11 Cancer

Burden, epidemiology and principles

for priority interventions
Hesham Gaafar, May Abdel-Wahab,
Pascal Bovet, André Ilbawi

This chapter provides a brief overview of the burden, epidemiology, public health
impact and main principles for the prevention and treatment of cancer, one of
the four diseases in the WHO Global NCD Action Plan. Cancer has a significant
socio-economic impact on individuals and their families. A substantial propor-
tion of cancer cases is attributable to the main modifiable NCD risk factors (e.g.
tobacco, unhealthy diet, alcohol, physical inactivity). A small number of cancers
(e.g. breast, cervical, colorectal and prostate), that together are responsible for 30%
of all cancer cases, are described in more detail in other chapters.

Disease burden
Epidemiological data on cancer are widely available.1,2,3,4 Cancer causes one in
six deaths globally. Lung, prostate, colorectal, stomach and liver cancers are the
most common types of cancer in men, while breast, colorectal, lung, cervical
and thyroid cancers are the most common among women. As the incidence of
cancer sharply increases with age, the lifetime risk of developing cancer is large,
e.g. 40–50% among men and 35–45% among women where life expectancy at
birth exceeds the age of 75–80 years. Table 11.1 provides data on the leading
causes of cancer deaths.5 Overall, the total number of people, or proportions
of the population, with cancer has increased between 1990 and 2019 in all
country-income group categories. However, the age-adjusted mortality rates
for cancer as a whole (which express the risk of developing cancer irrespec-
tive of population growth and age distribution) have decreased in all country-
income groups, although there has been an increase for a few specific cancers
(e.g. colon cancer in all country-income groups except HICs).

Cancer trends
The projected number of people living with, or dying from, cancer depends
on changes in several variables: life expectancy and population growth, expo-
sure to risk factors, screening and treatment. As a result, the total number of
cancer cases will increase in the coming years in most populations, particularly
in low- and middle-income countries. However, the trends in age-adjusted

DOI: 10.4324/9781003306689-13
Table 11.1 Mortality and fractions of mortality attributable to modifiable risk factors for leading cancers

All cancers Lung Colon Stomach Breast Oesophagus Prostate Liver Cervix
1990 2019 1990 2019 1990 2019 1990 2019 1990 2019 1990 2019 1990 2019 1990 2019 1990 2019
Number of deaths 5.75 10.1 1.1 2.0 0.52 1.1 0.78 0.96 0.38 0.70 0.32 0.50 0.23 0.49 0.37 0.48 0.19 0.28
(106)
Percent of all deaths
84 Hesham Gaafar et al.

All countries 12.3 17.8 2.3 3.6 1.1 1.9 1.7 1.7 0.82 1.2 0.68 0.88 0.50 0.86 0.78 0.86 0.40 0.50
High income 25.1 28.9 5.7 6.4 3.2 3.8 2.3 1.7 2.0 1.9 0.65 0.80 1.4 1.8 0.7 1.2 0.38 0.31
Upper middle 15.9 22.1 2.9 5.3 1.1 2.3 3.0 2.9 0.70 1.1 1.4 1.6 0.4 0.82 1.7 1.3 0.46 0.56
income
Lower middle 5.7 10.7 0.74 1.4 0.40 1.0 0.67 0.84 0.51 1.1 0.22 0.38 0.2 0.50 0.20 0.41 0.34 0.47
income
Low income 4.0 7.5 0.34 0.69 0.21 0.47 0.48 0.71 0.28 0.68 0.28 0.50 0.2 0.50 0.20 0.35 0.44 0.75
Age-standardized mortality rates (per 100,000)
High income 168 135 37 30 21 17 16 7.5 14 9.4 4.4 3.9 9.2 7.5 4.7 5.6 2.7 1.6
Upper middle 158 132 29 31 12 14 30 17 6.8 6.6 14 9.2 5.1 5.3 16 7.5 4.4 3.3
Lower middle 98 97 13 13 7.8 9.5 12 7.8 8.4 9.6 4.1 3.5 5.3 5.6 3.6 3.7 5.4 3.9
Low income 120 114 12 12 7.3 8.1 16 12 8.6 10.3 9.2 8.2 9.4 10.2 6.4 5.4 12 10.4
Attributable fractions (% of cancer mortality contributed by modifiable risk factor)
Tobacco 26 66 13 17 5 41 6 16 8
Dietary risk 7 4 34 7 3 13
Alcohol 5 9 5 22 19
Low physical 1 5 1
activity
High BMI 5 8 6 17 12
Drug use 14
Unsafe sex 2 98
Particulate matter 4 19
(pollution)
Occupational risk 3 14
Other 1 4
environmental
Red colour means an increase between 1990 and 2019; green colour, a decrease.
Cancer 85
86 Hesham Gaafar et al.
incidence of different cancers depend on trends in the prevalence of risk factors
in populations. Examples include:
• The decrease in tobacco use observed in many countries will lead to a
reduction in age-adjusted rates of oral, throat and lung cancers.
• The increase in levels of obesity, together with the increasing consump-
tion of ultraprocessed food, will lead to an increase in age-adjusted rates of
colon cancer in many populations.
• Increased vaccination coverage for human papillomavirus (HPV) and hep-
atitis B virus (HBV) will lead to a decrease in age-standardized incidence
of cervical and liver cancers, respectively.
The role of screening programmes is also important. Screening, along with
early diagnosis and treatment, has resulted in a 20% decrease in premature mor-
tality from cancer between 2000 and 2015 in HICs, and 5% in LICs.

Interventions at the population level

Table 11.1 shows that around one-half of all cancer deaths could be prevented
if modifiable risk factors were eliminated in the whole population (with 36%
of all cancer deaths attributable to tobacco and 7% to unhealthy diet). For lung
cancer, 66% of deaths are attributable to tobacco use and 19% to air pollution.
For cervix cancer, 98% of mortality is attributable to unsafe sex (through HPV
infection). These relationships underlie the importance of population-based
prevention interventions, which can range from taxing unhealthy products
such as tobacco or alcohol to HPV and HBV vaccination. At least 5–10% of
all cancers have a strong genetic component.4 Improved understanding of the
genetic causes of cancer is providing new opportunities for cancer prevention
(e.g. risk prediction, family counselling) and treatment (e.g. different treatments
according to genetic markers) and will continue to do so in future (Chapter 29).

Cancer control programmes

Comprehensive cancer control refers to the broad implementation of ethical and
proven measures to actively address the burden of cancer. Approaches should
range from prevention, early detection (including early diagnosis and screening)
to treatment, palliative care and rehabilitation. This also includes, ideally, a can-
cer registry and surveillance to strengthen the delivery of services and monitor
cancer programmes. Comprehensive cancer control programmes aim to reduce
the incidence, morbidity and mortality of cancer and to improve the quality of
life of cancer patients. These programmes should engage all levels of the national
health system and reach the entire population, from the healthy to those at high
risk (e.g. those with a family history) and to patients who are yet to show symp-
toms, have been diagnosed, are cured or are in the final stages of the disease.6
With access to the right treatment, many people with cancer can be cured
and/or treated effectively. It is therefore important that countries aim to increase
the resources available to cancer control programmes. These programmes
 Cancer 87
should prioritize the early detection of cancers that can be cured through early
treatment available in a particular setting and provide palliative/survivorship
care for less curable cancers.

Early detection
Early detection of cancer (through clinical presentation, or systematic or
opportunistic screening) is important, as is rapid treatment following cancer
detection, to maximize the prognosis for the patient. This approach assumes
even greater importance in the absence of organized systematic screening pro-
grammes targeting the general population.
Organized systematic cancer screening programmes aim to detect early
pre-cancer or cancer signs among asymptomatic individuals to reduce can-
cer incidence and/or outcomes (e.g. case-fatality rates and overall mortality).
Such programmes typically target the whole population of a certain age (e.g.
screening all women aged 30–49 years with a visual inspection, Pap smear or
HPV testing; this is a WHO best buy intervention). These programmes require
significant resources, and even in countries with well-run programmes, only
5% of all cancers are detected through screening (the greatest impact being
for cervical, breast and colorectal cancers).4 Screening programmes require
high participation rates and quality assurance to be effective. The availability
of a test is not sufficient for the establishment of a screening programme (see
Chapter 43 on screening and health checks). It is also important to recognize
that screening programmes, once initiated, are often very difficult to stop.
Many countries therefore pilot their programmes ahead of the full roll-out.

Treatment
Under optimal conditions, many cancers can now be effectively cured or
treated in a way that allows many years of productive life. Local and systemic
treatment (including a mix of one or several from surgery, radio-, chemo-, hor-
mone- and/or immunotherapy components) can all be effective, but resource
constraints may preclude their use in many countries. Rapid advances con-
tinue to be made, with up to 40% of all clinical trials in 2020 being in oncol-
ogy.4 Robust processes and mechanisms need to be in place to make decisions
around if, when and how new treatment should be introduced and sustained
(Chapter 45 on medical technologies), and to ensure that once introduced
treatment is accessible and affordable for everyone.7

Palliative and supportive care

Palliative and supportive care provides for the psychological, social and spiritual
needs of the patient and their family, as well as pain relief (including access to
opiate analgesia), fatigue, sleep deprivation, cognitive impairment, concerns
88 Hesham Gaafar et al.
about relationships and fertility, work and finances, and fear of recurrence
issues.8,9 Patient support groups have the potential to play an important role in
supporting people with cancer (Chapter 55).

An integrated approach to cancer services

National cancer control programmes, particularly in low-resource settings,
should focus on value for money (i.e. cost-effectiveness and affordability, and
not only effectiveness) with the appropriate selection and maintenance of
affordable innovative technologies (Chapter 44 and Chapter 45 on access to
medicines and medical technologies). An essential package of cancer services
can cost only US$ 2–9 per capita in low- and middle-income countries, yet
only 40% of national programmes in these countries include cancer in their
universal health coverage benefit packages.10 Diagnosis, treatment and care of
people with cancer require investing in well-trained multidisciplinary person-
nel (including protocols to be in place and being used) as well as the necessary
equipment and consumables. Many low- and middle-income countries have
an insufficient technical capacity and lack adequately trained staff to deliver a
well-functioning cancer control programme.11
Patient navigators are an important part of a comprehensive cancer con-
trol programme providing assistance to patients through screening, diagnosis,
treatment and follow-up. This includes assisting patients in: (i) communicating
with healthcare providers; (ii) setting up appointments for medical visits; (iii)
getting financial, legal and social support; (iv) liaising with insurance companies
and employers; and (v) initiating and/or completing treatment.

Cancer registries
Less than half of all countries report on cause-specific deaths and only a small
number of people with cancer are included in high-quality population-based
cancer registries. Cancer registries systematically collect, store and manage data
on persons who have been diagnosed with and/or treated for cancer.12 When
implemented effectively, cancer registries can be cost-saving institutions.13 Yet,
only one in three countries has high-quality incidence data.
Registries can be categorized as population-based cancer registries (PBCRs)
or hospital-based cancer registries (HBCRs). PBCRs focus on a particular geo-
graphical area, generating data for epidemiological and public health purposes,
including monitoring trends, distribution and priority setting. HBCRs collect
data within a particular facility (or several or all hospitals of a region), often
using data for administrative, research and educational functions. Findings from
PBCRs may have broader generalizability to the whole population but with
less detailed data, while findings from HBCRs may have lower generalizability
to the whole population (as not all cancer patients access hospitals) but can
 Cancer 89
include more detailed information (e.g. detailed information on treatment,
follow-up, etc.).
Frameworks need to be developed that encourage diagnostic and treatment
services (both public and private) to share relevant data (e.g. biopsy results,
staging, outcomes) while ensuring there are adequate levels of data protection.
It is crucial that data are held securely so that healthcare workers can confi-
dently encourage patients to provide informed consent to share personal data
so that registries can maximize their potential as a resource for monitoring and
evaluating health services, and for research.
Data on both PBCRs and HBCRs should be linked with well-functioning
civil mortality registration systems in the entire population (e.g. vital statistics)
to obtain reliable information on deaths and causes of death, but this is avail-
able in less than half of the world population. Civil registration data for the
whole population (including age distribution) are also necessary to produce
estimates of cancer frequency at the population level. In addition, cancer regis-
tries should be linked to, among others, vaccine and cancer screening registries
for maximal utility.
Two of the indicators in the WHO NCD Global Monitoring Framework
are dependent on functional cancer registries, allowing for reporting at national,
regional and global levels (Chapter 35).

Monitoring
SDG target 3.4.1
A one-third relative reduction in mortality from cardiovascular disease
(CVD), cancer, diabetes or chronic respiratory disease by 2030 against a 2015
baseline.

Other relevant WHO NCD Global Monitoring Framework targets and

indicators

Target Indicator
As per SDG target 3.4.1. • Unconditional probability of dying between the ages
of 30 and 70 from CVD, cancer, diabetes or chronic
respiratory diseases.
An 80% availability • Availability and affordability of quality, safe and
of affordable basic efficacious essential NCD medicines, including generics,
technologies and essential and basic technologies in both public and private
medicines, including facilities.
generics required to
treat major NCDs in
both public and private
facilities.
(Continued )
90 Hesham Gaafar et al.

Target Indicator
Additional indicators. • Access to palliative care assessed by morphine-equivalent
consumption of strong opioid analgesics (excluding
methadone) per death from cancer.
• Availability of cost-effective and affordable vaccines
against HPV.
• Number of third doses of HBV vaccine administered to
infants.
• Proportion of women aged 30–49 years screened for
cervical cancer at least once and for lower or higher age
groups according to national programmes or policies.
Examples of disease-specific targets and indicators are included in the other cancer chapters.

Notes
1 Lifetime risk of developing or dying from cancer. Cancer Org, 2020.
2 Global cancer observatory. IARC, 2022.
3 Global health observatory. WHO, 2020.
4 WHO report on cancer: setting priorities, investing wisely and providing care for all.
WHO, 2020.
5 Global Burden of Disease 2019 Cancer Collaboration. Cancer incidence, mortality, years
of life lost, years lived with disability, and disability-adjusted life years for 29 cancer
groups from 2010 to 2019: a systematic analysis for the Global Burden of Disease Study
2019. JAMA Oncol 2022;8:420–24.
6 Comprehensive cancer control. International Atomic Energy Agency. https://www​.iaea​
.org​/topics​/comprehensive​-cancer​-control.
7 Jan S et al. Action to address the household economic burden of non-communicable
diseases. Lancet 2018;391:2047–58.
8 Quality health services and palliative care: practical approaches and resources to support
policy, strategy and practice. WHO, 2021.
9 Cancer care: beyond survival. Lancet 2022;399:1441.
10 Health benefit packages survey 2020/2021: main findings. WHO. https://www​.who​.int​
/data​/stories​/health​-benefit​-packages​-a​-visual​-summary.
11 Trapani D et al. Distribution of the workforce involved in cancer care: a systematic
review of the literature. ESMO Open 2021;6:100292.
12 Cancer surveillance. The Cancer Atlas, https://canceratlas​.cancer​.org​/the​-burden​/the​
-burden​-of​-cancer/.
13 Cancer registries: the core of cancer control fundamentals of population-based registries.
IARC, 2021. https://gicr​.iarc​.fr​/about​-the​-gicr​/the​-value​-of​-cancer​-data​/Brochure​
_HD​.pdf.