Cancer epidemiology and prevention: opportunities, priorities and barriers to progress Julian Peto UKACR Sept 29th 2004 London School of Hygiene and Tropical Medicine, and The Institute of Cancer Research Cancer rates in migrants become similar to those in the local population Cumulative rate by age 75 (%) 15 Osaka 1970-71 Osaka 1988-92 10
Hawaiian Japanese 1988-92 Hawaiian Caucasian 1968-72 Hawaiian Caucasian 1988-92 5 0 prostate colon (m) stomach (m) breast (f)
Conclusion: Cancer rates in migrants show that most human cancer is environmental it is avoidable by a suitable lifestyle. Non sequitur: Most human cancer is caused by carcinogens in the environment. There is a gradually developing myth, partly promoted by those who derive a psychopathological delight in spreading alarm, that most human cancer is the result of an exposure to chemicals in the environment. John Barnes (1974) Essays in Toxicology 5: 5-15. 200 180
Annual m ale m esotheliom a deaths. A nnual U K asbestos im ports (1000 tons). UK asbestos imports & predicted mesothelioma deaths in men born before 1953 Average TEM concentrations of asbestos fibres >5um long before, during and after an asbestos removal programme from 0.1 a six-storey teaching block (Burdett et al 1989) TEMconcentrationof asbestos (f/ml). 0.065 0.01
0.008 0.0058 0.001 0.0004 <0.0003 <0.0002 0.0001 before removal 2 weeks (no activity) 9 weeks
(refurbishment) 26 weeks (refurbishment) 35 weeks (normal occupation) ambient (outside building) Sellafield Radioactive alpha discharges to the sea and authorised limits 6000 5000 Curies
25 30 Body mass index 35 40 45 Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease Collaborative Group on Hormonal Factors in Breast
Cancer Lancet (2002) 360:187-195 Reduction in risk: 3.0% per year for earlier age at first birth 7.0% per birth 4.3% per year of breastfeeding Predicted reduction in Western breast cancer rates if women had 6 or 7 children and breastfed each child for 2 years Lancet (2002) 360: 187-95 Since the introduction of screening and improvements in chemotherapy, UK breast cancer mortality below age 70 has fallen while incidence has risen 140 Incidence
Reduction in British cervical cancer mortality due to screening. (Peto et al (2004) Lancet 364:249-56) 6000 Cervical cancer deaths under age 75 that would have occurred without screening Annual deaths 5000 4000 Start of national screening programme in 1988
3000 2000 1000 Projected future mortality with improvements in screening British deaths up to 2000 0 1955 1965 1975 1985
1995 Year 2005 2015 2025 2035 UK cervical cancer trends Mortality trends in young women before the national cervical screening programme began in 1988 suggest that the UK cervical cancer rate would have increased to become one of the highest in the world.
About 10,000 future cases and 5,000 future deaths per year are now being prevented by cervical screening. UK male lung cancer mortality Largest reduction in the world, due to reduction in smoking among men (but much less among women) UK breast cancer mortality Largest reduction in the world, due to (i) Prolonged (5 years) tamoxifen treatment (ii) National breast screening programme (iii) Cytotoxic chemotherapy UK colorectal and prostate cancer mortality Substantial and continuing reduction, due to improvements in treatment and some screening UK mesothelioma mortality Continuing increase in old age, but large reduction in men aged under 45 since 1990 due to abrupt reduction
in asbestos use since the 1970s. Percentage of US cancer deaths that would be avoided by eliminating known risks Peto (2001) Nature 411: 390 Cause Current smokers Nonsmokers Smoking Known infections Alcohol Sunlight Air pollution
Occupation Lack of exercise Diet Overweight (BMI>25kg m 2) Other dietary factors Presently unavoidable 60 2 0.4 0.4 0.4 0.4 0.4 5 1
1 1 1 1 4 10 4 - 12? 10 - 30? About a quarter At least half The role of the influential expert in medical research and data protection Influential experts:
1. Roy Meadow Influential experts: 2. Ian Kennedy Kennedy told a Select Committee that HIV testing the anonymised discarded residue of blood samples from all pregnant women was unethical because a test must confer some benefit on the patient. October 2000: Revised Declaration of Helsinki Paragraph 1: All types of medical research, including epidemiology, are subject to the Declaration of Helsinki. The World Medical Association has developed the Declaration of Helsinki as a statement of ethical principles to provide guidance to physicians and other participants in medical research involving human subjects. Medical research involving human subjects includes research on identifiable human
material or identifiable data. Paragraph 9: These regulations should have the status of an international law. No government or ethical committee should be allowed to alter them. No national ethical, legal or regulatory requirement should be allowed to reduce or eliminate any of the protections for human subjects set forth in this Declaration. Paragraph 27: The results of any research that does not obey these rules should be suppressed. Reports of experimentation not in accordance with the principles laid down in this Declaration should not be accepted for publication. The Data Protection Act in the real world British medical research has become impossibly cumbersome and expensive. Humberside police erased the records of Ian Huntleys
sexual offences involving children because he had not been convicted. The General Medical Council instructed doctors that they might face litigation under the Data Protection Act if they notified their patients to cancer registries without obtaining fully informed consent. It is the Act, not police or medical training, that must be amended. Influential experts: 3. Lord Falconer Data can be used for any medical research purpose under the [Data Protection] Act, without the need for the consent of individuals. So Professor Julian Peto is simply wrong when he states that the Data Protection Act is preventing data from being passed to medical
researchers. (Lord Falconer. Letter to The Times, May 17th 2001.) It is alarming that those who enact and interpret radical social legislation should be so ignorant of its actual effects. (J Peto, BMJ editorial, May 1st 2004) Parliamentary Group on Cancer public meeting (Nov 5th 2002) 93% of the audience voted for this proposed law: 'Consent is not required for access to medical records for non-commercial medical research that has no effect on the individuals being studied and has been approved by an accredited research ethics committee.'
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