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The Cancer Continuum

An Overview of Interventions and Potential for Impact: Resource-appropriate, broad application of known interventions in each country can substantially reduce the morbidity and mortality associated with cancer.

Evidence-based, resource appropriate interventions for cancer prevention and control exist across the cancer continuum in each country, from prevention of risk factors to early detection, treatment, survivorship, and end-of-life care. (Figure 1) Tobacco use, the cause of the largest number of preventable cancers worldwide, can be substantially reduced through raising excise tax on tobacco products, smoke-free air laws, health warnings on tobacco packaging, and restrictions on promotion and advertising of tobacco products. (Figure 2a & b; also see Tobacco Control)
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Figure 1. Proportion (%) of countries with NCD plans/national cancer control plans that address key components across the cancer continuum, by income level, 2018. HPV vaccination is addressed in 70% of plans in High income countries; 68% of plans in Upper middle income countries; 66% of plans in Lower middle income countries; and 67% of plans in Low income countries. Cervical cancer screening is addressed in 90% of plans in High income countries; 89% of plans in Upper middle income countries; 82% of plans in Lower middle income countries; and 75% of plans in Low income countries. Breast cancer screening (opportunistic) is addressed in 20% of plans in High income countries; 50% of plans in Upper middle income countries; 55% of plans in Lower middle income countries; and 67% of plans in Low income countries. Breast cancer screening (population-based) is addressed in 74% of plans in High income countries; 31% of plans in Upper middle income countries; 18% of plans in Lower middle income countries; and 5% of plans in Low income countries. HBV vaccination is addressed in 52% of plans in High income countries; 64% of plans in Upper middle income countries; 66% of plans in Lower middle income countries; and 50% of plans in Low income countries. Radiotherapy is addressed in 56% of plans in High income countries; 42% of plans in Upper middle income countries; 46% of plans in Lower middle income countries; and 30% of plans in Low income countries. WHO Essential Medicines List is addressed in 14% of plans in High income countries; 33% of plans in Upper middle income countries; 42% of plans in Lower middle income countries; and 43% of plans in Low income countries. National treatment guidelines are addressed in 57% of plans in High income countries; 57% of plans in Upper middle income countries; 57% of plans in Lower middle income countries; and 26% of plans in Low income countries. Survivorship care is addressed in 60% of plans in High income countries; 17% of plans in Upper middle income countries; 26% of plans in Lower middle income countries; and 13% of plans in Low income countries. Palliative care is addressed in 43% of plans in High income countries; 45% of plans in Upper middle income countries; 50% of plans in Lower middle income countries; and 35% of plans in Low income countries. Pediatric cancer care is addressed in 53% of plans in High income countries; 32% of plans in Upper middle income countries; 45% of plans in Lower middle income countries; and 26% of plans in Low income countries. Vulnerable populations are addressed in 42% of plans in High income countries; 36% of plans in Upper middle income countries; 29% of plans in Lower middle income countries; and 22% of plans in Low income countries. Financial resources are addressed in 49% of plans in High income countries; 55% of plans in Upper middle income countries; 61% of plans in Lower middle income countries; and 68% of plans in Low income countries. Cost of the plan is addressed in 39% of plans in High income countries; 36% of plans in Upper middle income countries; 50% of plans in Lower middle income countries; and 45% of plans in Low income countries. Cancer registries are addressed in 94% of plans in High income countries; 82% of plans in Upper middle income countries; 89% of plans in Lower middle income countries; and 83% of plans in Low income countries. Cancer research is addressed in 72% of plans in High income countries; 44% of plans in Upper middle income countries; 53% of plans in Lower middle income countries; and 46% of plans in Low income countries.

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Figure 2a. PREVENTION: Cumulative probability (%) of death from lung cancer by attained age and smoking status, male.

Male never smokers have a 1.4% chance of dying of lung cancer by the age of 85. Male smokers who quit by age 40 have a 3.6% chance of dying of lung cancer by the age of 85. Male smokers who quit between age 40-49 have a 7% chance of dying of lung cancer by the age of 85. Male smokers who quit between age 50-59 have an 11.5% chance of dying of lung cancer by the age of 85. Male smokers who quit between age 60-69 have a 19.1% chance of dying of lung cancer by the age of 85. Male smokers who quit by age 70 or older have a 22.7% chance of dying of lung cancer by the age of 85. Male smokers who continue to smoke have a 28.4% chance of dying of lung cancer by the age of 85.

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Figure 2b. PREVENTION: Cumulative probability (%) of death from lung cancer by attained age and smoking status, female.

Female never smokers have a 1.1% chance of dying of lung cancer by the age of 85. Female smokers who quit by age 40 have a 1.9% chance of dying of lung cancer by the age of 85. Female smokers who quit between age 40-49 have a 4.9% chance of dying of lung cancer by the age of 85. Female smokers who quit between age 50-59 have a 7.7 % chance of dying of lung cancer by the age of 85. Female smokers who quit between age 60-69 have a 13.7% chance of dying of lung cancer by the age of 85. Female smokers who quit by age 70 or older have a 15% chance of dying of lung cancer by the age of 85. Female smokers who continue to smoke have a 21.3% chance of dying of lung cancer by the age of 85.

Unhealthy diet and physical inactivity can be reduced through increased public awareness about their health hazards and through public policies (e.g., excise tax on sweetened beverages) and structural and environmental interventions (e.g., pedestrian and bike lanes) (see Health Promotion). The hepatitis B virus (HBV) and human papillomavirus (HPV), infections that cause liver cancer (HBV) and cervical and other urogenital and oropharyngeal cancers (HPV), can be prevented through vaccination (see Vaccines).

If 70% of all eligible girls were vaccinated, an estimated 178,000 cervical cancer deaths could be avoided annually worldwide.
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Indoor and outdoor air pollution can be reduced through use of clean stoves, cleaner fuels, and proper ventilation, and air quality guidelines and policies. Protection from harmful sun exposure could reduce the risk of skin cancer. Cancer-causing occupational exposures could be prevented through improved work place safety. Addressing cancer risk factors can also have a shared impact on other non-communicable diseases.

Regular screening for cervical, colorectal, breast, and lung cancers allows detection of these diseases at an early stage, when treatments are more successful and the chance for survival and cure is high. (Map 1)

Map 1
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Screening for colorectal and cervical cancers also prevents cancer by detecting precancerous lesions for removal by surgery or other forms of treatment. A heightened awareness of warning signs for cancer of the oral cavity, skin, and some other cancers may also lead to detection of cancers at early stage (see Early Detection).

Effective treatment modes (surgery, radiation, chemotherapy, hormonal therapy, immunotherapy) have been developed for several cancers, including for cancers of the breast, colon and rectum, and testis and for many childhood cancers. (Figure 3; also see Management and Treatment) For certain cancers such as testis, treatment could lead to cure, even for advanced-stage disease. Awareness and availability of services to meet the needs of cancer survivors are increasing worldwide (Figure 4), and pain associated with cancer can be controlled by administration of analgesic drugs. (Figure 5; also see Pain Control)

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Figure 3. TREATMENT: Childhood cancer mortality trends, all cancer sites combined, males 0–19 years, 1975–2013. Age-standardized rate (world) per 100,000. Childhood cancer mortality rates in Japan and the United States have declined from about 6 in 1975 to about 2 in 2013. Childhood cancer mortality rates in Egypt, Colombia, and Brazil have remained around 5-6 during the same period.

Figure 4
SURVIVORSHIP: Breast Health Global Initiative resource allocations for monitoring breast cancer survivorship care
BASIC
Monitor for breast cancer recurrence, second primary cancers

Monitor for long-term conditions
LIMITED
Monitor for endocrine medication adherence
MAXIMAL
Genetic testing and counseling

Screening for high-risk cancers
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Figure 5. END-OF-LIFE CARE: Adult palliative care needs at the end of life by disease (%) worldwide, 2011. Worldwide palliative care needs at the end of life are comprised of cancer (34%), cardiovascular diseases (38%), chronic obstructive pulmonary disease (10%), HIV/AIDS (6%), diabetes mellitus (5%), and other (7%).

Page Sources

The number of annual worldwide deaths the HPV vaccination can prevent:
Van Kriekinge G, Castellsague X, Cibula D, Demarteau N. Estimation of the potential overall impact of human papillomavirus vaccination on cervical cancer cases and deaths. Vaccine. 2014;32(6):733–739.

Text:
Bleich SN. A road map for sustaining healthy eating behavior. N Engl J Med. 2018;379(6):507–509.

Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2014. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

Centers for Disease Control and Prevention. Strategies to prevent obesity and other chronic diseases: The CDC guide to strategies to increase physical activity in the community. Atlanta: U.S. Department of Health and Human Services; 2011.

Gelband H, Sankaranarayanan R, Gauvreau CL, et al. Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: Key messages from Disease Control Priorities, 3rd edition. Lancet. 2016;387(10033):2133–2144.

Plummer M, de Martel C, Vignat J, Ferlay J, Bray F, Franceschi S. Global burden of cancers attributable to infections in 2012: a synthetic analysis. Lancet Glob Health. 2016;4(9):e609-616.

World Health Organization. Reducing Global Health Risks Through Mitigation of Short-Lived Climate Pollutants: Scoping Report For Policy-makers. Geneva: World Health Organization; 2015.

Wu YP, Aspinwall LG, Conn BM, Stump T, Grahmann B, Leachman SA. A systematic review of interventions to improve adherence to melanoma preventive behaviors for individuals at elevated risk. Prev Med. 2016;88:153–167.

Figure 1:
Romero Y, Trapani D, Johnson S, et al. National cancer control plans: a global analysis. Lancet Oncol. 2018;19(10):e546-e555.

Figure 2:
Thun MJ, Carter BD, Feskanich D, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med. 2013;368(4):351–64. Unpublished additional analyses.

Map 1:
Cervical Cancer Action, http://www.cervicalcanceraction.org/comments/maps.php

Figure 3:
WHO IARC Cancer Mortality Database, http://www-dep.iarc.fr/WHOdb/WHOdb.htm

Figure 4:
Adapted from Breast Health Global Initiative. Survivorship care after curative treatment for breast cancer. Available at https://www.fredhutch.org/en/labs/phs/projects/breast-cancer-initiative_2-5/knowledge-summaries/survivorship-care-survivorship-care-after-curative-treatment-for.html

Figure 5:
Global Atlas of Palliative Care at the End of Life. Available from: http://www.who.int/cancer/publications/palliative-care-atlas/en/

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