Download Addressing the Growing International Challenge of Cancer

“”
C O M M E N TA R Y
cancer care and research within them—have
focused on cancers that most commonly affict their own citizens, using a variety of approaches and resources.
ere are several possible explanations for
this heterogeneity. First, countries difer substantially with respect to the kinds of cancers
that are prevalent locally and the underlying
environmental, behavioral, and genetic facHarold Varmus1* and Harpal S. Kumar2*
tors that predispose to those cancers. Second,
Leaders in cancer research and policy from 15 economically diverse countries met at the
countries have diferent fscal, professional,
U.S. National Institutes of Health in November 2012 to discuss opportunities to reduce
and political capacities to confront disease.
cancer incidence and mortality, improve cancer care, and increase our understanding of
Eforts in each national context may also be
disease pathophysiology. Here, we present recommendations that the participants believe
infuenced by competing health concerns,
will enable faster progress in addressing the growing international challenge of cancer.
such as infectious diseases (for example,
HIV/AIDS or malaria) or chronic conditions
INTRODUCTION
plans; implementation of better methods to (such as diabetes or cardiovascular diseases),
Te diseases grouped together as cancers prevent, detect, and treat cancers; and ways and by varying abilities to help address the
are among the major liabilities of human to expand and improve research on a wide plights of citizens of other nations. Finally,
life. e global burden of cancer includes range of cancer-relevant topics.
countries have distinct traditions—and indi12.7 million newly diagnosed cases per year,
vidual citizens have diferent
of which more than half occur in less develperspectives—that afect the
oped regions of the world (1). Cancers now
way their governments apaccount for more than 15% of the world’s
proach cancers. ese views
annual deaths (>7.5 million per year), and
may date to a time when
that number is rising, especially in less afmalignant diseases were
fuent countries (2). Moreover, cancers are
relatively rare and tools for
among the most feared medical conditions,
controlling them and their
ofen causing prolonged periods of sufercomplications were usually
ing, requiring substantial health-care exinefective.
penditures for advanced care, and being
e signatories to this
fought with medical tools that are relatively
article are individuals with
inefective and themselves frequently disinfuential positions at agenabling. [In this Commentary, the authors
cies and institutions that
represent the views of participants at an
perform or support research
international meeting of leaders in cancer
on various kinds of cancer in
research (complete list shown in Table 1).]
several countries.
e NoLeaders of institutions and organizavember 2012 meeting foltions that fund and perform cancer research
lowed an initial gathering
came from 15 countries to the U.S. National
of a similar group at Cancer
Institutes of Health (NIH) in November
Research UK in London in
2012 to discuss opportunities to reduce
2011. Participants at the two
cancer incidence and mortality, improve
meetings discussed how we
cancer care, and increase our understandcan augment our individual
ing of the many forms of the disease. Here, To address the growing international challenge of cancer, eforts: (i) by promoting
we present recommendations supported by our “reach should exceed [our] grasp” (26).
the application and expanthe meeting participants, who represented
sion of existing knowledge
more than half of the world’s population,
to prevent, detect, and treat
including citizens in low- and middle- AN EXPANDING PERSPECTIVE
cancers in many nations, and (ii) by seeking
income countries. We address several ar- Until recently, eforts to improve the world’s opportunities to foster pioneering research
eas that the group believes to be of great capacity to combat cancers have not ofen in laboratories and clinics on all aspects of
importance, such as development of can- been addressed in a globally coordinated these diseases, including cancers that take
cer registries and national cancer-control way. Notwithstanding critical work by pro- their greatest toll in the developing world.
fessional societies and by many international
We have been encouraged in our delibera1
National Cancer Institute, National Institutes of Health,
and national nongovernmental organizations tions by a variety of factors. ese include a
Department of Health and Human Services, Bethesda,
(NGOs) to improve care, increase awareness greater appreciation of epidemiological eviMD 20892, USA. 2Cancer Research UK, London EC1V
of cancer, and provide basic infrastructure dence for the large and growing burden of
4AD, UK.
and equipment, most countries—and those cancers, especially in developing countries;
*Corresponding author. E-mail: [email protected]
(H.V.); [email protected] (H.S.K.)
responsible for the support and conduct of major advances in the understanding of canPOLICY
CREDIT: Y. HAMMOND/SCIENCE TRANSLATIONAL MEDICINE
www.ScienceTranslationalMedicine.org 6 March 2013 Vol 5 Issue 175 175cm2
1
Downloaded from stm.sciencemag.org on March 12, 2013
Addressing the Growing
International Challenge of Cancer:
A Multinational Perspective
Table 1. Consensus statement. All participants at the November 2012 meeting at NIH are cosignatories to this article. They are listed alphabetically by country, with title and institutional
affiliation(s). The views expressed here are endorsed by the signatories as individuals and do not
necessarily represent the views or policies of their organizations or nations.
Country
Agency
Representative
Argentina
Union for International Cancer Control,
National Cancer Institute of Argentina
Eduardo Cazap
Immediate Past President
and Executive Council
Australia
Victoria Comprehensive Cancer Centre,
attending on behalf of the National Health
and Medical Research Council (NHMRC)
James Bishop
Executive Director and Professor
Brazil
Clinical and Translational Research, Instituto
Nacional de Câncer (INCA)
Carlos Gil Ferreira
Director
Canada
Canadian Institutes of Health Research
(CIHR), Institute of Cancer Research
Morag Park
Scientific Director
China
Sir YK Pao Centre for Cancer and the Hong
Kong Cancer Institute
France
National Cancer Institute, France
France
International Agency for Research on
Cancer (IARC)
India
Advanced Centre for Treatment, Research
and Education in Cancer (ACTREC)
Japan
Ministry of Health, Labor, and Welfare
Masato Mugitani
Assistant Minister for Global Health
Japan
Office of Medical Innovation, Cabinet
Secretariat
Yasuhiro Fujiwara
Deputy Secretary General
Mexico
National Cancer Institute of Mexico (INCAN)
Singapore
National Cancer Center of Singapore
South Korea
National Cancer Center Korea, Office of
Public Relations and Collaborations
South Korea
National Cancer Center Korea
Taiwan
Academia Sinica
Chi-huey Wong
President
Taiwan
National Taiwan University College of
Medicine
Pan-chyr Yang
Dean
Turkey
Hacettepe University
Murat Tuncer
Rector
Turkey
Cancer Control Department, Ministry of
Health, Turkey
Murat Gutelkin
Director
Turkey
Cancer Control Department, Ministry of
Health, Turkey
Ezgi Hacikamiloglu
Deputy Director
United
Kingdom
Cancer Research UK
United
Kingdom
Cancer Research UK and Manchester Cancer
Research Centre
United
Kingdom
Wellcome Trust, Sanger Institute
Karen Kennedy
Head of Strategic Relations
United States
National Cancer Institute (NCI)
Harold Varmus (Cochair)
Director
United States
National Cancer Institute (NCI)
Doug Lowy
Deputy Director
United States
Center for Global Health, NCI
Anthony T. C. Chan
Director
Fabien Calvo
Deputy General Director
Christopher Wild
Director
Rajiv Sarin
Director
Luis Herrera
Director of Research
Kee Chee Soo
Director
Seung Hoon Lee
Director
Jin Soo Lee
President
Harpal Kumar (Cochair)
Chief Executive
Nic Jones
Chief Scientist
Ted Trimble
Director
cers made possible by technologies that include genomics, cell and molecular biology,
microbiology, and informatics; and the development, over the past few decades, of more
efective methods to prevent and treat certain
types of cancers and their symptoms. We also
note and welcome the inclusion of cancer
in the 2011 United Nations Declaration on
Non-Communicable Diseases (www.un.org/
ga/search/view_doc.asp?symbol=A/66/L.1),
with a commitment to reduce preventable
deaths by 25% by the year 2025.
We write this article to make a larger audience aware of these features of cancer and to
share our aspirations to control cancer more
efectively and globally through joint activities. Our statements are directed toward two
general goals: to improve implementation of
those aspects of cancer control that research
has already validated and to promote new
research eforts that promise broad benefts
over the short and long terms.
Although most of us are primarily responsible for cancer research, not necessarily for medical care or public health policies,
we have a broad interest in controlling cancer
with all of the methods now available—most
of which have been developed and confrmed
through the kinds of research we support—
and in fnding better ways, through research,
to diminish cancer incidence and mortality.
It is from this perspective that we make recommendations directed at policy-makers,
the general public, and our own research
communities in the areas of registries, prevention, screening, treatment, and research.
CANCER REGISTRIES AND PATHOLOGY
Reliable, population-based registries that
defne the incidence, mortality, and survival
rates of diferent types of cancers are fundamental to the design of local, regional, and
national plans for improving cancer prevention and treatment and for investing in research. Yet, in many parts of the world, accurate assessments of the burden of cancer
and the distribution of its various types are
unavailable or inaccurate (3). For example,
the worldwide cancer estimates made by the
International Agency for Research Against
Cancer (IARC) depend on data from only
about one-third of 184 countries (4).
Support for infrastructure for populationbased cancer registries and for training of
specialized personnel to build and maintain
these resources is vital for a better accounting
of cancer. Another crucial need is adequate
access to the expertise of pathologists who
can characterize cancers accurately with tools
www.ScienceTranslationalMedicine.org 6 March 2013 Vol 5 Issue 175 175cm2
2
Downloaded from stm.sciencemag.org on March 12, 2013
“”
C O M M E N TA R Y
that range from conventional microscopy to
those enabling molecular classifcation of
cancer subtypes. We encourage governments
and other organizations to support eforts that
would increase the coverage and reliability of
cancer registries by investing in necessary infrastructure and personnel and by training
and recruiting skilled pathologists. Systems
of triage and use of telepathology to ascertain
difcult diagnoses could help make more effective use of scarce pathology resources.
CANCER PREVENTION
e most sensible and usually the most costefective means to reduce the burden of cancer
is through prevention. Yet, implementation of
measures to mitigate factors now known to
promote cancer—tobacco, certain infectious
agents, ultraviolet radiation, alcohol, obesity,
lack of exercise, and diet—is ofen inadequate,
even when methods that lower such risks are
scientifcally well established, as in the case of
tobacco control (5, 6). Sometimes these failures result from the difculty or cost of using
preventive strategies (such as expensive vaccines), while at other times cancer prevention
may be at odds with fnancial interests (such
as revenues generated from the production
and sale of tobacco).
Furthermore, as gauged by responses
around our own conference table, funding
organizations ofen spend too little on prevention research. ose funders among us
intend to explore ways in which we can increase the proportion of our activity on this
critical aspect of cancer control. Areas of
high interest include identifying clearer risk
factors with public health implications, developing and testing new interventions, determining how to increase the efectiveness
or uptake of those interventions, and testing
means to limit exposure to carcinogens.
Tobacco use. With respect to modifable
lifestyle risk factors for cancer, there is a
consensus that tobacco use remains, by far,
the most important at a global level. Governments play a critical role in the adoption
of measures that can prevent cancer, and we
urge them to recognize the health of their
citizens as a more important priority than
global trade agreements or the national
economic benefts of tobacco farming and
trade. Measures we recommend include
exemption of tobacco products, which are
both addictive and harmful to health, from
trade agreements, and the imposition of
higher taxes on the sale of tobacco products, a well-established means to both lower
tobacco use and raise revenues. ese are
important steps in country-wide adoption
of broader sets of tobacco-control policies,
such as those embodied in the Framework
Convention for Tobacco Control—policies
that are known to reduce the incidence of
cancers of the lung and other organs (7).
Governments can also act preemptively
to ensure that tobacco use does not rise
among those populations with currently
low rates of use—such as women in countries with cultural or religious prohibitions
against smoking and people living in SubSaharan Africa—by protecting them from
expected eforts by the tobacco industry to
expand into new markets. Use of tobacco
products by health professionals remains
a barrier to public recognition of its harms
and should be reduced. Eforts to deglamourize and decrease the social acceptability
of tobacco use should also be enhanced.
Because many strategies for tobacco control have been proposed but not carefully
evaluated, some of the meeting participants
intend to establish a global consortium to
coordinate such research eforts. e consortium should supplement work of the
World Health Organization and others and
address the design and value of tobaccocontrol measures in the general population,
in diferent parts of the world, and in highly
vulnerable populations (such as people with
mental illnesses or members of economically deprived communities).
Vaccines. Successful programs to administer human hepatitis B virus (HBV) vaccines to large segments of exposed populations, including those in areas of Africa and
Asia with high endemic rates of transmission, are reducing the incidence of HBV infection and virus-induced hepatoma (8–10).
However, with some exceptions, eforts to
use the human papilloma virus (HPV) vaccines to protect populations against HPVinduced cancer of the cervix—the leading
cause of cancer mortality among women
in many countries—have yet to be similarly
successful (11).
In Australia, where uptake of the HPV
vaccine is high (~80% in adolescent females), researchers have already observed
population-wide reductions in HPV prevalence and associated disease with short incubation times (12). But use of HPV vaccines
has fallen below expectations in most other
countries, even in economically developed
countries such as the United States, where
sociocultural sensitivities have limited vaccine uptake to about one-third of adolescent
girls and fewer than 5% of boys (13).
“”
A few economically underdeveloped
countries, such as Rwanda, are vaccinating girls against HPV with the support of
the GAVI Alliance (www.gavialliance.org).
However, in most developing nations, no
HPV vaccination programs have been initiated. is situation refects, in large part,
the high costs of the vaccine—which can be
up to $360 for a full course of immunization—but also the programmatic challenges
of vaccinating the at-risk population and the
unusual age (early adolescence) at which the
vaccine is best administered (14).
We urge governments and other organizations to consider ways to increase the
production and distribution of low-cost versions of HPV vaccines. Such e$orts could
also encourage research to develop prophylactic vaccines against other cancer-causing
infectious agents, such as hepatitis C and
Epstein-Barr viruses (15).
Chemoprevention. E$orts to employ
medication to lower the risk of cancer have
historically proven ine$ective. However, recent studies provide compelling evidence
that the use of daily, low-dose aspirin can
reduce the incidence of and mortality from
a variety of cancers (16, 17). e benefts of
aspirin need to be promulgated more widely
along with an assessment of its risks and
optimal strategy for use. In addition, public
health authorities should state, more clearly,
the cases for use of other cancer-preventing
agents, such as hormone inhibitors that can
reduce breast cancer incidence. We encourage and intend to undertake further research to defne the optimal dose and duration of use of such chemopreventive agents.
Other objectives include better means to
identify individuals who will gain the greatest benefts from the use of chemopreventive agents, because of a high risk for certain
cancers, and those who should avoid their
use, because of an increased risk of harmful
consequences.
CANCER SCREENING
e importance of screening individuals
for certain cancers (of the cervix, breast,
prostate, and colorectum, in particular) has
been emphasized in some countries and infuenced by resource availability and public
health priorities. While such practices can
substantially lower the risk of cancer incidence and mortality, as documented especially well for cervical and colorectal cancers
(18, 19), they also have the potential to promote “overtreatment” of indolent lesions that
would not have become lethal cancers even
www.ScienceTranslationalMedicine.org 6 March 2013 Vol 5 Issue 175 175cm2
3
Downloaded from stm.sciencemag.org on March 12, 2013
C O M M E N TA R Y
if lef undetected. is potential for harmful
consequences from screening has been recognized increasingly over the past few years
(20) and warrants enhanced e$orts to provide more balanced information to the public
on benefts and risks and to learn how to discriminate between lesions that are inherently
indolent and those that are likely to behave
aggressively. Moreover, the existence of reliable means to distinguish between clinically
benign and malignant lesions would encourage researchers to develop new strategies for
early detection, which will in turn improve
the cost-e$ectiveness of screening.
CANCER TREATMENT
Optimal cancer treatment is a complex process, requiring accurate and timely histological diagnosis and staging of tumors as
well as evidence-based choices among the
many available methods of care—including surgery, radiation therapy, anticancer
drugs, and several means to control the
symptoms of disease and the complications of ofen debilitating therapies. With
the advent of molecularly targeted therapies—both drugs and monoclonal antibodies (21)—therapeutic decisions ofen also
depend on complex tests for mutations and
gene expression.
Although appropriate cancer therapies
are ofen successful in curing disease, especially when it is diagnosed at relatively early
stages, or are able to hold disease at bay for
many years, we recognize that current treatments are far from perfect. First, the care of
cancer patients is an expensive proposition,
and the costs have continued to rise, limiting the capacity of countries across the entire
economic spectrum to deliver the best modern cancer therapies to all patients. Second,
there are major global disparities in the availability, a$ordability, and access to modern
multidisciplinary cancer care, especially in
poorer countries. ird, while some disseminated cancers, such as testicular carcinomas
and several leukemias and lymphomas, are
now curable, current treatments generally
fail to eliminate most metastatic cancers and
ofen control them briefy or not at all.
We envision several measures that
could be taken to improve this situation.
All countries, especially those relatively
poor countries that o$er very limited cancer therapy at present, should create or
strengthen national cancer plans to enable
more judicious use of available resources
and, thereby, improve the availability of
relatively low-cost cancer care (22). Second,
medical and scientifc communities should
strive to develop strategies that can deliver
the benefts of new forms of cancer therapy
more swifly and economically to all countries. Cancer research organizations should
continue to expand translational and clinical investigations with the goal of improving the repertoire and e$ectiveness of therapeutic options.
Development of new therapies will require greater enrollment of cancer patients
in clinical trials, and those trials will increasingly be international in scope. If expensive and difcult clinical research is to
be pursued with maximum e$ect, sharing
of information and harmonization of practices are essential. Funding agencies will
need to mandate the use of online registries
for clinical trials and require that the results
of all trials, whether with negative or positive outcomes, be made available to the scientifc community through publication or
entries in trial registries.
We also encourage e$orts to reduce
obstacles to the design and conduct of international trials by making the practices
of the major regulators of drug testing and
production as uniform as possible, such as
the U.S. Food and Drug Administration,
the European Medicines Agency, Japan’s
Pharmaceuticals and Medical Devices
Agency, and others, as exemplifed by the
International Conference on Harmonisation guidelines (www.ich.org/products/
guidelines.html).
To take full advantage of new opportunities for improved therapies as well as
preventive strategies, funding agencies—
including those listed in Table 1—must provide greater fnancial support for trials that
are sponsored by academic institutions,
especially when the work includes expensive procedures (such as multiple biopsies
and molecular tests), addresses rare cancer
types, or involves surgery, radiotherapy, or
the repurposing of existing drugs. We also
encourage pharmaceutical companies to
cooperate with each other and with funding
organizations in the design and conduct of
clinical trials that use multiple agents produced by more than one company, a situation that preclinical studies suggest will be
increasingly required to achieve maximal
benefts from targeted therapies.
EXPANDING THE REACH OF CANCER
RESEARCH
Basic and preclinical cancer research has
entered a phase in which advances are
“”
emerging at an increasing pace through the
use of new molecular technologies, such
as DNA sequencing and cell-based highthroughput genetic and chemical screening, and through the development of highly
informative models of many cancer types
in both tissue-culture systems and animals,
largely mice (23). Furthermore, research
results from academic laboratories are becoming increasingly relevant to epidemiological and clinical issues (causation, prevention, and classifcation and treatment of
tumors). Under these circumstances, international collaboration, sharing of data, and
adoption of global standards for biomedical
research becomes particularly important to
foster work that is more reproducible and
has worldwide signifcance.
We urge the international cancer research community to give greater attention
to principles that promote the best scientific practices and productive collaborations
within and across national boundaries. We
stress several measures that would encourage movement in these directions and that
we intend to adopt:
• Support of internet-based infrastructures and the adoption of practices that
allow the open exchange of information.
ese include public electronic libraries that
house scientifc articles and books, open access journals, Web sites that contain reliable
and accessible cancer-related information,
and the means for transmitting “negative”
as well as “positive” results and for storing
and using full sets of research data.
• Development of well-characterized
cell- and animal-based models of cancers
that can be relied upon for preclinical studies because they have been validated by internationally agreed-upon processes.
• Construction of standardized, interoperable, and internationally accessible databases that house information about cancer
genomes and other biological features related to cancers, incorporate clinical and
epidemiological information in accord with
ethical precepts, and operate under internationally accepted procedures.
• Opposition to patenting of genes or
gene mutations, thereby removing obstacles
to cancer research and to the design and
reasonable pricing of improved means to
classify and treat cancers based on genetic
information.
CONCLUSIONS
As leaders of institutions that fund and perform cancer research in many countries, we
www.ScienceTranslationalMedicine.org 6 March 2013 Vol 5 Issue 175 175cm2
4
Downloaded from stm.sciencemag.org on March 12, 2013
C O M M E N TA R Y
have prepared this joint statement to highlight opportunities to make greater and faster
progress against cancer by recognizing common concerns. As e$orts to improve public
health and achieve sustainable development
shif their emphasis from infectious and
childhood diseases to chronic conditions
of adults (24, 25), cancer will be among the
disorders that receive increasing attention.
Successful campaigns to control cancers with
existing methods and to improve current
strategies through research will increasingly
depend on a multinational consensus and
collaborative work. In that spirit, we intend
to take the lead in areas that are within our
remits. We also call upon governments and
NGOs to consider our recommendations.
3.
4.
5.
REFERENCES AND NOTES
1. Cancer Research UK, CancerStats, Cancer Worldwide
(2011); http://publications.cancerresearchuk.org/downloads/product/CS_CS_WORLD.pdf.
2. R. Lozano, M. Naghavi, K. Foreman, S. Lim, K. Shibuya,
V. Aboyans, J. Abraham, T. Adair, R. Aggarwal, S. Y. Ahn,
M. Alvarado, H. R. Anderson, L. M. Anderson, K. G. Andrews, C. Atkinson, L. M. Baddour, S. Barker-Collo, D. H.
Bartels, M. L. Bell, E. J. Benjamin, D. Bennett, K. Bhalla, B.
Bikbov, A. Bin Abdulhak, G. Birbeck, F. Blyth, I. Bolliger,
S. Boufous, C. Bucello, M. Burch, P. Burney, J. Carapetis,
H. Chen, D. Chou, S. S. Chugh, L. E. Coffeng, S. D. Colan,
S. Colquhoun, K. E. Colson, J. Condon, M. D. Connor, L.
T. Cooper, M. Corriere, M. Cortinovis, K. C. de Vaccaro,
W. Couser, B. C. Cowie, M. H. Criqui, M. Cross, K. C. Dabhadkar, N. Dahodwala, D. De Leo, L. Degenhardt, A.
Delossantos, J. Denenberg, D. C. Des Jarlais, S. D. Dharmaratne, E. R. Dorsey, T. Driscoll, H. Duber, B. Ebel, P. J.
Erwin, P. Espindola, M. Ezzati, V. Feigin, A. D. Flaxman,
M. H. Forouzanfar, F. G. Fowkes, R. Franklin, M. Fransen,
M. K. Freeman, S. E. Gabriel, E. Gakidou, F. Gaspari, R. F.
Gillum, D. Gonzalez-Medina, Y. A. Halasa, D. Haring, J. E.
Harrison, R. Havmoeller, R. J. Hay, B. Hoen, P. J. Hotez, D.
Hoy, K. H. Jacobsen, S. L. James, R. Jasrasaria, S. Jayaraman, N. Johns, G. Karthikeyan, N. Kassebaum, A. Keren,
J. P. Khoo, L. M. Knowlton, O. Kobusingye, A. Koranteng,
R. Krishnamurthi, M. Lipnick, S. E. Lipshultz, S. L. Ohno,
J. Mabweijano, M. F. MacIntyre, L. Mallinger, L. March, G.
B. Marks, R. Marks, A. Matsumori, R. Matzopoulos, B. M.
Mayosi, J. H. McAnulty, M. M. McDermott, J. McGrath,
G. A. Mensah, T. R. Merriman, C. Michaud, M. Miller, T. R.
Miller, C. Mock, A. O. Mocumbi, A. A. Mokdad, A. Moran,
K. Mulholland, M. N. Nair, L. Naldi, K. M. Narayan, K. Nasseri, P. Norman, M. O’Donnell, S. B. Omer, K. Ortblad, R.
Osborne, D. Ozgediz, B. Pahari, J. D. Pandian, A. P. Rivero,
R. P. Padilla, F. Perez-Ruiz, N. Perico, D. Phillips, K. Pierce, C.
A. Pope 3rd, E. Porrini, F. Pourmalek, M. Raju, D. Ranganathan, J. T. Rehm, D. B. Rein, G. Remuzzi, F. P. Rivara, T. Roberts, F. R. De León, L. C. Rosenfeld, L. Rushton, R. L. Sacco,
6.
7.
8.
9.
10.
11.
12.
13.
14.
J. A. Salomon, U. Sampson, E. Sanman, D. C. Schwebel,
M. Segui-Gomez, D. S. Shepard, D. Singh, J. Singleton,
K. Sliwa, E. Smith, A. Steer, J. A. Taylor, B. Thomas, I. M.
Tleyjeh, J. A. Towbin, T. Truelsen, E. A. Undurraga, N. Venketasubramanian, L. Vijayakumar, T. Vos, G. R. Wagner, M.
Wang, W. Wang, K. Watt, M. A. Weinstock, R. Weintraub,
J. D. Wilkinson, A. D. Woolf, S. Wulf, P. H. Yeh, P. Yip, A. Zabetian, Z. J. Zheng, A. D. Lopez, C. J. Murray, Global and
regional mortality from 235 causes of death for 20 age
groups in 1990 and 2010: A systematic analysis for the
Global Burden of Disease Study 2010. Lancet 380, 2095–
2128 (2012).
M. G. Valsecchi, E. Steliarova-Foucher, Cancer registration
in developing countries: Luxury or necessity? Lancet Oncol. 9, 159–167 (2008).
J. Ferlay, H. R. Shin, F. Bray, D. Forman, C. Mathers, D. M.
Parkin, GLOBOCAN 2008 v2.0, Cancer incidence and
mortality worldwide: IARC CancerBase No. 10 (International Agency for Research on Cancer, Lyon, France,
2010).
L. Joosens, M. Raw, The tobacco control scale 2010 in
Europe; www.ensp.org/sites/default/files/TCS_2010_in_
Europe_FINAL.pdf.
IARC Handbooks of Cancer Prevention in Tobacco Control,
vols. 12–14 (International Agency for Research on Cancer, Lyon, France, 2009 and 2011).
WHO report on the global tobacco epidemic, 2011:
Warning about the dangers of tobacco (World Health
Organization, Geneva, 2011).
M. H. Chang, Hepatitis B virus and cancer prevention.
Recent Results Cancer Res. 188, 75–84 (2011).
M. H. Chang, S. L. You, C. J. Chen, C. J. Liu, C. M. Lee, S. M.
Lin, H. C. Chu, T. C. Wu, S. S. Yang, H. S. Kuo, D. S. ChenTaiwan Hepatoma Study Group, Decreased incidence of
hepatocellular carcinoma in hepatitis B vaccinees: A 20year follow-up study. J. Natl. Cancer Inst. 101, 1348–1355
(2009).
H. Tajiri, H. Tanaka, S. Brooks, T. Takano, Reduction of hepatocellular carcinoma in childhood after introduction
of selective vaccination against hepatitis B virus for infants born to HBV carrier mothers. Cancer Causes Control
22, 523–527 (2011).
F. A. Bello, O. O. Enabor, I. F. Adewole, Human papilloma
virus vaccination for control of cervical cancer: A challenge for developing countries. Afr. J. Reprod. Health 15,
25–30 (2011).
S. N. Tabrizi, J. M. Brotherton, J. M. Kaldor, S. R. Skinner, E.
Cummins, B. Liu, D. Bateson, K. McNamee, M. Garefalakis,
S. M. Garland, Fall in human papillomavirus prevalence
following a national vaccination program. J. Infect. Dis.
206, 1645–1651 (2012).
A. Jemal, E. P. Simard, C. Dorell, A. M. Noone, L. E. Markowitz, B. Kohler, C. Eheman, M. Saraiya, P. Bandi, D.
Saslow, K. A. Cronin, M. Watson, M. Schiffman, S. J.
Henley, M. J. Schymura, R. N. Anderson, D. Yankey, B. K.
Edwards, Annual Report to the Nation on the status of
cancer, 1975–2009, Featuring the burden and trends in
human papillomavirus (HPV)–associated cancers and
HPV vaccination coverage levels. J. Natl. Cancer Inst. 105,
175–201 (2013).
S. J. Goldie, M. O’Shea, N. G. Campos, M. Diaz, S. Sweet,
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
S. Y. Kim, Health and economic outcomes of HPV 16,18
vaccination in 72 GAVI-eligible countries. Vaccine 26,
4080–4093 (2008).
J. I. Cohen, A. S. Fauci, H. Varmus, G. J. Nabel, Epstein-Barr
virus: An important vaccine target for cancer prevention.
Sci. Transl. Med. 3, 107fs7 (2011).
P. M. Rothwell, F. G. Fowkes, J. F. Belch, H. Ogawa, C. P.
Warlow, T. W. Meade, Effect of daily aspirin on long-term
risk of death due to cancer: Analysis of individual patient
data from randomised trials. Lancet 377, 31–41 (2011).
P. M. Rothwell, J. F. Price, F. G. Fowkes, A. Zanchetti, M.
C. Roncaglioni, G. Tognoni, R. Lee, J. F. Belch, M. Wilson,
Z. Mehta, T. W. Meade, Short-term effects of daily aspirin
on cancer incidence, mortality, and non-vascular death:
Analysis of the time course of risks and benefits in 51
randomised controlled trials. Lancet 379, 1602–1612
(2012).
W. S. Atkin, R. Edwards, I. Kralj-Hans, K. Wooldrage, A. R.
Hart, J. M. Northover, D. M. Parkin, J. Wardle, S. W. Duffy,
J. CuzickUK Flexible Sigmoidoscopy Trial Investigators,
Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: A multicentre randomised controlled trial. Lancet 375, 1624–1633 (2010).
J. Peto, C. Gilham, O. Fletcher, F. E. Matthews, The cervical
cancer epidemic that screening has prevented in the UK.
Lancet 364, 249–256 (2004).
Independent UK Panel on Breast Cancer Screening, The
benefits and harms of breast cancer screening: An independent review. Lancet 380, 1778–1786 (2012).
M. Diamandis, N. M. White, G. M. Yousef, Personalized
medicine: Marking a new epoch in cancer patient management. Mol. Cancer Res. 8, 1175–1187 (2010).
B. Rachet, C. Maringe, U. Nur, M. Quaresma, A. Shah, L.
M. Woods, L. Ellis, S. Walters, D. Forman, J. Steward, M.
P. Coleman, Population-based cancer survival trends in
England and Wales up to 2007: An assessment of the
NHS cancer plan for England. Lancet Oncol. 10, 351–369
(2009).
P. A. Pérez-Mancera, C. Guerra, M. Barbacid, D. A. Tuveson, What we have learned about pancreatic cancer
from mouse models. Gastroenterology 142, 1079–1092
(2012).
Non-communicable diseases: A major challenge of
the 21st century. In: World health statistics 2012 (World
Health Organization, Geneva, 2012).
J. de Beyer, C. Lovelace, A. Yürekli, Poverty and tobacco.
Tob. Control 10, 210–211 (2001).
From “Andrea Del Sarto” by Robert Browning.
Acknowledgments: We thank the participants and speakers
for their time and contributions to the meetings in London in
2011 and at NIH in 2012. We also acknowledge the support of
the staffs of Cancer Research UK and NIH for their efforts in organizing and hosting the two meetings.
10.1126/scitranslmed.3005899
Citation: H. Varmus, H. S. Kumar, Addressing the growing international challenge of cancer: A multinational perspective. Sci.
Transl. Med. 5, 175cm2 (2013).
www.ScienceTranslationalMedicine.org 6 March 2013 Vol 5 Issue 175 175cm2
5
Downloaded from stm.sciencemag.org on March 12, 2013
“”
C O M M E N TA R Y