Cancer Prevention

Simple Steps Can Have Big Benefits

Over half of all cancers can be prevented by a combination of healthy lifestyles and regular screening. This is a key message for a disease that is overwhelmingly the public’s number one health fear. Eight simple behaviors can greatly lower cancer risk as well as help prevent other serious diseases, like heart disease, stroke, diabetes, and osteoporosis.


Eight Ways to Prevent Cancer

Most cancers can be prevented.  This is a key message for a disease that is overwhelmingly the public’s number one health fear1.  Unfortunately, it’s also a message that nearly half of the public doesn’t take to heart or even really believe1.
 
Yet, beginning with Doll and Peto’s groundbreaking analyses in the 1980’s, overwhelming evidence now shows that over half of all cancers – and up to three quarters of some specific cancers -  could be avoided by a combination of healthy lifestyle and regular screening 2-4.

Although this conclusion is now agreed upon in nearly all scientific circles, it took some visionary thinking and research to bring us to this point.  The first studies that convincingly initiated the idea that cancer risk was something partly under a person’s control came from studies that compared the rates of cancer in different countries around the world.   These so called ecologic studies found that rates of cancer can vary wildly from population to population.  And while these differences could have been due in part to genetics and environmental exposures, they also pointed to the potential importance of lifestyle in cancer risk – a hypothesis made even more compelling by another set of groundbreaking studies looking at the cancer risk of migrants as they moved from low risk countries to high risk countries. These studies have found that migrant groups slowly take on the cancer risk profiles of the countries they move to, and the longer they stay there, the more their risk resembles that of the typical population (figure 15).  That the genetic make-up of these groups doesn’t change over time, the change in cancer risk points largely to the importance of  lifestyle.
  

Adding even more weight to the argument are the numerous studies clearly showing that certain lifestyle changes can lower cancer risk, such as research into the benefits of quitting smoking.  Finally,  randomized controlled trials show that drugs like Tamoxifen can cut breast cancer risk in half and that vaccines can prevent both cervical and liver cancer.

Taken together, the current evidence on cancer prevention points to eight simple behaviors that can greatly reduce overall cancer risk. While there are additional steps that can reduce the risk of some individual cancers (see Fourteen Preventable Cancers), these eight behaviors provide the greatest benefit for the most cancers and can also go a long way toward reducing the risk of other serious chronic diseases, like heart disease, stroke, diabetes, and osteoporosis.

1. Don't smoke
In the United States, smoking causes approximately 30 percent of all cancers and 90 percent of lung cancers.  About half of all smokers will die from a smoking-related disease, like cancer, heart disease, and chronic obstructive lung disease.  Globally, tobacco is estimated to cause just under five million deaths a year – a number that will likely rise dramatically over the next two generations 6, 7.

Linked primarily in the public’s mind with lung cancer, smoking and use of smokeless tobacco greatly increases the risk of many other cancers, including cancer of the head and neck, bladder, kidney, cervix, esophagus, pancreas, stomach, colon, rectum, and blood (certain leukemias)8.   

The single best way to prevent cancer and other chronic diseases is not to smoke.  In the United States alone, over 150,000 cancer deaths could be avoided each year if tobacco were somehow miraculously eliminated from the earth9

Preventing teens and young adults from taking up smoking provides the biggest health benefits, yet despite stepped up efforts to prevent tobacco use, over 20 percent of the United States population still smokes10.  Because of this, efforts to get smokers to stop smoking (cessation) have become increasingly common as well, yet only a small percentage of those trying to quit seek effective treatments that can help them stop11.  Despite this, cessation has huge benefits.  Within two years of quitting, the risk of many smoking-related diseases begins to drop, and after 10 – 20 years, the risk of lung cancer and most other tobacco-related diseases nearly equals that of non-smokers.

2. Maintain a healthy weight

Although weight is one of the most important risk factors for cancer, a recent survey commissioned by the American Cancer Society found that less than 10 percent of the public were aware that being overweight could increase the risk of cancer12.  Very good evidence shows, though, that about 90,000 deaths from cancer could be avoided each year in the United States if everyone stayed at a healthy weight throughout life13.

Carrying extra weight, particularly being obese ( defined as BMI greater than or equal to 30) (BMI calculator), has been strongly linked to an increased risk of cancers of the breast (after menopause), colon, kidney, pancreas, and esophagus (adenocarcinoma). And there is growing evidence that obesity also increases the risk of leukemia, lymphoma, multiple myeloma, and cancers of the liver and gallbladder. 
 
The way weight increases cancer risk varies from cancer to cancer.  For example, estrogen produced by fat cells likely increases risk of postmenopausal breast cancer; blood sugar and insulin problems linked to being overweight likely increases risk of colon and pancreatic cancer; and weight-related irritations caused by gallstones and acid reflux likely increase the risk of cancers of the gallbladder and esophagus, respectively.
 

The now well-known and disturbing trends in the prevalence of overweight and obesity in the United States predict a growing burden of not only weight-related cancers but also heart disease, stroke, and diabetes.  The latest data show that a full two thirds (66 percent) of the population is either overweight (BMI 25 – 29.9) or obese (BMI  greater than or equal to 30)14.  Over the last two decades, rates of obesity have significantly increased across the nation, with about a third of the population now considered obese (figure 2)14, 15.    Such trends, while most pronounced in the United States, are being expressed worldwide as well, pointing to a huge future global burden from weight-related diseases. 

Unfortunately, these trends show no sign of letting up and point to the need for a paradigm shift in weight control efforts, one modeled much more on national tobacco control efforts than individual action.  Such efforts are slowly beginning to surface16, 17, but much more widespread, cohesive policy initiatives will be needed to stem the tide of weight gain and then begin to reverse it. 

3. Exercise regularly

The health benefits of regular physical activity are well known.  In addition to lowering the risk of  heart disease, stroke, diabetes, osteoporosis, and high blood pressure, it also helps prevent cancer.  Overall, in the United States, it’s estimated that five percent of cancers are linked to lack of regular exercise, which is largely accounted for through the link with two common cancers, breast cancer and colon cancer 3

For breast cancer, the benefits of regular exercise seem biggest for premenopausal women, but postmenopausal women see lower risks from regular physical activity as well.  It’s believed that the lower lifetime exposure to estrogen caused by regular exercise is the main reason exercise helps prevent the disease.  High lifetime exposure to estrogen is a known risk factor for breast cancer.  Though data are still developing, some researchers theorize that childhood activity level may be even more important than adult activity, as this is a key time in growth and development.  Active girls tend to begin menstrual periods (menarche) later in life and tend to be leaner than other girls, two factors that can lower lifetime exposure to estrogen.

For colon cancer, the main mechanism seems to be that exercise can help control insulin levels, which can keep in check certain hormones and growth factors that can promote cancer in colon tissue.

For all its benefits, activity is not the preferred pastime of most people in the United States.  Over 50 percent of the population doesn’t get the recommended amount of activity each week – either 30 minutes of moderate activity (like brisk walking) five or more days per week, or 20 minutes of vigorous activity (like running) three or more days per week18.   Approximately 15 percent of the population is almost completely inactive18.

4. Eat a Healthy Diet

A healthy diet is key to overall health and can help lower the risk of many cancers.  While news coverage of the links between diet and cancer have been confusing at best, and misleading at worst, there is solid evidence that the way we eat has a real impact on cancer risk.  Perhaps surprisingly, it’s not fat or meat, or fruits and vegetables that is the most important part of diet when it comes to cancer risk; it’s simply calories19.  Keeping calories in check, so weight stays in check, is the single most important change in diet people can make.  Outside of calories, good evidence shows that a risk reducing diet is:  largely plant based (with a lot of fruits, vegetables, and whole grains);  low in animal products (like animal fat, red meat, and processed meat); low in sodium; and, for men, not too high in calcium (less than 1500mg/day)20

A daily multivitamin with folate can provide added protection against certain cancers and other chronic diseases21, 22.  Folate is a B vitamin that has been shown to lower the risk of colon cancer, as well as breast cancer in women who regularly drink alcohol.  The calcium and vitamin D in most multivitamins may also help provide added protection against colon cancer.

Cancers with a link to diet include:  breast cancer, colon cancer, esophageal cancer, lung cancer, oral cancer, pancreatic cancer, prostate cancer, and stomach cancer, as well as kidney and uterine cancer, which are linked through weight gain 4, 20, 23.

5. Drink alcohol in moderation, if at all

Alcohol plays a perplexing role in health.  While studies consistently show that drinking even a small amount of alcohol (less than one drink/day) can raise the risk of two common cancers (breast and colon), there’s also very good evidence that moderate consumption can significantly lower the risk of cardiovascular disease24. 

Balancing these risks and benefits is key to pubic health messages about alcohol intake:

  • Although the benefits of moderate intake are well established, the cancer risk and potential for alcohol dependence means that non-drinkers should not be encouraged to start drinking. 
  • Most of those who already drink moderately, though, don’t need to be encouraged to stop.  While cancer risk may be increased slightly in this group, the cardiovascular benefits are significant as well. 
  • All heavy drinkers should be encouraged to cut back to moderate levels, or stop altogether.

For both breast cancer and colon cancer, alcohol likely increases risk by lowering levels of folate in the body, though there are other possible reasons.  Folate has been shown in some studies to protect against cancer.  The lower levels caused by alcohol may therefore increase risk.   Good evidence, though, shows that taking a folate supplement (like a multivitamin) can help eliminate some of the cancer risk linked to alcohol25-27.

 

6. Protect yourself from the sun

Too much sun exposure is a well-known cause of skin cancer, including serious melanoma.  With melanoma rates rising steadily from year to year both in the United States and worldwide, proper sun protection is a key public health message.  Yet in the United States, an increasing number of people are experiencing severe sun exposure.  The percent of the population reporting a sun burn over the past year is rising, with a third reporting at least one sunburn, and about 20 percent reporting four or more 28

Clearly, such severe exposure is unsafe and greatly increases the risk of cancer.  Less clear, however, are the health hazards from very mild sun exposure.  Growing evidence shows there could be some overall benefits from five to 30 minutes of unprotected sun exposure twice a week29.   While there is likely some skin cancer risk from such light exposure, there may be a number of health benefits as well.  Sunlight causes the formation of vitamin D in the skin, and there is some good evidence that vitamin D can help protect against osteoporosis and colon cancer, and possibly cancers of the prostate, breast, and ovary as well29-31.

Taken together, the evidence on vitamin D’s benefits seems to point to a need to rethink current sun exposure recommendations, which are likely too restrictive to provide much, if any, of the cancer prevention benefits of vitamin D.  However, until there’s a clear paradigm shift, caution is in order, and the public should be encouraged to properly protect themselves (and their children) from the sun whenever possible, which includes: avoiding the sun as much as possible during peak burning hours (10am – 4pm); wearing long sleeve shirts, long pants, and wide-brimmed hats, and; properly applying broad-spectrum sun screen.

7.  Protect yourself from infections

Although not well known by the general public, infections play an important role in the development of some cancers.  Worldwide, approximately 15 percent of all cancers have been linked to infections. In developing countries, this number reaches almost 25 percent32.

Certain infections can either directly or indirectly cause changes that can lead to cancer. This can happen because of the chronic inflammation that some infections cause or by an infectious agent (like a virus) changing the behavior of infected cells. Infections that compromise the immune system (like HIV) also increase cancer risk by making the body less able to defend against infections that can cause cancer.

Not surprisingly, infection-associated cancers are not a health burden borne equally by all. The poor living conditions and inadequate health care experienced by many people worldwide increase the likelihood of cancer resulting from chronic infections.

There are at least ten infectious agents that are known to increase the risk of cancer (see table), and several of them are quite common. Yet, in most instances, only a small proportion of those infected actually go on to develop cancer because it takes a unique set of factors along with the infection to turn normal cells cancerous.
 
Still, these infectious agents have a substantial impact on cancer worldwide. Of particular importance are human papillomavirus (HPV), hepatitis B and C viruses, and Helicobacter pylori. HPV is a sexually transmitted virus that is linked to numerous cancers, with cervical cancer being the most important. It’s estimated that almost all cervical cancers are caused by HPV infection. Hepatitis B and C infect the liver and together account for the large majority of liver cancer. Finally, Helicobacter pylori, a bacteria that infects the stomach, has been estimated to cause upwards of 75 percent of all stomach cancers, the second most common cancer worldwide.
 

The promise of prevention is a bright spot when looking at the reach of infection-associated cancers. To lower their risk, individuals can take concrete steps like avoiding blood exposure (by not sharing needles, for example), practicing safer sex and, for women, getting regular Pap tests (which test for cervical cancer). There is also very strong evidence that vaccinating girls (around age 11 or 12) against HPV can greatly reduce the risk of cervical cancer later in life 33.   Growing use of the hepatitis B vaccine worldwide is expected to result in similar benefits in liver cancer34.  Advances on vaccines for other agents also offer much hope for prevention.   

 8. Get screening tests regularly

Having cancer screening tests at regular intervals is the single best way to protect against cancer.  Not only can screening tests find cancers early when they’re most treatable, in the case of colon and cervical cancer they can actually help prevent the disease.
 
Screening tests for colon cancer help prevent cancer by finding and removing adenomatous polyps, which are abnormal growths that can go on to become cancer. Regular screening with sigmoidoscopy, for example, has been shown to cut the risk of dying from colon cancer in half; fecal occult blood tests can cut colon cancer mortality by up to a quarter35.   Although an increasing proportion of adults 50 and older in the United States is actually getting screened for colon cancer, close to 40 percent are still missing recommended tests36.

Rates of screening are much better for the Pap test, which screens for cervical cancer.  Over 80 percent of the age-eligible women in the United States have had a Pap test within the last three years, which generally meets current guidelines.  Pap tests help find abnormal changes in the cells lining the cervix, which could go on to be cancerous.  The abnormal cells can then be treated or removed.  The Pap test is a huge success story of public health.  From the time it became widely used in the 1950’s, rates of death from cervical cancer have dropped by over 70 percent in the United States and other developed nations.

A recent addition to cervical cancer screening is the human papillomavirus (HPV) test, which can be offered to women beginning at age 30 in addition to their regular Pap test.  The tests detects whether a woman has an infection with a high-risk type of HPV that is strongly linked to cancer.  Women with these high-risk types can then have additional follow-up tests to look for abnormal changes to cells in the cervix. 

Outside of prevention, screening tests are key to finding cancer early when it is most treatable,  Breast, cervical, and colon screening should be priorities for women.  Colon and possibly prostate screening should be priorities for men. The American Cancer Society recommends a number of tests that protect against cancer.  In addition to the specific tests generally laid out below (see tables37), doctors should also perform an occasional exam for signs of cancer of the  thyroid, testicles, ovaries, lymph nodes, oral cavity, and skin.  Those at increased risk for a specific cancer may need to begin screening earlier, and get screening tests more often, than is recommended for most people. For details on all recommended tests, click here

Fourteen Preventable Cancers

Lifestyle can have a huge influence on the risk of cancer overall.  Not all cancers, though, have known lifestyle components.  Outlined below are fourteen of the more common cancers with lifestyle factors linked to their risk.  Some, like colon cancer, have a number of lifestyle factors, while others, like stomach cancer, have very few.

The tables that appear with each cancer show the lifestyle factors that have been found through high quality research studies to be definitely or probably linked to the cancer.  Factors with less solid evidence aren’t listed.  The arrows associated with each factor show in general how much that factor affects the risk of the cancer.  Up arrows show that the factor increases risk.  Down arrows show that it decreases risk. 

Bladder Cancer

About 67,000 new cases of bladder cancer are diagnosed each year in the United States.  While only a few lifestyle factors are linked to bladder cancer, they can have a large impact on risk.  Not smoking can greatly lower risk, as can not drinking water with a high arsenic content.  High arsenic levels are most common in well water, and all households with well water should have their drinking water tested.  For people who work with aromatic amines and other chemicals common in rubber and aluminum production, the best thing they can do is wear proper protective equipment in the workplace and be familiar with the chemicals they work with.

Breast Cancer (Women)

Breast cancer is the most common cancer among women in the US. About 178,000 American women are diagnosed with the disease each year, and it is leading killer of women in midlife (ages 30 – 55).  Despite thousands of studies on the causes of breast cancer, relatively few lifestyle factors have been linked to the disease, but lifestyle can have an important impact on risk.  Avoiding alcohol – or taking a multivitamin if you do drink – can help protect against the disease.  Being physically active and keeping weight in check can lower risk.  Avoiding birth control pills and postmenopausal hormones can also lower risk, but balancing the risks and benefits of such medications is important, and people should talk to a doctor to better understand the balance.  For women who are able to do so, breastfeeding for a total of one year (all children combined) also seems to have breast health benefits.                      

For women at high risk of breast cancer, the prescription drugs tamoxifen and raloxifene can cut the risk of the disease by about half.

Cervical Cancer (Women)

Cervical cancer is one of the most preventable types of cancer. Once a leading cause of cancer death in the US, cervical cancer rates have plummeted.  The main reason is the high percentage of American women getting regular Pap tests, which can help prevent the disease as well as catch it early when it’s most treatable. The new human papillomavirus (HPV) vaccine also shows great promise at further lowering rates of cervical cancer.  Not smoking, limiting the number of male sexual partners, and using condoms and/or diaphragms for birth control can help prevent the disease as well.

Colon Cancer
A full 75 percent of colon cancers could be avoided with healthy lifestyles. Keeping weight in check, getting regular exercise, and avoiding too much alcohol and red meat can go a long way toward preventing the disease. Taking a daily multivitamin and getting enough calcium and vitamin D can also lower risk, as can taking a daily aspirin (but check with a doctor beforehand).

Using birth control pills for a long period of time can lower risk. In postmenopausal women,  postmenopausal hormones can protect against the disease as well.  However, balancing the risks and benefits of such medications is important, and people should talk to a doctor to better understand the balance.

The single best way to lower the risk of colon cancer is to have colon cancer screening tests performed regularly from age 50 on.  Talking to a doctor about the specific tests can help patients decide which of the colon cancer tests are right for them (colonoscopy, sigmoidoscopy, barium enema, or fecal occult blood test) (see Get Regular Screening Tests).
 

 Esophageal Cancer

Esophageal cancer (cancer of the esophagus) strikes about 14,000 people a year in the United States.  Though not one of the most common cancers, it tends to be one of the more aggressive, with low survival rates once it’s diagnosed.  Some key lifestyle choices, however, can lower the risk of the disease.  These include keeping weight in check, avoiding alcohol and tobacco, and eating a diet rich in fruits and vegetables.  For smokers, quitting can have huge benefits, with smoking-related risk starting to drop just a few years after cessation; however, risk of the disease may never drop so much that it equals the risk of someone who never smoked.  

Kidney Cancer                       

Kidney cancer is fairly rare in the US.  Even so, over 51,000 Americans are diagnosed with the disease each year.  Steps people can take to lower their risk of kidney cancer include keeping weight in check, not smoking, and avoiding (or keeping under control) high blood pressure. 

Lung Cancer 

Not smoking is clearly the single most important thing people can do to prevent lung cancer.  Even for those who used to smoke, quitting has huge benefits (see figure 3).  Risk begins to drop after two years, and after 15 - 20 years risk is practically equal to that of someone who never smoked.   While hard, quitting is far from impossible.  A thousand people in the United States quit for good every day.  Doctors can help.

For those who don’t smoke, avoiding regular exposure to second hand smoke can help protect against lung cancer.  A diet rich in fruits and vegetables has also been found to lower risk.

Unprotected exposure to asbestos, radon, and chemicals common in some smelting/manufacturing jobs are also very important risk factors for lung cancer.  For people who must work with these substances, the best thing they can do is wear proper protective equipment in the workplace and be familiar with the substances they work with.

 

Oral Cancer

Oral cancer (cancer of the mouth) is relatively rare in the United States, but it has some very important lifestyle factors that can lower risk of the disease a great deal.  These include not smoking, avoiding alcohol, and eating a diet rich in fruits and vegetables.  For former smokers, quitting smoking has big benefits as well.  Just ten years after quitting, the smoking-related risk of oral cancer drops to near that of lifetime non-smokers. 

Ovarian Cancer (Women)
While there are steps women can take to lower the risk of ovarian cancer, most of them aren’t considered pure lifestyle choices. They are things many women have control over, but they are complicated choices with many different interests to consider outside of lowering the risk of cancer. These include breast feeding, taking birth control pills, having the fallopian tubes tied, and having a hysterectomy. For most of these, talking with a doctor beforehand about the overall risks and benefits is an important step.
 

Pancreatic Cancer
Pancreatic cancer is a fairly rare disease that is also fairly scary, since it’s often very aggressive and hard to treat. Yet, there are some steps people can take that can lower the risk of pancreatic cancer. Keeping weight in check, not smoking, and eating a diet rich in vegetables can help lower risk. Taking steps to avoid diabetes can also help (like exercising more and choosing more whole grain foods).

Prostate Cancer (Men)

Prostate cancer is the most common cancer in United States men.  Over 200,000 new cases are diagnosed each year, and although the disease isn’t usually fatal, diagnosis and treatment of the disease takes a huge toll on many men’s quality of life.  As with breast cancer in women, frustratingly few lifestyle factors have been linked to prostate cancer, but men can take a few key steps to lower their risk. These include eating a diet low in animal fat, eating more tomato-based foods, and avoiding too much calcium by sticking to the recommended 1000-1200 mg/day for most adults.

Skin Cancer: Melanoma
Sun protection is key to lowering the risk of melanoma, the most serious, deadly form of skin cancer. It is, of course, most important to protect children from sunburns, but to lower risk of all types of skin cancer, both children and adults should avoid as much exposure as possible during peak burning hours (10am – 4pm); wear long sleeve shirts, long pants, and wide-brimmed hats; and properly apply broad-spectrum sun screen.
 

Stomach Cancer   

Though fairly rare in the United States, stomach cancer is one of the most common cancers worldwide. The most important risk factor for stomach cancer is infection with a bacterium called Helicobacter pylori (H pylori). While it can be difficult to avoid getting H pylori, especially for populations in developing countries, treating it can greatly lower the risk from the infection. Treatment usually involves a combination of antibiotics and drugs that lowers acid levels in the stomach. Not smoking and eating a low sodium diet can also help protect against stomach cancer. 

Uterine Cancer (Women) 

Uterine cancer (also called endometrial cancer) is one of the most common cancers in women. Of the traditional lifestyle factors, keeping weight in check and avoiding diabetes with healthy behaviors like exercise and healthy diet can help lower the risk of uterine cancer. As for less traditional lifestyle factors, taking birth control pills for a long period can lower risk of the disease; and in postmenopausal women, avoiding postmenopausal hormones can protect against the disease. However, balancing the risks and benefits of such medications is important, and people should talk to a doctor to better understand the balance.

 

Inequality and Cancer

Race and class have a very powerful link with health, a relationship brought into the spotlight most recently by the scenes in New Orleans following Hurricane Katrina during that long week in late summer 2005. Yet, the tragic scenes of suffering at the Convention Center and Superdome experienced largely by poor and minorities go on every day, just without the glare of the media lights.
 

When looking at cancer specifically, large gaps exist between racial groups in rates of developing and dying from the disease.   African Americans experience cancer rates that are more than twice as high as American Indians, about 50 percent higher than Hispanics and Asian/Pacific Islanders, and 10 percent higher than whites. Racial and ethnic differences in deaths from cancer are even more pronounced, with African Americans again having the highest rates (see figure 4)38-41.

Looking outside of race, factors like income and education level – so called socioeconomic factors – also have a large influence on health:  so much so that many in the health field call poverty itself a carcinogen40, 42. 

Why such disparities exist isn’t perfectly clear.  Unequal access to quality health care and screening services is one very important reason41, 43, 44,  but there are other important issues around education, language, and living/work environments – to name just three.  Tied together with such things, race and income are also often linked to important health risk factors like smoking, being less active, and being overweight40, 41.

Important policy changes are needed to address these disparities that seem ingrained into the social fabric.  On the positive side, awareness of the issue is on the rise, and there is some movement by organizations and governments to address such health disparities.  But much more comprehensive approaches are needed on the local, state, and federal level if we’re going to make real, measurable progress at narrowing the gaps between groups and lowering rates of cancer for all.

Public Policy and Cancer Prevention

 The onus of living a healthy life is often placed on the individual.  But as highlighted in the “Inequality and Cancer” section above, there are a lot of different factors that influence an individual’s health and the health choices they make.  And while it ultimately comes down to each individual person whether he or she chooses the piece of fruit over the doughnut or decides to go out for a walk rather than watch television, a lot of other factors outside of a person’s control can make it hard to make healthy choices.

 It’s not easy to choose fruit, for example, when you live in a neighborhood where doughnut shops abound but not a single store sells fresh produce.  It’s hard to get out the door for a walk when there are no sidewalks to walk on or the neighborhood is unsafe.  Such examples highlight the huge influence our environments can have on health.  And this is why policy is so important when it comes to issues like health and cancer prevention.

Policies - whether those of workplaces, insurers, schools, or governments - can help create environments that promote and support a healthy, cancer-preventing lifestyle 45.  Policy changes can be as small as getting vending machines at work to stock more fruits and whole grains; they can be as grand as a federal excise tax placed on tobacco products.  Both levels of change are needed to realize real improvements in health behaviors population wide.

Momentum for positive policy changes has been slowly gaining in some areas.  Awareness of the need to stem the tide of childhood obesity is spurring action by many groups16, 17.  Restrictions on tobacco use continue to grow, even across Europe which once seemed impervious to such policies. Some cities are taking steps to help consumers make healthier food choices, most notably in New York City.

Still much more needs to be done at both the local, state, and federal levels if we’re to realize the huge potential of cancer prevention.  A small selection of needed policy changes include:

Tobacco
  • Further increases in local, state, and federal taxes on tobacco products, with steps that ensure the tax money goes to boost public health efforts
  • Better indoor air quality policies that further restrict smoking in workplaces, restaurants, bars, and other public or populated places
  • Better enforcement of laws that prohibit youth from buying tobacco products

Physical Activity
  • New building codes that require sidewalks in new developments and easily accessible stairs in larger buildings
  • Increases in school physical education and innovative teaching techniques that combine activity with key curriculum subjects (like reading and math)

Diet
  • Better support for the offering of healthier meals in school
  • Better support for the offering of healthier meals in workplace cafeterias and vending machines

Weight
  • Development and funding of a nationwide comprehensive weight control initiative that has incentives for schools, businesses, insurers, and local/state governments to take steps to promote weight control

Cancer Risk Assessment

 The last ten years have seen an explosion of online tools that allow people to estimate their risk of various chronic diseases, like cancer, heart disease, and diabetes.  By some counts, there are scores of such publicly available tools for cancer alone46.   And while their sheer number can make such tools compelling, even in the best of cases cancer risk assessment remains a difficult pursuit.

Much of the reason for this is simply that science is much better at predicting what might happen to a group of people than to a single person. Out of 100 women with a certain set of risk factors, for example, it’s not too hard to look at past research studies and accurately estimate what percentage of the women will go on to develop a certain disease. Much harder, though, is picking out which specific women of the 100 will get the disease. It’s similar to a weather forecast. Meteorologists can look at current whether patterns and compare them to past patterns and predict that there’s a 40 percent chance of rain today in the area. Harder, though, is figuring out whether or not it’s going to rain in your specific neighborhood.
 
Despite such difficulty, tools that estimate cancer risk are getting more accurate as understanding of the disease grows.  And many of the online sites can be very useful guides to opening a dialog with providers or other health professionals about cancer risk and lifestyle choices.  Of course, not all risk assessment sites are created equal, and people must be informed consumers of the sites they use.  As with seeking most health information on the Internet, it’s best to start with sites from known reputable organizations, such as universities, large health organizations, and the federal government.  When seeking out cancer risk assessment tools, it’s also very important to look for documentation showing that developers of the site have experience in the field.  While it’s easy to put up a cancer risk quiz on the Web, it’s much harder to get it right.

Two of the best-established cancer risk estimation websites are the National Cancer Institute’s “Breast Cancer Risk Assessment Tool” (link) and Washington University School of Medicine’s “Your Disease Risk” (link) which offers estimates of 12 different cancers.  Unlike many tools available on the Web, these have been scientifically validated in published studies 47-49.
 
 
The authors would like to thank Catherine Tomeo Ryan and Cynthia Stein for their previous work that informed many parts of this piece.


References

1.         American Institute for Cancer Research. Facts vs. Fears Survey. In; 2007.

2.         Doll R, Peto R. The causes of cancer:  quantitative estimates of avoidable risks of cancer in the United States today. J Natl Cancer Inst 1981;66:1191-308.

3.         Harvard Report on Cancer Prevention. Volume 1: Causes of human cancer. Cancer Causes Control 1996;7 Suppl 1:S3-59.

4.         Harvard Report on Cancer Prevention. Volume 2: Prevention of human cancer. Cancer Causes Control 1997;8 Suppl 1:S1-50.

5.         Flood DM, Weiss NS, Cook LS, Emerson JC, Schwartz SM, Potter JD. Colorectal cancer incidence in Asian migrants to the United States and their descendants. Cancer Causes Control 2000;11:403-11.

6.         Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347-60.

7.         Ezzati M, Lopez AD. Estimates of global mortality attributable to smoking in 2000. Lancet 2003;362:847-52.

8.         Colditz GA, Stein CJ. Handbook of cancer risk assessment and prevention. Sudbury, Mass.: Jones and Bartlett Publishers; 2004.

9.         Annual smoking-attributable mortality, years of potential life lost, and economic costs--United States, 1995-1999. MMWR Morb Mortal Wkly Rep 2002;51:300-3.

10.       Cigarette smoking among adults--United States, 2006. MMWR Morb Mortal Wkly Rep 2007;56:1157-61.

11.       NIH State-of-the-Science Conference Statement on Tobacco Use: Prevention, Cessation, and Control. NIH Consens State Sci Statements 2006;23:1-26.

12.       American Cancer Society. Few Americans Know Connection Between Excess Weight and Cancer Risk, Survey Finds. In; 2006.

13.       Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med 2003;348:1625-38.

14.       Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. Jama 2006;295:1549-55.

15.       Centers for Disease Control and Prevention. U.S. Obesity Trends 1985 - 2006. In; 2007.

16.       Strasburger VC. Children, adolescents, and advertising. Pediatrics 2006;118:2563-9.

17.       William J. Clinton Foundation. Alliance for a Healthier Generation. In; 2007.

18.       Adult participation in recommended levels of physical activity--United States, 2001 and 2003. MMWR Morb Mortal Wkly Rep 2005;54:1208-12.

19.       Willett WC. Diet and cancer. Oncologist 2000;5:393-404.

20.       World Cancer Research Fund., American Institute for Cancer Research. Food, nutrition, physical activity, and the prevention of cancer : a global perspective. Washington, DC: WCRF/AICR; 2007.

21.       Fairfield KM, Fletcher RH. Vitamins for chronic disease prevention in adults: scientific review. JAMA 2002;287:3116-26.

22.       Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA 2002;287:3127-9.

23.       Harvard Report on Cancer Prevention. Volume 1: Causes of human cancer, summary. Cancer Causes Control 1996;7 Suppl 1:S55-8.

24.       Gunzerath L, Faden V, Zakhari S, Warren K. National Institute on Alcohol Abuse and Alcoholism report on moderate drinking. Alcohol Clin Exp Res 2004;28:829-47.

25.       Linos E, Willett WC. Diet and breast cancer risk reduction. J Natl Compr Canc Netw 2007;5:711-8.

26.       Giovannucci E, Chen J, Smith-Warner SA, et al. Methylenetetrahydrofolate reductase, alcohol dehydrogenase, diet, and risk of colorectal adenomas. Cancer Epidemiol Biomarkers Prev 2003;12:970-9.

27.       Giovannucci E. Epidemiologic studies of folate and colorectal neoplasia: a review. J Nutr 2002;132:2350S-5S.

28.       Sunburn prevalence among adults--United States, 1999, 2003, and 2004. MMWR Morb Mortal Wkly Rep 2007;56:524-8.

29.       Holick MF. Vitamin D deficiency. N Engl J Med 2007;357:266-81.

30.       Garland CF, Garland FC, Gorham ED, et al. The role of vitamin D in cancer prevention. Am J Public Health 2006;96:252-61.

31.       Giovannucci E. The epidemiology of vitamin D and cancer incidence and mortality: a review (United States). Cancer Causes Control 2005;16:83-95.

32.       Franceschi S. Strategies to reduce the risk of virus-related cancers. Ann Oncol 2000;11:1091-6.

33.       Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007;56:1-24.

34.       Lavanchy D. Worldwide epidemiology of HBV infection, disease burden, and vaccine prevention. J Clin Virol 2005;34 Suppl 1:S1-3.

35.       Tomeo CA, Colditz GA, Willett WC, et al. Harvard Report on Cancer Prevention. Volume 3: prevention of colon cancer in the United States. Cancer Causes Control 1999;10:167-80.

36.       Increased use of colorectal cancer tests--United States, 2002 and 2004. MMWR Morb Mortal Wkly Rep 2006;55:308-11.

37.       Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects. In: CA Cancer J Clin. 2007/03/30 ed; 2007:90-104.

38.       Ries LAG, Melbert D, Krapcho M, et al., eds. SEER Cancer Statistics Review, 1975-2004. Bethesda, MD: National Cancer Institute; 2007.

39.       Recent trends in mortality rates for four major cancers, by sex and race/ethnicity--United States, 1990-1998. MMWR Morb Mortal Wkly Rep 2002;51:49-53.

40.       Albano JD, Ward E, Jemal A, et al. Cancer mortality in the United States by education level and race. J Natl Cancer Inst 2007;99:1384-94.

41.       Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin 2004;54:78-93.

42.       Broder S. Progress and challenges in the National Cancer Program. In: Brugge J, Curran T, Harlow E, McCormick F, eds. Origins of Human Cancer:  a Comprehensive Review. Plainview, NY: Cold Springs Harbor Press; 1991.

43.       Bickell NA, LePar F, Wang JJ, Leventhal H. Lost opportunities: physicians' reasons and disparities in breast cancer treatment. J Clin Oncol 2007;25:2516-21.

44.       Akers AY, Newmann SJ, Smith JS. Factors underlying disparities in cervical cancer incidence, screening, and treatment in the United States. Curr Probl Cancer 2007;31:157-81.

45.       Colditz GA, Samplin-Salgado M, Ryan CT, et al. Harvard report on cancer prevention, volume 5: fulfilling the potential for cancer prevention: policy approaches. Cancer Causes Control 2002;13:199-212.

46.       Waters EA. Personal Communication. In; 2008.

47.       Costantino JP, Gail MH, Pee D, et al. Validation studies for models projecting the risk of invasive and total breast cancer incidence. J Natl Cancer Inst 1999;91:1541-8.

48.       Rockhill B, Spiegelman D, Byrne C, Hunter DJ, Colditz GA. Validation of the Gail et al. model of breast cancer risk prediction and implications for chemoprevention. J Natl Cancer Inst 2001;93:358-66.

49.       Kim DJ, Rockhill B, Colditz GA. Validation of the Harvard Cancer Risk Index: a prediction tool for individual cancer risk. J Clin Epidemiol 2004;57:332-40.

Comments

Cancer early diagnosis

Cancer can be best prevented by early diagnosis. Read articles on how Vedic astrology achieves this successfully at http://www.decisioncare.org/medical-astrology/cancer-diagnosis-and-treatment-timing/

Vedic Astrology

Sep 4, 2009 11:33 PM
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Healthy diet

Thank you for this article, it is very useful. In the article you wrote that keeping your weight in balance is the most important thing from a dietary point of view. What about spicy food? I found articles on Google Scholar that correlate capsaicin rich diet with gastric or colon cancer. I am very fond of Chinese food and is very important for me to know how much spicy food is safe to eat.

I would like to know if I should quit eating stir fried meat and vegetables and in the case I use this technique, what king of oil is safest to use.

And could you tell me if weight gained from bodybuilding exercises promotes cancer or any other pathologies? If I have a BMI that indicates that I am overweight due to muscle mass, should I worry?

Respectfully, Sergiu Darjan


Last edited Jul 24, 2008 2:23 PM
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Graham Colditz, MD, DrPH
Graham Colditz, MD, DrPH
Associate Director of Prevention and Control, Siteman Cancer Center at Washington University School of Medicine at Washington University School of Medicine
Saint Louis, MO
  • Hank Dart
    Siteman Cancer Center at Washington University School of Medicine
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