Lectures Oncology and
Public Health
Course of the minor Biomedical Topics in Health Care (VU)
Content
Introduction to the course ................................................................................................................................................ 1
Introduction in public health ............................................................................................................................................ 2
Introduction in oncology ................................................................................................................................................... 6
Oncogenesis; tumor biology and clinical behaviour ....................................................................................................... 14
Prevention and screening ............................................................................................................................................... 21
Tumor diagnosis and treatment ..................................................................................................................................... 28
Targeted therapy and immunotherapy .......................................................................................................................... 34
Cancer epidemiology ...................................................................................................................................................... 44
Pyscho oncology.............................................................................................................................................................. 53
Netherlands Cancer Registry........................................................................................................................................... 59
Adolescents and Young Adults with cancer (AYAs) ........................................................................................................ 61
Late effects of diagnosis and treatment for Hodgkin lymphoma ................................................................................... 63
End-of-life and palliative care ......................................................................................................................................... 67
Pain management ........................................................................................................................................................... 73
E-health in oncology ....................................................................................................................................................... 79
Nutrition .......................................................................................................................................................................... 87
Cognitive functioning ...................................................................................................................................................... 95
Cancer and work ........................................................................................................................................................... 100
Rare cancers .................................................................................................................................................................. 105
Distress .......................................................................................................................................................................... 110
Risk communication ...................................................................................................................................................... 113
Shared decision making ................................................................................................................................................ 120
,Introduction to the course
Practical information of the course
- Working groups (30% mark)
- Reflection report: based on the patient’s experiences (pass/fail)
- Written examen (open questions (70% mark)
Final terms, the student is able to:
1. Recall basic principles of tumor development and progression, diagnosis and treatment
2. Explain basic principles of cancer screening programs and cancer epidemiology
3. Describe basic public health related issues in oncology related to phases: prevention, diagnosis and
treatment, survivorship and the end of life
4. Explain late effects and long-term consequences of cancer diagnosis and treatment, and possible
intervention strategies, managing these consequences and their effectiveness
5. Illustrate patients’ experiences and point out translation of research into clinical practice
6. Identify a relevant oncology and public health problem for an assigned topic, to formulate a research
question, to find answers in the scientific literature, rate the quality of studies and systematically report the
results
Brief introduction public health & oncology
Definition public health
- The science and art of preventing disease, prolonging life and promoting health through the organized
efforts of society
- Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or
infirmity
Oncology and public health
- Cancer significant public health problem
- WHO factsheet on cancer 2018:
- One of leading causes of death globally, estimated 9,6 million deaths in 2018
- Globally, about 1 in 8 deaths is due to cancer
- Around one third of deaths from cancer are due to 5 leading behavioural and dietary risks: high body
mass index, low fruit and vegetable intake, lack of physical activity, tobacco use, alcohol use
- Cancer in the Netherlands:
- Leading cause of death (all types together)
- Most common types: lung, colon, breast, prostate
COVID-19 and cancer
- Population based screenings stopped
- Patients hesitant to go to GP or hospital → consequences?
- Regular care including cancer care stopped → consequences?
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,Introduction in public health
Definition of public health
‘The science and art of preventing disease, prolonging life and promoting health through the organized efforts of
society’
- Health is a state of complete physical, mental and social well-being and not merely the absence of disease or
infirmity
- Organized efforts and informed choices of society, organizations, public and private, communities and
individuals
- Focus on groups rather than individuals
- It refers to collective actions to improve population health
- WHO: all organized measures (whether public or private) to prevent disease, promote health and prolong
life among the population as a whole
Application of public health
Three fields of public health research:
- Epidemiology and community diagnosis
- Collective prevention and health promotion
- Health care organization and performance (cost-effectiveness, safety) → everyone needs to have access
Application:
- Population: from local areas to the world population
- Causes of disease (‘causes of causes’): from behaviours to broader environments → why are people with
low-income prone to be more obese?
- Prevention of disease: from individual patients to national policies
- General health outcomes: from quality of life to healthy life expectancy
Public health functions
Main public health functions (WHO):
- Assessment and monitoring of the health of communities and population at risk to identify health problems
and priorities
- The formulation of public policies designed to solve identified local and national health problems and
priorities
- Assure that all populations have access to appropriate and cost-effective care, including health promotion
and disease prevention services
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,Major public health achievements
Since 1900:
- Vaccination
- Safer workplaces
- Control of infectious diseases
Since 1920:
- Safer and healthier foods
- Healthier mothers and babies (mortality of babies hugely improved)
- Family planning
Since 1965:
- Fluoridation of drinking water
- Motor-vehicle safety
- Recognition of tobacco use as a health hazard
- Decline in deaths from coronary heart disease and stroke
Biggest success in public health: improved sewage disposal and clean water supply systems
Current/future public health challenges
Examples:
- Infectious disease (Ebola, Covid-19)
- Chronic diseases
- Overweight and obesity
- Mental health
- Environmental quality
- Social issues, such as violence, drug abuse,
teenage pregnancy
Global burden of cancer
- Cancer is the leading cause of death
- 1 in 8 deaths worldwide
- 2030: about 50% more cases and deaths
- Why is an increase expected?
- Increasing global population
- Increasing age
- Screening: more new cases → breast, cervix and colon cancer
- Increases in risk factors: smoking, obesity, physical inactivity, unhealthy diet
Geographic variations
- Stomach cancer: 7x increased risk in Japan and Korea (consumption smoked fish)
- Breast and prostate cancer: less frequent in Asian vs. Caucasian people (Asian vs. Western diet)
- Melanoma: Australia + sunny parts south US
- Liver cancer: south-east Asia and east Africa (Hepatitis B)
- Thyroid cancer: deficiency of iodine in local food and water supplies (e.g. Swiss Alps, Rocky mountains,
Andes, Himalayas)
➔ Not everywhere the burden of cancer is the same
Prevention of cancer
National Institute for Public Health and the Environment (RIVM)
Prevention:
- Primary prevention: prevent the disease from occurring
- Secondary prevention: detect and treat the disease in an early phase before symptoms occur
- Tertiary prevention: prevent damage and pain from the disease, slow down the disease and prevent the
disease from causing other problems
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,Cancer prevention:
- Primary: encourage healthy lifestyles, legislation (increase tax on tobacco/alcohol → results in less
consumption), HPV vaccination for prevention of cervical cancer
- Secondary: screening for breast, cervical or colon cancer
- Tertiary: survivorship care – improve HRQOL, prevention of cancer recurrence
Factors influencing cancer risk
Cancer risk can be reduced by 30% by living healthy
In the Netherlands:
- About 19.000 people a year get cancer from smoking
- 19% less cancer and 28% less people would die from cancer if no one smokes
- Not enough fruit, vegetables and too much red meat (9500 people a year get cancer from this)
- Obesity (3600 people a year get cancer from this)
- Drinking alcohol (2900 people a year get cancer from this)
- Not enough physical activity (2100 people a year get cancer from this)
- Direct sunlight/UV
WCRF recommendations
World Cancer Research Fund International
WCRF network:
- World Cancer Research Fund International
- The American Institute for Cancer Research
- Wereld Kanker Onderzoek Fonds
- World Cancer Research Fund Hong Kong
How do we study cancer risks? → epidemiology (observational studies, prospective cohort studies)
- Case control studies for rare cancers
Physical activity and colon cancer:
Combine different studies in meta-analysis:
- Case-control studies: little overestimation of the effect
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,WCRF matrix
Increased risk:
- Overweight or obese: colorectum, breast (post-menopause), gallbladder, kidney, liver, oesophagus, ovary,
pancreas, prostate, stomach, endometrium
- Weight gain in adulthood: breast (post-menopause)
- Salt-preserved foods: stomach
- Arsenic in drinking water: bladder, lung, skin
- Alcohol drinks: colorectum, breast, liver, mouth, pharynx, larynx, oesophagus, stomach
- Beta-carotene supplements: lung
- Mate (South American herbal tea): oesophagus
- Cantonese style salted fish: nasopharynx
- Processed meat: colorectum, stomach
- Red meat: colorectum
- Glycaemic load (raise in blood sugar by diet): endometrium
- Aflatoxins (toxins produced by cretin fungi): liver
- Height (being tall): colorectum, breast, kidney, ovary, pancreas, prostate → no recommendations yet
- Greater birth weight: breast → no recommendations yet
Decreased risk:
- Non-starchy vegetables: mouth, pharynx, larynx
- Fruit: lung, mouth, pharynx, larynx
- Physical activity: colon, breast, endometrium
- Dietary fibre: colorectum
- Breast feeding: breast
- Coffee: liver, endometrium → unanswered questions: no recommendations
- Garlic: colorectum
- Greater body fatness: breast (pre-menopause) → but strong evidence for increased risk of other cancers
- Greater body fatness between 18-30 years: breast (post-menopause) → but strong evidence for increased
risk of other cancers
- Diets high in calcium: colorectum → unanswered questions link milk/dairy and other cancers → no
recommendations
- Alcohol: kidney → but strong evidence for increased risk of other cancers
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, Recommendations
- Stop smoking → most important in reducing cancer risk
- Healthy weight
- This overall recommendation can best be achieved by maintaining energy balance throughout life
by: being physically active, eating a diet rich in wholegrains, vegetables, fruits and pulses, limiting
fast food consumption and other processed foods high in fat, starches or sugar, limiting
consumption of sugar sweetened drinks
- Move more, sit less
- Avoid high-calorie foods and sugary drinks
- Enjoy more grains, vegetables, fruit and beans
- Limit red meat and avoid processed meat
- For cancer prevention, don’t drink alcohol
- Eat less salt and avoid mouldy grains and cereals
- For cancer prevention, don’t rely on supplements
- If you can, breastfeed your baby
- Cancer survivors should follow our recommendations where possible
Why public health policy?
- Much of behaviour passive reflection of ‘upstream’ factors rather than active choice
- Environmental, economic and social factors (outside most people’s control)
- Example: policy is needed to enable people to achieve and maintain a healthy weight by influencing
food environment, food system, built environment and behavioural change communication
- Thus effectiveness of behavioural change relies on policies that influence upstream factors and social norms
that determine people’s behaviours (‘causes of causes’)
➔ Public health policy (i.e. laws, regulations, guidelines) therefore is an important and sometimes even critical
determinant of population health
Introduction in oncology
Study goals
- What is cancer?
- What are the hallmarks of cancer?
- What are the causes and risk factors for cancer?
What is cancer?
- Our bodies consist of about 30 trillion cells, these group together to form tissues and organs
- Organs work together, so we can live
- Cancer can arise in any of those cells
- Cancer is a large group of diseases characterized by abnormal cells, which continuously proliferate, invade
local tissues and spread to other organs
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