Prevention Knowledge into Action Cancer Control WHO Guide for Effective Programmes This second module, Prevention, provides practical advice for programme managers in charge of developing or scaling up cancer prevention activities. It shows how to implement cancer prevention by controlling major avoidable cancer risk factors. It also recommends strategies for establishing or strengthening cancer prevention programmes. Using this Prevention module, programme managers in every country, regardless of resource level, can confi dently take steps to curb the cancer epidemic. They can save lives and prevent unnecessary suffering caused by cancer. The World Health Organization estimates that 7.6 million people died of cancer in 2005 and 84 million people will die in the next 10 years if action is not taken. More than 70% of all cancer deaths occur in low and middle income countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent. Yet cancer is to a large extent avoidable. Over 40% of all cancers can be prevented. Some of the most common cancers are curable if detected early and treated. Even with late cancer, the suffering of patients can be relieved with good palliative care. Cancer control: knowledge into action: WHO guide for effective programmes is a series of six modules offering guidance on all important aspects of effective cancer control planning and implementation. ISBN 92 4 154711 1 Prevention Knowledge into Action Cancer Control WHO Guide for Effective Programmes WHO Library Cataloguing-in-Publication Data Prevention. (Cancer control : knowledge into action : WHO guide for effective programmes ; module 2.) 1.Neoplasms – prevention and control. 2.Health planning. 3.National health programs – organization and administration. 4.Health policy. 5.Guidelines. I.World Health Organization. II.Series. ISBN 92 4 154711 1 (NLM classifi cation: QZ 200) © World Health Organization 2007 All rights reserved. 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The Prevention module of the Cancer Control Series is a joint effort of the following departments at WHO headquarters: Chronic Diseases and Health Promotion; Ethics, Trade, Human Rights and Law; Immunization, Vaccines and Biologicals; Immunization, Vaccines and Research; Measurement and Health Information Systems; Mental Health and Substance Dependence; Public Health and Environment and the Tobacco Free Initiative; and also the WHO International Agency for Research on Cancer, Lyon, France. The Prevention module was produced under the direction of Catherine Le Galès-Camus (Assistant Director-General, Noncommunicable Diseases and Mental Health), Robert Beaglehole (Director, Chronic Diseases and Health Promotion), Serge Resnikoff (Coordinator, Chronic Diseases Prevention and Management) and Cecilia Sepúlveda (Chronic Diseases Prevention and Management, coordinator of the overall series of modules). Andreas Ullrich (Chronic Diseases Prevention and Management) was the coordinator for this module and provided extensive editorial input. Editorial support was provided by Anthony Miller (scientifi c editor), Inés Salas (technical adviser), Angela Haden (technical writer and editor) and Paul Garwood (copy editor). Proofreading was done by Ann Morgan. The production of the module was coordinated by Maria Villanueva. Core contributions for the module were received from the following WHO staff: Teresa Aguado, Antero Aitio, Timothy Armstrong, Annemieke Brands, Alexander Capron, Zhanat Carr, Felicity Cutts, Poonam Dhavan, JoAnne Epping-Jordan, Kathleen Irwin, Ivan Dimov Ivanov, Ingrid Keller, Colin Mathers, Yumiko Mochizuki, Isidore Obot, Armando Peruga, Vladimir Poznyak, Eva Rehfuss, Dag Rekve, Heide Richter-Airijoki, Craig Shapiro, Kurt Straif (IARC), Kate Strong, Angelika Tritscher, Colin Tukuitonga, Andreas Ullrich, Emilie van Deventer, Steven Wiersma and Hajo Zeeb. Valuable input, help and advice were received from a number of people in WHO headquarters throughout the production of the module: Caroline Allsopp, David Bramley, Raphaël Crettaz, Maryvonne Grisetti and Rebecca Harding. Cancer experts worldwide, as well as technical staff in WHO headquarters and in WHO regional and country offi ces, also provided valuable input by making contributions and reviewing the module, and are listed in the Acknowledgements. Design and layout: This document’s design is based on the Chronic Diseases and Health Promotion Department Style Guide developed by Reda Sadki, Paris, France. Further design and layout by L’IV Com Sàrl, Morges, Switzerland. Printed in Switzerland More information about this publication can be obtained from: Department of Chronic Diseases and Health Promotion World Health Organization CH-1211 Geneva 27, Switzerland The production of this publication was made possible through the generous fi nancial support of the National Cancer Institute (NCI), USA, and the National Cancer Institute (Institut national du cancer, INCa), France. We would also like to thank the Public Health Agency of Canada (PHAC), the National Cancer Center of Korea (NCC), the International Atomic Energy Agency (IAEA) and the International Union Against Cancer (UICC) for their fi nancial support. Cancer is a leading cause of death globally. The World Health Organization estimates that 7.6 million people died of cancer in 2005 and 84 million people will die in the next 10 years if action is not taken. More than 70% of all cancer deaths occur in low- and middle-income countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent. But because of the wealth of available knowledge, all countries can, at some useful level, implement the four basic components of cancer control – prevention, early detection, diagnosis and treatment, and palliative care – and thus avoid and cure many cancers, as well as palliating the suffering. Cancer control: knowledge into action, WHO guide for effective programmes is a series of six modules that provides practical advice for programme managers and policy-makers on how to advocate, plan and implement effective cancer control programmes, particularly in low- and middle-income countries. Cancer is to a large extent avoidable. Many cancers can be prevented. Others can be detected early in their development, treated and cured. Even with late stage cancer, the pain can be reduced, the progression of the cancer slowed, and patients and their families helped to cope. iii Series overview Cancer Control Series Introduction to the 6 Prevention Knowledge into Action Cancer Control WHO Guide for Effective Programmes PREVENTION a practical guide for programme managers on how to implement effective cancer prevention by controlling major avoidable cancer risk factors. Early Detection Knowledge into Action Cancer Control WHO Guide for Effective Programmes EARLY DETECTION A practical guide for programme managers on how to implement effective early detection of major types of cancer that are amenable to early diagnosis and screening. Diagnosis and Treatment Knowledge into Action Cancer Control WHO Guide for Effective Programmes DIAGNOSIS AND TREATMENT A practical guide for programme managers on how to implement effective cancer diagnosis and treatment, particularly linked to early detection programmes or curable cancers. Palliative Care Knowledge into Action Cancer Control WHO Guide for Effective Programmes PALLIATIVE CARE A practical guide for programme managers on how to implement effective palliative care for cancer, with a particular focus on community-based care. Policy and Advocacy Knowledge into Action Cancer Control WHO Guide for Effective Programmes POLICY AND ADVOCACY A practical guide for medium level decision-makers and programme managers on how to advocate for policy development and effective programme implementation for cancer control. The WHO guide is a response to the World Health Assembly resolution on cancer prevention and control (WHA58.22), adopted in May 2005, which calls on Member States to intensify action against cancer by developing and reinforcing cancer control programmes. It builds on National cancer control programmes: policies and managerial guidelines and Preventing chronic diseases: a vital investment, as well as on the various WHO policies that have infl uenced efforts to control cancer. Cancer control aims to reduce the incidence, morbidity and mortality of cancer and to improve the quality of life of cancer patients in a defi ned population, through the systematic implementation of evidence-based interventions for prevention, early detection, diagnosis, treatment, and palliative care. Comprehensive cancer control addresses the whole population, while seeking to respond to the needs of the different subgroups at risk. COMPONENTS OF CANCER CONTROL Prevention of cancer, especially when integrated with the prevention of chronic diseases and other related problems (such as reproductive health, hepatitis B immunization, HIV/AIDS, occupational and environmental health), offers the greatest public health potential and the most cost-effective long-term method of cancer control. We now have suffi cient knowledge to prevent around 40% of all cancers. Most cancers are linked to tobacco use, unhealthy diet, or infectious agents (see Prevention module). Early detection detects (or diagnoses) the disease at an early stage, when it has a high potential for cure (e.g. cervical or breast cancer). Interventions are available which permit the early detection and effective treatment of around one third of cases (see Early Detection module). There are two strategies for early detection: • early diagnosis, often involving the patient’s awareness of early signs and symptoms, leading to a consultation with a health provider – who then promptly refers the patient for confi rmation of diagnosis and treatment; • national or regional screening of asymptomatic and apparently healthy individuals to detect pre-cancerous lesions or an early stage of cancer, and to arrange referral for diagnosis and treatment. iv Planning Knowledge into Action Cancer Control WHO Guide for Effective Programmes PLANNING A practical guide for programme managers on how to plan overall cancer control effectively, according to available resources and integrating cancer control with programmes for other chronic diseases and related problems. A series of six modules Treatment aims to cure disease, prolong life, and improve the quality of remaining life after the diagnosis of cancer is confi rmed by the appropriate available procedures. The most effective and effi cient treatment is linked to early detection programmes and follows evidence-based standards of care. Patients can benefi t either by cure or by prolonged life, in cases of cancers that although disseminated are highly responsive to treatment, including acute leukaemia and lymphoma. This component also addresses rehabilitation aimed at improving the quality of life of patients with impairments due to cancer (see Diagnosis and Treatment module). Palliative care meets the needs of all patients requiring relief from symptoms, and the needs of patients and their families for psychosocial and supportive care. This is particularly true when patients are in advanced stages and have a very low chance of being cured, or when they are facing the terminal phase of the disease. Because of the emotional, spiritual, social and economic consequences of cancer and its management, palliative care services addressing the needs of patients and their families, from the time of diagnosis, can improve quality of life and the ability to cope effectively (see Palliative Care module). Despite cancer being a global public health problem, many governments have not yet included cancer control in their health agendas. There are competing health problems, and interventions may be chosen in response to the demands of interest groups, rather than in response to population needs or on the basis of cost-effectiveness and affordability. Low-income and disadvantaged groups are generally more exposed to avoidable cancer risk factors, such as environmental carcinogens, tobacco use, alcohol abuse and infectious agents. These groups have less political infl uence, less access to health services, and lack education that can empower them to make decisions to protect and improve their own health. • Leadership to create clarity and unity of purpose, and to encourage team building, broad participation, ownership of the process, continuous learning and mutual recognition of efforts made • Involvement of stakeholders of all related sectors, and at all levels of the decision-making process, to enable active participation and commitment of key players for the benefi t of the programme. • Creation of partnerships to enhance effectiveness through mutually benefi cial relationships, and build upon trust and complementary capacities of partners from different disciplines and sectors. • Responding to the needs of people at risk of developing cancer or already presenting with the disease, in order to meet their physical, psychosocial and spiritual needs across the full continuum of care. • Decision-making based on evidence, social values and effi cient and cost- effective use of resources that benefi t the target population in a sustainable and equitable way. • Application of a systemic approach by implementing a comprehensive programme with interrelated key components sharing the same goals and integrated with other related programmes and to the health system. • Seeking continuous improvement, innovation and creativity to maximize performance and to address social and cultural diversity, as well as the needs and challenges presented by a changing environment. • Adoption of a stepwise approach to planning and implementing interventions, based on local considerations and needs. (see next page for WHO stepwise framework for chronic diseases prevention and control, as applied to cancer control). v Series overview BASIC PRINCIPLES OF CANCER CONTROL  PLANNING STEP 1 Where are we now? 1 Investigate the present state of the cancer problem, and cancer control services or programmes. WHO stepwise framework vi  PLANNING STEP 2 Where do we want to be? 2 Formulate and adopt policy. This includes defi ning the target population, setting goals and objectives, and deciding on priority interventions across the cancer continuum.  PLANNING STEP 3 How do we get there? 3 Identify the steps needed to implement the policy. The planning phase is followed by the policy implementation phase. Implementation step 1 CORE Implement interventions in the policy that are feasible now, with existing resources. Implementation step 2 EXPANDED Implement interventions in the policy that are feasible in the medium term, with a realistically projected increase in, or reallocation of, resources. Implementation step 3 DESIRABLE Implement interventions in the policy that are beyond the reach of current resources, if and when such resources become available. Series overview 1 KEY MESSAGES 2 TAKING ACTION TO PREVENT CANCER 4 CANCER RISK FACTORS 7 PLANNING STEP 1: WHERE ARE WE NOW? 10 How to assess risk factors 11 Use risk assessment to identify priorities for action to prevent cancer 15 PLANNING STEP 2: WHERE DO WE WANT TO BE? 16 What works in prevention? 17 PLANNING STEP 3: HOW DO WE GET THERE? 26 Appoint a focal point 27 Select core risk factors and core interventions 28 Control tobacco use 30 Promote a healthy diet and physical activity and the reduction of overweight and obesity 34 Reduce harmful alcohol use 36 Immunize against hepatitis B virus 38 Prepare to immunize against human papilloma virus 39 Reduce exposure to environmental carcinogens 39 Reduce exposure to occupational carcinogens 41 Reduce exposure to radiation 43 CONCLUSION 45 REFERENCES 46 ACKNOWLEDGEMENTS 48 PREVENTION MODULE CONTENTS 1 Contents PREVENTION 2 KEY MESSAGES Cancer prevention is an essential component of all cancer control plans because about 40% of all cancer deaths can be prevented. p Important cancer risk factors – such as tobacco use – are also risk factors for other chronic diseases, including cardiovascular disease and diabetes. Cancer prevention should, therefore, be planned and implemented in the context of other chronic disease prevention programmes, as well as in the context of overall cancer control planning. p Gender plays a signifi cant role in exposure to risks. p Many effective interventions to reduce cancer risk are appropriate for resource-constrained settings. p Activities that are immediately feasible and likely to have the greatest impact for the investment should be selected for implementation fi rst. This is at the heart of a stepwise approach. p Monitoring trends in cancer risk factors in the population is important for predicting the future cancer burden and for rational decision- making in terms of prioritizing scarce resources. p A comprehensive surveillance and evaluation system should be an integral element of prevention policies and programmes. p Regardless of resource level, every country can take steps to curb the cancer epidemic by undertaking primary prevention actions and thereby avoid unnecessary suffering and premature death. 3 Key messages Sridhar Reddy, 52 years old, India “ HIS TOBACCO USE AND DRINKING HABITS ARE TO BLAME, ” THE ONCOLOGIST SAYS Like millions of others in 2005, K. Sridhar Reddy died from a cancer that could have been prevented. Still a young man at the age of 52, Sridhar left behind his grieving wife and daughter, and also a substantial debt that was incurred by his treatment costs. Sridhar chewed tobacco since his teenage years and drank alcohol daily for more than 20 years. “Too much stress,” Sridhar explained when the photographer came to visit him in hospital. Sridhar had a fi rst malignant tumour removed from his right check in 2004, and a second one from his throat in 2005. By the time of his interview, his cancer had spread to his lungs and liver. Despite being cared for at the renowned Chennai Cancer Institute, Sridhar’s physicians were powerless to cure him. His cancer was simply too aggressive and sadly, Sridhar died only a short time after he was interviewed. WHO estimates that 40% of all cancer deaths is preventable. Tobacco use and harmful alcohol use are among the most important risk factors for the disease. Source: adapted from Preventing chronic diseases: a vital investment, World Health Organization, 2005. Photo © WHO/Chris de Bode. [...]... together responsible for 274 000 cancer deaths per year; harmful alcohol use – responsible for 351 000 cancer deaths per year; sexually transmitted human papilloma virus (HPV) infection – responsible for 235 000 cancer deaths per year; air pollution (outdoor and indoor) – responsible for 71 000 cancer deaths per year; occupational carcinogens – responsible for at least 152 000 cancer deaths per year... alone account for 40% of endometrial (uterus) cancer Overweight, obesity and physical inactivity collectively account for an estimated 159 000 colon and rectum cancer deaths per year, and 88 000 breast cancer deaths per year 7 PREVENTION ALCOHOL USE is a risk factor for many cancer types including cancer of the oral cavity, pharynx, larynx, oesophagus, liver, colorectum and breast Risk of cancer increases... through the WHO Global InfoBase http://infobase .who. int The WHO Regional Office for Europe also maintains an alcohol database http://data.euro .who. int/alcohol/ www HEPATITIS B VIRUS Information about the prevalence of HBV is usually available from in-country sources Links to WHO data sources on the hepatitis B virus include: l Data about hepatitis http://www .who. int/csr/disease/hepatitis/HepatitisB_whocdscsrlyo2002_2.pdf... in order to strengthen national tobacco control, particularly in low- and middle-income countries, including countries with economies in transition Information on the WHO Framework Convention on Tobacco Control is available at http://www .who. int/tobacco/framework 17 PREVENTION There are many cost -effective interventions for tobacco control (World Bank, 1999; WHO, 2004) that can be used in different... causally related to cancer of the lung, bladder, larynx and skin, leukaemia and nasopharyngeal cancer is well documented Mesothelioma (cancer of the outer lining of the lung or chest cavity) is to a large extent caused by work-related exposure to asbestos Occupational cancers are concentrated among specific groups of the working population, for whom the risk of developing a particular form of cancer may be... estimates for risk factors (tobacco use, body mass index, overweight, fruit and vegetable consumption, physical activity, alcohol use) for all chronic diseases including cancer The WHO STEPwise approach to Surveillance (STEPS) is a simple, standardized method for collecting, analysing and disseminating data on the established risk factors for chronic diseases in WHO Member States http://www .who. int/chp/steps/riskfactor/en/index.html... profiles and other information resources regarding cancer prevention and control This information is available at http://www .who. int /cancer/ en 10 www www www Planning step 1 HOW TO ASSESS RISK FACTORS TOBACCO Surveillance mechanisms are required to: p understand tobacco use patterns; p understand the effects of tobacco use in the country; p monitor the impact of tobacco control policies Information is needed...PREVENTION TAKING ACTION TO PREVENT CANCER Cancer prevention is an essential component of the fight against cancer Unfortunately, many prevention measures that are both cost -effective and inexpensive have yet to be widely implemented in many countries Cancer prevention must be considered in the context of activities to prevent other chronic diseases, especially those with which cancer shares common... estimated to cause almost all cases of cervical cancer, 90% of anal cancers and 40% of cancers of the external genitalia HPV also causes cancer of the oral cavity and the oropharynx Of the many HPV genotypes, types 16, 18 and more than 10 other types are causal for cervical cancer The most common high-risk genotypes, 16 and 18, account for about 70% of cervical cancer cases worldwide There is, however, some... consumed The risk from heavy drinking for several cancer types (e.g oral cavity, pharynx, larynx and oesophagus) substantially increases if the person is also a heavy smoker Attributable fractions vary between men and women for certain types of alcohol-related cancer, mainly because of differences in average levels of consumption For example, 22% of mouth and oropharynx cancers in men are attributable to . effective cancer control planning and implementation. ISBN 92 4 154711 1 Prevention Knowledge into Action Cancer Control WHO Guide for Effective Programmes WHO. the 6 Prevention Knowledge into Action Cancer Control WHO Guide for Effective Programmes PREVENTION a practical guide for programme managers on how to implement effective