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2013 | Book

Epidemiologic Studies in Cancer Prevention and Screening


About this book

Epidemiologic Studies in Cancer Prevention and Screening is the first comprehensive overview of the evidence base for both cancer prevention and screening. This book is directed to the many professionals in government, academia, public health and health care who need up to date information on the potential for reducing the impact of cancer, including physicians, nurses, epidemiologists, and research scientists. The main aim of the book is to provide a realistic appraisal of the evidence for both cancer prevention and cancer screening. In addition, the book provides an accounting of the extent programs based on available knowledge have impacted populations. It does this through: 1. Presentation of a rigorous and realistic evaluation of the evidence for population-based interventions in prevention of and screening for cancer, with particular relevance to those believed to be applicable now, or on the cusp of application 2. Evaluation of the relative contributions of prevention and screening 3. Discussion of how, within the health systems with which the authors are familiar, prevention and screening for cancer can be enhanced. Overview of the evidence base for cancer prevention and screening, as demonstrated in Epidemiologic Studies in Cancer Prevention and Screening, is critically important given current debates within the scientific community. Of the five components of cancer control, prevention, early detection (including screening) treatment, rehabilitation and palliative care, prevention is regarded as the most important. Yet the knowledge available to prevent many cancers is incomplete, and even if we know the main causal factors for a cancer, we often lack the understanding to put this knowledge into effect. Further, with the long natural history of most cancers, it could take many years to make an appreciable impact upon the incidence of the cancer. Because of these facts, many have come to believe that screening has the most potential for reduction of the burden of cancer. Yet, through trying to apply the knowledge gained on screening for cancer, the scientific community has recognized that screening can have major disadvantages and achieve little at substantial cost. This reduces the resources that are potentially available both for prevention and for treatment.

Table of Contents


Prevention of Cancer

Chapter 1. Health Promotion Approaches to Reducing Cancer Incidence
Three strategies for reducing disease incidence are presented. These include scaling up preventive maneuvers in primary care settings, using high-reach, low-cost programs (using print and electronic media), and creating environments that promote healthy behavior patterns. The three approaches can work in concert. The third strategy, environmental change through public policy (within and beyond public health and health care systems), is fundamentally important and has been demonstrated to be effective in reducing disease at population levels. Research, evaluation, and surveillance all provide critical evidence for guiding progress. Evaluations of innovative policies as they are implemented are particularly important. Interorganizational coordination and mechanisms that enable research, policy, and practice communities to work together are vital for enabling deliberate, efficient generation and use of evidence to advance progress in reducing the incidence of cancer and other diseases.
Roy Cameron, Jon Kerner
Chapter 2. Preventing Cancer by Ending Tobacco Use
Tobacco use is the leading cause of cancer and many other diseases. For over 50 years, it has been known that prevention of tobacco use would prevent millions of deaths, yet tobacco use remains stubbornly persistent. Progressively more restrictive tobacco control measures that are mainly aimed at changing the smoking behaviour of individuals have slowed the progress of the tobacco epidemic somewhat. Tobacco companies have become expert in adapting to tobacco control measures and neutralizing or mitigating their effect. The profit-seeking motivation that directs corporate behaviour will likely lead to their continuing adaptive behaviour in the future. A continued focus on smokers, characteristic of many current tobacco control measures, may slow the progress of the tobacco epidemic but is unlikely to bring it to an end. In the future, in addition to more and more effective measures that will influence individual behaviour, tobacco control will need to be expanded to include measures directed at changing the ways tobacco suppliers do business.
Neil Collishaw, Cynthia Callard
Chapter 3. Prevention of Occupationally Induced Cancer
A number of workplace exposures are known to cause cancer. In fact, the workplace has been a major source of information regarding causes of cancer. In most countries, there are sizable public and private efforts to control occupational exposures to minimize disease risks. Despite these considerable and appropriate, preventive efforts, there is relatively little information on their effectiveness. The few studies available do indicate that controlling occupational exposures leads to a reduction in cancer risk. However, details regarding this reduction, e.g., time-dependent changes in risk following intervention and potential confounding and effect modification from other occupational exposures or personal habits, are largely lacking. Such information is needed to identify and characterize successful exposure-reduction approaches and to reduce the cancer burden on our working population in a timely manner.
Aaron Blair, Karin Hohenadel, Paul Demers, Loraine Marrett, Kurt Straif
Chapter 4. Human Papillomavirus Vaccination for the Prevention of Cervical and Other Related Cancers
Academic research described in the late 1980s the causal association between human papillomavirus (HPV) and cervical cancer, later expanded to significant fractions of all other genital tract cancers in both genders as well as a proportion of the cancers of the oral cavity and oropharynx. Prophylactic phase III HPV vaccine trials have shown complete type-specific vaccine efficacy against two HPV types, namely, HPV 16 and 18, that together account for over 70 % of cervical cancer worldwide. HPV vaccines have proven in trials to have an excellent safety record. Most developed populations have introduced HPV vaccines as part of their routine vaccination schemes, and introduction into developing countries is being actively planned. In 2012, over 100 million vaccine doses have been delivered, and records of continuous efficacy and safety are encouraging. Comprehensive strategies of HPV vaccination and HPV-based screening tests could theoretically eliminate cervical cancer in defined populations.
F. Xavier Bosch
Chapter 5. Prevention of Cancers Due to Infection
Several infectious agents have been identified as causes of human cancer in the last 30 years. Among the cancers due to infection, hepatocellular carcinoma (HCC) caused by chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, stomach cancer attributed to Helicobacter pylori (H. pylori) infection, and cancer of uterine cervix induced by human papilloma virus (HPV) are the most prevalent in the world. Multiple preventive measures have been developed against these three cancers; there are vaccines against HBV and HPV type 16 and 18, antiviral therapy for chronic hepatitis B and C patients, H. pylori eradication by antibiotics, and cervical cytologic screening to prevent invasive cervical cancer, although these effective measures are often tempered by socioeconomic issues in many countries. In addition, accumulated epidemiological evidence has indicated that some behavioral changes in these infected individuals, such as smoking cessation, alcohol abstinence (in patients with chronic hepatitis B and C), and reduction of salt intake (in H. pylori carriers), can reduce the corresponding cancer risks.
Among all malignancies around the world in the year 2002, the percentage of infection-related neoplasms was conservatively estimated to be 18 % as reported by Parkin (Int J Cancer 118:3030–3044, 2006). This chapter summarizes epidemiologic views focusing on prevention of hepatitis virus-related HCC and prevention of stomach cancer caused by H. pylori infection. HPV vaccination and screening for cervical cancer are described in chapters by Bosch and Hakama, respectively. Some other minor but important infectious agents to be considered in terms of cancer prevention are described in this chapter.
Hideo Tanaka
Chapter 6. Applying Physical Activity in Cancer Prevention
Physical activity is a modifiable lifestyle risk factor associated with a decreased risk of several cancer sites. Sedentary behavior is emerging as a risk factor for cancer that should be considered independently from physical activity. We systematically reviewed the observational epidemiological literature on physical activity, sedentary behavior, and risk for colon, breast, endometrial, ovarian, lung, and prostate cancers. We present the hypothesized biologic mechanisms whereby physical activity and sedentary behavior may influence the risk of these cancers. Finally, we provide an overview of the public health implications for physical activity in cancer prevention. Strong and consistent evidence exists that physical activity reduces the risk of colon and breast cancers and possibly also of endometrial cancer. The evidence is weaker and less consistent for lung, prostate, and ovarian cancers and currently insufficient for all other cancer sites. There is some evidence that sedentary behavior increases the risk of colon, endometrial, and ovarian cancers and insufficient evidence for other cancer sites. The main biologic mechanisms that are likely operative between physical activity, sedentary behavior, and cancer risk are adiposity, endogenous sex hormones, inflammation, and insulin resistance. There is considerable public health benefit to be gained through increased physical activity and decreased sedentary behavior, but efforts to date have not met this potential. A coordinated approach at multiple jurisdictional levels is needed to achieve significant decreases in cancer incidence at a population level.
Christine M. Friedenreich, Brigid M. Lynch, Annie Langley
Chapter 7. Cancer Prevention in the United States
The steps undertaken in the United States for cancer prevention are reviewed, especially those relating to smoking, and obesity prevention and healthy nutrition. It is concluded that the knowledge and tools to prevent many cancers and cancer deaths now exist. Cancer prevention interventions, if fully implemented, could potentially prevent several hundred thousand cancer deaths per year. If this is to be achieved, much of the emphasis should be on children as most prevention interventions are most useful when deployed early in life. Consistent application of cancer prevention may not occur without effective interventions at the individual, clinical, community, and policy levels. This is a public health challenge at national and local levels.
Otis W. Brawley, Barnett S. Kramer
Chapter 8. The Role of Nutrition in Cancer Prevention
30 years ago diet (excluding alcohol) was estimated to account for the greatest proportion of cancers (about 35 %) worldwide, but there was a lot of uncertainty and this was before the identification of infective causes; smoking was estimated to cause 30 % of global cancers. Since then, migrant studies have shown two- to fourfold changes in cancer incidence once people have migrated and changed their diet, but it has taken numerous studies with increasing emphasis on large prospective studies to begin to reveal specific dietary factors which either promote or inhibit specific cancers. Yet animal experiments have provided ample evidence that diet profoundly affects the susceptibility to cancer, and the increasing understanding of the multiple steps of genetic change which lead to cancer has also been related to specific mutagenic and protective factors in food. Human dietary studies to assess relevant hormonal and mutagen generation changes can be illuminating but are too sparse in comparison with the huge effort put into epidemiological studies. Exhaustive literature searches and meta-analyses reveal an array of foods with probable or convincing cancer promotional or protective properties. Obesity is now also emerging as a major risk factor, and new evidence highlights the problem of obtaining valid dietary data in large numbers of subjects needed in epidemiological studies. So an emphasis on biomarker studies of both intake and the carcinogenic process is needed as are dietary trials in cancer survivors. Evidence is growing that the contribution of diet in the causation of has previously been underestimated.
W. Philip T. James
Chapter 9. Chemoprevention of Cancer: From Nutritional Epidemiology to Clinical Trials
This chapter considers the evidence for chemoprevention of the more common cancers, breast, colon, lung, and prostate, emphasizing the findings from stage III clinical trials. Nutritional epidemiology has generated a number of provocative findings regarding the role of dietary elements in cancer risk and prevention. These findings have led to the hope that the most important bioactive compounds in foods might be isolated and administered to populations, much as vitamins are used to ward off nutritional deficiency diseases. Therapeutic agents in widespread use, including nonsteroidal, anti-inflammatory, and hormone-focused drugs, have also been proposed as chemopreventive agents. To date, formal testing of these agents in randomized, placebo-controlled trials has indicated that their preventive effects are modest to negligible or that their toxicities are unacceptable for use in average-risk populations. An approach which may prove fruitful for chemoprevention may be for testing to be undertaken in populations at elevated risk of cancer: individuals with premalignant lesions, such as intraepithelial neoplasms of the colon or prostate, or even with early cancers. In such populations, toxicity may be more acceptable than in average-risk populations.
Mary Reid, James Marshall
Chapter 10. The Role of Hormonal Factors in Cancer Prevention
Women should be informed that early age at the birth of one’s first child protects against breast cancer and that risk of both breast and ovarian cancers declines with increasing duration of breast-feeding. Combined oral contraceptives afford long-term protection against endometrial and ovarian cancers, and these benefits outweigh the small increase in risk of breast and liver cancers in users of these products. Long-acting injectable progestational contraceptives also protect against endometrial cancer. Users of both of these hormonal contraceptives are at increased risk of cervical cancer, and services that provide these products present an opportunity for screening and prevention of deaths from this condition. Long-term postmenopausal therapy with estrogens increases risk of cancers of the endometrium and ovary. The addition of a progestogen to the regimen reduces the excess occurrence of these neoplasms; but, because this beneficial effect is outweighed by an increase in the risk of breast cancer and multiple noncancerous conditions, use of these combined products, as well as estrogens alone, should be avoided.
David B. Thomas
Chapter 11. Controlling Environmental Causes of Cancer
Controlling the environmental causes of cancer requires a coordinated effort for the identification of exposed populations, particularly in low-income countries, and for effective primary prevention policies. Examples of common environmental carcinogens are aflatoxins, heavy metals, PCBs and dioxins. However, reducing exposure to chemicals identified as human carcinogens (through epidemiological studies) is not enough. Given the limitations of epidemiology, we also need to rely upon animal experiments. The total burden of cancers due to environmental exposures (pollutants, i.e. excluding personal behaviours such as tobacco smoking and infectious agents) is currently unknown. Estimates vary widely, from 3 % to 19 %. Such variation is due both to the use of different criteria in defining the environment and to different interpretations of the results of the literature. However, in spite of these uncertainties, millions of cancers could be prevented by cleaning the general environment, particularly in low-income countries. Also, prevention is characterized by the fact that people benefiting from prevention may be more than those to whom we address interventions. For example, because of herd immunity people who are not vaccinated derive benefit, and similar cumulative advantages can be achieved with reduction of exposure to environmental carcinogens.
Paolo Vineis
Chapter 12. A Historical Moment: Cancer Prevention on the Global Health Agenda
The recognition by the United Nations that non-communicable diseases (NCDs, including cancer) are a threat, not only to public health, but to nations’ economies, was built upon the work by the World Health Organization in the areas of cancer control and risk-reduction strategies, especially directed to tobacco, diet and nutrition and alcohol. This culminated in the UN General Assembly High-level Meeting on NCDs in 2011. This historical window for setting the pace to address NCDs needs now to be used so that the necessary changes at the global, regional and national health agendas are implemented.
Andreas Ullrich

Screening for Cancer

Chapter 13. Evidence-Based Cancer Screening
The fundamental method to evaluate screening for cancer is the randomized screening trial. This is the only acceptable method to use when a screening test is proposed for a cancer for which efficacy of screening has not yet been demonstrated. However, as these trials are expensive and take many years to reach the accepted outcome (mortality from the cancer under consideration or incidence if a precursor is detected by the screening test), other approaches are needed when a new screening test is proposed for a cancer where the efficacy of screening has already been demonstrated. There is no ideal methodology to use under these circumstances. However, unless the test has advantages that increase the efficiency of screening, or reduce costs, that dictate its adoption, simply demonstrating improvement in relative sensitivity is not sufficient because of the likelihood of increased overdiagnosis and increased costs. It is then necessary to demonstrate that the new test reduces the occurrence of progressive disease by means of a short-term randomized screening trial before its adoption is promulgated.
Anthony B. Miller
Chapter 14. Comprehensive Cervical Cancer Control: Strategies and Guidelines
Cancer of the uterine cervix is the second most important cancer among women in the world, in nearly all low- and middle-income (LMI) countries; it is number one in importance. There are many challenges for cervical cancer control programmes. They include the need to reform health-care systems in many countries and ensure the availability of human resources because of a shortage of trained health workers for vaccinating, screening and treating. An adequate organization is essential to ensure effective programmes. The WHO recommends a comprehensive and integrated approach to cervical cancer control of which HPV vaccination is one element.
Nathalie Broutet
Chapter 15. Screening for Cervical Cancer
This chapter considers screening for cancer of the cervix from the point of view of routine screening and its applicability as a public health policy. Sensitivity is an essential indicator in the comparison of several competing tests. Currently, convincing evidence on sensitivity of screening for cervix cancer is with the Pap smear. The HPV test is likely to have similar sensitivity as the Pap test but at the risk of more overdiagnosis. In a developing country, it is likely that visual inspection works, but at the cost of more overtreatment. The effectiveness of screening for cervical cancer was demonstrated by studies that followed the large-scale application of the Pap test in routine screening, in Canada, and in the Nordic countries. In spite of attaining coverage of the total target population, screening for cervical cancer can be relatively inexpensive; those programs with the largest effect have been low in cost. An important future determinant of screening for cervix cancer will be vaccination against HPV infection, though screening for cervix cancer will continue to have an important role in cancer control.
Matti Hakama
Chapter 16. Screening for Colon Polyps and Cancer
Colorectal cancer (CRC) carries a significant health burden, accounting for 610,000 deaths worldwide in 2008. CRC is the fourth most common malignancy and the second leading cause of cancer-related death in the United States. Colon screening is arguably the greatest cancer prevention success story of the last 25 years contributing substantially to over a 40 % reduction in CRC mortality in the USA since 1975. Screening rates in the USA currently exceed 60 % and are steadily rising. Randomized screening trials have demonstrated a 33 % reduction in CRC mortality with the use of annual fecal occult blood testing (FOBT) and a 27–31 % reduction in CRC mortality with flexible sigmoidoscopy (FS). Despite this robust evidence for FOBT and FS, colonoscopy use has been on the rise in the USA and has emerged as the preferred colon screening modality. Colonoscopy has a conceptual advantage as it is the only single-step test that allows visualization of the entire colon and removal of polyps simultaneously. Retrospective data suggests that colonoscopy may not be as protective of colon cancer in the proximal colon; however, prospective data on the impact of colonoscopy screening on incidence and mortality is not yet available. Computerized tomography colonography (CTC) and fecal DNA testing are newer technologies that have a great deal of potential as screening modalities as technology advances. Although colon screening can be expensive depending on the test used, any type of screening appears to be cost-effective when taking into account the rising costs of CRC treatment.
Swati G. Patel, Dennis J. Ahnen
Chapter 17. Breast Cancer Screening
The evidence derived from randomized screening trials and from the surveillance of populations where mass screening for breast cancer has been introduced is reviewed. Nearly all the randomized screening trials were performed in the era before modern adjuvant therapy for breast cancer was introduced, apart from the Canadian National Breast Screening Study and the UK age trial. The former found no benefit from mammography screening, and the latter, a nonsignificant benefit from screening women by annual mammography from ages 39 to 41 for 7 years. The evidence from population-based surveillance is mixed, most such studies having failed to address the benefit gained from improved therapy, which has largely replaced the benefit previously obtained from screening. It is concluded that we may have reached the point of negligible benefit in screening for invasive breast cancer.
Anthony B. Miller
Chapter 18. Prostate Cancer Screening
The benefits and harms from the use of prostate-specific antigen (PSA) as a screening test are reviewed in the light of the updated results from two major randomized trials of screening for prostate cancer, the prostate component of the Prostate, Lung, Colon and Ovary (PLCO) trial in the United States and the European Randomized Study of Screening for Prostate Cancer (ERSPC). Neither trial found a reduction in prostate cancer mortality during the first 7 years after initiation of screening, and this lack of benefit persisted through 13 years for PLCO. In ERSPC, however, lower mortality from prostate cancer emerged after 7 years in the screening group compared to the control resulting in a 21 % significant reduction in prostate cancer mortality for the core group of subjects (aged 55–69) by the end of the reported follow-up (median 11 years) though differences in treatment of prostate cancer in the control group compared to those detected in the screening group could have been responsible for this mortality differential. Currently, there is no justification for the introduction of population-based organized screening for prostate cancer at any age; while in view of the potential harms associated with screening, physicians should generally recommend against PSA testing for asymptomatic men.
Anthony B. Miller
Chapter 19. Applying Cancer Screening in the Context of a National Health Service
The context of a national health service affects how the science underpinning screening is applied. Decisions taken about the introduction of screening need to be tempered by the availability of resources, and both the introduction and the withdrawal of screening can have political ramifications. This chapter, based largely on experience in the UK, describes how operating a service paid from public funds influences decision making about a screening service and its operations. Operating screening in this context allows a population approach to be taken which can have many advantages in terms of the ability to quality assure a programme, to use the programme to develop knowledge about screening and the disease screened for, to have an equitable approach to screening across all groups in society and to operate a highly efficient and cost-effective service. However, it does require some central direction to achieve all this, and it does make it difficult to tailor screening to an individual’s preferences.
Julietta Patnick

Impact of prevention and screening in populations

Chapter 20. Do International Trends in Cancer Incidence and Mortality Reflect Expectations from Cancer Screening?
The goal of cancer screening is to reduce the risk of cancer death by detecting cancers when they are not yet clinically apparent, at a stage they are less life threatening and more curable. An immediate consequence of this goal is that the ability of a cancer-screening test to reduce the risk of cancer death is tightly bound to its capacity to prevent the occurrence of advanced cancer. So, if screening for a specific cancer works, then reductions in mortality rates from that cancer should be preceded by reductions in the incidence rates of patients diagnosed with advanced stage. A growing body of data indicates that cancer screening when precursor lesions exist (e.g., cervical and colorectal cancers) succeeds in reducing incidence rates of advanced cancer, whereas cancer screening when no precursor lesion exists (e.g., breast cancer) hardly influences the incidence of advanced cancer. Hence, incidence rates of advanced cancer in populations where screening is widespread may inform on the effectiveness and public health relevance of cancer-screening methods.
Philippe Autier
Chapter 21. Using Mathematical Models to Inform Public Policy for Cancer Prevention and Screening
This chapter introduces the reader to the use of mathematical modeling applied to policy questions in cancer screening and prevention. While randomized trials and observational studies are the mainstays for evaluating the effectiveness of screening and prevention interventions, situations may arise where these methods may not be feasible due to time, ethical, or other constraints. Mathematical models can help to fill these gaps by synthesizing available evidence, often from disparate sources, and estimating outcomes across a range of policy alternatives. Predictions from models can aid policymakers in understanding the trade-offs in benefits and risks among policies under design or evaluation. The goal of this chapter is to help orient policymakers to this methodology. An overview of the methods is provided followed by examples to illustrate the range of policy applications where modeling can be used as well as how policymakers and modelers can collaborate. Real-world examples include the use of modeling to aid the design of the national cervical cancer screening program in the Netherlands, modeling to develop a package of tobacco control policies in the USA, and modeling to evaluate the contributions of cancer screening and treatment to observed trends in breast cancer mortality.
Natasha K. Stout, Michelle C. Dunn, J. Dik F. Habbema, David T. Levy, Eric J. Feuer
Chapter 22. Role of the Oncologist in Cancer Prevention
As oncologists have steadily improved their treatment of cancer, their success has evoked calls from various sectors for them to become more involved in cancer prevention, especially since the treatments they prescribe contribute to an increase in second primary malignancies. Oncologists’ professional organizations and peer group leaders have reinforced these calls by forming committees and curricula to overcome barriers to involvement in cancer prevention. However, oncologists have been slow to respond to these challenges. A description is provided of their present piecemeal involvement in various aspects of primary and secondary cancer prevention, but their choice to concentrate on tertiary prevention (treatment of established disease) is recognized. This chapter suggests an innovative way for how oncologists could lead the development of a comprehensive survivorship care plan for each survivor. This new role would automatically involve them in more comprehensive cancer prevention and rehabilitation by focusing on their own patients who have already overcome the first attack of the disease.
William Hryniuk
Chapter 23. Integrating Prevention and Screening for Lung Cancer into Clinical Practice
Lung cancer is the leading cause of cancer mortality worldwide. When diagnosed at an early stage, lung cancer 5-year survival is 60–70 %, but when diagnosed clinically, most cancers are advanced and overall 5-year survival is 16 %. Exposure to tobacco smoke is the dominant risk factor, but other environment and host factors are also important. Lung cancer prevention and early detection through screening have the potential to reduce lung cancer morbidity and mortality. Risk prediction models can be helpful in defining target populations for both prevention and screening. Prevention is currently based on avoidance of tobacco use and exposure. There are no established chemoprevention agents for lung cancer, but this remains an area of active investigation. The National Lung Screening Trial (NLST) demonstrated for the first time that screening with low-dose computed tomography (LDCT) reduces lung cancer mortality among a high-risk population. Efforts to better define the optimal approach to screening and the development of lung cancer screening guidelines are now underway. Discovery of biomarkers capable of detecting lung cancer at an early stage is another area of great promise. The combination of LDCT and biomarkers in the future should help improve the accuracy and clinical utility of screening programs. All screening programs should incorporate access to tobacco cessation resources.
William Hocking
Chapter 24. Early Detection of Cancer in Asia (Including Australia)
Asia contains over half of the world’s population and most countries are lower middle income in economic development, with a small number of high-income and very low-income countries. Asia also has the largest cancer burden of any region in the world with over one-third of all new cancer cases and nearly half of all cancer deaths in 2008, with a mortality to incidence ratio which indicates that about two-thirds of patients diagnosed with cancer will die of the disease. The five commonest cancers in men are lung, stomach, liver, esophagus, and colorectum and in women breast, cervix, lung, stomach, and colorectum. Leukemia and lip and oral cavity cancers in both men and women and prostate cancer in men make up the 10 commonest cancers in Asia. Primary and/or secondary prevention (early detection) interventions are possible for all except leukemia, but there are economic and cultural barriers to the rapid implementation of known effective early detection cancer control strategies. The current status and future prospects for early detection of cancer in Asia are explored in this chapter.
Robert Burton, Cheng-Har Yip, Marilys Corbex
Chapter 25. Prevention and Screening for Cancer in Primary Health Care
This chapter builds on the evidence presented in previous chapters. It focuses on the application of that evidence to practice in the primary care context. We present the current state of the evidence about what works for the implementation of cancer prevention and screening in primary care. In this chapter, the role of primary care practitioners in educating patients and supporting lifestyle changes to reduce exposure to cancer risk factors is highlighted. The organization of health-care delivery in primary care practices plays a key role in cancer prevention, and the targeting of specific populations is also supported by the evidence. We raise the issue of balancing the potential benefits and harms of screening and the need to inform patients of the risks involved. As genetic testing to assess cancer risk becomes more mainstream, primary care providers should be prepared to counsel their patients on hereditary cancer risk based on analysis of family history and to work with a genetic counselor when genetic risk assessment is warranted.
Alan Katz, Jennifer Enns
Chapter 26. Finale: What Can We Expect from Cancer Prevention and Screening?
Theoretically, it should be possible to prevent at least 50 % of cancer cases and deaths from them occurring by applying what we know about causation of cancer and at least a further 10 % of cancer deaths by screening. Yet, we seem unable to achieve this, though remarkable success has been achieved in preventing smoking-attributable cancers from occurring. The success for smoking was largely due to the application of a fiscal weapon, combined with restrictions on smoking in public places. This has led to calls for taxing unhealthy foods, yet governments have been remarkably resistant to that suggestion.
Anthony B. Miller
Epidemiologic Studies in Cancer Prevention and Screening
Anthony B. Miller
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Springer New York
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