco, alcohol consumption and obesity 4.Ensure universal coverage of the HBV/HPV vaccine 5.Dispel damaging myths and misconceptions 6.More cancers diagnosed via screening and early detection 7.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

10 Percent cancer preventable by lifestyle changes and vaccinations* High income countries Worldwide Lifestyle Smoking29%21% Alcohol4%5% Overweight/obesity3%2% Physical inactivity2% Diet:low fruit & vegetable 3%5% Sun exposure2%1% Vaccines HPV/Hepatitis BMinor impact8-16% * Based on Colditz and Biers 2010

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

12 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

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 :

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 :

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

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

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 ( ) 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 WomenMen Adenocardinoma of the oesophagus 1.46 Colon Myeloid leukaemia1.35 Aggressive prostate-1.29 Uterus1.27- Kidney1.17 Postmenopausal breast1.13- Rectum1.12

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 PrincipleExample Behaviour is planned on the basis of reasoning in order to satisfy personal needs and goals The more positively valued outcomes & the more social approval expected from engaging in a particular behaviour, the more likely is that behaviour to occur Using argument and visual evidence to change the belief that a suntan enhances physical appearance Mass media campaigns 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 PrincipleExample Some behaviours can be learned by observation Behaviour more likely to be copied if seen in liked / admired other person or if seen to produce a desired outcome Swimming pool lifeguards wore hats, sunscreen and protective clothing while on duty Many elements of Australian SunSmart campaigns

37

38 (Objective) Capacity PrincipleExample Behaviour can only occur if resources are available Providing shade structures in school playgrounds

39 Source: Dobbinson et al, BMJ, 2009

40 (Subjective) Capacity PrincipleExample 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

41

42 Remembering PrincipleExample 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

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 PrincipleExample Probability of an action being repeated is increased if it is followed by a desirable (positive) experience Probability of an action being repeated is decreased if it is not followed by a desirable experience or if it is followed by an undesirable (negative) 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 Raising the cost of smoking through taxation 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

51 China: Perceived cancer risks

52 China: Perceived cancer risks and level of evidence for actual risk Low High

53 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

54 Join us at the 2010 World Cancer Congress 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

55 Join us at the 2010 World Cancer Congress August 2010 – Shenzhen, China For more information:www.worldcancercongress.org

56 Thank you for inviting me to Shanghai !


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