More than half of cancer is preventable now

The media release from the Washington University School of Medicine, yesterday, on our review of the potential to prevent cancer and barriers slowing our progress in acting on what we already know. (For article link here) Colditz, Wolin, and Gehlert collaborate on a number of cancer prevention projects through Siteman Cancer Center Prevention and Control Program.

More than half of all cancer is preventable, and society has the knowledge to act on this information today, according to Washington University public health researchers at the Siteman Cancer Center in St. Louis.

In a review article published in Science Translational Medicine March 28, the investigators outline obstacles they say stand in the way of making a huge dent in the cancer burden in the United States and around the world. “We actually have an enormous amount of data about the causes and preventability of cancer,” says epidemiologist Graham A. Colditz, MD, DrPH, the Niess-Gain Professor at the School of Medicine and associate director of prevention and control at the Siteman Cancer Center. “It’s time we made an investment in implementing what we know.” Colditz What we know, according to Colditz and his co-authors, is that lifestyle choices people make and that society can influence in a number of ways — from tobacco use to diet and exercise — play a significant role in causing cancer. Specifically, the researchers cite data demonstrating that smoking alone is responsible for a third of all cancer cases in the United States. Excess body weight and obesity account for another 20 percent. But beyond individual habits, they argue that the structure of society itself — from medical research funding to building design and food subsidies — influences the extent of the cancer burden and can be changed to reduce it. The obstacles to implementing broad cancer prevention strategies are: Skepticism that cancer can be prevented. Smoking rates in different states demonstrate that 75 percent of lung cancer in the United States could be prevented with elimination of cigarette smoking. The short-term focus of cancer research. Benefits of prevention may be underestimated because they take decades to show up, and research funding often spans five years or less. Intervening too late in life to prevent cancer. Strategies like vaccination against cancer-causing viruses, such as the human papilloma virus that causes cervical cancer, work best when begun early, in this case before young people begin sexual activity. Research focuses on treatment, not prevention. Treatments focus only on a single organ after diagnosis but behavioral changes reduce cancer and death rates from many chronic diseases. Debate among scientists. They say health experts have a moral responsibility to highlight cancer risk factors even without knowing the biological mechanism by which they cause cancer. Societal factors that affect health. Tobacco policy and government subsidies don’t do enough to discourage unhealthy behavior, and in some cases they make the unhealthy options more accessible, especially in low-income communities. Lack of collaboration across disciplines. Scientists and health experts must work together to learn what causes cancer, communicate that to the public and work with community leaders to implement policies that help people lead healthier lives, they say. The complexity of implementing broad changes. With so many players involved, from health-care providers to government regulators to individuals, it will be difficult to implement broad change over the long term. According to the American Cancer Society, an estimated 1,638,910 new cancer cases will be diagnosed this year in the United States. Also this year, 577,190 Americans are expected to die of cancer. Only heart disease kills more people in this country. And Colditz’s research has shown that these cancer prevention strategies would reduce the burden of heart disease and other chronic conditions as well. Despite the obstacles, Colditz and his colleagues point to some successes that they say demonstrate that broad change is possible. One example is the relatively quick elimination of unhealthy trans fats from the national diet. And the National Cancer Institute (NCI) has reported that lung cancer rates are declining in both men and women, supporting the benefits of tighter tobacco control policy. “After working in public health for 25 years, I’ve learned that if we want to change health, we need to change policy,” says co-author Sarah J. Gehlert, PhD, the E. Desmond Lee Professor of Racial and Ethnic Diversity at the Brown School of Social Work and the School of Medicine. “Stricter tobacco policy is a good example. But we can’t make policy change on our own. We can tell the story, but it requires a critical mass of people to talk more forcefully about the need for change.”

Preventing Colon Cancer Now.

As we complete April, colon cancer awareness month, the topic of strategies to improve our population risk profile and reduce the cancer burden in our families, our workplaces, our communities and our state, I am reminded of many times we have written and talked on this topic. We have written on physical activity and colon cancer prevention from many angles (1-6) and used titles such as “walk away from colon cancer” or at the Eat and Run conference in Sydney Australia, 2002, we concluded that what we don’t know is how best to conduct community based interventions to reduce weight gain through increased physical activity.

It remains clear that higher levels of exercise protects against colon cancer, most likely through insulin pathways (7, 8). While further research may refine this understanding and identify potential points for intervention – keeping active through adolescent and adult years reduces risk of many chronic conditions including heart disease and diabetes. The pay-off for wellness is clear.

Writing in the American Journal of Public Health in 2001, I emphasized the need for action to implement our understanding of sun exposure as a cause of the epidemic of melanoma we are currently experiencing in the US. The messages for cancer prevention from this time over a decade ago, apply just the same today as we work to prevent colon and other major cancers. “It is time to implement existing cancer prevention strategies through providers, regulatory changes, and programs focused on individuals: programs to encourage smoking cessation and counter trends in youth smoking initiation as well as programs that encourage people to eat a healthy diet, avoid weight gain, be physically active, drink in moderation if at all, practice safe sex, and avoid sunburns and excessive sun exposure”(9). We can act on our understanding of the power of prevention and bring healthier life to our country reducing health expenditures in the future as an added benefit.

For tips and strategies on how to adopt a healthier lifestyle for you, your family, and your community go to:Your Disease Risk

See the Community Action button for strategies to promote wellness and prevent cancer in your community.

Literature cited

1.         G. Colditz, C. Cannuscio, A. Frazier, Physical activity and colon cancer. Cancer Causes Control 8,  (1997).

2.         M. E. Martinez, E. Giovannucci, D. Spiegelman, D. J. Hunter, W. C. Willett, G. A. Colditz, Leisure-time physical activity, body size, and colon cancer in women.  Nurses' Health Study Research Group. J Natl Cancer Inst 89, 948 (1997).

3.         K. Y. Wolin, Y. Yan, G. A. Colditz, Physical activity and risk of colon adenoma: a meta-analysis. British Journal of Cancer 104, 882 (2011); published online EpubMar 1 (10.1038/sj.bjc.6606045).

4.         K. Y. Wolin, Y. Yan, G. A. Colditz, I. M. Lee, Physical activity and colon cancer prevention: a meta-analysis. British Journal of Cancer 100, 611 (2009); published online EpubFeb 24 (10.1038/sj.bjc.6604917).

5.         K. Y. Wolin, K. Carson, G. A. Colditz, Obesity and cancer. Oncologist 15, 556 (2010)10.1634/theoncologist.2009-0285).

6.         E. Giovannucci, A. Ascherio, E. B. Rimm, G. A. Colditz, M. J. Stampfer, W. C. Willett, Physical activity, obesity, and risk for colon cancer and adenoma in men. Ann Intern Med 122, 327 (1995).

7.         E. Giovannucci, Metabolic syndrome, hyperinsulinemia, and colon cancer: a review. Am J Clin Nutr 86, s836 (2007); published online EpubSep (

8.         E. Giovannucci, Insulin and colon cancer. Cancer Causes Control 6, 164 (1995).

9.         G. Colditz, Cancer culture: epidemics, human behavior, and the dubious search for new risk factors. Am J Public Health 91, 357 (2001).

Prevention of Colon Cancer: time for action is now

Recent updated evidence from the United States National Health And Nutrition Survey (NHANES) show that the majority of US adults have more than one modifiable risk factor for colon cancer that needs attention (see article). While screening is advocated for prevention of colon cancer and supported by evidence from randomized controlled trials (1), we have shown that even after screening, those with poor risk profiles remain at elevated risk of colon cancer (2). In particular, and analyzing data from the Nurses’ Health Study, Wei and colleagues show that lack of physical activity, red meat consumption and high alcohol intake and lack of regular aspirin use, leave women who have been screened for colon cancer at substantially elevated risk of cancer in subsequent years.

What do we know about the US population and primary prevention of colon cancer?

Analyzing the NHANES data, Joshu and colleagues tracked colon cancer risk factors form 1999 to 2008 (3). Obesity, physical inactivity, red meat consumption, and alcohol intake, together account for more than 70% of colon cancer (4). Over this decade of repeated surveys the adult US population remained largely unchanged in their poor risk profile for colon cancer. 4 out of 5 US adults had one or more risk factors that could be modified. This was true for men and women, for White, Black, and Hispanic populations, and for each age group from 20 to 69. Almost 20% of adults have 3 or more modifiable risk factors. Thus they could take action now to lower their risk of colon cancer.

Why lower your risk?

Lifestyle changes significantly lower risk of colon cancer. 

It is time to act on what we know and reduce the population burden of colon cancer - a leading cause of cancer mortality. In fact, treatment of colon cancer accounted or 11% of all US cancer care expenditures in 2010. That is some 14 billion dollars spent on treating a cancer that is highly preventable. 

We can all take action now that will reduce the number of cases diagnosed over the coming years and the suffering that goes with this disease; save unnecessary expenditures; and improve quality of life. 

For help identifying risk factors you can work on today, visit our award winning web site your disease risk .

Related posts

Cancer News in Context: Aspirin prevents colon cancer

Cancer News in Context: Primary prevention of colon cancer, time to ...

Cancer News in Context: You Can Prevent Colorectal Cancer

Cancer News in Context: Cancer Prevention Works

Web resources
Your Disease Risk

Literature cited

1.         W. S. Atkin, R. Edwards, I. Kralj-Hans, K. Wooldrage, A. R. Hart, J. M. Northover, D. M. Parkin, J. Wardle, S. W. Duffy, J. Cuzick, Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 375, 1624 (2010); published online EpubMay 8 (S0140-6736(10)60551-X [pii]10.1016/S0140-6736(10)60551-X).

2.         E. K. Wei, G. A. Colditz, E. L. Giovannucci, C. S. Fuchs, B. A. Rosner, Cumulative Risk of Colon Cancer up to Age 70 Years by Risk Factor Status Using Data From the Nurses' Health Study. Am J Epidemiol,  (2009); published online EpubSep 1 (kwp210 [pii]10.1093/aje/kwp210).

3.         C. E. Joshu, G. Parmigiani, G. A. Colditz, E. A. Platz, Opportunities for the primary prevention of colorectal cancer in the United States. Cancer prevention research 5, 138 (2012); published online EpubJan (10.1158/1940-6207.CAPR-11-0322).

4.         E. A. Platz, W. C. Willett, G. A. Colditz, E. B. Rimm, D. Spiegelman, E. Giovannucci, Proportion of colon cancer risk that might be preventable in a cohort of middle-aged US men. Cancer Causes  and Control 11, 579 (2000).

Smoking cessation reduces lung cancer mortality

A new rigorous analysis funded by the National Cancer Institute is published this month in the JNCI. Moolgavkar and colleagues (see report) now estimate that over 790,000 lung cancer deaths have been avoided by cessation from cigarette smoking since the 1964 Surgeon General's first Report on Smoking and Health was released. This represents only a fraction of all deaths that can be avoided by more comprehensive implementation of what we know works for tobacco control. 


A detailed report from the CDC estimates that each year cigarette smoking and exposure to second hand smoke cause over 400,000 or 1 in 5 deaths. See Tobacco Control State Highlights 2010 for a detailed break down by state. This report highlights how substantial the range of implementation of effective and proven programs is, even within the US, where policies and practice vary enormously from one state to the next. 


Implementing programs that we know work can reduce the burden of not just lung cancer, but many other chronic diseases which drive up costs of health care in this country. To see how much risk is reduced for individuals who stop smoking, go to our web site Your Disease Risk. More details are also provided in our Prevention Snapshot accessed through the tab above.

"Your Disease Risk" to be Featured in NCI Webinar on Risk Assessment Tools

Don't miss out.  Our award-winning website Your Disease Risk (yourdiseaserisk.wustl.edu) will be a featured part of next week's NCI webinar: "Communication Science and Online Risk Assessment Tools."

Launched in January 2000, Your Disease Risk has been a steady and trust-worthy source of personalized estimates of disease risk and tips for prevention. Drs Graham Colditz and Erika Waters will review the history, science, and theory behind the site's long-term success in their presentation: "Your Disease Risk: The Culmination of 17 Years of Transdisciplinary Research."

Webinar details:
Communication Science and Online Risk Assessment Tools
March 22, 1:00pm - 4:00pm EDT.
Registration day-of @ 1:00pm EDT - limited to first 250

You Can Prevent Colorectal Cancer

Colorectal cancer kills over 50,000 Americans each year. Lung cancer is the only cancer that kills more people. Both men and women can get colorectal cancer, and it usually strikes those over the age of 50.

The good news: Colorectal cancer is one of the most preventable cancers. No matter what your age, there is a lot you can do to lower your risk of getting the disease - from getting regular screening tests to making healthy changes to your lifestyle. 

Use this guide to decide which changes you should make. Start with a few. Then move on to the others. Remember to talk to a health care professional before making any big changes in your lifestyle.

Screening
The best way to prevent colorectal cancer is to get screening tests on a regular basis after age 50. These tests can find non-cancerous tumors, called polyps, that sometimes turn into cancer. By finding polyps early and having them removed, you can prevent cancer from starting.

The screening tests aren’t as uncomfortable as you might think, and the benefits make them well worth it.

Talk to a health care professional about which screening test might be right for you. If you are at increased risk for colorectal cancer, you may start screening earlier than most people.

Start getting screened at age 50, using one of the following:

• Home fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year
• Flexible sigmoidoscopy every 5 years
• Barium enema every 5 years
• Virtual colonoscopy every 5 years
• Colonoscopy every 10 years
• Stool DNA test (ask doctor how often)

Get at least 30 minutes of physical activity every day
A lot of things count as physical activity. Try walking, jogging or dancing—whatever you enjoy! In general, the more activity you get, the better. And any amount is better than none.

Maintain a healthy weight

The best way to maintain a healthy weight is to be physically active and make healthy food choices. Body mass index is a good way to gauge how you’re doing with your weight. Visit this link to see where you fall: BMI calculator.

Eat no more than 2 to 3 servings of red meat a week

The less red meat you eat, the better. Choose chicken, fish, or beans instead of beef, pork, lamb, or veal. A serving of cooked meat is 3 ounces—the size of a deck of cards.

Take a multivitamin with folate every day
Taking a multivitamin with folate (also called folic acid) can give you added protection against colorectal cancer.

Have no more than one alcoholic drink a day
Drinking alcohol increases your risk of colorectal cancer, but it can have positive and
negative effects on your health. Talk to a health care professional about how alcohol may affect you.

Get your calcium every day
Low-fat dairy products, like milk and yogurt, are the best sources of calcium.Daily calcium supplements, calcium-fortified foods like orange juice, and darkgreen leafy vegetables are good too. Try to get about 1,000 – 1,200 mg a day.

Get your vitamin D every day

In addition to being good for bone health, vitamin D can help lower the risk of colon cancer. Supplements are usually the best choice since not many food are rich in the vitamin. Try to get about 1,000 mg a day.

____

A note on aspirin: Long term daily use of a single aspirin (325mg) can lower the risk of colorectal cancer. Aspirin can also have some serious side effects for some people. Talk to a health care professional before you start taking it regularly. 

____

Web resources
National Cancer Institute
American Cancer Society
Your Disease Risk
Your Disease Risk – Twitter Feed
Harvard School of Public Health – Nutrition Source


Thanks to Catherine Tomeo Ryan for her work on an earlier version of this piece.

Cancer capacity building in Guatemala

As part of our current training program at Washington University in St. Louis in collaboration with Instituto Nacional de Cancerología (National Cancer Institute, INCAN, Guatemala) (funded by Fogarty International Center, NIH: 1R24TW008820-01), we have held our third annual scientific meeting in Guatemal. ^1,2 Our pilot program trained Washington University and INCAN participants in research methodology, cultural competency, and research ethics and simultaneously initiated mentoring relationships and collaborations between diverse faculty and trainees from the two institutions. This experience has informed Institute for Public Health discussions and planning for University-wide global health training, which now embraces goals of culturally appropriate preparation for all global health students across the University campuses and a commitment to bi-directional training; the latter involves bringing trainees to Washington University and sending Washington University faculty and trainings to low and middle income countries (LMICs) to help build capacity on the ground. It is one such training that we are completing today with over 300 medical students, residents fellows and practicing physicians and surgeons in attendance.

Underlying the training in research design and methodology for global health interventions is the evidence-based recommendation that knowledge of ethnicity, socioeconomic and other cultural variables is crucial for interventions that seek to communicate benefits of cancer prevention and control such as the risks of tobacco use and the benefits of tobacco control in ways that distinctive populations can understand and use.^3,4 Reflecting this vision, our meeting opened Wednesday evening with Prof Peter Benson reviewing issues on culture and cancer as they can directly impact participation in detection treatment and completion of appropriate cancer therapy.

Cancer in Guatemala

In response to the increasingly important role of non-communicable chronic diseases on global human health and development, the United Nations has set non-communicable diseases, or chronic disease prevention and control as a world-wide priority, with a particular emphasis on developing countries.⁵ These diseases cause more than 36 million deaths (or about 2/3 of all deaths) world-wide, and they profoundly diminish economic and social development.^6,7 While the chronic disease pandemic is attributable in part to poverty, it also contributes to poverty by hindering social advancement;⁸ this is especially the case in low- and middle-income countries, where an estimated 80% of all non-communicable disease deaths occur.^6,9

Guatemala is a middle-income country that struggles with one of the highest poverty rates in Latin America.¹⁰ Compounding a fight with inequality on multiple levels, Guatemala is currently undergoing an epidemiologic transition; today it faces the “double burden of disease,” or an increase in chronic diseases, while infectious diseases remain a considerable challenge.¹¹ As its population has aged and the prevalence of risk factors such as smoking and a high-fat diet has increased, Guatemala has experienced a shift in balance between infectious agents and chronic diseases as leading causes of death.¹²  

The World Health Organization (WHO) estimates that 21% of non-communicable disease deaths worldwide are due to cancer, and that cancer incidence is increasing more rapidly in low and middle-income countries than in higher-income countries. Nearly 20% of the world’s cancer burden is attributable to infectious causes (e.g. human papillomavirus, Helicobacter pylori, and hepatitis virus).⁶  In Guatemala, cancer causes 11% of all deaths, and the estimated 5-year survival probability following diagnosis is less than 2%.¹³ The Instituto Nacional de Cancerologia (National Cancer Institute, INCAN) serves as the primary referral site for cancer diagnosis and treatment in Guatemala.  It is also the primary source for the country’s cancer data.  However, as noted by the WHO and its International Agency for Research on Cancer (IARC), cancer data are often unreliable in low-resource countries.^6,14 Guatemala’s data collection system is outdated and relies on paper records that may be incomplete and unverifiable.  Yet in the absence of a national surveillance system and/or registry, INCAN’s data provide some useful insights into cancer trends and survival.

Table 1: Leading  cancer diagnoses in Guatemala by gender, 2005
Male Site (%)	Female site (%)
Stomach (10.4%)	Cervical (39%)
Prostate (10.4%)	Breast (14.7%)
Testicular (6.6%)	Ovarian (3.0%)
Non-Hodgkin lymphoma (5.7%)	Endometrial (2.9%)
Colon (3.8%)	Stomach (2.8%)
Source: National Cancer Registry, INCAN

 In 2005 (the year for which most recent data are available) INCAN saw 5,858 new patients, 42% of whom had a malignant neoplasm.  Cervical cancer was the most frequent invasive cancer diagnosed in women, followed by breast and ovarian cancers (Table 1).  In men, stomach, prostate, and testicular cancers were the most frequent diagnoses.  However, these data should be interpreted with caution, since cancer patients may seek care in other parts of the country’s healthcare system, and some cancers are never diagnosed. Thus, INCAN’s data may not be generalizable to all of Guatemala.

Although funding to address non-communicable diseases has traditionally been overlooked by governmental and non-governmental agencies in low and middle-income countries, growing attention by the United Nations and the WHO has motivated some countries to more formally examine this health burden.¹

Regardless of the limitations of Guatemala’s cancer data, it is clear that the leading cancers among men (stomach) and women (cervix) have known infectious causes and that death from several of the most important cancers (cervical, testicular, breast) can be decreased by proven, cost-effective strategies for earlier detection and/or treatment. Cervical cancer is a disease where an immediate impact can be made.  Worldwide, most cases (86%) and deaths (88%) occur in developing countries.¹⁶ Guatemala’s cervical cancer incidence and mortality are among the highest in the Americas, ranking 10th out of 33 countries.¹⁶  Furthermore, cervical cancer occurs at a relatively young age in Guatemala and results in proportionally more life-years lost compared to other major cancers.¹⁷  In wealthier countries, effective screening programs have led to substantial declines in cervical cancer incidence and mortality.^18,19  Cytological testing (Pap testing) has been the mainstay of cervical cancer screening in wealthier countries, but in low-resource settings screening for high risk strains of human papilloma virus (HPV) by DNA testing or visual inspection of the cervix with acetic acid (VIA) may be more practical and cost-effective.²⁰  Following screening, effective treatment must also be available to prevent disease progression and mortality.²⁰  Unfortunately Guatemala is far from implementing a comprehensive cervical cancer control program.  For example, an estimated 49% of women have never had a pelvic exam, and only 40% are considered to have effective screening coverage.²¹  There is thus a critical need to design, implement and evaluate cervical cancer control programs in Guatemala.  

 

Stomach cancer is the leading cancer diagnosed among men and the fifth most common among women in Guatemala (Table 1). In many industrialized countries stomach cancer incidence has decreased dramatically in the past 70 years.²²  Several factors may have contributed to the decrease, but the decline in prevalence of chronic Helicobacter pylori infection is plausibly the most important explanation.²² In fact, Peleteiro et al argue that H. pylori is the necessary cause and that the induction period is substantially longer than first assumed. ²³  As with cervical cancer, most (70%) new gastric cancer cases and deaths now occur in LMICs.²⁴  Guatemala again lacks a comprehensive evidence-based stomach cancer control strategy.  Screening is of unproven benefit and would likely be unfeasible given the limited resources available in Guatemala, so approaches such as H. pylori screening and eradication are worth considering. ^{23 25}

Tobacco use is the most important chronic disease risk factor worldwide,²⁶ and Guatemala ratified the WHO Framework Convention on Tobacco Control (FCTC) in November 2005 to address the tobacco epidemic. Nevertheless, Guatemala’s National Institute of Statistics does not systematically collect data on prevalence of and trends in tobacco use.  Historically speaking, Guatemala has perhaps the oldest tradition of tobacco use.  The ancient Maya occupied most of present-day Guatemala from the third until the tenth centuries A.D., and tobacco was a key element of folklore and ritual in their culture.²⁷  Many components of traditional Mayan culture have persisted across much of rural Guatemala, including languages, religious practices, kinship, clothing, and ritual life, yet there has been surprisingly little research on tobacco use and beliefs about tobacco within Guatemala.  This is especially relevant given that Mayan culture has traditionally regarded tobacco as having special healing and medicinal uses.²⁷ What remains of these cultural factors and what has changed with the acculturation of the Maya to the Ladino (Mestizo) culture and the global expansion of Western-style cigarettes are yet to be determined.  Research into this topic can contribute to a growing literature on cultural factors and tobacco use prevalence and trends.^3,4 Tobacco control and prevention are feasible in the Guatemalan context if culturally-relevant evidence-based policies and community interventions are developed and implemented. 

Our recent short course in Guatemala.

Our collaborative approach with INCAN aims to build capacity in Guatemala through in-country short courses and also train a cadre of chronic disease prevention and control scientists from Guatemala and global scholars from Washington University in St Louis. By conducting short courses open to the broader public health and academic community in Guatemala we reinforce bi-directional training and further expand the impact of the program. Bidirectional training, cultural competency and grounding in implementation sciences for resource scarce settings will underpin this program.

In 2010 Drs. Barnoya, Colditz, and Greenberg collaborated to provide a short course on canner prevention and control at INCAN. Subsequently, in 2011 with funding from Fogarty International Center, NIH, a week long program at INCAN focused on building research capacity. Attendees included trainees in our capacity building program from faculty members at INCAN and faculty from Washington University and the SWOG biostatistical coordinating center. Each morning a presentation was attended by 50 or more staff at INCAN. Topics included epidemiology and prevention of cancer; design of clinical trials; culture and its potential impact on cancer care in Guatemala.

In 2012, our training expanded again to bring a focused program on breast cancer that could highlight research design methods and implementation issues in the context of cancer care in Guatemala. The 2012 breast cancer short course included topics from culture and cancer to the growing global burden of cancer; prevention and treatment strategies, grounded in several presentations on biology of premalignant breast lesions and biologic markers and their implications for treatment and survival outcomes after breast cancer. Surgical approaches to breast cancer and therapeutic strategies with new agents and neoadjuvant approaches. 8 faculty members from the breast program at Siteman Cancer Center and Washington University in St Louis spent 2 days in presentations and group meetings to share experience relevant to improving care across the continuum in Guatemala.

Related links

Listing of World Bank classification of low and middle income economies

8 ways to prevent breast cancer

Literature cited

1.         Arnold L, Benson P, Colditz G, Stamatakis K, Beers C, Barnoya J. Development of an interdisciplinary cancer research training program for Guatemala. American Public Health Association Meeting. Washington, DC2011.

2.         Barnoya J, Kennedy R. Increasing chronic disease research capacity in Guatemala through a fellowship program. American Public Health Association Meeting. Washington, DC2011.

3.         Kohrman M, Benson P. Tobacco. Annual Review of Anthropology. 2011.

4.         Nichter M. Smoking: what does culture have to do with it? Addiction. May 2003;98 Suppl 1:139-145.

5.         United Nations General Assembly. Prevention and control of non-communicable diseases.  Report of the Secretary-General. New York: United Nations,;2011.

6.         World Health Organization. Global status report on noncommunicable diseases, 2010. Geneva, Switzerland: WHO;2011.

7.         Beaglehole R, Bonita R, Alleyne G, et al. UN High-Level Meeting on Non-Communicable Diseases: addressing four questions. Lancet. Jul 30 2011;378(9789):449-455.

8.         Geneau R, Stuckler D, Stachenko S, et al. Raising the priority of preventing chronic diseases: a political process. Lancet. Nov 13 2010;376(9753):1689-1698.

9.         World Health Organization. Mortality and burden of disease estimates for WHO Member States in 2008. Geneva, Switzerland2010.

10.         Pan American Health Organization. Health in the Americas. Washington, D.C.: PAHO;2007.

11.         Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. Nov 27 2001;104(22):2746-2753.

12.         Estrada Galindo G. El sistema de salud en Guatemala, 9: Sintesis2008.

13.         Pan American Health Organization. PAHO Plan of Action for Cancer Prevention & Control:  Cancer Stakeholders Meeting.  Fact Sheet. Washington, DC2008.

14.         Curado M, ed Cancer Incidence in Five Countries. Lyon, France: International Agency for Research on Cancer,; 2007. IARC, ed; No. IX.

15.         Anderson GF. Missing in action: international aid agencies in poor countries to fight chronic disease. Health affairs. Jan-Feb 2009;28(1):202-205.

16.         Arbyn M, Castellsague X, de Sanjose S, et al. Worldwide burden of cervical cancer in 2008. Annals of oncology : official journal of the European Society for Medical Oncology / ESMO. Apr 6 2011.

17.         Yang BH, Bray FI, Parkin DM, Sellors JW, Zhang ZF. Cervical cancer as a priority for prevention in different world regions: an evaluation using years of life lost. International journal of cancer. Journal international du cancer. Apr 10 2004;109(3):418-424.

18.         US Center for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program (NBCCEDP). 2011; http://www.cdc.gov/cancer/nbccedp/about.htm. Accessed November 17, 2011.

19.         Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet. Jul 17-23 2004;364(9430):249-256.

20.         Maine D, Hurlburt S, Greeson D. Cervical cancer prevention in the 21st century: cost is not the only issue. American journal of public health. Sep 2011;101(9):1549-1555.

21.         Gakidou E, Nordhagen S, Obermeyer Z. Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities. PLoS medicine. Jun 17 2008;5(6):e132.

22.         Lochhead P, El-Omar EM. Gastric cancer. British medical bulletin. 2008;85:87-100.

23.         Peleteiro B, La Vecchia C, Lunet N. The role of Helicobacter pylori infection in the web of gastric cancer causation. European journal of cancer prevention : the official journal of the European Cancer Prevention Organisation. Aug 22 2011.

24.         Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA: a cancer journal for clinicians. Mar-Apr 2011;61(2):69-90.

25.         Greenberg ER, Anderson GL, Morgan DR, et al. 14-day triple, 5-day concomitant, and 10-day sequential therapies for Helicobacter pylori infection in seven Latin American sites: a randomised trial. Lancet. Aug 6 2011;378(9790):507-514.

26.         Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Correction: Actual Causes of Death in the United States, 2000. JAMA: The Journal of the American Medical Association. January 19, 2005 2005;293(3):293-294.

27.         Robicsek F. The Smoking Gods.  Tobacco in Maya Art, History, and Religion. Oklahoma: University of Oklahoma; 1978.