health and well-being and to overcome resistance from the private sector. Strong legal frameworks must be supplemented by effective public health messages to influence perceptions of cancer risk factors and promote behavioural change (Box 3.3;
26).
Application of “best buys” to reduce tobacco and alcohol use and inadequate physical activity was evaluated in seven countries in Asia (Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam). Progress was observed in regulation and awareness, such as advertising of alcohol, restrictions on sales (except in one country) and mass media campaigns against smoking. Few countries met the WHO FCTC requirement for taxes on tobacco, and only two had activities to increase physical exercise. The poor results were related to inadequate funding, limited institutional capacity, difficulty in implementing multisectoral actions and lack of monitoring systems and also to resistance from the private sector to some policies.
Similar slow, uneven implementation of
“best buys” was observed in five African countries (Cameroon, Kenya, Malawi, Nigeria and South Africa). Implementation research should be conducted on effective interventions for “best buys” in LMIC, with greater political support and resources to improve uptake of evidence-based programmes and policies (21—23).
Box 3.2. Case study: implementing WHO “best buys”
in cancer prevention programmes
Box 3.3. Case study: Effective messaging in cancer prevention
There have never been so many means to communicate sound evidence on the prevention of cancer. Social media have extended the ways of reaching target populations and delivering tailored messages to specific groups. Reminders and text messages to people over 55 to increase their physical activity, apps for setting goals, activity tracking and reminders and websites with virtual coaching have been shown to be effective (26). For example, a digital intervention
increased physical activity by 28% more than a non-digital intervention. Social media activities could be combined with more traditional approaches, such as printed leaflets. Use of social media should be optimized to the target population and the characteristics of the message. For instance, in an analysis of Facebook pages related to cancer in Brazil,
“testimonies” or “real-life stories” generated high engagement but were posted in only a small percentage of cases.
Decisions on the main targets for primary prevention of cancer should involve all relevant stakeholders, from government to civil society, at all levels of planning, implementation and evaluation of programmes. Priorities for interventions should be set according to the importance of each risk factor in the country, the pattern of incident cancers and the potential success of prevention interventions, in addition to the most efficient use of resources. First, governments could evaluate the risk factors that significantly affect the population, exacerbate inequities and stall economic growth.
One measure of the burden of a risk factor is the “population attributable fraction”, which is the estimated proportional reduction in population disease or mortality that would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario. Preventive interventions could also be evaluated by tumour site or by prevention strategy to facilitate priority-setting (Table 3.2).
Section II 64
Factor Sample carcinogenic
risk factor PAF Prevention strategy Multisectoral partners
Behavioural Tobacco
Reduced alcohol consumption (SAFER) Nut rition (ENA) and physical activity interventions (Global action plan on physical activity 2018-2030)
Hepatitis B and C H. pylori
13%b,f Vaccination
Early diagnosis and treatment of infections (e.g. H. pylori)
Health care workers Pharmaceutical companies Legislative bodies
Civil society Environmental Occupational exposures
Air pollution Ultraviolet radiation Radon and other radiation Aflatoxins
3-8%a,g 5%a,h 1%b,i
Environmental standards and regulations Robust energy policies, reduction of household kerosene
Regulation, justification and optimization of procedures.
Hereditary risk factors 5-10%a,j Chemoprevention, surgical procedures (e.g.
prophylactic mastectomy)
Health care workers Genetic counsellors Pharmaceutical companies Civil society
Table 3.2. Types of interventions for primary prevention of cancer
Adapted from reference 27. PAF, population attributable fraction;
MPOWER, set of six cost-effective and high impact measures that help countries reduce demand for tobacco; SAFER, set of five high-impact strategies to prevent and reduce alcohol harm and related health, social and economic consequences; ENA, essential nutrition
a Percentage reflects PAF for deaths from relevant cancer types b Percentage reflects PAF for cases from relevant cancer types c Global health data exchange. Seattle (WA): Institute for Health Metrics and Evaluation; 2020 (http://ghdx.healthdata.org/ihme_
data, accessed January 2020).
d Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018 (https://www.who.int/substance_abuse/
publications/global_alcohol_report/en/, accessed January 2020).
e Arnold M, Pandeya N, Byrnes G, Renehan PAG, Stevens GA, Ezzati PM, et al. Global burden of cancer attributable to high body-mass index in 2012: a population-based study. Lancet Oncol.
2015;16(1):36 -46.
f de Martel C, Georges D, Bray F, Ferlay J, Clifford GM. Global burden of cancer attributable to infections in 2018: a worldwide incidence analysis. Lancet Glob Health.
g Preventing disease through a healthier and safer workplace.
Geneva: World Health Organization; 2018 (https://www.who.int/
publications-detail/preventing-disease-through-a-healthier-and-safer-workplace,
h Ambient air pollution: a global assessment of exposure and
Comprehensive primary prevention should include all measures, from health promotion to clinical interventions, and involve all sectors to maximize its impact.
Prioritizing health promotion: In the Shanghai Declaration (2016), governments made a commitment to increase investment in all pillars of health promotion (good governance, healthy cities and health literacy) to achieve the SDGs (28; see also chapter 2.2) The aim of all such activities should be to deliver knowledge, skills and information to allow healthy choices and behaviour change.
Health literacy ensures equitable access to information on cancer prevention and better health outcomes; however, education must be accompanied by an enabling environment and supportive
3.4 Integrated approach to cancer primary prevention
national policies (29,30). Health messages must be consistent and coordinated to avoid misinterpretation. Both mass media campaigns and programmes in schools have been shown to be effective in optimizing nutrition and physical activity (31). Public health messages about risks of skin cancer from solar radiation for specific populations and residential radon exposure is also effective for specific populations (15, 16).
The approach used in the European Union (with technical support from IARC and the European Code against Cancer) is a simple, clear, comprehensive, evidence-based set of 12 messages for preventing cancer (Box 3.4).
burden of disease. Geneva: World Health Organization; 2016 (https://
apps.who.int/iris/bitstream/handle/10665/250141/9789241511353-eng.pdf?sequence=1,
i Cancers attributable to UV radiation (website). Lyon: International Agency for Research on Cancer; 2020 (http://gco.iarc.fr/causes/uv/
home, accessed January 2020).
j Wild CP, Weiderpass E, Stewart BW, editors. World cancer report.
Cancer research for cancer prevention. Lyon: International Agency for Research on Cancer; 2019:section 3.3 (https://apps.who.int/iris/
bitstream/handle/10665/326043/9789241516204-eng.pdf?ua=1, accessed January 2020).
TO REDUCE
are exposed to radiation from high radon levels in your home; reduce high radon levels.For women: To reduce your child’s risk of cancer, ensure that your children are vaccinated against:
Take part in organized cancer screening programmes for:
11.
Do not smoke or use
any form of tobacco. Make your home smoke-free, and support smoke-free policies in your workplace.
Maintain a healthy
body weight. Be physically active in everyday life, and limit the time you spend sitting.
Eat a healthy diet. Limit your intake of alcohol of any type, or don’t drink alcohol.
Avoid too much exposure to the sun, especially children; use sun protection; do not use sunbeds.
In the workplace, protect yourself against
cancer-causing substances by following health and safety instructions.
bowel cancer (men and women), breast cancer (women) and cervical cancer (women).
hepatitis B (for newborns) and human papillomavirus (HPV).
Breastfeed your baby if you can, as breastfeeding reduces your risk for cancer.
Limit the use of hormone replacement therapy, which increases the risks for certain cancers.
Eat a lot of whole grains, pulses, vegetables and fruit.
Limit consumption of high-calorie foods (high in sugar or fat), and avoid sugary drinks.
Avoid processed meat, and limit red meat and foods with a high salt content.
Box 3.4. European Code against Cancer: 12 ways to reduce cancer risk Source: reference 32
Fiscal, legislative and regulatory measures to reduce exposure:
Policies to reduce exposure to cancer risk factors have a demonstrable, well-established impact. Major progress in reducing the prevalence of tobacco use has been achieved through implementation of WHO FCTC measures. Stringent prohibition
and regulation of tobacco consumption reduce exposure, generate further political will and provide long-term health benefits (3,33).
Countries with fewer public health warnings and fewer restrictions on the promotion, advertising and sponsorship of tobacco products become targets for tobacco companies, particularly as Section II 66