The causes of cancer · 2015-03-24 · The causes of cancer: how much can be attributed to causes...

The causes of cancer:how much can be attributed to

causes that we can modify?

David Whiteman B Med Sc, MBBS (Hons), PhD, FAFPHM

Head, Cancer Control Group

Outline

The burden of cancer

Strategies for cancer control

Estimating the ‘preventable fraction’

8 ways to prevent cancer

Summary

Burden of disease, Australia 2003

Fatal burden of disease, Australia 2003

How does Australia compare internationally?

Incidence rate

How does Australia compare internationally?

Mortality-to-incidence ratio

Diagnoses of cancer over time in Australia

Deaths from cancer over time in Australia

The top 10 cancers for Australian men

0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000

Prostate (C61)

Skin - melanoma (C43)

Bronchus - lung (C34)

Colon (C18, C19)

Rectum (C20)

Kidney (C64-C66)

Bladder (C67)

UPS (C80)

Pancreas (C25)

Stomach (C16)

Number of cancers diagnosed 2010

The top 10 cancers for Australian women

0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000

Breast (C50)

Colon (C18, C19)

Bronchus & lung (C34)

Endometrial (C54, C55)

Thyroid (C73)

Rectum (C20)

UPS (C80)

Ovary (C56)

Pancreas (C25)

Outline

Summary

BirthOnset

of cancer

Primary

prevention

Diagnosis

of cancer

Secondary

prevention

Tertiary

prevention

Causal factors Screening Therapies

Target cell

The causes of cancer – generally speaking

Environment

Smoking

Alcohol

Sunlight

Viruses

Chemicals

Radiation

Medication

The causes of cancer - specifically

Factor Cancers caused

Alcohol Oral cavity, Pharynx, Larynx, Colon, Rectum, Liver, Breast

Tobacco Oral cavity, Pharynx, Larynx, Oesophagus, Lung, Stomach, Liver,

Pancreas, Colorectal, Bladder, Kidney, Cervix, Ovary, Leukaemia

Obesity Breast (post-menopausal), Colorectum, Endometrium, Gallbladder,

Kidney, Oesophageal (adeno), Pancreas

Diet – Inadequate Fibre

– Red & Processed Meat

Colorectal

Diet – Inadequate Fruit*

– Inadequate Vegetables

Oral cavity, Pharynx, Larynx, Oesophagus, Stomach, (Lung)*

Radiation – UV (sun+solaria) Melanoma, SCC, BCC

Factor Cancers caused (*prevented)

Breastfeeding < 12 months Breast

Hormones – OCP Breast, Cervix

*Endometrium, Ovary

Hormones – HRT Breast, Endometrium, Ovary

*Colorectum

Infections HPV:

Hep B:

Hep C:

H. pylori:

Oral, Pharynx, Tonsil , Larynx, Cervix, Vulva, Vagina, Penis, Anus

Nasopharynx, Burkitt’s lymphoma, Hodgkin’s lymphoma

Liver, NHL

Stomach

NHL, Kaposi’s Sarcoma,

Kaposi’s Sarcoma

Inadequate Physical Activity Breast (post-menopausal), Colon, Endometrium

Radiation – Ionising All cancers

Outline

Summary

Ip- I0=

“The population attributable fraction is the proportion by which the

incidence rate of the outcome among the entire population would be

reduced if the exposure were eliminated.”

Last, Dictionary of Epidemiology 3rd Edition.

Some methodology

“healthy weight” “overweight”

60% 40%

Force of morbidity

Cases of

cancer

Number of excess cases

in population

attributable to exposure

“healthy weight” “overweight”

PAFNumber of excess cases

Total number of cases

= 16.7%

60% 40%

Task Source

Assess causality WCRF, IARC, (USPSTF)

Obtain prevalence data

Australian National Health Survey

Other national collections

Population-based epi studies

Grey literature

Obtain risk estimates WCRF, IARC, meta-analyses

Generate PAF estimates Standard formulae

Overview of estimation process

0 5000 10000 15000 20000

Lack of breast feeding

Radiation - Ionising*

Post-menopausalhormones

Insufficient physical activity

Alcohol

Infections

Overweight and obesity

Inadequate Diet

Radiation - UV

Tobacco

Number of cancer cases

Vegetables

DIETARY ITEMS

3920 (3.4%)

6948 (6.0%)

7219 (6.2%)

3259 (2.8%)

3204 (2.7%)

1811 (1.6%)

539 (0.5%)

431 (0.4%)

235 (0.2%)

15522 (13.3%)

* radon and background radiation only

Australia UK

International comparisons

Alcohol

Cancers considered Oral cavity and pharynx

Oesophagus (SCC)

Rectum

Larynx

Breast

Prevalence of

exposure in Australian

population:

(aged 18 yrs and over)

53% Men

40% Women

2001 National Health Survey

18-24 yrs25-34 yrs

35-44 yrs45-54 yrs

55-64 yrs65-74 yrs

75+ yrs

Alcohol – intake in Australian males

Men Women

PAF Excess Cancers PAF Excess Cancers

Oral cavity and pharynx 38% 534 13% 77

Oesophagus (SCC) 36% 101 11% 25

Colon 12% 669 4% 198

Rectum 16% 394 5% 75

Liver 16% 159 5% 17

Larynx 22% 119 8% 7

Breast - - 6% 829

Total 3%* 1977 3%* 1228

* % of all cancers diagnosed in 2010, in adults (25+ yrs), excluding SCC and BCC of the skin

How many cancers in Australia are due to alcohol?

Men Women

Colon 12% 669 4% 198

Rectum 16% 394 5% 75

Liver 16% 159 5% 17

Larynx 22% 119 8% 7

Breast - - 6% 829

Total 3%* 1977 3%* 1228

Men Women

Colon 12% 669 4% 198

Rectum 16% 394 5% 75

Liver 16% 159 5% 17

Larynx 22% 119 8% 7

Breast - - 6% 829

Total 3%* 1977 3%* 1228

18-24 yrs

25-34 yrs35-44 yrs

45-54 yrs55-64 yrs

65-74 yrs75+ yrs

Alcohol – intake in Australian males

18-24 yrs

25-34 yrs35-44 yrs

45-54 yrs55-64 yrs

65-74 yrs75+ yrs

Alcohol – revised intake in Australian males

Primary

Analysis

Redistribute

equally

Redistribute

proportionally

PAF PAF PAF

Oral cavity and pharynx 31% 32% 32%

Oesophagus (SCC) 25% 26% 26%

Colon 8% 9% 9%

Rectum 12% 13% 13%

Liver 13% 13% 13%

Larynx 20% 21% 21%

Breast 6% 7% 7%

Total 2.8% 3.0% 3.0%

Target cell

Tumour development

Reduced repair and control

Increased cell turnover

Metabolic

pathways

Hormonal

pathways

Endometrium

Breast

Oesophagus

How does excess body fat cause cancer?

Cancers considered Oesophagus (adenocarcinoma only)

Rectum

Gall bladder

Pancreas

Breast (post-menopausal)

Endometrium

Kidney

Prevalence of obesity

in Australian

population:

52% men

37% women (2001 National Health Survey).

How many cancers in Australia are due to obesity?

Men Women

Oesophagus (adeno) 32% 182 29% 33

Colon 14% 780 6% 320

Rectum 7% 186 3% 44

Gall bladder 15% 16 14% 30

Pancreas 9% 129 6% 78

Breast (post-menopausal) - - 7% 970

Endometrium - - 26% 596

Ovary - - 4% 46

Kidney 20% 340 17% 171

Total 3%* 1632 5%* 2288

Men Women

Colon 14% 780 6% 320

Rectum 7% 186 3% 44

Pancreas 9% 129 6% 78

Ovary - - 4% 46

Kidney 20% 340 17% 171

Total 3%* 1632 5%* 2288

Men Women

Colon 14% 780 6% 320

Rectum 7% 186 3% 44

Pancreas 9% 129 6% 78

Ovary - - 4% 46

Kidney 20% 340 17% 171

Total 3%* 1632 5%* 2288

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends Among U.S. Adults

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Does losing weight reduce risk of cancer?

Cancer

incidence

Females

Surgery

patients

Non-surgery

patients

Cancer

incidence

Surgery

patients

Non-surgery

patients

Cancers considered Colon (C18, C19) and rectum (C20)

Prevalence of

exposure in Australian

population:

Daily use

•14% of men

•8% of women

•Varies +++ with age

(Australian Cancer Study controls)

Aspirin

Aspirin – how the story took hold

~25-30% reduced deaths from CRC with aspirin

Aspirin – get more data on all outcomes!

Aspirin – cancers vs other outcomes

Aspirin – get more data on rarer cancers!

Compare RCT vs observational studies for non-CRC cancer effects

Men Women

PF Prevented PF Prevented

Colorectal (C18-C20) 2% 195 2% 131

Oesophagus (C15) 6% 35 7% 8

Aspirin

• Considerations:

– Australian prevalence data not readily available.

– Jury still out on effective dose and frequency of aspirin

for cancer prevention.

– Adverse effects of aspirin use not considered.

Aspirin

Outline

Summary

http://www.siteman.wustl.edu/contentpage.aspx?id=4514

1. Maintain a healthy weight

2. Exercise regularly

3. Don’t smoke

4. Eat a healthy diet

5. Alcohol in moderation, if at all

6. Sun protection

7. Protect yourself from STI

8. Get screening tests

Graham Colditz MBBS PhD

Washington University, St Louis

3. Don’t smoke

6. Sun protection

•Choose small portions and eat slowly

•Eat diet rich in fruits, vegetables and whole grains

•Integrate physical activity into your life

FOR PARENTS / GRANDPARENTS

•Limit children’s TV and computer time

•Encourage healthy snacking on fruits and vegetables

•Encourage activity during free time

3. Don’t smoke

6. Sun protection

•Choose activities you enjoy – walking, gardening etc

•Make exercise a habit

•Exercise with others – helps motivation!

•Play active games with kids

•Play outside!

•Walk to school

3. Don’t smoke

6. Sun protection

•Keep trying! Most people take 6 or 7 attempts to quit

•Talk to your GP for help

•Join a quit-smoking program

•Try to quit as soon as possible

•Don’t smoke in home or car

•Talk to kids about dangers of smoking

3. Don’t smoke

6. Sun protection

•Fruit and veg at every meal – e.g. fruit on cereal

•Choose chicken, fish or beans instead of red meat

•Choose whole-grain cereal, brown rice over refined

products

•Limit fast food and processed snacks

•Limit fizzy drinks

3. Don’t smoke

6. Sun protection

•Choose non-alcoholic beverages at meals and parties.

•Avoid occasions centred around alcohol.

•Talk to GP if you feel you have a problem with alcohol

•Avoid making alcohol an essential part of family

gatherings.

•Discuss the dangers of drug and alcohol abuse with

children.

3. Don’t smoke

6. Sun protection

3. Don’t smoke

6. Sun protection

•Practice safe sex

•Vaccinate boys and girls against HPV

•Discuss safe sex

3. Don’t smoke

6. Sun protection

•Women: Pap tests; mammography

• Men and women: FOBT

•Skin exams for high-risk people

Outline

Summary

How much cancer can we prevent?

• 13 exposures – combined PAF* 32% in 2009 (excl. BCC and SCC)

– ≈ 37,000 cancers (or 100 per day)

– 33% in men

– 31% in women

• Exposures with highest PAFs:

– Men:

• Tobacco (16%), UVR (7%), alcohol (3%)

– Women:

• Tobacco (11%), UVR (5%), overweight/obesity (4%)

0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000

Prostate (C61)

Colon (C18, C19)

Rectum (C20)

Kidney (C64-C66)

Bladder (C67)

UPS (C80)

Pancreas (C25)

Stomach (C16)

How many of the top 10 cancers could we prevent?

0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000

Prostate (C61)

Colon (C18, C19)

Rectum (C20)

Kidney (C64-C66)

Bladder (C67)

UPS (C80)

Pancreas (C25)

Stomach (C16)

0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000

Breast (C50)

Colon (C18, C19)

Thyroid (C73)

Rectum (C20)

UPS (C80)

Ovary (C56)

Pancreas (C25)

0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000

Breast (C50)

Colon (C18, C19)

Thyroid (C73)

Rectum (C20)

UPS (C80)

Ovary (C56)

Pancreas (C25)

Stop smoking!

Start exercising!

Lose weight!

Slip! Slop! Slap!

Drink less!

And for goodness sake …

SEE YOUR GP!

to stay

healthy

Acknowledgements

Cancer Council Australia

Public Health Committee

Chief Investigators

David WhitemanHead, Cancer Control Group

Penelope WebbHead, Gynaecological Cancers Group

Adele GreenHead, Cancer and Population Studies Group

Rachel NealeHead, Cancer Aetiology and Prevention Group

Lin Fritschi Head, Epidemiology Group, Curtin University, Perth

Associate Investigators

Annika Antonsson

Renee Carey

Maria Celia Hughes

Torukiri Ibiebele

Susan Jordan

Bradley Kendall

Kyoko Miura

Christina Nagle

Catherine Olsen

Nirmala Pandeya

Susan Peters

Research Assistant

Louise Wilson

Advisors

Christopher Bain

Max Parkin

Prostate and Breast cancer trends in Australia

Bowel cancer trends in Australia

Melanoma trends in Australia

Lung cancer trends in Australia

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