Politics of cancer
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POLITICS OF CANCER. position cancer as a case study: trends in prevalence and approaches outline current theories about cancer: causes and responses ‘conventional’ personal risk factors ‘radical’ structural and environmental factors ‘pyschosocial’ perspectives policy implications.

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Politics of cancer

  • position cancer as a case study: trends in prevalence and approaches

  • outline current theories about cancer: causes and responses

    • ‘conventional’ personal risk factors

    • ‘radical’ structural and environmental factors

    • ‘pyschosocial’ perspectives

  • policy implications

Extra reading

  • the Guardian and The Observer website has several articles: http://www.guardianunlimited.co.uk

    • Truths and myths: the cancer report, parts one and two 50 things you need to know about the Big C. Peter Silverton, Sun Oct 15th, 2000

    • eg George Monbiot: Are man-made chemicals turning against us? Jan 11th 2001, plus letters

  • Department of Health website for National Cancer Plan; Saving Lives: our Healthier Nation

  • articles BMJ and JECH

  • many websites

What is cancer

  • group of diseases affecting different part of body

  • uncontrolled reproduction of cells’:

    • CARCINOMA(85-90%) from cells of tissues that cover internal and external surfaces of the body

    • SARCOMA (2% of cancers) originate in muscles, bones, fat and lymphatic vessels

  • TUMOURS (neoplasms) can be:

    • MALIGNANT invade normal tissue; cancerous cells separate, travel via blood stream to other parts of body, can form new growths (secondaries or metasteses)

    • BENIGN ‘stay in place’; less dangerous but can block blood vessels, nerves, or grow in confined spaces

  • feared: ability to spread generates anxiety - ever ‘cured?’; metaphorical power ‘being eaten away’

Cancer current trends

  • leading cause mortality, 1 in 4 deaths in UK - 130,000/yr; not only because ageing population?

  • not ‘disease of affluence’ but of the poorest (not breast cancer);  in poorer ‘South’ countries too

  • 4 in 10 people will be diagnosed with cancer some time in their life

  • risk of developing disease  ->200,000 new cases annually

  • much of increase since WWII was lung cancer (now  men  women); breast, colon and cervix remained stable? stomach declined

  •  death rates but survival rates poor compared other European countries; ++ variation in UK

Cancer mortality rates 1971 onwards social trends


Lung Rising ?

Breast Rising

Cervix/ovary Stable*

Stomach Falling

Skin Rising

* rates rising among younger age groups


Lung Fallling

Prostate/ testicle* Rising

Stomach Falling

Colon/rectum Stable

Skin Rising

* rates rising among younger age groups

CANCER MORTALITY RATES 1971 onwards (Social Trends)

Most common killers saving lives our healthier nation
MOST COMMON ‘KILLERS’ (Saving Lives; Our Healthier Nation)

  • lung cancer

    • one fifth all diagnosed cancers; ¼ cancer deaths in men; survival rate 5 yrs= 6/100; cost £130 million

  • breast cancer (women)

    • one third diagnosed cancers women; one fifth all cancer deaths; survival rate=66/100; cost £150 million

  • prostate cancer (men)

    • 1 in 7 all diagnosed cancers men; one eighth all cancer deaths in men; survival rate=40/100; cost £100 million

  • colorectal cancer

    • 1 in 7 all diagnosed cancers; one ninth all cancer deaths; survival rate=40/100; cost £250 million

Cancer role of biology

  • age - accounts for some of increased rates;

    • 70% all cancers deaths in those >65yrs;

    • rates also <65s, only 5% male, 9% female <45s

    • 0.6% in <15s (1/3 leukaemia of whom 50% survive)

  • general ageing process in cells

  • heredity -

    • identical twins only 10% chance same cancer (prostate most heritable), ie heritability low

    • screening ‘risky’ individuals - treat/prevent/insure?

  • infectious agents

    • some role - stomach, cervical, liver

  • biological factors account for ~20% variation

Social patterning cancers

  • social or environmental causes ~80% variation; rates strongly patterned by class, gender, ‘race’:

    • deaths lung cancer unskilled men 5x professionals

    • deaths stomach cancer unskilled 3x professionals

    • death rates lung and cervical cancer 20% higher north England than national average

    • women born in Caribbean 25% less likely to die from breast cancer than other women living in UK

    • women more likely than men to contract skin cancer but less likely to die from it

  • differences in incidence and in experience

Causes different views

  • ‘establishment’ view: individualist, behaviour Doll, Peto OHN (McVie, Nurse)

    • tobacco: smoking is linked to 35% cancers, specifically lungs, major cause for mouth, larynx, pancreas, bladder; part in kidney, oesophagus, stomach and leukaemia; 120,000 die in UK/year

    • diet: linked to 30% cancers;  fruit/veg intake linked to  risk lung, stomach, colon; saturated fat intake associated higher risks colon, prostate, breast (not causative?); selenium, fibre protective?

    • excessive alcohol consumption linked to  cancer mouth, oesophagus, larynx, liver

    • reproductive and sexual behaviour: early age inter-course and promiscuity linked to cervical

Causes different views1

  • ‘radical view’ environmental lobby, Trades Unions Doyal, Epstein

    • exposure to chemicals/toxic substances at work and at home

    • pollutants in the environment, including components diesel engines, organo-chloride residues, radioactive discharges

  • neither denies importance of any of these risk factors; argument is over proportion - establishment puts work/industrial hazards/pollution risks at 4-5%; radical view estimates 20-40%

Causes establishment

CAUSE % deaths

Diet 35

Tobacco 30

Infection 10??

Rep. & Sex. Behav. 7

Occupation 4 (2 - 8%)

Alcohol 3

Geophysical Factors 3

Pollution 2

Food additives 1

Chemical Industries Association ‘best estimates’; based on Doll & Peto, The Causes of Cancer

Evidence occupations work

  • coal miners 2.5 x more likely to get cancer pancreas than general population

  • woodworkers 2x more likely to get nasal cancer

  • agricultural workers 5x more likely cancer of the lip

  • plasterers 1.5x more likely cancers of lung, trachea, bronchus

  • BUT, few official carcinogenic links made for many occupations, though specific chemicals known

  • symptoms take many years to develop

  • carcinogenic substances also released into air, water; working classes live in most polluted areas

  • workers bring toxic substances home with them

Challenges in positions

  • ‘establishment’ view rejects environmental views because lack of epidemiological evidence

  • smoking and dietary causes account for >70% cancers and major causes death

  • argue environmentalists exaggerating risks, and indifferent to costs

  • treat smoking and diet as individualist/ ‘lifestyle’ risks, seldom as structural? (recent shifts?)

  • tobacco industry big employer, generates tax, sponsors sport and culture; political ‘clout’

  • industry regulation controversial? difficult to do technically and politically

Psychosocial influences

  • evidence linking cancer incidence and outcomes to stress is mixed (mostly studies of ‘life events’)

  • psychosocial, emotional factors do play some role

  • Wilkinson: inequalities in income lead to power-lessness, internalized anger, poor social cohesion - ‘chronic strain’ - differential health experiences

  • ?Type C personalities? similar to Type A but emotionally inexpressive; ‘repressive coping styles’ (Greer in Heller et al)

  • structural factors on ‘lifestyles’: women smoke to ‘cope’ with poverty (Graham); men and women smoke to cope with boring work (Theorell, Marmot)

Policy implications

  • ‘establishment’ view: screening for early detection, encourage lifestyle changes; partnership individual and government to enable structural support

  • ‘radical’ view: remove carcinogenic substances from environment, prevent new ones entering it; crucial role of government in monitoring and enforcing legislation; industrial response

  • ‘psychosocial view’: action to reduce social and economic influences that affect ‘quality of life’ and shape lifestyles; learning new behaviour to deal with negative ‘coping’

Nhs cancer plan doh 2000

  • existing Smoking Kills targets:  28%-24% adults smoking by 2010

  • national targets on  smoking gap socio-economic groups: manual  32%-26% by 2010

  • explicit local targets for 20 Health Authorities with highest smoking rates

  • new targets to  waiting times diagnosis, referral, treatment - aim is one month max:

    • already true: acute leukaemia, children, testicular

    • milestones for other cancers

  • extra £50 million NHS funding for palliative care