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Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 1-5

Reflections on cancer control in the era of the Sustainable Development Goals

Cancer Survival Group, London School of Hygiene and Tropical Medicine, London, UK

Date of Submission20-Apr-2023
Date of Decision22-Apr-2023
Date of Acceptance23-Apr-2023
Date of Web Publication16-May-2023

Correspondence Address:
Prof. Michel P Coleman
Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aort.aort_8_23

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How to cite this article:
Coleman MP, Allemani C. Reflections on cancer control in the era of the Sustainable Development Goals. Ann Oncol Res Ther 2023;3:1-5

How to cite this URL:
Coleman MP, Allemani C. Reflections on cancer control in the era of the Sustainable Development Goals. Ann Oncol Res Ther [serial online] 2023 [cited 2023 May 31];3:1-5. Available from: http://www.aort.info/text.asp?2023/3/1/1/376899

In 2015, the United Nations published the Sustainable Development Goals (SDGs), with the overall aim of promoting prosperity and protecting the planet in the 15 years up to 2030.[1] Among the 17 broad SDGs, the third is: “Ensure healthy lives and promote well-being for all ages.”

Progress toward each SDG is monitored with several quantitative targets. For cancer, the key target (3.4) is: “By 2030, reduce by one-third [the] premature mortality from noncommunicable diseases (NCDs) through prevention and treatment and promote mental health and well-being.” The target was set relative to the levels of mortality in 2015. It includes four groups of NCDs: cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes. Premature mortality was defined as the cumulative probability of dying from one of these NCDs in the age range 30-69 years: not all ages, as in the SDG goal.

It is worth considering three questions: whether cancer should have been considered separately from the other NCDs; whether a global target based on mortality is appropriate to monitor progress for cancer, in particular, the restriction to the age range 30–69 years; and whether prevention and treatment are both suitable approaches to achieving the target for cancer.

Cancers are very different from the other three NCD groups. They comprise an extremely heterogeneous family of over 100 conditions that arise from uncontrolled proliferation of the body's own cells. The causes also differ between cancers, and they may be behavioural, or external (e.g., chemicals, viruses, parasites, etc.), or inherited genetic disorders. For about half of all cancers, the causes are still unknown, so primary prevention is not possible.

Cancer is also unique in that population-based cancer registries in many countries capture the basic details of the person, the pathology of the tumor, and the final outcome for every person diagnosed with cancer in the resident population of the territory that they cover. Some registries, mainly in high-income countries, also collect data on the stage at diagnosis and the treatment. Registries provide direct evidence of trends in cancer incidence, which guide priorities for prevention. Many registries also capture data on the death of all registered patients, regardless of the cause of death. This enables direct monitoring of trends in cancer survival.

The quantitative evidence from people diagnosed with cancer during life is thus far more detailed than for the other NCDs. When an estimated 20 million people are diagnosed with cancer every year, it would not have been misplaced to set targets for cancer incidence and survival, as well as mortality.

  Cancer Mortality Top

Trends in cancer mortality reflect the joint impact of past trends in cancer incidence and cancer survival. Mortality trends therefore provide a blurred and delayed reflection of trends in the effectiveness of cancer treatment, because for many cancers, especially those with high or increasing survival, the people who die from cancer in a given year may have been diagnosed and treated several or many years earlier. Taken in isolation, therefore, trends in cancer mortality cannot be usefully interpreted as markers of recent progress in cancer control.[2]

It is estimated that 41 million (71%) of the 58 million deaths each year around 2020 were from NCDs, but on a global scale, the data on cancer mortality are surprisingly deficient. According to WHO, two-thirds of the deaths that occurred in 2014 were not registered at all.[3] Where deaths are registered, only 64 of 115 countries that reported mortality data to WHO in 2003 included certification of the cause of death,[4] mainly because of insufficient resources for registration of deaths and medical certification of the cause(s) of death.[5]

Thus, in the absence of high-quality mortality data from every country, by age, cause of death and year of death, progress toward the SDG target for NCDs can only be assessed using model-based indicators of mortality. For countries where observed data on the registration of deaths are inadequate or unavailable, the indicators are derived indirectly.[6] These models require a wide range of assumptions, some of which cannot be tested.[7] This causes uncertainty about the true extent of progress toward the SDG target for NCDs.

  Mortality by Age Top

The mortality trends in the SDG target are restricted to the age range 30–69 years. This age range only includes half (53%) of the estimated total number of deaths from cancer in 2020 [Table 1].[8] About 45% of all cancer deaths occurred in elderly persons (aged 70 years or over), and this proportion is likely to increase with the ageing and growth of the world population. Only about 2% of all cancer deaths occurred in children, adolescents and young adults (aged 0–29 years), but 5-year survival from leukaemias, the most common group of malignancies in this age range, varies widely by world region.[9] In Africa, where 9% of all cancer deaths occur in the age range 30–69 years, the proportion in the age range 0–29 years is 28%.
Table 1: Estimated number of deaths from cancer* in 2020: age and world region

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Monitoring of progress toward the SDG target for NCDs, including cancer, will, therefore, provide no information on cancer mortality trends in elderly persons, or among children, adolescents and young adults, where the need for progress is most especially urgent in Africa.

The proportion of all cancer deaths in children, adolescents and young adults may be small, but it represents a huge and potentially avoidable loss of life. It is estimated that 11 million children will die from cancer between 2020 and 2050 unless substantial investments are made to improve access to health care; 9 million (84%) of these deaths will be in low-income and lower-middle-income countries.[10] Investment in delivering cost-effective interventions for cancer in children could avert more than half of these premature deaths. The global investment over this period would need to be massive – an estimated US$594 billion. That would require worldwide political and financial commitment, but it would also be expected to deliver even larger gains in lifetime productivity – $2580 billion: a three-fold return on the investment – especially in poorer countries. Focus on reducing cancer mortality in the age range 30–69 years ignores this issue.

  Prevention and Treatment Top

Prevention will always be better than cure, and it remains a crucial long-term priority in cancer control. The priority is reinforced by demographic projections and projected trends in cancer incidence rates suggesting that the number of new patients who will be diagnosed in 2070 may be double the estimated number diagnosed in 2020.[11]

For most cancers, however, the latency between carcinogenic exposure(s) and diagnosis is much longer than the 15 years between 2015, when the SDGs were set, and the year 2030, now only 7 years away. This severely limits the potential of preventive strategies that were set in 2015 to achieve the SDG target on premature mortality by 2030.

Further, long delays often arise between the discovery of the cause(s) of cancer, then the design and implementation of preventive measures, and any subsequent reduction of cancer incidence rates. Exposure to tobacco smoke has been known to cause cancer since 1950. In 2020, 70 years later, WHO estimated that 37% of men and 8% of women were still using tobacco.[12] Given the carcinogenicity of tobacco smoke, this is not a promising sign for the rapid implementation of primary prevention programmes.

The potential for eradication of cervical cancer by vaccination against oncogenic human papillomavirus strains in young girls and boys is a welcome exception. Even so, children vaccinated aged 11–14 years since 2015 will not have reached the age of 30 by 2030, so their vaccination will not reduce cervical cancer mortality in women aged 30–69 years by then. Trends in the incidence of invasive cervical cancer provide a more relevant measure of the success of the vaccination programme.[13]

For most cancers, a preventive strategy implemented since 2015 cannot be expected to produce a substantial reduction by 2030 in incidence in the age range 30–69 years, still less in cancer mortality. Most persons who will die from cancer in the target age range before 2030 have already been diagnosed and treated, or are harbouring a malignancy that is currently subclinical but will be diagnosed before 2030. For those persons, primary prevention is not applicable.

Mortality rates have been declining for many cancers since the turn of the century. Premature mortality from all four major NCD groups combined fell by an average of 1.6% a year worldwide over the decade 2000–2010. Even before the COVID-19 pandemic began in 2020, however, that decline had slowed to an average of 1.1% a year over the 6 years 2011–2016. WHO described this as an “alarming slowdown.”[14] In July 2020, only 6 months after the COVID-19 pandemic erupted, the United Nations High-Level Political Forum on Sustainable Development reported that the pandemic had further stalled progress toward the SDG targets. In some countries, progress had even reversed, and inequalities in health had widened.[15]

If we cannot expect prevention to reduce cancer incidence substantially in the near future, then reducing cancer mortality by 2030 will also require improving survival for those people who do develop cancer. That will require more investment in health services, with wider access to early diagnosis, prompt investigation and effective treatment. Most cancer deaths already occur in low-income and middle-income countries, so it will be particularly important for improvements in survival to be delivered in those countries.

In 2018, WHO launched the Global Initiative for Childhood Cancer (GICC), perhaps partly to address the exclusion of children from the SDG target for cancer and other NCDs. In contrast with the SDG target to reduce premature mortality, the GICC goal is to increase [5-year] survival for children with cancer from 30% to 60% by 2030.[7],[16] GICC aims to increase the prioritisation of childhood cancer by helping countries to plan fully costed programmes for cancer diagnosis and treatment and to include childhood cancer in national strategies for cancer control. Since it is currently impossible to prevent most cancers in children, the best way to reduce the cancer burden in children will be to deliver prompt, accurate diagnosis, and access to effective therapy.[16] The Global Platform for Access to Childhood Cancer Medicines, launched in 2021 by WHO and St. Jude Children's Research Hospital in the US, aims to redress the “unacceptable imbalance” in survival from childhood cancer by ensuring access to cancer medicines in countries that cannot afford them. Population-based survival metrics will be required to evaluate these approaches.

  Cancer Survival Top

The most effective way of reducing cancer mortality rates in the medium term (by 2030) will be to improve survival. Strategies could include campaigns to improve public awareness for earlier diagnosis, but especially the implementation of national cancer plans,[17],[18] to ensure prompt and universal access to effective treatment. If improvements in population-based survival are needed to help reduce cancer mortality by 2030, then evidence will be required on whether such improvements are actually happening. The Sustainable Development Goals do not explicitly mention this.

The International Agency for Research on Cancer monitors incidence trends (from cancer registries)[19] and mortality trends (from the WHO database).[4] WHO should consider including global trends in cancer survival in its strategic planning for cancer control.[20]

Survival estimates are derived by analysis of individual tumour records held by population-based cancer registries that capture details of the diagnosis and vital status of all cancer patients. Cancer survival cannot be reliably assessed in a country where no data are available from population-based cancer registries. Only about 20% of the world's population is covered by cancer registration, and many of the poorest countries do not have a cancer registry. It would be unwise to use mortality-to-incidence ratios from countries with both data streams to estimate cancer incidence and survival in countries that do not have cancer registration.[21]

Real-world evidence on the global burden of cancer is required to replace complex statistical models based on incomplete data and questionable assumptions. That will require nothing less than a revolution in the coverage and timeliness of cancer registration,[22] underpinned by the necessary political, legislative and financial support.[17],[20]

Delivering more timely data is a question of political will. The technology exists. The cost is not prohibitive.[23] The COVID-19 pandemic has proved that monitoring of a disease can now be delivered on a global scale, in real time, where recognition of its public health importance co-exists with the political imperative to address it. Politicians should consider the magnitude of a public health threat, not just its immediacy, as the two key criteria for action: a steadily rising toll of 10 million cancer deaths a year should be sufficient evidence.

The timeliness of cancer registration has improved since 2000, but delays of a year or more in reporting cancer incidence should no longer be necessary. The diagnosis of cancer is more complex than for communicable diseases, but the diagnosis of most cancers is confirmed by pathology or imaging. Both data streams are accessible from the same health-care facilities that have provided information on a daily basis about COVID-19 infections and deaths around the world to the European Centre for Disease Prevention and Control in Sweden.

Ironically, perhaps, while governments were ready to change laws to ensure rapid access to data on COVID cases and deaths, access to data from cancer registries has become more difficult, especially since the European Union's General Data Protection Regulation became law in May 2018. The law does permit epidemiological and scientific research with personal data under clearly defined circumstances, but researchers may now have to spend a year or more struggling with bureaucratic misinterpretation of the law before being given access.[24],[25],[26],[27]

It seems reasonably safe to conclude that the one-third reduction in premature NCD mortality by 2030, as defined in the Sustainable Development Goals, is not achievable solely on the basis of prevention, at least not for cancer. Equitable access to effective treatment will be required to improve survival. Progress should therefore be evaluated with trends in survival, as well as mortality.

Long-term investments are required on several fronts: in effective strategies for prevention; in health systems, to improve equity of access to diagnosis and optimal treatment; and in cancer registration, to enable assessment of progress. These steps would reduce cancer incidence, improve survival, and increase the quality of life for cancer patients. As a consequence, they would reduce cancer mortality. Such an approach to global cancer control would also produce substantial economic gains for society, not just for the rest of the decade to 2030, but for the rest of the 21st century.

  References Top

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Extramural Committee to Assess Measures of Progress Against Cancer. Measurement of progress against cancer. J Natl Cancer Inst 1990;82:825-35.  Back to cited text no. 2
World Health Organisation. Civil Registration: Why Counting Births and Deaths is Important (Fact sheet N 324); 2014. Available from: http://www.who.int/mediacentre/factsheets/fs324/en/. [Last accessed on 2023 Apr 01].  Back to cited text no. 3
World Health Organisation. Mortality Database, 2018. Available from: http://www.who.int/healthinfo/mortality_data/en/. [Last accessed on 2023 Apr 01].  Back to cited text no. 4
Jha P. Reliable direct measurement of causes of death in low and middle-income countries. BMC Med 2014;12:19.  Back to cited text no. 5
NCD Countdown 2030 Collaborators. NCD countdown 2030: Pathways to achieving Sustainable Development Goal target 3.4. Lancet 2020;396:918-34.  Back to cited text no. 6
Bhakta N, Force LM, Allemani C, Atun R, Bray F, Coleman MP, et al. Childhood cancer burden: A review of global estimates. Lancet Oncol 2019;20:e42-53.  Back to cited text no. 7
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Ssenyonga N, Stiller C, Nakata K, Shalkow J, Redmond S, Bulliard JL, et al. Worldwide trends in population-based survival for children, adolescents, and young adults diagnosed with leukaemia, by subtype, during 2000-14 (CONCORD-3): analysis of individual data from 258 cancer registries in 61 countries. Lancet Child Adolesc Health 2022;6:409-31.  Back to cited text no. 9
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World Health Organisation. WHO Global Report on Trends in Prevalence of Tobacco Use 2000-2025. 4th ed. Geneva: World Health Organisation; 2021. Available from: https://www.who.int/publications/i/item/9789240039322. [Last accessed on 2023 Apr 01].  Back to cited text no. 12
Lei J, Ploner A, Elfström KM, Wang J, Roth A, Fang F, et al. HPV vaccination and the risk of invasive cervical cancer. N Engl J Med 2020;383:1340-8.  Back to cited text no. 13
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United Nations Economic and Social Council. Report of the High-Level Political Forum on Sustainable Development Convened Under the Auspices of the Economic and Social Council at its 2020 Session (E/HLPF/2020/6). New York NY: ECOSOC; 2020. Available from: https://digitallibrary.un.org/record/3886523?ln=zh_CN. [Last accessed on 2021 Jan 05].  Back to cited text no. 15
World Health Organisation. WHO Global Initiative for Childhood Cancer: An Overview. Geneva: World Health Organisation; 2018. Available from: https://www.who.int/publications/m/item/global-initiative-for-childhood-cancer. [Last accessed on 2023 Apr 01].  Back to cited text no. 16
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