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COMMENTARY Primary Prevention of Cancer: Planning and Policy Considerations Ernst L Wynder* The progress of science requires discovery and its application. At times, the application of newly gained knowledge is more difficult than~the discovery itself. My experience has also shown that it's easier to discover the cause of a cancer than to reduce or eliminate : such causes: Louis M. Carrese' gave valuable atten= tion to this: issue and thus contributed much to the deWelopment and success~ of' the National Cancer Program. The question before us now is how can we best realize the : health objectiives we have set for ourselves to reduce the incidence of cancer byy the year 2000 (1), In designing & plan, be it in business or in science, one first has to set a goal. For the plan to succeed, the : goal must be feasible-scientificaily, economically, and sometimes political- ly, Once the end point is established, the game plan for achiev- ing,the goal can then be decided. Lou1 Carrese emphasized that though the map may often have to: be changedi, the stated des• tination has to be kept, in focus. At the outset, we can agree that cancer, atherosclerosis, and most other noncommunicable diseases are not an inevitable con- sequence of aging, For primary cancer, prevention+, that, means we need to identify the causes of cancer and then evaluate how we can modify, if not eliminate, these causes. Cancer prevention has, one goal-the reduction of the incidence of' cancer. The method to achieve this goal is to reduce the risk factors for each specific cancer. among blacks than among whites, with the exception of urinary bladder cancer (2): Clearly, elimination of tobacco products would result~ in~ al major decline in~ incidence of'and mortality from several kinds of cancer. In addition„tobacco smoking,has a major impact on the rate of cardiovascular diseases, pulmonary obstructive disease, gastric ulcer, and'other diseases, so that any change in smoking, habits wouldi have a broad effecn on our nation's health istatus and health care costs. Similarly, it has long, been established that alcohol abuse in- creases the risk of cancers of the upper respiratory and alimen- tary tracts, as well as of'cirrhosis of the liver,,traffic fatalities,, and other conditions. More recently, nutrition-particularly the total intake off dietary fat andI the specific type of fat-has been implicated ini the development of severalltypes of rnajor cancers, such as can- cers of the: breast, ovary, endometrium, prostate,, and colon. Major evidence comes from comparing the distinctly different cancer incidence rates of the United States and Japan (Fig 1) (3). so o. o. o. d. Q :. ro~ so~ d so~ a a Ca'uses U' 40 In defi'ning, causes of cancer, we recognize two important points: first, a causative : factor is one that increases: the risk of' cancer, although it does non have to be a "necessary" cause; and second, workable preventive strategies do: not, require: a com- plete delineation of the.mechanisms of pathogenesis of'a given cancer. We should add that a single cause may contribute to several types of disease. For decades ~ now, we have known that tobacco, in its various forms, causes a significant proportion off cancer deaths in men, and increasingly so in, women. In the United States, mosn tobacco-related cancers are more prominent 0 L+Y+/t.d stat.a O i diprn Fimala f.. d Braast Ovary Colon = Prostata Colon Fig 1. Age-standardized!incidence for cancer of selected sites in the United. States and Japan for 1980. Received November 13; 1990; revised January 4, 1991, accepted January 1'7., 1991 L 'This commentary is dedicated to the memory of 1.ouis M. Cirrese; former *Correspondlncr to: Ernst L Wynder, MD. American Health FoimdAtiomt. Associate Directorfor Planningand Analysis at theNatiooal Cancer Institute., 320 E 43rd ISt;,New York,,NY 10017: Vol. 83; No. 7; April 3, 1!991 COMMENTARY 475 2015000412

176' These differences are not due to genetic factors. as is evidentt from the increase in these cancers in Japanese immigrants to the United States. Many of the risk factors leading to these:chronic diseases relate to metabolic overlbad; that is, human metabolic defenses are not prepared'for excessive exposures to~tobacco smoke, alcohol, and dietary fat. Other risk factors, with impact on severalidiseases, include occupational exposures such as as- bestos, sunlight, and unsafe sexual practices. Although excessive weight is readily acknowledged to be a risk factor for disease and disability, it took us some time to recognize that an excess of saturated fat leads to atherosclerosis. Even now„ we find it difficult to see that excessive dietary fats, particularly polyunsaturated fats, play a role in several types of cancer. Perhaps as we compare the fat intake.inJapan over three or four decades and relate it to respective rates of coronary artery disease and several kinds of cancer, we may have a better appreciation,of'the optimal amounts, and types of fat for lower disease risk (Fig,1) (3). For optimal health, we need!to consider the : definition of an optimal diet, and we must also recognize thar such a diet,rrtust be palatable to the majprity of'our people, and'affordable. We also need toaeknowledge that preventive strategies aimedd at cancer ean simultaneously reduce the incidence of a broad range of diseases. Therefore, as a matter of national public health policy, such strategies must receive fullicooperationfrom different institutes within, the National Institutes of Health; the Centers for Disease Control, and'the Public Health Service and, where necessary, shouldl fbster interdepartmental collaboration, such as that between the CDC and the United States Department of Agriculture. Application of Discovery The good news about cancer etiology is that many of the causative factors for,cancer are knowni The bad news is that the eliminationi of these factors requires the active involvement of the individual. This fact helps explain some of the impediments that hinder or delay the application of diseoveries about cancer causation: The first impediment is that many individuals suffer from an illusion of immortality. We tend to live for the moment and f nd it difficult to "sacrifice" aiperceived pleasant habit for a potent tial future benefit. Regrettably, such thinking, is more often found! among groups with little education or income: While we can take satisfaction from the increased quit rate among smokers, this rate, particularly in rnen. is closelyrelated tollevel of educationi(Fig 2) (?I): Edtrcationai status has less of an effect on stnoking cessation: among women,, which suggests that women have greater fear of weight gain. These inherent obstacles to smoking cessation, along with recommended dietary changes, alcohol use and abuse, and sexual practices must be addressed1by healthieducators.. The second impedimenr is the benign disinterest that most physicians andl other health professionals have toward be- havioral tnedicine: This attitude is due in part' to the low academic rewards and the poor economic retum realized from the practice of health promotioni It continues to amaze me thar there are still physicians who do not counsel their patients about, 70 C. • .' n 401 ao~ :01 10. Fig,2. Smoking "quit ratd"by, levetlof'.education. 52 Orad1 School smoking, habits. Equally astonishing is how little the profession knows about nutrition and how few nutritional intervention programs are :provided by hospitals. The third impediment, is the active opposition to health promotion activities by the tobacco industry, segments of the food industry, and some of'the media that, depend on support from such industries. Recognizing these major obstacles, what should our plan and policy be for primary cancer prevention? Health EducatSon/Prontotion Adults We need to, provide broadly based, continuing, education to adults through the: major national, state, and regional publicc health authorities that concentrate on.the community. Here, as in therapy, the dose ! makes the cure. Various social support sys- tems can influence health behavior, eg, parents, friends, spouses, health professionals, housing, schools, religious institutions, thee community, and the ntedia: For some groups, we may dissemi- nate information through religious institutions, and housing, agencies, for those employed, we can engage the worksite, andi for a111 the community at large. We know,,of course, that educa- tion begins in the home, but this factor is largely influenced by the socioeconomic status and! composition of a family unit: Thus, we have to supplernent what is learned at home. Promo- tion of general health behavior also depends on the conditions of employment, housing, neighborhood, and personal relationships. The government, through its social policies, can have a major impact on health behavior, not only on risk factors that relate to: cancer, butalso on other risk factors such as drug use and!unsafe and promiscuous sexual practices, Nongovernmental organizations can also provide economic incentives for low-risk groups; thereby encouraging more heaithfull beh.:vtor. Several life insurance companies have ak ready done this. One company provides a20%-30'~'r reduction in premiums for confirmed nonsmokers (valiidated by urinary tests) and a40!90-509o reduction in premiums for nonsmokers with a good driving record, lower salr intake, and participation in exer- Journal of theNatfional Cancer Institute m I M.I.r B F.mal.s i 67' 2015000413

cise programs (Dudas J, Allstate Life Insurance Co; Chicago, III: personal communication). Such incentives should apply to all life insurance policies and eventualhy, to health insurance rates; as well. In view of' the high incidence of man-made, and thus avoidable„ illness, the government needs to concede that money spent for health promotion may well be money saved in terms of health care costs. The legislative and executive branches of our state and federal governments must get involved in the task of' reducing, the enormous burden of disease care costs. Financial incentives in the fotm of tax credits for health promotion programs established by employers wouldl lead to an important expansion of such programs. Children Most risk factors for preventable diseases are established during childhood. Ideally, basic positiwe healthihabits would be instilled in preschool children while they are still atihome. How- ever, many families do not live in an ideal environment„ so society must promote healthful behavior as early in life as pos• sible: A resulting,ancillary benefit is that children with increased health knowledge and education often, positively influence the behavior of parents and other adults ~. As a major policy for the National Institutes of Health (twldH), for, the Public Health Service; for each istate; and for the country, I suggest mandating comprehensive school healthi education from preschoollthrough high schooll Such an education program would be made up of the following components (5); 1) Annual health iscreening 2) Specific health science and integrated curriculum (student workbooks, teacher guides). 3) Health-conscious extracurricular activities 4) Evaluation (attitude„knowledge, behavior). 5) Full-time teacher/coordinator We have recently reported on the success of such a program for smoking prevention. There was a significant reduction in the onset of cigarette smoking, among the 10- to 15-year-old stu- dents who participated in, our "Know Your Body"' program (6). Several recent'studies have shown that unifactorial intervention programs aimed exclusively at smoking late in the students' school years are not very successful (7,8). We know that children are most susceptible to molding, in their preteens and that school health education must be multifactorial because all' risk factor education is interrelated. Here again, different NIiHH institutes. including those concerned with heart disease, cancer, aging;,drug use, AIDS, and the.environrrtent, must unite their in- terests and expertise to formulate a comprehensive school healthh education program. As part of a long-terrrt plan and goal I for health maintenance and, disease prevention, the NIH should take a lead in demonstration programs of this type in various parts of the country. We [rche American Health Foundation] expect to con= ducnsuch a program in the Washingtoni DC, school system with the cooperation of Howard University's School of Medicine. We are carrying out similar pilot programs with private local and corporate suppornthrough "adoption" of'schools around the country. Such pilot programs should serve as an example to the vol. 83, No. 7; Apri13, 19!91 US Department of Education and encourage legislators in every state to enact legislation that makes such programs mandatory for every school in the nation. Suchi an1 effort is not onlycrucial' for raising a generation of healthy ehildren; itis also signifii:ant- ly more cost effective than our present policy of curing drug- addicted and AIDS-infected children and adults; less expensive than the ways in which we deal with adolescent alcohol abuse and teenage pregnancy, and less expensive than treating, all the tobacco-, alt:ohol~_ and nutrition-related!diseases that cut short the productive.lives of our citizens: Manageriai' Pt•eventive Medicine In addition to educational programs for the individua9, we must consider "managerial?' preventive strategies or product modificationi Ideally, this would prevent, the onseti of cancer by "protecting" the cell,, an approach currently being explored' through a series of studies in chemoprevention at our Founda- tion and!elsewhere. This, however is a long-range goal. As long, as tobacco products are legal. large segments of our population, will use them: For, these individuais, we need to assure that thee tar yields of all cigarettes are not higher than 10 mg. Epidemiological data have shown that smoking such low-tar cigarettes poses a!lowercancer risk than smoking cigarettes with, highertan yields (.9). Although there cannot, be a safe cigarette, to the extent possible. specific toxic and tumorigenic smoke constituents should be reduced throughl modification of tobacco4 filtration, and certain inhibitory additives (lOl. We must recog- nize, however4 thatia reduction~in~nicotinen the habituating agent initobacco, will not lead1to.a reduction in coronary risk, primari- ly because smokers of low-yield' cigarettes adjust for their nicotine needs by smokiiog: more and inhaling more intensely: They, thus, counteract any reduction in tar exposure and in- crease exposure to toxic carbon monoxide (71). In; view of the associations between nutrition and cancer, as well as nutrition and heart disease, we are suggesting a new food plan (Fig 3) that is practical andl economical' for this p Typieal Am.riean Die't p AHF Reeomm.nd.d. Diet 40 25 11 0.7 e,-I'll 450 5i 25 ,; i Fal 0/s: Ra6oo cho4sl..a goo,um ~(Aetuy F~perITofKCal (Ratao/Poly, 1-0/1p(Oay,) (0, FromF.ili unsatwatsd aYli Oayl. to Saturatsa Fall 'satt-4q+i sotliuirn 1 tsp sa11.2' fl sodium Fig 3. American HeaithiFound+ution 1AHF) food plan. COMMENTARY 477 2015000414.

country. Variedl expertise and specific interests among food companies and leaders in agriculture can make this type of food plan an integral part of the American dietary scene. Less fat, a relative increase in desirable otrtegar3'fatty acids, an increase in both soluble and insoluble f bers; and a higher intake of vegetable proteins, micronutment vitamins, and minerals are all part of this plan. Legislative Preventive Medicine Scientists at the NIH andl in academia are generally not in- volNed' in promoting legislation.Z While this ought not to be one of our principall tasks, there are numerous ways we can effec- tively influence legislation, from increasing taxes on alcohol and tobaeco'to reducing the fat content of specific food' products to limiting', the levels of such toxic components as aflatox~in in foods and those of pollutants in our urban air: Here, we need to be cautious that the law does not run ahead of scientific evidence: The Delaney Clause' and' the : unfounded carcinogen scares from A'Iar to fluoride all require our attention. We must do better~ in assessing and managing low-level risks, like: car- cinogen, exposure, to ensure: that the public is not unduly frightened, concerned, and ultimately desensitized to actual risks. Moreover, surveillance.by scientists can prevent industries from ~ needlessly being, damaged by recommendations that have no established scientific base. Policy considerations, therefore, need to heed both sides of an issue, those that! do present and those that do not present a problem for public health. Quantita- ti've aspects of the exposure and risk equation are important; yer't are often ignored, a~keyelement in view of'the power of analyti- call chemistry, to measure: minute amounts of environmental' chemicals.. Cancer Prevention Centers From the study of epidemimlogy to various laboratory scien- ces to: health promotion, a cancer center should try to identify causative factors relating to different kinds ofl cancer andd develop science-based recommendations fior, the prevention of these cancers. Attention should be focused on the major cancer sites andlon the major risk factors in the belief that, as an estab- lished principle ofl public health, medical research should eon} centrate on the most common dis'eases and their causes, Signifcant progress is being made to establish hormone-re- lated markers, particularly those associated with breast and pros, tate cancers, as well as markers for colon cancer, such as bile acid flow and cell cycling, which: permit a determination and possible manipulation oflrisk.. We are conducting' health promotion programs among minority populations and in inner city schools. We wouldll'ike to see similar cancer prevention centers established elsewhere in this cotlntry. Centers like these, which focus specifically on etiological research and health promotion, are likely to con- tribute more to cancer prevention and control'i than clinical centers, where the principal task is treatment of disease. This is not, however,,to deny that comprehensive clinical centers or, for that matter, general medical l centers could not play a significant role in'di~ease'prevention and Icontrol.. Cancer Prevention Units Another specific policy suggestion concerns the manner in, which hospitals in general and comprehensive: clinical cancer centers in particular can contribute to the applicatibn ofexistingf cancer prevention information to their communities through a cancer control unit (12): Such a unit should be an integral part of every comprehensive clinical cancer center and should target their effort to schools, worksites, hospitals, churches, the com- munity, and the media. Its tasks should include the compilationn of''epidemiolbgical inforrnation: for each patient, which, if basedd on a uniform history for all cancer centers, would provide an ex- tensive data bank of etiolbgical'information. If tied into the NCI Surveillance, Epidemiolbgy, and End Htesults.Program, this dataa bank couldlprov'ide important epidemiological andlmechanistic informationi that would point to the etiblogy and modes of prevention of cancer and other diseases. This unit would also be responsible for providing information onicancer prevention and control for its in-house population, their families; and the com, munity, including early detection of cancer that improves the chances for effective therapy. Epi'liogue. These comments have focused on plans for decreasing the in- cidence of lifestyde-related cancers andlother diseases by reduc- ing or eliminating established risk factors. The plan brings together various segments of academic and nonacademic society. In its execution,, we are aware of inherent social, economic, andlpoliticallimpediments. A disease (cancer) control unit'. could be readily instituted l by any hospital and' could thus make a contribution to' a successful national policy for disease prevention and controC The ultimate aim of medicine, after all, is not to cure disease but to prevent ic'. The concepts delineated are medically feasible andisocially and fiscally imperative. An adage holds that it should be the'function of medicine "to help people die young, as late in life as possible." This should indeed bethe intended!goal of any plan in medical research. The only unavoidable cause of death is the, running down of our genetic clock. References (1). GREENwALDP. SONDIKE. EDS: Cancer Control Ollxcti4esfor theNation:. 1983-2(100: NCI Monogr 2. 1986' (T). DIVISION OF CANCER'.PREVENTION ANDCON7RDL. SURVEILLANCE.PROG.R~A'M.. NATIONAL CANCERINSTITIUiE: Cancer statistics review 1973-1987:..Dh1HS Publ No. (Nltiil90-2769 Bethesda. Md: National Cancer Institute.J990: 'Employees of the federal I government are prohibited from doing, so. Ed! (.1'.). wyNDEREL. FUJITA Y. HARRIS' RE. ETiA'L: Comparative epidemiology.of note: JThe Delaney Clause'is the 33-year-old law that requires the Foodiand Drug cancer between the United States and lapana A second look. Cancer' 67146-763:119911 Administration to ban any food additive that is found, to: cause cancer in, (4) KABAT GC, WYNDER EL: Determinants of'quitting smoking: Amer J laboratory'animals or humanL-Ed'' note, PublirHealth 77:1301-1303. 1987' 'I7g Joutnalofthe'dilationalCa»cerIns'titute , 2(lrti 5000415 _