Download - 젠더의 관점에서 본 환경건강 의제 PPT(2007)
This presentation is dedicated to my women friends
• Some who died of cancer such as Francesca Capeletto or 2 of the 4 nominees for France for the 1000 women for the Peace Nobel Prize 2005, Dr Solange Fernex and Christina Pezenas de Montcel
• Others who are bravely fighting against metastatic breast cancer, such as Dr Annie Hubert
Cancer and globalization:A European perspective with a focus
on women’s health
Annie J. Sasco, MD, DrPHTeam leader, Epidemiology for Cancer Prevention
Inserm, U 593Victor Segalen Bordeaux University, France
Visiting Professor, University of Sao Paulo, Brazil
This presentation solely reflects the point of view of the author and cannot be taken as official views of the Inserm, the University or any other institutions
XXI st century
• A century of globalization• For commercial products and life-
style• For disease occurrence (cancer,
reproductive outcomes, etc..)• For action
Cancer: Evolutionary perspective• Not just a disease of the old age in
western populations• An ancient phenomenom (dinosaurs,
mummies) which has always been part of (pluricellular) life
• Existing in all species (humans, animals)
• In all populations of the world (with different frequencies)
• Increasing over time
World cancer burden in 2002
10.9 million new cancer cases- 5.1 in women- 5.8 in men
6.7 million cancer deaths- 2.9 in women- 3.8 in men
ParkinParkin et al., 2005et al., 2005
Geography of cancer
after correction for different population sizes and age-structures
→age-standardized (world population) rates
enabling us to compare populations
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 man-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 woman-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 man-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 woman-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 woman-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 woman-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 woman-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 man-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 man-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 man-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 woman-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 woman-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 man-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 man-years
Globocan 2000, 2001
*ASR : age-standardized (world) incidence rate, expressed as number of new cases per 100 000 woman-years
Breast cancer
1 cancer out of 10 in the world
Concerns almost exclusively women
Sasco, 2004Sasco, 2004
Incidence of breast cancer : ASR* (world) (all ages) Korea
18,612,7
20,920.0
0
20
40
60
80
100
Busan Daegu Kangwha Seoul
*ASR : age-standardized incidence rate expressed in number of new cases per 100 000 woman-years
Parkin et al, 2002
Incidence of breast cancer : ASR* (world) (all ages) Japan
36,6 33,1 29,823,6
28,328.0
0
20
40
60
80
100
Hiroshima Miyagi Nagasaki Osaka Saga Yamagata
*ASR : age-standardized incidence rate expressed in number of new cases per 100 000 woman-years
Parkin et al, 2002
Incidence of breast cancer : ASR* (world) (all ages) China
24,6
36,2
9,1
27,2 31,324,7
18,110.0
0
20
40
60
80
100
Beijing HongKong
Jiashan Qidongcountry
Shanghai Taiwan Tianjin Wuhan
*ASR : age-standardized incidence rate expressed in number of new cases per 100 000 woman-years
Parkin et al, 2002
How can we explain these differences ?
Life styleGenetics
Environment
How do we evaluate the relative importance of these influences ?
The study of migrant populations
Breast cancer incidence rate by age in various groups of population
from Waterhouse et al., 1982
Sasco, 1989
San Francisco, WhiteSan Francisco, ChineseLos Angeles, ChineseChinese, Shanghai (P.R.C.)
Temporal epidemiology
- age- time-trends
Breast cancer rates by age - Singapore
Rate (per 100,000)
0
50
100
150
200
0-14 15-44 45-54 55-64 65+
IncidenceMortality
Age (years)
Expressed in number of new cases or deaths per 100 000 woman-yearsGlobocan 2000, 2001
Trends in world cancer burden
3,2 3,9 4,3 5,3
3,13,8 3,8
4,7
0
2
4
6
8
10
12
1980 1985 1990 2000
womenmen
6.37.6 8.1
10.0
Million
Total number of annual estimated new casesTotal number of annual estimated new cases
based on the mostbased on the most 1616 1818 2525 2424
common cancerscommon cancers
Parkin Parkin et al, 1988et al, 1988 19931993 19991999 20012001
Time-trends in cancerWorld breast cancer burden
471063324100298000224200
579285
471500422000347900
0
300000
600000
900000
1200000
1980 1985 1990 2000
industrialized
other
572100720000
795600
Total number of annual estimated new Total number of annual estimated new casescases Sasco, 2003
adapted from Parkin et al 1988, 1993, 1999 and Parkin 2001
1050348
What are the global trends in cancer ?
• In terms of burden of disease : Clear increases for most cancers at most places due to :– population increases– aging of the population– true increases of the disease
• In terms of age-standardized rates :Contrasting pictures depending on :– mortality / incidence– geography
Mortality of breast cancer Mortality of breast cancer -- TimeTime--trendstrendsWorldWorld
19501950 19551955 19601960 19651965 19701970 19751975 19801980 19851985 19901990 19951995
JapanJapan
USAUSA
FranceFrance
NetherlandsNetherlands
ItalyItaly
SwedenSweden
UKUK
Incidence - Breast cancer - Women
0
20
40
60
80
100
1955 1965 1970 1975 1980 1985 1990 1995
USA, ConnecticutUSA, Connecticut
Japan, MiyagiJapan, Miyagi
UK, BirminghamUK, Birmingham
France, BasFrance, Bas--RhinRhin
Canada, AlbertaCanada, Alberta
DenmarkDenmark
Sasco, 2004
Age-standardized (world population) incidence rates, expressed in number of new cases per 100,000 woman-years
based on Cancer Incidence in Five Continents, volumes I (1966) to VIII (2002)
Incidence of breast cancer –Time-trends - Asia
0
10
20
30
40
50
1955 1965 1970 1975 1980 1985 1990 1995
Japan, MyagiJapan, Myagi
India, BombayIndia, Bombay--MumbaiMumbai
HongHong--KongKong
China, ShanghaiChina, Shanghai
Sasco , 2004
based on Cancer Incidence in Five Continents, volumes I (1966) to VIII (2002)
Age-standardized (world population) incidence rates, expressed in number of new cases per 100,000 woman-years
What are the global trends in cancer ?• In terms of incidence rates :
– some almost universal decreases (stomach cancer)
– some decreases for some cancers in countries previously having high rates
ex : - male lung cancer and some other tobacco/alcohol related cancers in Northern America and Europe
- some other cancers (plateau for breast cancer in the USA or Canada)
– increases for most cancers in many countries- increases in the less developped countries (Africa, China,
India, ...)- increases still occuring in parts of the Western world
(Central European countries) and for specific cancer types (tobacco-related cancers but also hormono-dependant cancers)
Controversy surrounding increases in cancer rates
• How much is due to ?– improvement in therapy and impact on mortality
• clear role for testicular cancer in young men• role in survival from childhood cancer
– earlier diagnosis• true for most cancers with some impact on mortality• unlikely to affect incidence rates to any notable extent
– screening• undeniable role for prostate cancer in the USA• some role for breast cancer
– real increases• My own contention is that most of the
increases are real
Etiologic epidemiology: the search for the causes of cancer
• Genetics less than 10% of all cancersa role for genetic polymorphisms and epigeneticphenomena
• Life-stylesmoking, alcohol drinking, diet, physical exercise, sunexposure, sexual and reproductive life, use of legal andillegal drugs
• Environment
Other identified causes of cancer
• Many recognized carcinogenschemicalphysical agentsbiological
• Present in occupational and environmental settings
The IARC Monographs programme on the evaluation of carcinogenic risks to humans
Classification
Group Number1 : Carcinogenic to humans 1082A : Probably carcinogenic to humans 642B : Possibly carcinogenic to humans 2403 : Not classifiable as to carcinogenicity
to humans 4874 : Probably not carcinogenic to humans 1
Total evaluated 900
How much of cancer is due to the presence of carcinogens in
the environment?The answer will depend on:
• the cancer considered• the definition of the environment• the person answering the question
from 2 to 80%
A very difficult question
• Difficulty in identifying precise compoundsof interest (and their metabolites)
• Difficulty in assessing low dose effects
• Difficulty in estimating cumulativeexposures
• Huge difficulty in assessing potential interactions between many low dose agents
Three approaches to primary cancer Three approaches to primary cancer preventionprevention
Genetic interventionGenetic intervention
Modulation ofModulation ofcarcinogenic carcinogenic mechanismsmechanisms
GeneGene
EnvironmentEnvironmentCancerCancer
Avoidance of risk factorsAvoidance of risk factors
Sasco, 1995Sasco, 1995
Avoidance of risk factors
• Recognition of risk factors
• Levels of control
individualcollective
European Code Against Cancer (third version)Many aspects of general health can be improved, and many cancer deaths prevented, if we adopt healthier lifestyles:
1. Do not smoke: if you smoke, stop doing so. If you fail to stop, do not smoke in the presence of non-smokers.
2. Avoid obesity.3. Undertake some brisk, physical activity every day.4. Increase your daily intake and variety of vegetables and fruits: eat at
least five servings daily. Limit your intake of foods containing fats from animal sources.
5. If you drink alcohol, whether beer, wine or spirits, moderate your consumption to two drinks per day if you are a man or one drink per day if you are a woman.
6. Care must be taken to avoid excessive sun exposure. It is specifically important to protect children and adolescents. For individuals who have a tendency to burn in the sun active protective measures must be taken throughout life.
Boyle et al, 2003Boyle et al, 2003
What about exposures which are beyond the level of control of the individual?
examples : - Air pollution and cancer- Use of growth promoters in animal production- Pesticide residues in food- Exposure to radiations
The precautionary principle should, whenever possible, be enacted to prevent unnecessary exposures in particular at specific periods of vulnerability (fœtal life,childhood, ...) with a triple objective:
- protect all- protect the most susceptible- social justice
European Code Against Cancer (third version)
7. Apply strictly regulations aimed at preventing any exposure to known cancer-causing substances. Follow all health and safety instructions on substances which may cause cancer. Follow advice of National Radiation Protection Offices.
Boyle et al, 2003
But :- What about carcinogens which are not regulated?- Which rules should apply to low dose exposures?- Is there room for the precautionary principle?
How much did we need to act ?John Snow and the cholera epidemic in London
Knowledge:- maps of cases in London- map of water supply
Action:- Snow removed the handle of the pump
in absence of absolute proofin the name of precautionary principle
How much do we now need to act?
• evidence of carcinogenicity• evidence of toxicity• balance of benefits/harms to the person
exposed
For exposures which can be controlledby the individual, correct information ofthe person exposed (labelling) and freedomto decide ?
The European REACH directive
Register, Evaluate and Authorize ChemicalsA screening effort to try to prove inocuity of products
before putting them on the market rather than later demonstrating their dangerProblematic choice of which products to evaluate (quantity)Far from being sufficient but a step in the right direction
The need to reform the international trade
• The role of the World Trade Organisation in health related mattersMy own experience: the use of growth promoters inanimal productionCountries cannot defend the health of their populationsResisting the entry to dangerous products is not an unfairbarrier to free tradeRegulations should be uniform all over the world
Not a conclusion: The way to the future!• Women have long demonstrated they are
survivors, much more resistant than men, and yet never getting their fair share
• Women care about the future because many of them had a future, independant being growing inside of them when they were pregnant and they know the responsability of bringing a child to the world
• They are the only ones capable of changing the world, making it a better, cleaner, fairer place to live
• We owe to our daughters to start NOW!