Carolina Espina

European Code against Cancer 4th Edition: Diet and cancer

Lifestyle factors, including diet, have long been recognised as potentially important determinants of cancer risk. In addition to the significant role diet plays in affecting body fatness, a risk factor for several cancers, experimental studies have indicated that diet may influence the cancer process in several ways. Prospective studies have shown that dietary patterns characterised by higher intakes of fruits, vegetables, and whole-grain foods, and lower intakes of red and processed meats and salt, are related to reduced risks of death and cancer, and that a healthy diet can improve overall survival after diagnosis of breast and colorectal cancers. There is evidence that high intakes of fruit and vegetables may reduce the risk of cancers of the aerodigestive tract, and the evidence that dietary fibre protects against colorectal cancer is convincing. Red and processed meats increase the risk of colorectal cancer. Diets rich in high-calorie foods, such as fatty and sugary foods, may lead to increased calorie intake, thereby promoting obesity and leading to an increased risk of cancer. There is some evidence that sugary drinks are related to an increased risk of pancreatic cancer. Taking this evidence into account, the 4th edition of the European Code against Cancer recommends that people have a healthy diet to reduce their risk of cancer: they should eat plenty of whole grains, pulses, vegetables and fruits; limit high-calorie foods (foods high in sugar or fat); avoid sugary drinks and processed meat; and limit red meat and foods high in salt.

European Code against Cancer 4th Edition: Physical activity and cancer.

Physical activity is a complex, multidimensional behavior, the precise measurement of which is challenging in free-living individuals. Nonetheless, representative survey data show that 35% of the European adult population is physically inactive. Inadequate levels of physical activity are disconcerting given substantial epidemiologic evidence showing that physical activity is associated with decreased risks of colon, endometrial, and breast cancers. For example, insufficient physical activity levels are thought to cause 9% of breast cancer cases and 10% of colon cancer cases in Europe. By comparison, the evidence for a beneficial effect of physical activity is less consistent for cancers of the lung, pancreas, ovary, prostate, kidney, and stomach. The biologic pathways underlying the association between physical activity and cancer risk are incompletely defined, but potential etiologic pathways include insulin resistance, growth factors, adipocytokines, steroid hormones, and immune function. In recent years, sedentary behavior has emerged as a potential independent determinant of cancer risk. In cancer survivors, physical activity has shown positive effects on body composition, physical fitness, quality of life, anxiety, and self-esteem. Physical activity may also carry benefits regarding cancer survival, but more evidence linking increased physical activity to prolonged cancer survival is needed. Future studies using new technologies - such as accelerometers and e-tools - will contribute to improved assessments of physical activity. Such advancements in physical activity measurement will help clarify the relationship between physical activity and cancer risk and survival. Taking the overall existing evidence into account, the fourth edition of the European Code against Cancer recommends that people be physically active in everyday life and limit the time spent sitting.

European Code against Cancer 4th Edition: 12 ways to reduce your cancer risk

This overview describes the principles of the 4th edition of the European Code against Cancer and provides an introduction to the 12 recommendations to reduce cancer risk. Among the 504.6 million inhabitants of the member states of the European Union (EU28), there are annually 2.64 million new cancer cases and 1.28 million deaths from cancer. It is estimated that this cancer burden could be reduced by up to one half if scientific knowledge on causes of cancer could be translated into successful prevention. The Code is a preventive tool aimed to reduce the cancer burden by informing people how to avoid or reduce carcinogenic exposures, adopt behaviours to reduce the cancer risk, or to participate in organised intervention programmes. The Code should also form a base to guide national health policies in cancer prevention. The 12 recommendations are: not smoking or using other tobacco products; avoiding second-hand smoke; being a healthy body weight; encouraging physical activity; having a healthy diet; limiting alcohol consumption, with not drinking alcohol being better for cancer prevention; avoiding too much exposure to ultraviolet radiation; avoiding cancer-causing agents at the workplace; reducing exposure to high levels of radon; encouraging breastfeeding; limiting the use of hormone replacement therapy; participating in organised vaccination programmes against hepatitis B for newborns and human papillomavirus for girls; and participating in organised screening programmes for bowel cancer, breast cancer, and cervical cancer.

European Code against Cancer 4th Edition: Medical exposures, including hormone therapy, and cancer

The 4th edition of the European Code against Cancer recommends limiting - or avoiding when possible - the use of hormone replacement therapy (HRT) because of the increased risk of cancer, nevertheless acknowledging that prescription of HRT may be indicated under certain medical conditions. Current evidence shows that HRT, generally prescribed as menopausal hormone therapy, is associated with an increased risk of cancers of the breast, endometrium, and ovary, with the risk pattern depending on factors such as the type of therapy (oestrogen-only or combined oestrogen-progestogen), duration of treatment, and initiation according to the time of menopause. Carcinogenicity has also been established for anti-neoplastic agents used in cancer therapy, immunosuppressants, oestrogen-progestogen contraceptives, and tamoxifen. Medical use of ionising radiation, an established carcinogen, can provide major health benefits; however, prudent practices need to be in place, with procedures and techniques providing the needed diagnostic information or therapeutic gain with the lowest possible radiation exposure. For pharmaceutical drugs and medical radiation exposure with convincing evidence on their carcinogenicity, health benefits have to be balanced against the risks; potential increases in long-term cancer risk should be considered in the context of the often substantial and immediate health benefits from diagnosis and/or treatment. Thus, apart from HRT, no general recommendations on reducing cancer risk were given for carcinogenic drugs and medical radiation in the 4th edition of European Code against Cancer. It is crucial that the application of these measures relies on medical expertise and thorough benefit-risk evaluation. This also pertains to cancer-preventive drugs, and self-medication with aspirin or other potential chemopreventive drugs is strongly discouraged because of the possibility of serious, potentially lethal, adverse events.

European Code against Cancer 4th Edition: Process of reviewing the scientific evidence and revising the recommendations

The European Code Against Cancer is a set of recommendations to give advice on cancer prevention. Its 4th edition is an update of the 3rd edition, from 2003. Working Groups of independent experts from different fields of cancer prevention were appointed to review the recommendations, supported by a Literature Group to provide scientific and technical support in the assessment of the scientific evidence, through systematic reviews of the literature. Common procedures were developed to guide the experts in identifying, retrieving, assessing, interpreting and summarizing the scientific evidence in order to revise the recommendations. The Code strictly followed the concept of providing advice to European Union citizens based on the current best available science. The advice, if followed, would be expected to reduce cancer risk, referring both to avoiding or reducing exposure to carcinogenic agents or changing behaviour related to cancer risk and to participating in medical interventions able to avert specific cancers or their consequences. The information sources and procedures for the review of the scientific evidence are described here in detail. The 12 recommendations of the 4th edition of the European Code Against Cancer were ultimately approved by a Scientific Committee of leading European cancer and public health experts.

Delayed presentation and diagnosis of breast cancer in African women: a systematic review

Purpose Africa has low breast cancer incidence rates but high mortality rates from this disease due to poor survival. Delays in presentation and diagnosis are major determinants of breast cancer survival, but these have not been comprehensively investigated in Africa. Methods MEDLINE, Embase, and Global Health were searched to identify studies reporting on delays in presentation and/or diagnosis of breast cancer published between January 1, 2000 and May 31, 2016. Data were synthesized in narrative, tabular, and graphical forms. Meta-analyses were not possible due to between-study differences in the way delays were reported. Results Twenty-one studies were included in the review. Study-specific average times between symptom recognition and presentation to a health care provider ranged from less than 1 to 4 months in North Africa and from less than 3 to greater than 6 months in sub-Saharan Africa. Study-specific average times from presentation to diagnosis were less than 1 month in North Africa but ranged from less than 3 to greater than 6 months in sub-Saharan Africa. Reported reasons for these delays included patient-mediated (e.g., socioeconomic factors) and health system–mediated factors (e.g., referral pathways). Conclusions This systematic review revealed marked delays in presentation and diagnosis of breast cancer in Africa. Identification of their drivers is crucial to the development of appropriate control strategies in the continent.

Cancer prevention policy in the EU: Best practices are now well recognised; no reason for countries to lag behind

Highlights • National Cancer Control Programmes (NCCPs) are key elements in cancer control.• NCCPs’ role in national cancer policies of EU countries has grown significantly.• Few quantitative assessments are available to evaluate success or failure of the implementation of NCCPs.• Research on methodologies to better assess the effectiveness of cancer prevention policies should be enhanced.