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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
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
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
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
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
Females

Lung Rising ?

Breast Rising

Cervix/ovary Stable*

Stomach Falling

Skin Rising

* rates rising among younger age groups

Males

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
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 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
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
CAUSES: DIFFERENT VIEWS
  • ‘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
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
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
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
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
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
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