Carcinogenesis Advance Access originally published online on May 18, 2006
Carcinogenesis 2006 27(6):1126-1127; doi:10.1093/carcin/bgl020
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ANTHONY DIPPLE CARCINOGENESIS AWARD |
Cancer prevention: strategy for the future
Department of Medicine, Department of Cell/Developmental Biology and Department of Cancer Biology, The Vanderbilt-Ingram Cancer Center, Nashville, TN 37232, USA
To whom correspondence to be addressed at: The Vanderbilt-Ingram Cancer Center, 698 Preston Research Building, 2300 Pierce Avenue, Nashville, TN 37232-6838, USA Email: raymond.dubois{at}vanderbilt.edu
Practicing physicians today are mostly focused on caring for patients who present with symptoms of advanced or chronic diseases like cancer. However, over the past several years, the idea of prevention has been worming its way into our collective psyche. Many of us have begun to think that we may be able to devise ways to detect and treat many different types of cancer before they reach advanced stages. Is this really possible? Considering the rapid progress being made in genomic and proteomic technology, there might be reason to hope that we will assess risk and predict the onset of disease long before it occurs. This is commonly referred to now as ‘personalized medicine’ or in this case ‘personalized oncology.’ Using cardiovascular disease as a benchmark, over the past few decades, cardiologists have achieved great success in extending survival and in preventing end-stage disease by having patients modulate their cholesterol and/or take drugs such as aspirin to modify their risk. Can we expect to see these same kind of successes in oncology? Things appear to be moving in that direction.
The International Agency for Research on Cancer (IARC) has established a mission to coordinate and conduct research on the causes of human cancer, the mechanisms of carcinogenesis, and to develop scientific strategies for cancer control. This organization aims to find effective approaches for cancer prevention, which includes both primary prevention and early detection. IARC studies cancer incidence, mortality and survival in numerous countries and plays a leading role in cancer registration worldwide. In a similar fashion, the Office of Disease Prevention and Health Promotion in the U.S. Department of Health and Human Services (HHS) works to strengthen disease prevention and health promotion priorities in the United States. Along these lines, the department has supported the ‘Healthy People 2010’ initiative, which challenges individuals, communities and professionals to take specific steps to ensure that good health, as well as long life, is enjoyed by all. Not surprisingly, the leading health indicators include physical activity, weight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization and access to health care. Some individual states in the United States have even adopted plans to improve the health of citizens within their region of the country. This issue has gained some national attention. HHS Secretary Mike Leavitt has put forth his 5000-day plan to improve the health of the citizens in this country. A key element of this plan involves novel, early cancer prevention and detection strategies to increase healthy life potential since cancer is more curable when detected at an early stage. A simple ban on smoking in all public places could have an enormous impact.
Prevention strategies can be successfully applied to most types of cancer. Some of these strategies will depend on additional research to develop advanced technologies. A short list of some health conditions that relate to increased cancer risk with a preventable component include obesity—by modifying caloric intake and physical activity; gastrointestinal malignancies; viral hepatitis (especially Hepatitis B since effective vaccines are available); Helicobacter pylori-related complications, such as gastric cancer, hepatocellular carcinoma related to hemochromatosis; and several others. On the other hand, physicians all over the world are faced with the difficult task of modifying patient behaviors that affect disease risk. Soon, over 20% of our population will be older than 65 years of age, utilizing perhaps 50% of our total health-care costs. Given that an aging population will certainly expand the number of people diagnosed with cancer, we must strengthen our resolve to focus on prevention. Cancer will become a chronic disease, like diabetes and hypertension, which requires long-term care and periodic intervention.
Colorectal cancer is a great example of a disease in which the general physician, subspecialist and cancer biologist can play major roles in disease prevention. Most cancers are highly curable when detected early, and the detection and removal of precancerous adenomatous polyps can prevent the disease. The National Cancer Institute Colorectal Cancer Progress Review Group, co-chaired by Drs DuBois and Levin some years ago, concluded that wider use of screening could save 
20 000 lives annually. Despite the acknowledged benefits of screening, studies indicate that the majority of Americans are not being screened for colorectal cancer. Only 20–30% of the target population over 50 is actually getting screened appropriately. In the past, we faced a similar challenge of low compliance rates for breast cancer screening. However, remarkable progress has been made in increasing health-care professionals' endorsement of screening and women's use of mammography and clinical screening approaches. Now, 80% of women aged 
40 years have undergone a mammogram in this country—which has led to a significant decline in breast carcinoma mortality rates. Some of this success has been driven by ‘action groups,’ which raise awareness of screening to the public and government leaders.
Taking a lesson from breast cancer advocacy groups, we can continue to exert the same efforts for saving those at risk for developing colorectal cancer. The first step, certainly, is to incorporate more aspects of disease prevention into our training programs. In addition, this problem needs to be addressed in a multipronged assault, including public and professional education; establishing a nationally and internationally accepted screening policy for all practitioners; engaging health policy makers, health insurance agencies and appropriate government officials in the process; devoting resources for the development of easier and more efficient screening techniques; and decreasing overall costs associated with screening. Only when we begin working together and attacking this problem on several fronts will we be able to notice positive changes in cancer prevention. The impact of these efforts will be long-lasting and worldwide.
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