Environmental and occupational interventions for primary prevention of cancer: a cross-sectorial policy framework

'It Felt Like Finding Hope Only to Lose It Again': A Grounded Theory Study of Rare Cancer Policies in Bulgaria

Rare cancers, defined by an annual incidence of fewer than 6 per 100,000 cases, pose significant challenges due to their complexity, lack of expertise, and limited treatment options. In Bulgaria, these challenges are compounded by limited resources, fragmented care, and outdated policies. This study investigates policy stakeholder perspectives to identify gaps and propose policy alternatives for rare cancer care in Bulgaria, with implications for the broader European Union (EU) context. A grounded theory qualitative research design was employed to explore stakeholder insights. Eight key stakeholders, including policymakers, healthcare providers, patient advocates, and pharmaceutical representatives, participated in semi-structured interviews. Data was analyzed through thematic coding to map policy gaps and develop viable alternatives. Stakeholders highlighted significant gaps in funding, access to innovative therapies, and care organization. Four policy approaches emerged: Liberal, advocating for inclusivity and decentralized care; Conservative, emphasizing cost control and centralization; Balanced, integrating elements of both; and Status Quo, retaining the current system. While centered on Bulgaria, these findings address universal challenges in rare cancer care, offering a framework adaptable to other EU countries. Adopting tailored policies can reduce disparities, improve patient outcomes, and align national strategies with EU objectives, particularly under Europe's Beating Cancer Plan and the EU Cancer Mission.

Gender differences in awareness and practices of cancer prevention recommendations in Korea: a cross-sectional survey

OBJECTIVES

Gender is a major determinant of health behaviors that influences cancer prevention awareness and practices. This study investigated the relationship of the awareness and practice rates of cancer prevention recommendations with gender and socioeconomic status.

METHODS

We used data from the Korean National Cancer Prevention Awareness and Practice Survey (2023). The sample included 4,000 men and women aged 20-74 years. We conducted multiple logistic regression analyses to evaluate associations with the awareness and practices of cancer prevention, and a joinpoint regression analysis using age-standardized rates to analyze trends in awareness and practice rates from 2007 to 2023.

RESULTS

The awareness rates were 79.4% and 81.2% for men and women, respectively. The overall practice rates were substantially lower (43.1% for men and 48.9% for women). For men, awareness rates did not differ significantly by socio-demographic characteristics, but practice rates increased with age (20-29: 15.9%; 60-74: 53.8%). For women, both awareness (20-29: 73.0%; 60-74: 85.7%) and practice (20-29: 16.8%; 60-74: 67.5%) rates increased with age. The easiest recommendations to follow were "reducing salt intake and avoiding burnt or charred foods" (men: 29.9%; women: 28.4%), whereas the most difficult recommendation was "engaging in regular physical activity" (men: 32.5%; women: 34.4%).

CONCLUSIONS

While awareness of cancer prevention recommendations was high, the practice of these recommendations was low. Gender influenced changes in awareness and practice rates over time, reflecting a large gap in practice. Future research should explore appropriate intervention points for cancer prevention practices and the development of more effective cancer prevention policies.

Lung Cancer in Missouri

Lung Cancer remains one of the leading causes of cancer related diagnoses and deaths in Missouri and across the United States. It is a major source of morbidity, mortality, and economic impact in Missouri. Over the past several years, major insights to the underlying risk factors of lung cancer have been discovered. Lung cancer screening has evolved and there are new updates to guideline recommendations on screenings. Here we outline the epidemiology and etiology of lung cancer, mitigation strategies for risk factor reduction, and review updates to lung cancer screening recommendations.

Cancer Prevention and Treatment on Chinese Social Media: Machine Learning-Based Content Analysis Study

BACKGROUND

Nowadays, social media plays a crucial role in disseminating information about cancer prevention and treatment. A growing body of research has focused on assessing access and communication effects of cancer information on social media. However, there remains a limited understanding of the comprehensive presentation of cancer prevention and treatment methods across social media platforms. Furthermore, research comparing the differences between medical social media (MSM) and common social media (CSM) is also lacking.

OBJECTIVE

Using big data analytics, this study aims to comprehensively map the characteristics of cancer treatment and prevention information on MSM and CSM. This approach promises to enhance cancer coverage and assist patients in making informed treatment decisions.

METHODS

We collected all posts (N=60,843) from 4 medical WeChat official accounts (accounts with professional medical backgrounds, classified as MSM in this paper) and 5 health and lifestyle WeChat official accounts (accounts with nonprofessional medical backgrounds, classified as CSM in this paper). We applied latent Dirichlet allocation topic modeling to extract cancer-related posts (N=8427) and identified 6 cancer themes separately in CSM and MSM. After manually labeling posts according to our codebook, we used a neural-based method for automated labeling. Specifically, we framed our task as a multilabel task and utilized different pretrained models, such as Bidirectional Encoder Representations from Transformers (BERT) and Global Vectors for Word Representation (GloVe), to learn document-level semantic representations for labeling.

RESULTS

We analyzed a total of 4479 articles from MSM and 3948 articles from CSM related to cancer. Among these, 35.52% (2993/8427) contained prevention information and 44.43% (3744/8427) contained treatment information. Themes in CSM were predominantly related to lifestyle, whereas MSM focused more on medical aspects. The most frequently mentioned prevention measures were early screening and testing, healthy diet, and physical exercise. MSM mentioned vaccinations for cancer prevention more frequently compared with CSM. Both types of media provided limited coverage of radiation prevention (including sun protection) and breastfeeding. The most mentioned treatment measures were surgery, chemotherapy, and radiotherapy. Compared with MSM (1137/8427, 13.49%), CSM (2993/8427, 35.52%) focused more on prevention.

CONCLUSIONS

The information about cancer prevention and treatment on social media revealed a lack of balance. The focus was primarily limited to a few aspects, indicating a need for broader coverage of prevention measures and treatments in social media. Additionally, the study's findings underscored the potential of applying machine learning to content analysis as a promising research approach for mapping key dimensions of cancer information on social media. These findings hold methodological and practical significance for future studies and health promotion.

Cancer burden attributable to risk factors, 1990-2019: A comparative risk assessment

An up-to-date comprehensive assessment of the cancer burden attributable to risk factors is essential for cancer prevention. We analyzed the population attributable fraction (PAF) of cancer disability-adjusted life years (DALYs) attributable to 11 level 2 risk factors using data from the Global Burden and Disease Study (GBD) 2019. We highlighted that almost half of the cancer DALYs can be preventable by modifying relevant risk factors. The attributable cancer DALYs increased by 60.42%-105.0 million from 1990 to 2019. Tobacco, dietary risks, alcohol use, high body-mass index, and air pollution were the top five risk factors. The PAFs attributable to high fasting plasma glucose, high body-mass index, and low physical activity have increased worldwide from 1990 to 2019. Unsafe sex was the leading risk factor for women before age of 54. Tailored prevention programs targeted at specific populations should be scaled up to reduce the cancer burden in the future.

Mapping the European cancer prevention research landscape: A case for more prevention research funding

Despite the strong evidence of prevention as a prime defence against the disease, the majority of cancer research investment continues to be made in basic science and clinical translational research. Little quantitative data is available to guide decisions on the choice of research priorities or the allocation of research resources. The primary aim of the mapping of the European cancer prevention research landscape presented in this paper is to provide the evidence-base to inform future investments in cancer research. Using bibliometric data to identify funders that are active in prevention research in Europe and in the world, we have identified that 14% of cancer research papers had a focus on prevention research and those were funded by 16% of all the European cancer research funders. An important finding of our study is the lack of research on primary prevention with primary prevention funders accounting for 25% of European cancer prevention funders, meaning that less than 4% of all European cancer research funders identified show an interest in primary prevention. An additional analysis revealed that 7% of European cancer prevention research papers are categorised as implementation projects, meaning that only 1% of all cancer research publications are implementation research in cancer prevention. This paper highlights that the narrow focus on biology and treatment in Europe needs to be widened to include such areas as primary prevention and secondary prevention and a larger concentration on implementation research. These data can help support a more policy-focused cancer research agenda for individual European governments and charitable and philanthropic organisations and stimulate joining efforts across Europe to create a more systematic and structured approach to cancer prevention.

TPE-based fluorescent probe for dual channel imaging of pH/viscosity and selective visualization of cancer cells and tissues

The development of efficient fluorescence-based detection tools with high contrast and accuracy in cancer diagnosis has recently attracted extensive attention. Changes in the microenvironments between cancer and normal cells provide new biomarkers for precise and comprehensive cancer diagnosis. Herein, a dual-organelle-targeted probe with multiple-parameter response is developed to realize cancer detection. We designed a tetraphenylethylene (TPE)-based fluorescent probe TPE-PH-KD connected with quinolinium group for simultaneous detection of viscosity and pH. Due to the restriction on the double bond's rotation, the probe respond to viscosity changes in the green channel with extreme sensitivity. Interestingly, the probe exhibited strong emission of red channel in acidic environment, and the rearrangement of ortho-OH group occurred in the basic form with weak fluorescence when pH increased. Additionally, cell colocalization studies revealed that the probe was located in the mitochondria and lysosome of cancer cells. Following treatment with carbonyl cyanide m-chloro phenylhydrazone (CCCP), chloroquine, and nystatin, the pH or viscosity changes in the dual channels are also monitored in real-time. Furthermore, the probe TPE-PH-KD could effectively discriminate cancer from normal cells and organs with high-contrast fluorescence imaging, which sparked more research on an efficient tool for highly selectively visualizing tumors at the organ level.

Global burden of tracheal, bronchus, and lung cancer attributable to occupational carcinogens in 204 countries and territories, from 1990 to 2019: results from the global burden of disease study 2019

BACKGROUND

Occupational-related cancers are a substantial global health issue. The largest proportion of occupational-related cancers is tracheal, bronchus, and lung (TBL) cancer. This study aimed to explore the geographical and temporal trends in occupational carcinogens related to TBL cancer.

METHODS

Data on TBL cancer attributable to occupational carcinogens were collected from the Global Burden of Disease Study 2019. Numbers and age-standardized rates (ASRs) of deaths, disability-adjusted life years (DALYs), and corresponding average annual percentage change (AAPC) were evaluated and stratified by geographic location, socio-demographic index (SDI) quintiles, age, and sex.

RESULTS

Globally, ASRs of deaths and DALYs in TBL cancer attributable to occupational carcinogens showed a downward trend (AAPC = - 0.69%, - 1.01%) while increases were observed in the low, low-middle, and middle SDI quintiles. Although males accounted for 82.4% and 81.5% of deaths and DALYs in 2019, respectively, it showed an upward trend of ASRs in females (AAPC = 0.33%, 0.02%). Occupational exposure to asbestos, silica and diesel engine exhaust were the top three causes of age-standardized TBL cancer deaths and DALYs. Over the past three decades, the percentage of age-standardized TBL cancer deaths and DALYs attributable to occupational asbestos and silica exposure decreased by 18.24, 6.71 and 20.52%, 4.00% globally, but increased significantly in lower SDI regions, while the burden attributable to occupational diesel engine exhaust exposure increased by 32.76, 37.23% worldwide.

CONCLUSIONS

Occupational exposure remains an important risk factor for TBL cancer. The burden of TBL cancer attributable to occupational carcinogens showed obvious heterogeneity which decreased in higher SDI but increased in lower SDI regions. The burden of males was significantly higher than females, but the females showed an increasing trend. Occupational exposure to asbestos was the main causes of the burden. Therefore, effective prevention and control measures tailored to local conditions are necessary.

Exposures to pesticides and risk of cancer: Evaluation of recent epidemiological evidence in humans and paths forward

Knowledge of the role in cancer etiology of environmental exposures as pesticides is a prerequisite for primary prevention. We review 63 epidemiological studies on exposure to pesticides and cancer risk in humans published from 2017 to 2021, with emphasis on new findings, methodological approaches, and gaps in the existing literature. While much of the recent evidence suggests causal relationships between pesticide exposure and cancer, the strongest evidence exists for acute myeloid leukemia (AML) and colorectal cancer (CRC), diseases in which the observed associations were consistent across several studies, including high-quality prospective studies and those using biomarkers for exposure assessment, with some observing dose-response relationships. Though high-quality studies have been published since the IARC monograph on organophosphate insecticides in 2017, there are still gaps in the literature on carcinogenic evidence in humans for a large number of pesticides. To further knowledge, we suggest leveraging new techniques and methods to increase sensitivity and precision of exposure assessment, incorporate multi-omics data, and investigate more thoroughly exposure to chemical mixtures. There is also a strong need for better and larger population-based cohort studies that include younger and nonoccupationally exposed individuals, particularly during developmental periods of susceptibility. Though the existing evidence has limitations, as always in science, there is sufficient evidence to implement policies and regulatory action that limit pesticide exposure in humans and, hence, further prevent a significant burden of cancers.

Burden of occupational cancer in Brazil and federative units, 1990-2019

OBJECTIVE

To analyze the spatiotemporal distribution of the burden of occupational cancer in Brazil and federative units between 1990 and 2019.

METHODS

Data were extracted from the Global Burden of Disease (GBD) study. Deaths from cancer whose attributable risk factor was occupational carcinogens were considered. Spatial analysis was performed with the first and last years of the series (1990 and 2019). Age-adjusted mortality rates were used to estimate the global Moran's Index (Moran's I), and the local indicator of spatial association (LISA) to identify clusters in the country with the respective statistical significance. The occupational cancer mortality rate, adjusted for age, was analyzed based on its trend for Brazil and federative units, in the period between 1990 and 2019.

RESULTS

Between 1990 and 2019, occupational cancer mortality rate showed a decreasing trend (R2=0.62; p<0.001) as well as the burden of disease indicator - DALY (R2=0.84; p<0.001). However, mortality is increasing in most states, suggesting that a minority of federative units induce the country's global trend. There is also the development of a spatial pattern of autocorrelation, indicating clusters of states with low mortality and DALY rates in the Northeast and high values in the South of the country.

CONCLUSION

The overall decreasing trend in the trend of occupational cancer masks the heterogeneity across states. This scenario may be associated with the diversity of economic activities, and suggests a decentralized and equitable plan for occupational cancer surveillance.

Carga de câncer relacionado ao trabalho no Brasil e unidades da federação, 1990–2019

RESUMO: Objetivo: Analisar a carga de câncer relacionado ao trabalho no Brasil e unidades da federação, entre 1990 e 2019. Métodos: Extraímos os dados do estudo Carga Global de Doenças (GBD). Consideramos as mortes por câncer cujo fator de risco atribuível fossem agentes ocupacionais carcinogênicos. A análise espacial foi realizada com o primeiro e último anos da série (1990 e 2019). As taxas de mortalidade ajustadas por idade foram utilizadas para calcular o índice de Moran global (I de Moran) e o indicador local de associação espacial (LISA). A taxa de mortalidade por câncer relacionado ao trabalho, ajustada por idade, foi analisada com base em sua tendência, para Brasil e unidades da federação, no período entre 1990 e 2019. Resultados: No período citado, a taxa de mortalidade por câncer relacionado ao trabalho exibiu tendência de decréscimo (R2=0,62; p<0,001), assim como o indicador de carga de doença — DALY (R2=0,84; p<0,001). Contudo, a mortalidade é crescente na maioria dos estados, o que sugere que uma minoria de unidades induz a tendência global do país. Há ainda formação de um padrão espacial de autocorrelação, indicando agrupamentos de estados com baixas taxas de mortalidade e DALY no Nordeste e valores altos no Sul do país. Conclusão: A tendência global de decréscimo na tendência do câncer relacionado ao trabalho mascara a heterogeneidade entre estados. Esse cenário pode estar associado à diversidade de atividades econômicas e sugere um plano descentralizado e equitativo da vigilância do câncer relacionado ao trabalho.

Synthesis and application of the fluorescent furan and imidazole probes for selective in vivo and in vitro cancer cell imaging

Development of imaging probes for identification of tumors in the early stages of growth can significantly reduce the tumor-related health hazards and improve our capacity for treatment of cancer. In this work, three different furan and imidazole fluorescent derivatives abbreviated as Cyclo X, SAC and SNO are introduced for in vivo and in vitro imaging of cancer cells. The fluorescence quantum yield values were 0.226, 0.400 and 0.479 for Cyclo X, SAC and SNO, respectively. The excitation and emission wavelengths of maximum intensity were (360, 452), (350, 428) and (350, 432) nm for Cyclo X, SAC and SNO, respectively. The MTT reduction assay was used to estimate the cytotoxic activity of the proposed derivatives against HT-29 (cancer) and Vero (normal) cell lines. Cyclo X showed no cytotoxic effect, while SAC and SNO showed significantly higher cytotoxicity against the tested cell lines than cisplatin as a well-known anticancer drug. In vitro fluorescence microscopic images obtained using HT-29 cells showed that Cyclo X produced very bright images. The in vivo cancer cell imaging using 4T1 tumor-bearing mice revealed that Cyclo X is selectively accumulated in the tumor without distribution in the mice body organs. The spectral and structural stability, large Stokes shift, non-cytotoxicity and high level of selectivity for in vivo imaging are properties that make Cyclo X a suitable candidate to be used for long-term monitoring of cancer cells.

Distinguishing cancer cells from normal cells with an organelle-targeted fluorescent marker

In this paper we report a hemicyanine dye that is used to distinguish cancer cells from normal cells with its ability to target different organelles. Probe 1, a red emission hemicyanine functional dye, was connected to oxazolo[4,5-b]pyridine and diethylaminobenzene with a double bond. The maximum absorption peaks of probe 1 were located in the 509-552 nm range in organic solvents. Meanwhile, the probe possessed a high molar extinction coefficient (5.50 × 10⁴ M^-1 cm^-1 in DMSO) with high photostability. The maximum emission wavelength of the probe ranged from 572 nm to 644 nm, and it also had a large Stokes shift (126 nm in DMSO). In particular, the probe showed weak fluorescence in water (Φ = 0.016), whereas it displayed strong fluorescence at 595 nm in β-cyclodextrin (β-CD) solution (Φ = 0.13). In addition, cell colocalization experiments showed that probe 1 (3 μM) was located in the endoplasmic reticulum in cancer cells, while it could target lysosomes in normal cells. What's more, further cell imaging experiments demonstrated that the average fluorescence intensity of probe 1 (0.3 μM) in cancer cells increased with the addition of β-CD, but it did not occur in normal cells. The study provides a convenient way to distinguish cancer cells from normal ones, which has potential for application in the early detection of cancer.

Health Economics Research in Primary Prevention of Cancer: Assessment, Current Challenges, and Future Directions

In the past 2 decades, the demand for information on health economics research to guide health care decision making has substantially increased. Studies have provided evidence that eliminating or reducing tobacco use; eating a healthy diet, including fruit and vegetables; being physically active; reducing alcohol consumption; avoiding ultraviolet radiation; and minimizing exposure to environmental and occupational carcinogenic agents should substantially reduce cancer incidence in the population. The benefits of these primary prevention measures in reducing cancer incidence are not instantaneous. Therefore, health economics research has an important role to play in providing credible information to decision makers on the health and economic benefits of primary prevention. This article provides an overview of health economics research related to primary prevention of cancer. We addressed the following questions: 1) What are the gaps and unmet needs for performing health economics research focused on primary prevention of cancer? 2) What are the challenges and opportunities to conducting health economics research to evaluate primary prevention of cancer? and 3) What are the future directions for enhancing health economics research on primary prevention of cancer? Modeling primary prevention of cancer is often difficult given data limitations, long delays before the policy or intervention is effective, possible unintended effects of the policy or intervention, and the necessity of outside expertise to understand key inputs or outputs to the modeling. Despite these challenges, health economics research has an important role to play in providing credible information to decision makers on the health and economic benefits of primary prevention of cancer.

The effects of vitamins and dietary pattern on epigenetic modification of non-communicable diseases

Background: Non-communicable diseases (NCDs) have received more attention because of high prevalence and mortality rate. Besides genetic and environmental factors, the epigenetic abnormality is also involved in the pathogenesis of NCDs. Methylation of DNA, chromatin remodeling, modification of histone, and long non-coding RNAs are the main components of epigenetic phenomena. Methodology: In this review paper, the mechanistic role of vitamins and dietary patterns on epigenetic modification was discussed. All papers indexed in scientific databases, including PubMed, Scopus, Embase, Google Scholar, and Elsevier were searched during 2000 - 2021 using, vitamins, diet, epigenetic repression, histones, methylation, acetylation, and NCDs as keywords. Results: The components of healthy dietary patterns like Mediterranean and dietary approaches to stop hypertension diets have a beneficial effect on epigenetic hemostasis. Both quality and quantity of dietary components influence epigenetic phenomena. A diet with calorie deficiency in protein content and methyl-donor agents in a long time, with a high level of fat, disrupts epigenetic hemostasis and finally, causes genome instability. Also, soluble and insoluble vitamins have an obvious role in epigenetic modifications. Most vitamins interact directly with methylation, acetylation, and phosphorylation pathways of histone and DNA. However, numerous indirect functions related to the cell cycle stability and genome integrity have been recognized. Conclusion: Considering the crucial role of a healthy diet in epigenetic homeostasis, adherence to a healthy dietary pattern containing enough levels of vitamin and avoiding the western diet seems to be necessary. Having a healthy diet and consuming the recommended dietary level of vitamins can also contribute to epigenetic stability.

Epidemiological Research on Occupational and Environmental Carcinogens

The cancer risk associated with exposure to environmental and occupational carcinogens such as asbestos, benzene, radiation, or lifestyle carcinogens such as cigarette smoking depends on the entire history of exposure to the carcinogen, including the age of exposure and the time-varying intensity of exposure [...].

Assessment of hematological parameters of petrol filling workers at petrol stations in Gondar town, Northwest Ethiopia: a comparative cross-sectional study

Background

Petrol is the non-specific term for petroleum which is used for inside combustion of engines. Petrol filling workers are highly vulnerable to occupational exposure to these harmful substances which lead to hemato-toxicity and blood disorders such as leukemia, aplastic anemia, and dysplastic bone marrow. Thus, this study was aimed to assess hematological parameters of petrol filling workers in Gondar town, Northwest Ethiopia.

Methods

A comparative cross-sectional study was conducted from January to March 2019 in Gondar town, Northwest Ethiopia. A total of 110 study participants comprising 55 study groups and 55 controls group were recruited by a convenient sampling technique. Socio-demographic data were collected using a structured questionnaire, and 3 ml of venous blood was collected for the determination of hematological parameters. The data were entered into Epi info 7.2.0.1 and analyzed by SPSS version of 20. Mean, standard deviation, median, and interquartile ranges were used to present the data. Independent t test and Mann-Whitney U test were used to compare the mean or median difference between parametric and non-parametric hematological parameters, respectively. Moreover, Pearson product-moment and Spearman’s rank-order bivariable correlations analyses were used to describe the correlation between hematological parameters and duration of exposure to petrol. A P value of ≤ 0.05 was considered statistically significant.

Results

The study revealed that mean red blood cell count and hemoglobin level as well as the median hematocrit, mean cell hemoglobin concentration, platelet count, absolute lymphocytes count, and red cell distribution width values of petrol filling workers showed a significant increment compared with the control group. On the other hand, the mean cell hemoglobin value of petrol filling workers showed a significant decrement compared with healthy controls. Moreover, the duration of exposure to petrol showed a significant positive correlation with red blood cell count and mean cell hemoglobin concentration; however, a significant negative correlation was observed with mean cell volume.

Conclusion

This study showed that the majority of hematological parameters of petrol filling workers showed an increment compared with healthy controls which might be associated with exposure to petrol chemicals. However, further longitudinal study with a larger sample size should be conducted to explore the impact of petrol exposure on hematopoiesis.

Resistance training in advanced cancer: a phase II safety and feasibility trial—home versus hospital

Background

Resistance training (RT) is an effective way to increase muscle mass but little is known about its role to prevent sarcopenia in advanced cancer. Furthermore, the preferred setting for this training is not known. Considering home is frequently the place of care and death preferred by cancer patients, it is important to find out whether this would also be the best training setting as opposed to the most common one, hospital.

Objectives

We aimed to test if RT at home and in hospital is feasible (primary outcome) and safe in advanced cancer, with a view to inform a phase III trial.

Methods

Phase II randomised controlled trial including adults (≥18 years) with incurable solid tumours, randomised into one of three arms: (1) supervised RT at home; (2) supervised RT in hospital; (3) standard care with information leaflet. Both training programmes were similar, ran one-to-one with therapists and planned to last 12 weeks (three sessions/week). Feasibility included adherence (proportion of completed sessions) and acceptability (proportion of completed exercises), compared using Fisher’s test.

Results

We included 15 patients (53% men, median age 68), 5 per arm. The home intervention had higher adherence (49% vs 9% in hospital; p<0.001). Acceptability was similar (93% in home and 95% in hospital; p=0.179). No adverse events were recorded.

Conclusions

RT is a safe intervention, more feasible at home than in hospital in advanced cancer. Ways to increase adherence to the home intervention could further improve its potential benefit.

Trial registration number

NCT02930876.

Environmental geochemistry and cancer: a pertinent global health problem requiring interdisciplinary collaboration

Primary prevention is a key strategy to reducing the global burden of cancer, a disease responsible for ~ 9.6 million deaths per year and predicted to top 13 million by 2030. The role of environmental geochemistry in the aetiology of many cancers-as well as other non-communicable diseases-should not be understated, particularly in low- and middle-income countries where 70% of global cancer deaths occur and reliance on local geochemistry for drinking water and subsistence crops is still widespread. This article is an expansion of a series of presentations and discussions held at the 34th International Conference of the Society for Environmental Geochemistry and Health in Livingstone, Zambia, on the value of effective collaborations between environmental geochemists and cancer epidemiologists. Key technical aspects of each field are presented, in addition to a case study of the extraordinarily high incidence rates of oesophageal cancer in the East African Rift Valley, which may have a geochemical contribution. The potential merit of veterinary studies for investigating common geochemical risk factors between human and animal disease is also highlighted.

Improving Education and Training to Reduce the Burden of Occupational Cancer. The Riga-European Association of Schools of Occupational Medicine (EASOM) Statement on Work-Related Cancer

Reducing the burden of occupational cancers (OCs) is currently one of the most challenging Occupational Health (OH) issues. The European Union (EU) has made efforts to improve the existing legal framework and developed specific legislation aimed at reducing the burden of OC. However, available data suggest that OC are underreported. In August 2019, the European Association of Schools of Occupational Medicine (EASOM) adopted a statement that highlighted the importance of improving the education and training of Medical Doctors (MDs) to facilitate improvements in recognizing and reporting OC. To achieve this, EASOM proposes to promote OH education and training of MDs at undergraduate and postgraduate levels, foster harmonization of OH education and teaching standards and programs across EU countries, and enhance cooperation between universities and international scientific associations. Finally, we suggest that occupational data should be recorded in cancer and medical registers. By engaging MDs more fully in the debate about OCs, they will become more aware of the Occupational Physician’s role in reducing the burden of OCs and, furthermore, embed consideration of occupation as a potential cause of cancer into their own practice. These interventions will help promote the implementation of policies and interventions aimed to reduce OC in the workplace.

Global and regional burden of cancer in 2016 arising from occupational exposure to selected carcinogens: a systematic analysis for the Global Burden of Disease Study 2016

OBJECTIVES

This study provides a detailed analysis of the global and regional burden of cancer due to occupational carcinogens from the Global Burden of Disease 2016 study.

METHODS

The burden of cancer due to 14 International Agency for Research on Cancer Group 1 occupational carcinogens was estimated using the population attributable fraction, based on past population exposure prevalence and relative risks from the literature. The results were used to calculate attributable deaths and disability-adjusted life years (DALYs).

RESULTS

There were an estimated 349 000 (95% Uncertainty Interval 269 000 to 427 000) deaths and 7.2 (5.8 to 8.6) million DALYs in 2016 due to exposure to the included occupational carcinogens-3.9% (3.2% to 4.6%) of all cancer deaths and 3.4% (2.7% to 4.0%) of all cancer DALYs; 79% of deaths were of males and 88% were of people aged 55 -79 years. Lung cancer accounted for 86% of the deaths, mesothelioma for 7.9% and laryngeal cancer for 2.1%. Asbestos was responsible for the largest number of deaths due to occupational carcinogens (63%); other important risk factors were secondhand smoke (14%), silica (14%) and diesel engine exhaust (5%). The highest mortality rates were in high-income regions, largely due to asbestos-related cancers, whereas in other regions cancer deaths from secondhand smoke, silica and diesel engine exhaust were more prominent. From 1990 to 2016, there was a decrease in the rate for deaths (-10%) and DALYs (-15%) due to exposure to occupational carcinogens.

CONCLUSIONS

Work-related carcinogens are responsible for considerable disease burden worldwide. The results provide guidance for prevention and control initiatives.

Global and regional burden of disease and injury in 2016 arising from occupational exposures: a systematic analysis for the Global Burden of Disease Study 2016

OBJECTIVES

This study provides an overview of the influence of occupational risk factors on the global burden of disease as estimated by the occupational component of the Global Burden of Disease (GBD) 2016 study.

METHODS

The GBD 2016 study estimated the burden in terms of deaths and disability-adjusted life years (DALYs) arising from the effects of occupational risk factors (carcinogens; asthmagens; particulate matter, gases and fumes (PMGF); secondhand smoke (SHS); noise; ergonomic risk factors for low back pain; risk factors for injury). A population attributable fraction (PAF) approach was used for most risk factors.

RESULTS

In 2016, globally, an estimated 1.53 (95% uncertainty interval 1.39-1.68) million deaths and 76.1 (66.3-86.3) million DALYs were attributable to the included occupational risk factors, accounting for 2.8% of deaths and 3.2% of DALYs from all causes. Most deaths were attributable to PMGF, carcinogens (particularly asbestos), injury risk factors and SHS. Most DALYs were attributable to injury risk factors and ergonomic exposures. Men and persons 55 years or older were most affected. PAFs ranged from 26.8% for low back pain from ergonomic risk factors and 19.6% for hearing loss from noise to 3.4% for carcinogens. DALYs per capita were highest in Oceania, Southeast Asia and Central sub-Saharan Africa. On a per capita basis, between 1990 and 2016 there was an overall decrease of about 31% in deaths and 25% in DALYs.

CONCLUSIONS

Occupational exposures continue to cause an important health burden worldwide, justifying the need for ongoing prevention and control initiatives.

There are good clinical, scientific, and social reasons to strengthen links between biomedical and environmental research

Clinical epidemiology rarely addresses biological, clinical, epidemiological, environmental, economic, and other social and scientific issues posed by environmental chemical contaminants such as endocrine-disrupting chemicals. There is a considerable gap between research and practice in clinical medicine and in environmental health. Organizations often fail to appreciate the human and economic costs of the diseases that environmental chemical contaminants contribute to cause. Also, the relative lack of attention to environmental causes of disease by researchers in medicine and clinical epidemiology cannot be explained just on scientific grounds. Many scientists have shown the virtues of integrative research. Knowledge on the causes of disease is often secondary in clinical practice, but in other instances, to help patients, clinicians tackle causes of diseases. We can better address how environmental contaminants influence negatively not just the occurrence of disease but its course. To do so, we can generate better evidence and strengthen the social conversation on environmental influences on all dimensions of health and disease.

Cancer Prevention Europe

The case for cancer prevention in Europe is the same as for all other parts of the world. The number of cancers is increasing, driven by demographic change and evolution in the exposure to risk factors, while the cost of treating patients is likewise spiralling. Estimations suggest that around 40% of cancers in Europe could be prevented if current understanding of risk and protective factors was translated into effective primary prevention, with further reductions in cancer incidence and mortality by screening, other approaches to early detection, and potentially medical prevention. However, the infrastructure for cancer prevention tends to be fragmented between and within different countries in Europe. This lack of a coordinated approach recently led to the foundation of Cancer Prevention Europe (Forman et al., 2018), a collaborative network with the main aims of strengthening cancer prevention in Europe by increasing awareness of the needs, the associated required resources and reducing inequalities in access to cancer prevention across Europe. This article showcases the need for strengthening cancer prevention and introduces the objectives of Cancer Prevention Europe and its foreseen future role in reducing the European cancer burden.

Primary prevention: a need for concerted action

The burden of cancer is increasing worldwide, and Europe is no exception in this regard. Cancer incidence rate for men in 2018, excluding nonmelanoma skin cancers, averaged over the 40 UN-defined European countries has been estimated as 436/100 000. For women, the estimated incidence rate is 332.6/100 000. Although mortality rates are declining in most European countries, the total number of cancer deaths continues to rise due to an increase in the number of older people in the age range when the cancer typically occurs. The increase in incident cases and cancer deaths increases the pressure on healthcare infrastructure and related costs, thus presenting a challenge to health service sustainability in countries. In the general population, there remains a perception of an ever-increasing cancer risk. Hence, treatment alone is not a solution to address the cancer burden. At the same time, recent estimates of preventable fractions of cancer suggest that about half of all cancer cases could be prevented through rigorous implementation of successful prevention measures, among other actions, by following the cancer prevention recommendations of the European Code against Cancer. Smoking alone explains almost half of all preventable cancers, and the scattered way of implementing tobacco control in Europe with still increasing numbers of lung cancers in women demonstrates the gap between prevention potential and effectively implemented prevention. Cancer prevention clearly needs more resources, stronger support from decision-makers and society, and a solid network to better speak with one voice. The newly established 'Cancer Prevention Europe' (Forman et al., ) offers promising opportunities for the latter.

Radon concentration in hydrogeothermal deposit and spas of Boyacá, Colombia

Inhaled radon and its progenies induce health concern due to high activity-concentration in selected thermal spas of Boyacá region. Hydrogeothermal water sources in a high risk seismic area, are studied to determine by water bubbling method radon concentration values; their occurrence is between few hundreds and 2000 Bq dm^-3. Deposits, existing in this area, reach at the surface soil gas radon concentration up to 210 kBq m^-3. Maintenance workers, health tourists and visitor's possible detrimental health effects, are discussed in relation to radon balneotherapy beneficial aspects.

Ex vivo classification of spinal cord tumors using autofluorescence spectroscopy and immunohistochemical indexes

Spinal cord tumors are complicated and infrequent, which poses a major challenge to surgeons during neurosurgery. Currently, the intraoperative identification of the tissues' pathological properties is usually difficult for surgeons. This issue influences the decision-making in treatment planning. Traditional pathological diagnoses can facilitate judging the tissues' properties, but the diagnosis process is complex and time-consuming. In this study, we evaluated the potential of autofluorescence spectroscopy for the fast pathological diagnosis of specific spinal cord tumors. The spectral properties of six types of spinal cord tumors were acquired ex vivo. Several peak intensity ratios were calculated for classification and then associated with the pathological immunohistochemical indexes. Our results revealed the spectral properties of three types of intramedullary tumors different from those of the other three types of extramedullary tumors. Furthermore, some peak intensity ratios revealed a high correlation with the immunohistochemical index of glial fibrillary acidic protein (GFAP). Thus, we believe that autofluorescence spectroscopy has the potential to provide real-time pathological information of spinal cord tumors and help surgeons validate tumor types and perform precise tumor resection.

Diagnosing lung cancer using etoposide microparticles labeled with 99mTc

The diagnosis of lung cancer mostly occurs when the cancer is already in an advanced stage. In this situation, there are few options for the treatment and most of them have few chances of success. In this study, we developed and tested etoposide microparticles as a diagnostic agent for imaging lung cancer at early stages of development. We tested etoposide microparticles labeled with technetium 99m in inducted mice. The results demonstrated that over 10% of the total dose used was uptake by the tumor site. Also, the results showed that the microparticles had a good renal clearance and low uptake by liver and spleen. The data suggest that these micro-radiopharmaceuticals may be used for lung cancer imaging exam, especially single-photo emission computed tomography (SPECT).[Formula: see text].

Establishing a Policy Framework for the Primary Prevention of Occupational Cancer: A Proposal Based on a Prospective Health Policy Analysis

BACKGROUND

Despite our knowledge of the causes of cancer, millions of workers are involuntarily exposed to a wide range of known and suspected carcinogens in the workplace. To address this issue from a policy perspective, we developed a policy framework based on a prospective health policy analysis. Use of the framework was demonstrated for developing policies to prevent cancers associated with diesel engine exhaust (DEE), asbestos, and shift work, three occupational carcinogens with global reach and large cancer impact.

METHODS

An environmental scan of existing prospective health policy analyses was conducted to select and describe our framework parameters. These parameters were augmented by considerations unique to occupational cancer. Policy-related resources, predominantly from Canada, were used to demonstrate how the framework can be applied to cancers associated with DEE, asbestos, and shift work.

RESULTS

The parameters of the framework were: problem statement, context, jurisdictional evidence, primary prevention policy options, and key policy players and their attributes. Applying the framework to the three selected carcinogens illustrated multiple avenues for primary prevention, including establishing an occupational exposure limit for DEE, banning asbestos, and improving shift schedules. The framework emphasized the need for leadership by employers and government.

CONCLUSION

To our knowledge, this is the first proposal for a comprehensive policy framework dedicated to the primary prevention of occupational cancer. The framework can be adapted and applied by key policy players in Canada and other countries as a guide of what parameters to consider when developing policies to protect workers' health.

Environmental and Economic Strategies for Primary Prevention of Cancer in Early Life

This article summarizes the evidence for environmental toxic exposures contributing to cancers in early life, focusing on the most common cancer sites in this age group. It provides examples of widespread avoidable exposures to human carcinogens through air, water, and food and then describes recent examples of successful initiatives to reduce exposure to chemicals linked to these cancer sites, through government policy, industry initiatives, and consumer activism. State government initiatives to reduce toxic chemical exposures have made important gains; the Toxics Use Reduction Act of Massachusetts is now 25 years old and has been a major success story. There are a growing number of corporate initiatives to eliminate toxics, especially carcinogens, from the products they manufacture and sell. Another important opportunity for cancer prevention is provided by online databases that list chemicals, their toxicity, and lower-toxicity alternatives; these can be used by businesses, health care institutions, consumers, and workers to reduce exposures to chemicals of concern. The article concludes by inviting pediatricians and public health professionals to include elimination of carcinogen exposures in their work to promote primary prevention of cancer in early life.

Environmental variables associated with vacationers' sun protection at warm weather resorts in North America

BACKGROUND

Vacationing at sunny, warm weather locations is a risk factor for excessive solar ultraviolet (UV) radiation exposure and skin cancer.

OBJECTIVES

This study examined the association of environmental variables related to UV levels with vacationers' sun protection.

METHODS

Vacationers at 41 summer resorts in 17 states and 1 Canadian Province were interviewed (n=3531) and observed (N=4347) during 2012 and 2013. Clothing coverage, sunglasses, and shade use were observed. Use of sunscreen and sunburns were self-reported. Environmental information was recorded by research staff or acquired from ground stations and the weather service.

RESULTS

Temperature was positively associated with sun protection behaviors; however clothing coverage was negatively associated with temperature. Cloud cover was negatively associated with sun protection, with the exception of clothing coverage which was positively associated with it. Elevation showed a mixed pattern of associations with vacationer's sun protection. Latitude of a resort was negatively associated with most sun protection behaviors, such that sun protection increased at more southerly resorts. Similarly, the farther south a vacationer traveled to the resort, the less sun protection they employed. The UV index showed a weak, positive relationship with some sun protection behaviors even when controlling for temperature.

CONCLUSIONS

Vacationers appeared aware that UV is higher at southern latitudes and may learn UV is intense when living in southern regions. However, many used temperature, an unreliable cue, to judge UV intensity and seemed to adjust clothing for warmth not UV protection. Efforts are needed to help individuals make more accurate sun safety decisions.

Health risk assessment of migrant workers' exposure to polychlorinated biphenyls in air and dust in an e-waste recycling area in China: Indication for a new wealth gap in environmental rights

Migrant workers who work and live in polluted environment are a special vulnerable group in the accelerating pace of urbanization and industrialization in China. In the electronic waste (e-waste) recycling area, for example, migrant workers' exposure to pollutants, such as PCBs (polychlorinated biphenyls), is the result of an informal e-waste recycling process. A village in an electronic waste recycling area where migrant workers gather was surveyed. The migrant workers' daily routines were simulated according to the three-space transition: work place-on the road-home. Indoor air and dust in the migrant workers' houses and workplaces and the ambient air on the roads were sampled. The PCB levels of the air and dust in the places corresponding to the migrant workers are higher than those for local residents. The migrant workers have health risks from PCBs that are 3.8 times greater than those of local residents. This is not only caused by the exposure at work but also by their activity patterns and the environmental conditions of their dwellings. These results revealed the reason for the health risk difference between the migrant workers and local residents, and it also indicated that lifestyle and economic status are important factors that are often ignored compared to occupational exposure.

European Code against Cancer 4th Edition: Environment, occupation and cancer

People are exposed throughout life to a wide range of environmental and occupational pollutants from different sources at home, in the workplace or in the general environment - exposures that normally cannot be directly controlled by the individual. Several chemicals, metals, dusts, fibres, and occupations have been established to be causally associated with an increased risk of specific cancers, such as cancers of the lung, skin and urinary bladder, and mesothelioma. Significant amounts of air pollutants - mainly from road transport and industry - continue to be emitted in the European Union (EU); an increased occurrence of lung cancer has been attributed to air pollution even in areas below the EU limits for daily air pollution. Additionally, a wide range of pesticides as well as industrial and household chemicals may lead to widespread human exposure, mainly through food and water. For most environmental pollutants, the most effective measures are regulations and community actions aimed at reducing and eliminating the exposures. Thus, it is imperative to raise awareness about environmental and occupational carcinogens in order to motivate individuals to be proactive in advocating protection and supporting initiatives aimed at reducing pollution. Regulations are not homogeneous across EU countries, and protective measures in the workplace are not used consistently by all workers all the time; compliance with regulations needs to be continuously monitored and enforced. Therefore, the recommendation on Environment and Occupation of the 4th edition of the European Code against Cancer, focusing on what individuals can do to reduce their cancer risk, reads: "In the workplace, protect yourself against cancer-causing substances by following health and safety instructions."

Breast Cancer and Occupation: The Need for Action: APHA Policy Statement Number 20146, Issued November 18, 2014

Breast cancer is the most prevalent cancer among women in the United States and other countries, making it a major public health concern. Despite significant scientific evidence about its known or suspected causes, research and prevention measures to identify and eliminate occupational and other environmental hazards and risk factors for breast cancer remain largely overlooked. As a result, hazards continue unabated for women generally, especially those who work outside the home. The science linking breast cancer and occupation in particular is growing. Researchers have identified commonly used chemicals that induce breast tumors in test animals. Animal studies link chemicals that mimic reproductive hormones to elevated breast cancer rates. Other animal and human studies link chemical exposures to increased breast cancer rates, including two recent investigations focused on occupational hazards. But the latter are the exception. Studies that attempt to identify and characterize workplace agents linked to breast cancer, as well as intervention studies focusing on the use of less toxic processes and substances, are limited. In what might be construed as a case of gender and social class bias, many research and funding agencies have ignored or downplayed the role of occupational studies despite their relevance to prevention efforts. Action required starts with making a national priority of promoting and supporting research on occupational and other environmental causes of breast cancer. Other public health actions include hazard surveillance and primary prevention activities such as reductions in the use of toxic materials, informed substitution, and green chemistry efforts. The original document is accessible at the APHA website, http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/07/14/55/breast-cancer-and-occupation.

The current deconstruction of paradoxes: one sign of the ongoing methodological "revolution"

The current deconstruction of paradoxes is one among several signs that a profound renewal of methods for clinical and epidemiological research is taking place; perhaps for some basic life sciences as well. The new methodological approaches have already deconstructed and explained long puzzling apparent paradoxes, including the (non-existent) benefits of obesity in diabetics, or of smoking in low birth weight. Achievements of the new methods also comprise the elucidation of the causal structure of long-disputed and highly complex questions, as Berkson's bias and Simpson's paradox, and clarifying reasons for deep controversies, as those on estrogens and endometrial cancer, or on adverse effects of hormone replacement therapy. These are signs that the new methods can go deeper and beyond the methods in current use. A major example of a highly relevant idea is: when we condition on a common effect of a pair of variables, then a spurious association between such pair is likely. The implications of these ideas are potentially vast. A substantial number of apparent paradoxes may simply be the result of collider biases, a source of selection bias that is common not just in epidemiologic research, but in many types of research in the health, life, and social sciences. The new approaches develop a new framework of concepts and methods, as collider, instrumental variables, d-separation, backdoor path and, notably, Directed Acyclic Graphs (DAGs). The current theoretical and methodological renewal-or, perhaps, "revolution"-may be changing deeply how clinical and epidemiological research is conceived and performed, how we assess the validity and relevance of findings, and how causal inferences are made. Clinical and basic researchers, among others, should get acquainted with DAGs and related concepts.

IARC monographs: 40 years of evaluating carcinogenic hazards to humans

BACKGROUND

Recently, the International Agency for Research on Cancer (IARC) Programme for the Evaluation of Carcinogenic Risks to Humans has been criticized for several of its evaluations, and also for the approach used to perform these evaluations. Some critics have claimed that failures of IARC Working Groups to recognize study weaknesses and biases of Working Group members have led to inappropriate classification of a number of agents as carcinogenic to humans.

OBJECTIVES

The authors of this Commentary are scientists from various disciplines relevant to the identification and hazard evaluation of human carcinogens. We examined criticisms of the IARC classification process to determine the validity of these concerns. Here, we present the results of that examination, review the history of IARC evaluations, and describe how the IARC evaluations are performed.

DISCUSSION

We concluded that these recent criticisms are unconvincing. The procedures employed by IARC to assemble Working Groups of scientists from the various disciplines and the techniques followed to review the literature and perform hazard assessment of various agents provide a balanced evaluation and an appropriate indication of the weight of the evidence. Some disagreement by individual scientists to some evaluations is not evidence of process failure. The review process has been modified over time and will undoubtedly be altered in the future to improve the process. Any process can in theory be improved, and we would support continued review and improvement of the IARC processes. This does not mean, however, that the current procedures are flawed.

CONCLUSIONS

The IARC Monographs have made, and continue to make, major contributions to the scientific underpinning for societal actions to improve the public's health.

Mosquito coil exposure associated with small cell lung cancer: A report of three cases

Mosquito coils, which are commonly used as residential insecticides in Asia, contain different concentrations of octachlorodipropyl ether (S-2) as a synergist or an active ingredient. As bis(chloromethyl) ether (BCME) is an extremely potent lung carcinogen that can be produced by the thermolytic degradation of S-2, contact with mosquito coils is likely to expose individuals to a certain level of BCME, and therefore increase the risk of lung cancer. However, the significance of exposure is uncertain, as clinical and epidemiological studies concerning mosquito coil users and workers are lacking. The present study describes three cases of small cell lung cancer treated at the Shanghai Pulmonary Hospital that were likely to be the result of exposure to mosquito coils. All patients had worked in the mosquito coil manufacturing industry, with an mean occupational duration of 9.1 years, and presented with similar respiratory symptoms, such as cough and dyspnea. Upon diagnosis, no metastasis to other organs was identified in any of the cases. Subsequently, the three patients were treated with chemotherapy as well as radiotherapy in one case, however, all patients succumbed to the disease, with a mean overall survival time of 10.7 months. We conclude that contact with mosquito coils is likely to expose individuals to a level of S-2 that may increase the risk of SCLC.

Nutrition transition in South Asia: the emergence of non-communicable chronic diseases

Overview: South Asian countries have experienced a remarkable economic growth during last two decades along with subsequent transformation in social, economic and food systems. Rising disposable income levels continue to drive the nutrition transition characterized by a shift from a traditional high-carbohydrate, low-fat diets towards diets with a lower carbohydrate and higher proportion of saturated fat, sugar and salt. Steered by various transitions in demographic, economic and nutritional terms, South Asian population are experiencing a rapidly changing disease profile. While the healthcare systems have long been striving to disentangle from the vicious cycle of poverty and undernutrition, South Asian countries are now confronted with an emerging epidemic of obesity and a constellation of other non-communicable diseases (NCDs). This dual burden is bringing about a serious health and economic conundrum and is generating enormous pressure on the already overstretched healthcare system of South Asian countries.

Objectives: The Nutrition transition has been a very popular topic in the field of human nutrition during last few decades and many countries and broad geographic regions have been studied. However there is no review on this topic in the context of South Asia  as yet. The main purpose of this review is to highlight the factors accounting for the onset of nutrition transition and its subsequent impact on epidemiological transition in five major South Asian countries including Bangladesh, India, Nepal, Pakistan and Sri Lanka. Special emphasis was given on India and Bangladesh as they together account for 94% of the regional population and about half world’s malnourished population.

Methods: This study is literature based. Main data sources were published research articles obtained through an electronic medical databases search.

Implementation science in cancer prevention and control: a framework for research and programs in low- and middle-income countries

Implementation science is a set of tools, principles, and methodologies that can be used to bring scientific evidence into action, improve health care quality and delivery, and improve public health. As the burden of cancer increases in low- and middle-income countries, it is important to plan cancer control programs that are both evidence based and delivered in ways that are feasible, cost-effective, contextually appropriate, and sustainable. This review presents a framework for using implementation science for cancer control planning and implementation and discusses potential areas of focus for research and programs in low- and middle-income countries interested in integrating research into practice and policy.

The use of expensive technologies instead of simple, sound and effective lifestyle interventions: a perpetual delusion

A dangerous distortion of priorities seems to be currently apparent in the dominant approaches to major public health problems, including cardiovascular disease, diabetes, obesity, cancer and some infectious diseases. Relevant examples suggest an apparently inappropriate tendency to prioritise technocratic, partial solutions rather than confronting their true behavioural and structural determinants. Technically oriented preventive medicine often takes excessive precedence over simpler, more sensible approaches to modify lifestyles, the environment and the social structure. Structural factors (social, cultural, financial, familiar, educational, political or ideological factors) that act as determinants of individual behaviours should be effectively addressed to confront the essential causes of the most prevalent and important health problems. Some consumer-directed commercial forces seem to be increasingly driving many aspects of the current sociocultural environment, and may eventually compromise the main pursuits of public health. Population-wide strategies are needed to create a healthy sociocultural environment and to empower individuals and make themselves resistant to these adverse environmental and structural pressures. Otherwise most public health interventions will most likely end in failures.

Intraoperative imaging-guided cancer surgery: from current fluorescence molecular imaging methods to future multi-modality imaging technology

Cancer is a major threat to human health. Diagnosis and treatment using precision medicine is expected to be an effective method for preventing the initiation and progression of cancer. Although anatomical and functional imaging techniques such as radiography, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) have played an important role for accurate preoperative diagnostics, for the most part these techniques cannot be applied intraoperatively. Optical molecular imaging is a promising technique that provides a high degree of sensitivity and specificity in tumor margin detection. Furthermore, existing clinical applications have proven that optical molecular imaging is a powerful intraoperative tool for guiding surgeons performing precision procedures, thus enabling radical resection and improved survival rates. However, detection depth limitation exists in optical molecular imaging methods and further breakthroughs from optical to multi-modality intraoperative imaging methods are needed to develop more extensive and comprehensive intraoperative applications. Here, we review the current intraoperative optical molecular imaging technologies, focusing on contrast agents and surgical navigation systems, and then discuss the future prospects of multi-modality imaging technology for intraoperative imaging-guided cancer surgery.

The environmental roots of non-communicable diseases (NCDs) and the epigenetic impacts of globalization

BACKGROUND

Non-communicable diseases (NCDs) are increasing worldwide. We hypothesize that environmental factors (including social adversity, diet, lack of physical activity and pollution) can become "embedded" in the biology of humans. We also hypothesize that the "embedding" partly occurs because of epigenetic changes, i.e., durable changes in gene expression patterns. Our concern is that once such factors have a foundation in human biology, they can affect human health (including NCDs) over a long period of time and across generations.

OBJECTIVES

To analyze how worldwide changes in movements of goods, persons and lifestyles (globalization) may affect the "epigenetic landscape" of populations and through this have an impact on NCDs. We provide examples of such changes and effects by discussing the potential epigenetic impact of socio-economic status, migration, and diet, as well as the impact of environmental factors influencing trends in age at puberty.

DISCUSSION

The study of durable changes in epigenetic patterns has the potential to influence policy and practice; for example, by enabling stratification of populations into those who could particularly benefit from early interventions to prevent NCDs, or by demonstrating mechanisms through which environmental factors influence disease risk, thus providing compelling evidence for policy makers, companies and the civil society at large. The current debate on the '25 × 25 strategy', a goal of 25% reduction in relative mortality from NCDs by 2025, makes the proposed approach even more timely.

CONCLUSIONS

Epigenetic modifications related to globalization may crucially contribute to explain current and future patterns of NCDs, and thus deserve attention from environmental researchers, public health experts, policy makers, and concerned citizens.

Modes of delivery in preventive intervention studies: a rapid review

BACKGROUND

This review was commissioned to generate broad discussion about how to select intervention delivery modes when designing a complex, preventive intervention aimed at chronic disease through the promotion of physical activity, healthy diet and/or medication adherence. In this context, we asked, what are the delivery modes? What are the important design considerations? And how do these compare (e.g. strengths, limitations)?

MATERIALS AND METHODS

This review utilized the methods of rapid review, an emerging methodology arising from health technology assessment. The search strategy was applied in Embase and MEDLINE. A qualitative, narrative synthesis was performed on included articles.

RESULTS

After screening, 21 articles remained for synthesis (10 systematic reviews, including 1 review of reviews; four trials or studies; three commentaries or conference proceedings; and 2 were scoping projects). Our synthesis determined that major categories of design considerations when selecting intervention delivery modes include attention to the (i) candidate mode types, (ii) settings and social environment, (iii) intensity and timing, (iv) provider, (v) study population and participants, (vi) cost, (vii) behaviour change technique and (viii) theoretical basis.

CONCLUSION

An array of modes of delivery is available for each of the intervention strategies under consideration (i.e. physical activity, dietary change and medication adherence). No single delivery mode was clearly more appropriate or more effective than another, each having unique strengths and limitations. Delivery mode decisions that take the above-mentioned factors (i-viii) into account will be more fit-for-purpose than those that do not.

Age and cancer risk: a potentially modifiable relationship

This article challenges the idea that cancer cannot be prevented among older adults by examining different aspects of the relationship between age and cancer. Although the sequential patterns of aging cannot be changed, several age-related factors that contribute to disease risk can be. For most adults, age is coincidentally associated with preventable chronic conditions, avoidable exposures, and modifiable risk behaviors that are causally associated with cancer. Midlife is a period of life when the prevalence of multiple cancer risk factors is high and incidence rates begin to increase for many types of cancer. However, current evidence suggests that for most adults, cancer does not have to be an inevitable consequence of growing older. Interventions that support healthy environments, help people manage chronic conditions, and promote healthy behaviors may help people make a healthier transition from midlife to older age and reduce the likelihood of developing cancer. Because the number of adults reaching older ages is increasing rapidly, the number of new cancer cases will also increase if current incidence rates remain unchanged. Thus, the need to translate the available research into practice to promote cancer prevention, especially for adults at midlife, has never been greater.

Relative effects of educational level and occupational social class on body concentrations of persistent organic pollutants in a representative sample of the general population of Catalonia, Spain

Scant evidence is available worldwide on the relative influence of occupational social class and educational level on body concentrations of persistent organic pollutants (POPs) in the general population. The objective was to analyse such influence in a representative sample of the general population of Catalonia, Spain. Participants in the Catalan Health Interview Survey aged 18-74 were interviewed face-to-face, gave blood, and underwent a physical exam. The role of age, body mass index (BMI), and parity was analysed with General Linear Models, and adjusted geometric means (GMs) were obtained. Crude (unadjusted) concentrations were higher in women and men with lower education, and in women, but not men, in the less affluent social class. After adjusting for age, in women there were no associations between POP levels and social class or education. After adjusting for age and BMI, men in the less affluent class had higher p,p'-DDE concentrations than men in class I (p-value=0.016), while men in class IV had lower HCB than men in the upper class (p-value<0.03). Also in contrast with some expectations, positive associations between education and POP levels were observed after adjusting for age and BMI in men; e.g., men with university studies had higher HCB concentrations than men with first stage of primary schooling (adjusted GM 153.9 and 80.5ng/g, respectively) (p-value<0.001). When education and social class were co-adjusted for, some positive associations with education in men remained statistically significant, whereas class remained associated only with p,p'-DDE. Educational level influenced blood concentrations of POPs more than occupational social class, especially in men. In women, POP concentrations were mainly explained by age/birth cohort, parity and BMI. In men, while concentrations were also mainly explained by age/birth cohort and BMI, both social class and education showed positive associations. Important characteristics of socioeconomic groups as age and BMI may largely explain crude differences among such groups in internal contamination by POPs. The absence of clear patterns of relationships between blood concentrations of POPs and indicators of socioeconomic position may fundamentally be due to the widespread, lifelong, and generally invisible contamination of human food webs. Decreasing historical trends would also partly explain crude socioeconomic differences apparently due to birth cohort effects.