EU Programs Combat ‘Manmade’ Lung Cancer Epidemic

NEW YORK—The invention of the manufactured cigarette in Cuba in 1875 sparked "the manmade epidemic of lung cancer" and other smoking-related diseases that emerged in the 20th century, said Prof. Peter Boyle, director of the Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy.

The best hope for reducing the global burden of cancer today is to discourage tobacco use, Prof. Boyle said at a symposium on living with cancer sponsored by cancer patient support organizations Gilda’s Club Worldwide (New York) and Marie Curie Cancer Care (Edinburgh, Scotland). Approximately one third of all cancer deaths in developed countries could be avoided by the elimination of cigarette smoking, he said.

The opportunity to dramatically reduce cancer burden by reducing smoking is much more clearly defined than for other avoidable causes of cancer, Prof. Boyle said. About 30% of all cancers are related to tobacco consumption. By contrast, only about 3% of cancers are associated with alcohol. Another 35% are probably associated with diet, though what particular aspects of diet are most important is unclear.

In the European Union (EU), smoking directly causes 32% of all deaths in middle-aged men and 10% in middle-aged women (although the proportion in women is rising dramatically, tracking increased cigarette smoking among women in the 20th century).

Statistics from the United States tell a similar story. In 1990, smoking was the direct cause of 17% of all deaths, and 26% of deaths among middle-aged persons, Prof. Boyle said.

European Prevention Efforts

Recent experience suggests that targeted interventions to reduce cancer burden can be successful when properly implemented and supported.

One example, Prof. Boyle said, is the nearly universal adoption of correct chemotherapeutic regimens for testicular cancer in developed countries, which has reduced the death rate in this disease to virtually zero despite a soaring incidence rate. The exception in Europe was in Eastern bloc countries, where treatment was not affordable and proper medical training was not available.

The situation improved in Slovakia, however, following the establishment of a government-sponsored treatment center in 1982. Likewise, German reunification has improved the situation in eastern Germany, Prof. Boyle said.

Another example is the Europe Against Cancer program, launched in the mid-1980s by the European Commission and directed by a high-level committee of cancer experts. This program sought to reduce the expected incidence of cancer mortality by 15% by the year 2000.

The European initiative encapsulated numerous new and existing efforts to reduce risk in three areas: prevention, education and training, and screening.

The initiative also sparked the creation of the European Code Against Cancer, which encouraged smoking cessation, moderation in consuming alcohol, increased intake of fruits and vegetables, exercise, sunscreen use, and careful regulation and use of known cancer-causing substances. The code also encouraged people to see a doctor for suspicious lumps, sores, moles, or bleeding, and specifically advocated participation of women in organized screening programs for cervical and breast cancer.

The result was a reduction of the relative risk of dying from all forms of cancer in almost every country involved from the beginning of the program to 2000, including Austria, Finland, and the United Kingdom. However, there was no change in Denmark, and increases were seen in Portugal and Spain.

The statistics suggest the European Union is "winning the battle on tobacco" in men, Prof. Boyle said, noting a substantial overall drop in risk of dying of lung cancer in most countries and overall, despite continual increases in Portugal and Greece.

Tragically, however, there were enormous increases in lung cancer incidence among women in 14 of 15 member states. Because of these data, tobacco control in women over the next 5 years has become a priority goal for the EU cancer expert committee.

There is also consensus that something must be done to reduce tobacco use in the poorest, most deprived populations. Statistics from Scotland show a striking upward gradient of lung cancer incidence from the most affluent group (10%) to the most deprived (45%) group.

"If we want to cut substantially the risk of dying from cancer, the best thing we can do is limit smoking, and we have to prioritize this target in women and the disadvantaged," Prof. Boyle said.