THE Cancer Atlas: Third Edition

THE
CANCER
ATLAS
Third Edition
Ahmedin Jemal
Lindsey Torre
Isabelle Soerjomataram
Freddie Bray
Published by the American Cancer Society, Inc.
250 Williams Street
Atlanta, Georgia 30303 USA
www.cancer.org
THE
Copyright ©2019 The American Cancer Society, Inc.
All rights reserved. Without limiting under copyright reserved above, no part of
this publication may be reproduced, stored in, or introduced into a retrieval system
or transmitted in any form by any means (electronic, mechanical, photocopying,
recording, or otherwise) without the prior written consent of the publisher.
CANCER
ISBN 978-1-60443-265-7
Printed in the United States of America.
ATLAS
This edition was printed by OneTouchPoint.
Library of Congress Control Number:2019949680
Managing Editor: John M. Daniel

Editorial Coordinator: Rabia Khan
Suggested Citation:
Jemal A, Torre L, Soerjomataram I, Bray F (Eds). The Cancer Atlas. Third Ed. Atlanta,
GA: American Cancer Society, 2019. Also available at: www.cancer.org/canceratlas.
Design:
Language Dept. www.languagedept.com
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The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of the American
Cancer Society concerning the legal status of any country, territory, city, or area
of its authorities, or concerning the delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not Third Edition
imply that they are endorsed or recommended by the American Cancer Society
in preference to others of a similar nature that are not mentioned. Errors and
omissions excepted, the names of proprietary products are distinguished by initial
Ahmedin Jemal
capital letters. The American Cancer Society does not warrant that the information Lindsey Torre
contained in this publication is complete and correct and shall not be liable for any
damages incurred as a result of its use. The authors alone are responsible for the
Isabelle Soerjomataram
views expressed in this publication. Freddie Bray
The Cancer Atlas can be found online at www.cancer.org/canceratlas. The online

version of the Atlas provides additional resources and information unique to the
online interactive version.
CONTENTS
PART ONE 16 PART TWO 34
RISK FACTORS THE BURDEN

Forewords 8 02 Overview of Risk Factors 18 10 The Burden of Cancer 36 18 Latin America and Caribbean 52
Gary Reedy, CEO, American Cancer Society Farhad Islami, MD, PhD, Surveillance and Health Services Freddie Bray, PhD, Section of Cancer Surveillance, International Marion Piñeros, MD, MSc, Section of Cancer Surveillance,
Cary Adams, CEO, Union for International Research Program, American Cancer Society Agency for Research on Cancer International Agency for Research on Cancer
Cancer Control Ahmedin Jemal, DVM, PhD, Surveillance and Health Services Isabelle Soerjomataram, PhD, Section of Cancer Surveillance, Freddie Bray, PhD, Section of Cancer Surveillance,
Elisabete Weiderpass, Director, International Agency Research Program, American Cancer Society International Agency for Research on Cancer International Agency for Research on Cancer
for Research on Cancer Isabelle Soerjomataram, PhD, Section of Cancer Surveillance,
03 Risks of Tobacco 20 11 Lung Cancer 38 International Agency for Research on Cancer
Editors 12 Michael Thun, MD, Cancer Epidemiology and Surveillance Isabelle Soerjomataram, PhD, Section of Cancer Surveillance,
(retired), American Cancer Society International Agency for Research on Cancer 19 Northern America 54
Freddie Bray, PhD, Section of Cancer Surveillance, Rebecca Siegel, MPH, Surveillance and Health Services
Acknowledgments 13 04 Infection 22 International Agency for Research on Cancer Research Program, American Cancer Society
Gary M. Clifford, PhD, Infections and Cancer Epidemiology
Group, International Agency for Research on Cancer 12 Breast Cancer 40 20 Southern, Eastern, and 56
01 Introduction 14 Catherine de Martel, MD, PhD, Infections and Cancer Isabelle Soerjomataram, PhD, Section of Cancer Surveillance, South-Eastern Asia
Epidemiology Group, International Agency for Research International Agency for Research on Cancer Les Mery, Section of Cancer Surveillance, International
Ahmedin Jemal, DVM, PhD, Surveillance and
on Cancer Freddie Bray, PhD, Section of Cancer Surveillance, Agency for Research on Cancer
Health Services Research Program, American
International Agency for Research on Cancer Freddie Bray, PhD, Section of Cancer Surveillance,
Cancer Society
05 Body Weight, Physical Activity, Diet, 24 International Agency for Research on Cancer
and Alcohol 13 Cancer in Children 42 Isabelle Soerjomataram, PhD, Section of Cancer Surveillance,
Eva Steliarova-Foucher, PhD, MSc, Section of Cancer International Agency for Research on Cancer
What’s New! cancer color guide Susan M. Gapstur, PhD, MPH, Behavioral and Epidemiology
Surveillance, International Agency for Research on Cancer
Research Group, American Cancer Society
This fully updated edition Bladder 21 Europe 58
presents the most 14 Human Development Index Transitions 44
recent cancer patterns
Brain, central nervous system
Breast
06 Ultraviolet Radiation 26 Freddie Bray, PhD, Section of Cancer Surveillance,
Isabelle Soerjomataram, PhD, Section of Cancer Surveillance,
International Agency for Research on Cancer
and evidence on cancer Adèle C. Green, PhD, Population Health Department, QIMR
Cervix International Agency for Research on Cancer Freddie Bray, PhD, Section of Cancer Surveillance,
prevention and control. Berghofer Medical Research Institute and CRUK Manchester
Colorectum Isabelle Soerjomataram, PhD, Section of Cancer Surveillance, International Agency for Research on Cancer
Institute and Faculty of Biology Medicine and Health,
Use this cancer color Esophagus International Agency for Research on Cancer
University of Manchester
guide to find data on Gallbladder 22 Northern Africa, 60
the top global cancers Kaposi sarcoma
Astrid J. Rodriguez-Acevedo, PhD, Population Health 15 Cancer in Indigenous Populations 46 West and Central Asia
Department, QIMR Berghofer Medical Research Institute
throughout the book. Diana Sarfati, MBChB, MPH, PhD, FNZCPHM, Department
Kidney Louisa G. Gordon, PhD, Population Health Department, QIMR Ariana Znaor, MD, PhD, Section of Cancer Surveillance,
of Public Health, University of Otago
For the companion Leukemia Berghofer Medical Research Institute International Agency for Research on Cancer
Bridget Robson, BA, DPH, Eru Pomare Māori Health Research
digital experience visit Lip, oral cavity Isabelle Soerjomataram, PhD, Section of Cancer Surveillance,
Centre, Department of Pubic Health, University of Otago
canceratlas.cancer.org Liver 07 Reproductive and Hormonal Factors 28 Gail Garvey, PhD, Wellbeing and Preventable Chronic
Lung Mia M. Gaudet, PhD, Behavioral and Epidemiology Research Freddie Bray, PhD, Section of Cancer Surveillance,
Diseases Division, Menzies School of Health Research
Lymphoma Group, American Cancer Society International Agency for Research on Cancer
Nina Scott, FNZCPHM, MPH, MBChB, DipComChildH,
Melanoma Carol E. DeSantis, MPH, Surveillance and Health Services
Non-Hodgkin lymphoma Research Program, American Cancer Society
DipChildH, Hei Ahuru Mowai, Māori Cancer Leadership
Aotearoa; Clinical Director Māori Public Health, Waikato
23 Oceania 62
Marc J. Gunter, PhD, Nutrional Epidemiology Group, Les Mery, Section of Cancer Surveillance, International
Ovary District Health Board
International Agency for Research on Cancer Agency for Research on Cancer
Pancreas
Freddie Bray, PhD, Section of Cancer Surveillance,
Prostate
08 Environmental and Occupational Exposures 30 REGIONAL DIVERSITY International Agency for Research on Cancer
Stomach
Neil Pearce, PhD, Department of Medical Statistics, London Isabelle Soerjomataram, PhD, Section of Cancer
Thyroid
Uterus
School of Hygiene and Tropical Medicine
Manolis Kogevinas, PhD, ISGlobal, Barcelona Biomedical
16 Overview of Geographical Diversity 48 Surveillance, International Agency for Research on Cancer
Other Freddie Bray, PhD, Section of Cancer Surveillance,

Research Park (PRBB)
09 Human Carcinogens 32 Isabelle Soerjomataram, PhD, Section of Cancer Surveillance,
Identified by the IARC Monographs Program
Kurt Straif, MD, MPH, PhD, Section of Evidence Synthesis and 17 Sub-Saharan Africa 50
Classification, International Agency for Research on Cancer Freddie Bray, PhD, Section of Cancer Surveillance,
Béatrice Lauby-Secretan, PhD, IARC Handbooks of Cancer International Agency for Research on Cancer
Prevention Group, Section of Evidence Synthesis and Isabelle Soerjomataram, PhD, Section of Cancer Surveillance,
Classification, International Agency for Research on Cancer International Agency for Research on Cancer
4 canceratlas . cancer . org canceratlas . cancer . org 5

CONTENTS
PART THREE 68
TAKING ACTION
24 Cancer Survival 64 26 The Cancer Continuum 70 33 Cancer Surveillance 84 APPENDIX
Isabelle Soerjomataram, PhD, Section of Cancer An Overview of Interventions and Les Mery, Section of Cancer Surveillance, International Agency
Surveillance, International Agency for Research for Research on Cancer History of Cancer 100
on Cancer
Potential for Impact Isabelle Soerjomataram, PhD, Section of Cancer Surveillance,
Freddie Bray, PhD, Section of Cancer Surveillance, Ahmedin Jemal, DVM, PhD, Surveillance and Health Services International Agency for Research on Cancer
International Agency for Research on Cancer Research Program, American Cancer Society Freddie Bray, PhD, Section of Cancer Surveillance, Glossary 108
Lindsey Torre, MSPH, Surveillance and Health Services International Agency for Research on Cancer
25 Cancer Survivorship 66 Research Program, American Cancer Society
Julia Rowland, PhD, Smith Center for Healing 34 Research 86 Sources and Methods 111
and the Arts
27 Health Promotion 72 Ahmedin Jemal, DVM, PhD, Surveillance and Health Services
K. Robin Yabroff, PhD, Surveillance and Health A Population and Systems Approach Research Program, American Cancer Society
Services Research Program, American
Cancer Society
Kristen R. Sullivan, MPH, MS, Nutrition and Physical Activity,
Cancer Control, American Cancer Society 35 The Economic Burden of Cancer 88 Index 130
Jeffrey Drope, PhD, Economic & Health Policy Research K. Robin Yabroff, PhD, Surveillance and Health Services
Program, American Cancer Society Research Program, American Cancer Society
Jacqui Drope, Global Cancer Prevention and Early Detection, Jingxuan Zhao, MPH, Surveillance and Health Services
American Cancer Society Research Program, American Cancer Society
Xuesong Han, PhD, Surveillance and Health Services Research
28 Tobacco Control 74 Program, American Cancer Society
Jeffrey Drope, PhD, Economic & Health Policy Research Zhiyuan Zheng, PhD, Surveillance and Health Services
Program, American Cancer Society Research Program, American Cancer Society
Michal Stoklosa, MA, Economic & Health Policy Research
Program, American Cancer Society 36 Building Synergies 90
Lisa Stevens, PhD, Center for Global Health, National
29 Vaccines 76 Cancer Institute
Lauri E. Markowitz, MD, National Center for Immunization
and Respiratory Diseases, Centers for Disease Control 37 Uniting Organizations 92
and Prevention* Sonali Johnson, PhD, Knowledge Advocacy and Policy, Union
Francisco Averhoff, MD, MPH, National Center for HIV/AIDS, for International Cancer Control
Viral Hepatitis, STD, and TB Prevention, Centers for Disease Zuzanna Tittenbrun, Knowledge Advocacy and Policy, Union
Control and Prevention* for International Cancer Control
Iacopo Baussano, MD, PhD, Infections and Cancer
Epidemiology Group, International Agency for Research 38 Global Relay for Life 94
on Cancer Kristen Solt, MSC, Global Relay for Life, American
Cancer Society
30 Early Detection 78 Matt Lewis, Global Relay for Life, American Cancer Society
Partha Basu, MD, Screening Group, International Agency for
Research on Cancer 39 Policies and Legislation 96
Maqsood Siddiqi, PhD, Cancer Foundation of India Jonathan Liberman, MPub&IntLaw, McCabe Centre for Law
and Cancer, Associate Professor in Law and Global Health,
31 Management and Treatment 80 University of Melbourne
Eva Johanna Kantelhardt, MD, Department of Gynaecology and
Institute of Medical Epidemiology, Biostatistics and Informatics 40 Universal Health Coverage 98
Medical Faculty Martin Luther University Halle-Wittenberg André Ilbawi, MD, Department of Noncommunicable Diseases,
Assefa Mathewos, MD, Radiotherapy Center, Tikur Anbessa World Health Organization
Referral Hospital, School of Medicine, Addis Ababa University Filip Meheus, PhD, Early Detection & Prevention Section,
Ahmedin Jemal, DVM, PhD, Surveillance and Health Services International Agency for Research on Cancer
Research Program, American Cancer Society
32 Pain Control 82
Meg O’Brien, PhD, Global Cancer Treatment, American
Cancer Society
*The findings and conclusions in this publication are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and Prevention.

FOREWORDS
“
Over the last several decades, the world has seen to reduce tobacco use and save millions of lives.
incredible progress in the fight against cancer. But they can only work if leaders around the world
Thanks to advances in cancer prevention, early prioritize, embrace, and implement them.
detection, treatment, and support for those facing The American Cancer Society is proud to work
This much is clear:

the disease, more people than ever before have with partners in the United States and around the
reason to hope. For example, the cancer mortality globe to save lives, celebrate lives, and lead the
rate in the United States has declined 27% since fight for a world without cancer. Together with
we simply must do
1991, averting more than 2.6 million cancer deaths. our 1.5 million volunteers, we convene partners to
Despite extraordinary advances in what we create awareness and impact; fund cancer research
know about cancer, not everyone has benefitted breakthroughs; build communities to support
GARY REEDY
better to ensure
from this progress equally. Cancer is a growing people facing cancer; and provide direction
burden among people living in low- and middle- by empowering people with the information
income countries, and many people living in they need. In the USA, the American Cancer
everyone can benefit

Chief Executive these areas cannot access the information or Society Cancer Action Network, our nonprofit,
interventions that could save their lives. By 2040, nonpartisan advocacy affiliate, works at the state
Officer, American considering only population growth and aging, and federal levels of government to ensure patients
Cancer Society
from advances
the global cancer burden is expected to grow to can obtain and maintain quality, affordable, and
27.5 million new cancer cases per year, up from comprehensive health insurance that enables
17 million new cases in 2018. When we consider access to cancer care— from prevention through
in the fight against

lifestyle factors such as smoking, unhealthy diet, treatment. Globally, we collaborate with our
and physical inactivity, the number of new cancer partners to increase access to information that
cases will likely be considerably larger. is relevant and culturally appropriate, as well as
cancer. As you will

This much is clear: we simply must do better to to increase access to prevention, early detection,
ensure everyone can benefit from advances in the treatment, and palliative care that is affordable and
fight against cancer. As you will see in the pages universally available. For example, the American
of this Cancer Atlas, Third Edition, progress is not Cancer Society collaborates with public and private
see in the pages of

only possible, but also achievable. For example, sector partners to expand access to essential cancer
cervical cancer death rates have declined by 70% treatment medications across sub-Saharan Africa
or more in many high-income countries that to make high-quality treatment more affordable
this Cancer Atlas,

began prioritizing cervical cancer screening in and accessible. Only by increasing access to care
the 1970s. This type of dramatic progress should can we truly realize progress against cancer for all.
not be limited to women living in high-income While we face great challenges in this work,
Third Edition, progress

nations. Interventions such as HPV vaccination we also have the proven interventions, dedicated
and cervical cancer screening can be implemented global partners, and momentum we need to truly
even in low-resource settings, where nearly nine address the global cancer burden. This Cancer
is not only possible,

out of 10 deaths from cervical cancer occur. Public Atlas, Third Edition is an important source of
and private sector leaders must work to ensure that information to help the global cancer community
women have access to screening and girls and boys achieve our shared goal of a world without cancer.
but also achievable.

have access to HPV vaccination. Tobacco control is Working together with leaders around the world,
another area of tremendous potential. Tobacco use we can ensure that recent progress does not stop,
remains the leading preventable cause of cancer but instead accelerates and benefits everyone.
deaths worldwide, and tobacco control remains
vitally important to preventing cancer. We have
— Gary Reedy the tools— taxation, smoke-free environments,
restrictions on product marketing, graphic warning
labels on packaging, and more—that are proven

FOREWORDS
The last time I wrote a foreword for The Cancer responses as we enter what we hope will be a Cancer is an issue of sustainable development. state-of-the-art resource to shape strategies for
Atlas was in 2014. I started by referencing the decade of action. It is associated with high morbidity, disability, cancer prevention. The Cancer Atlas presents a
landmark High-Level Meeting (HLM) on Non- The UICC and its 1100 members in 170 and mortality, and thus places an overwhelming global overview of the latest available data on
communicable Diseases (NCDs) which took countries continue to press for national action social and economic burden on individuals, cancer burden and trends—notably drawing on
place in September 2011 in New York. Since that to ensure that the global wins we have secured communities, and societies. The global burden the IARC Global Cancer Observatory—as well as
first meeting, which confirmed the importance are properly followed through by national of cancer is increasing, due to demographic the associated risk factors and measures of cancer
of cancer and other NCDs in the global health governments. The International Agency for transitions and changes in exposures to risk factors prevention and control that have been proven to
agenda, there have been new milestones. NCDs Research on Cancer (IARC) forecasts an increasing as a result of globalization. In 2018, there were be effective. The publication is targeted at cancer
have been debated at two further HLMs (2014 and cancer burden, primarily due to the aging and estimated to be more than 17 million new cases of researchers, public health professionals and
2018) and, through the concerted advocacy efforts growing world population, and that this burden cancer and more than 9 million deaths from cancer advocates, governments, and society as a whole.
CARY ADAMS of the cancer and NCD communities, a target to

reduce premature deaths caused by NCDs was
will fall on parts of the world least able to cope
with the increase. We will ensure that governments
ELISABETE worldwide, and about 70% of all cancer deaths
occurred in low- and middle-income countries.
Facing the cancer problem is a prerequisite
for addressing social and economic inequities,
included in the Sustainable Development Goals take tobacco control seriously, encourage healthy
WEIDERPASS Cancer can be treated, but better still, it can stimulating economic growth, and accelerating
Chief Executive (SDGs) adopted in September 2015 by the UN behaviors, implement vaccination and screening be prevented. The cost of treating patients is sustainable development. I hope that this book
General Assembly. On top of the “25 by 25” target programs, improve cancer registries, and invest ballooning, while at least 40% of all cancer cases will find widespread use, because prevention is,
Officer, Union of the Global Action Plan on NCDs, we now have in the infrastructure required to treat the most Director, could be prevented based on current knowledge, and should continue to be, the first line of attack
for International global commitments to reduce premature deaths common cancers.
International
by minimizing exposure to risk factors and in tackling the challenges posed by the global
caused by NCDs by one third by 2030. The Cancer Atlas has proved to be an implementing effective prevention strategies. cancer epidemic.
Cancer Control At the same time, The Union for International outstanding publication in the past, helping the Agency for Cancer mortality can also be reduced through early
“
Cancer Control (UICC) and its members around cancer community communicate the progress we detection and adequate, affordable, and timely
the world advocated for an updated resolution on have or have not made, the challenges we face and
Research on treatment. Apart from economic considerations—
cancer to guide Member States on the steps they the areas of focus for future years. Its beautifully Cancer prevention is much more cost-effective than
should take to improve cancer control in their own crafted presentations of facts and evidence help us treatment alone— a major advantage of prevention
countries. Member States welcomed this view and construct compelling messages to better articulate lies in the avoidance of suffering altogether. Facing the cancer problem is a prerequisite for
adopted a Cancer Resolution (70.12) at the 70th the problem and present solutions. This new The International Agency for Research on addressing social and economic inequities, stimulating
economic growth, and accelerating sustainable
session of the World Health Assembly (WHA) in edition will once again be circulated widely and Cancer (IARC), the specialized cancer agency
development. I hope that this book will find widespread
2017, once more signalling the need to place cancer inspire those of us who want to see change happen. of the World Health Organization (WHO), has
use, because prevention is, and should continue to be,
as a priority in all national health plans. These We all know that there is much to do. The next a pivotal role in the production and evaluation
the first line of attack in tackling the challenges
efforts over the last years appear to be working. In decade will test the tenacity of the community of knowledge for cancer prevention worldwide, posed by the global cancer epidemic.
research conducted by UICC with the World Health as we press for change, helping governments to guide the formulation of global policies of
Organisation, NCI, and other partners in late 2017, fulfil the promise of their global commitments to high public health relevance to fight against
we discovered that the number of countries with cancer control. The Cancer Atlas is a key resource cancer. IARC’s overarching objectives are to
operational cancer plans had increased from 66% for researchers, advocates, patients and cancer ensure leadership on interdisciplinary cancer
in 2013 to 81%—a significant improvement. This planners. My thanks to ACS, IARC and the many prevention research for the public good, to promote
progress increases our confidence that 2030 will others who have contributed to such a wonderful international collaboration, and to contribute to
indeed see more cancers prevented, detected early, resource for our community. the capacity-building of the international scientific
and treated successfully. community in cancer prevention research, with
“
As I write this piece, the health community the ultimate goal of tackling the global cancer
is preparing for a HLM on Universal Health burden. Through a closely interwoven network
Coverage in New York in September 2019. It is of collaborations, IARC plays its part in cancer
imperative that cancer features in that discussion prevention in support of WHO programs in the
The next decade will test the tenacity of the
and that countries re-confirm their commitment countries that are most in need.
community as we press for change, helping
to improve cancer control globally. Such a governments fulfill the promise of their global Building on the success of the second edition
commitment on the back of three HLMs on NCDs commitments to cancer control. The Cancer Atlas is of The Cancer Atlas, published in 2014, this
and the WHA Cancer Resolution will provide a key resource for researchers, advocates, patients third edition along with its website provides an
the impetus to significantly gear up national and cancer planners. accessible, easily manageable, and comprehensive

EDITORS ACKNOWLEDGEMENTS
Dr. Jemal is the Scientific Vice President of the cancer surveillance and health services researchers The editors of The Cancer Many individuals have donated their time and • Bart Kiemeney, Radboud University, Cancer
Surveillance & Health Services Research Program to promote the application of evidence-based expertise in the preparation of the Atlas. In Epidemiology Group
at the American Cancer Society. He also holds an cancer prevention and control in the USA and Atlas, Third Edition would like particular, we would like to thank Rabia Khan • Betsy Kohler, North American Association
at the American Cancer Society for invaluable of Central Cancer Registries
to thank the American Cancer
appointment as adjunct Professor of Epidemiology worldwide. Dr. Jemal has published more than 350
at the Rollins School of Public Health, Emory articles in peer-reviewed journals. logistical and editorial support, and Mathieu • Martha Linet, National Cancer Institute (USA)
University. Dr. Jemal’s principal research Society and the International Laversanne at the International Agency for • Joe Lipscomb, Emory University, Winship
interests include cancer disparities and the social Research on Cancer for supplying datasets Cancer Institute
determinants of health and health services and Agency for Research on and analytical support. For their individual • Loraine D. Marrett, University of Toronto,
School of Public Health
outcomes research. His main goal at the American
Cancer for their support of contributions to the Atlas, we would like to thank
AHMEDIN JEMAL Cancer Society has been to build a strong team of Shacquel Woodhouse, Vanika Jordan, Kimberly D. • Franco Merletti, University of Turin, Department
this edition. We would also Miller, Ann Goding Sauer, Ka Kit Liu, Liora Sahar, of Medical Sciences – Cancer Epidemiology Unit
Katina Lett, Qiana Davis, Blake Sanders, Kenny • Max Parkin, University of Oxford , African Cancer
Ms. Torre is an epidemiologist in the Surveillance also conducts and collaborates on research focused like to thank the Union for Oxley, Lorraine McCawley, Luke Ndekhedehe, Registry Network
and Health Services Research group at the
American Cancer Society. She concentrates on
on global cancer control, with particular emphasis
on risk factors, disparities, and cancer in women.
International Cancer Control Kathy Pourmehr, and Derek Ricard at the
American Cancer Society.
• Neil Pearce, London School of Hygiene and Tropical
Medicine, Department of Non-communicable
global cancer surveillance and has authored over Ms. Torre received a BS in International for its generous support of the Disease Epidemiology
20 peer-reviewed publications, including book Political Economy from Georgetown University We would also like to express our deep appreciation • M.R. Rajagopal, Pain and Palliative Care Clinic,
chapters and American Cancer Society service and an MSPH in Global Epidemiology from the dissemination of this edition. for our authors and peer reviewers. Our peer Medical College, Calicut
publications. She is the lead author of Global Rollins School of Public Health, Emory University. reviewers include: • Jonathan Samet, University of Southern
Cancer Facts & Figures, 3rd and 4th editions, • Ben Anderson, University of Washington, California, Institute for Global Health
an editor of The Cancer Atlas, Second and Third Department of Surgery • Bernard Stewart, University of New South Wales –
Edition, and a contributor to the annual American • Carmen Audera-Lopez, World Health Organization Sydney, School of Women’s and Children’s Health
LINDSEY TORRE Cancer Society Facts & Figures publication. She • Afsan Bhadelia, Harvard School of Public • Robert Smith, American Cancer Society
Health, Health Systems Group • Julie Torode, Union for International Cancer Control
• Graham Colditz, Washington University • David Whiteman, QIMR Berghofer
Dr. Soerjomataram is Deputy Head of the Section project involving over than 60 experts in France Institute for Public Health and School • Christopher Wild, International Agency for
of Cancer Surveillance at the International Agency estimates the proportion of cancer attributable to of Medicine Research on Cancer
for Research on Cancer (IARC). She is a medical known lifestyle and environmental risk factors. • Sally Cowal, American Cancer Society • Walter Willett, Harvard University, School
epidemiologist with a special interest in prevention She is also leading global estimation of attributable • Susan Devesa, National Cancer Institute of Public Health
of cancer and improving cancer outcomes. She fractions for cancers related to various risk factors. • Paul Dickman, Karolinska Institutet, Department • Martin Wiseman, World Cancer Research
took a position at IARC in 2011, where she is In addition, she leads cancer survival projects of Medical Epidemiology and Biostatistics Fund International
currently assessing international variation in in high-, and low-, and middle-income settings • Paul Doria-Rose, National Cancer Institute (USA) • K. Robin Yabroff, American Cancer Society
the cancer burden and survival using mainly assessing the effectiveness of the local health • Brenda Edwards, National Cancer Institute
population-based datasets and how policy can system as well as influence of major risk factors (USA) A number of individuals and organizations
ISABELLE mitigate the rising burden of cancer. such as obesity. • Michael Eriksen, Georgia State University,
School of Public Health
provided additional expertise on specific chapters:
• Laia Bruni, Catalan Institute of Oncology
In addition to her research activities, she is
SOERJOMATARAM co-coordinating several large projects. One seminal • Silvia Franceschi, International Agency for • Jeffrey Drope, American Cancer Society
Research on Cancer • Robert Eckford, Campaign for Tobacco Free Kids
• Patricia Ganz, University of California - • Michal Stoklosa, American Cancer Society
Dr. Bray is Head of the Cancer Surveillance current paucity and an ever-increasing cancer Los Angeles, School of Public Health • Cesar Victora, Federal University of Pelotas, Brazil
Section at the International Agency for Research problem, Dr. Bray leads the Global Initiative • Sumit Gupta, University of Toronto, Institute
on Cancer (IARC) in Lyon, France. His areas for Cancer Registration (http://gicr.iarc.fr), an of Health Policy, Management and Evaluation Finally, for their diverse talents and design
of research revolve around the descriptive international multi-partner program designed to • Rolando Herrero Acosta, International Agency expertise, we would like to thank the team at
epidemiology of cancer, including the estimation of ensure a sustainable expansion of the coverage for Research on Cancer Language Dept.: Sarah Asip, Jenn Cash, Jesse
the global cancer burden and the analysis of time and quality of population-based cancer registries • Andre Ilbawi, World Health Organization Lankford, Jenna Park, Tanya Quick, Rachel Shim,
trends of cancer including predictions of the future in low- and middle-income countries through • Mazda Jenab, International Agency for Nikki Taliaferro, and Jada Vogt.
scale and profile of cancer globally linked to human tailored, localized support and advocacy to Research on Cancer
development transitions. individual countries. • Sonali Johnson, Union for International
In support of the overwhelming need for high Cancer Control
FREDDIE BRAY quality cancer surveillance systems given their • Tim Key, University of Oxford, Cancer
Epidemiology Unit

01 INTRODUCTION
THIRD EDITION
ACCESS CREATES PROGRESS
The Cancer Atlas

aims to open readers’
eyes to the facts and
This third edition unites these topics under
the theme of “Access Creates Progress,”
drawing attention not only to the problem
at hand, but also the means of tackling
financial burden of cancer are highlighted.
A new chapter on cancer in Indigenous
populations describes the specific
challenges facing these underserved
Estimated increase in the number of cancer cases
by site worldwide from 2018 to 2040 “
…a major difference can be made in the incidence,
management, and [control] of cancer, even in
the poorer countries of the world… [and] this
can be done in cost-effective and affordable ways.
Understanding and determination are the
deficiencies most in need of change.
the cancer burden through access to populations around the world.
figures of cancer: the
— Amartya Sen, awarded the
information and services—addressing 30,000,000 Nobel Prize in Economics
not only the immediate causes of cancer The final section, TAKING ACTION, describes The worldwide cancer burden
scale and magnitude but also the underlying drivers of disease major interventions across the cancer
is expected to increase by about
continuum, from the prevention of risk
globally, the major and disparities.
factors to early detection, treatment, and
60% from 2018 to 2040
due to population aging and
causes, and the This third edition of The Cancer Atlas
maintains the structure of the previous
palliative care, highlighting disparities
in the availability and implementation of
25,000,000 growth alone.
different ways the editions, with chapters grouped into three these interventions across the world. It
disease can be
sections: Risk Factors, The Burden, and also portrays the multiple organizations
Taking Action. working in cancer control and the
prevented and treated. The first section, RISK FACTORS, highlights
importance of policies and legislation and 20,000,000
building synergies between diseases and
It is a comprehensive regional and international variations in health systems for broad implementation
many of the major risk factors for cancer,
global overview that including tobacco use, infections, excess
of known interventions. In this edition, a
new chapter on universal health care and
equally highlights body weight, and ultraviolet radiation.
Tobacco smoking continues to be the
“Access Creates Progress” text boxes in 15,000,000
chapters throughout the book highlight
the distinct patterns predominant cause of cancer in most high- successful strategies to address the
and inequities in
income countries, while infections still play cancer burden.
a major role in many sub-Saharan African
the present cancer and Asian countries. The importance In summary, The Cancer Atlas is intended
10,000,000
of excess body weight as a major risk to deliver a rapid but comprehensive
burden, the associated factor for cancer continues to escalate in grasp of the global essentials of cancer.
risk factors, and the most parts of the world, including many
economically transitioning countries.
This book and its accompanying website
(canceratlas.cancer.org) were carefully
prospects for cancer The second section, THE BURDEN, describes
designed to ensure user-friendly, 5,000,000
accessible, and downloadable descriptions
prevention and control. the geographic diversity in cancer and graphics can be easily used by cancer
occurrence worldwide and, in separate control advocates, government and private
chapters, for each of the major world public health agencies, and policymakers,
regions. This burden is also described in as well as patients, survivors and the 0
terms of the national Human Development general public. The Cancer Atlas is an 2018 2040
Index, the primary measure of a country’s illustrative guide to cancer’s diversity and
societal and economic development used disparities, but also a positive vehicle CANCER COLOR GUIDE
in this book. Profiles of cancer survival and for the promotion and delivery of cancer
cancer survivorship are expanded in this prevention and cancer control worldwide.
Lung Liver Non-Hodgkin lymphoma Lip, oral cavity Kaposi sarcoma
Breast Esophagus Pancreas Brain, central nervous system Other
third edition, and global cancer survival
Colorectum Cervix Leukemia Ovary
statistics are presented for the first time
Prostate Thyroid Kidney Melanoma
in print, while pressing issues such as the Stomach Bladder Uterus Gallbladder

XX SECTION TITLE
RISK FACTORS
This section describes the prevalence of major cancer risk factors around the
world. Tobacco smoking remains the predominant cause of cancer in most high-income
countries, while infections play a major role in many low-income countries.
ACCESS
CREATES
PROGRESS
Progress in tobacco control
legislation over the last
decade means 1.5 billion
people in 55 countries are
now protected by smoke-
free legislation.
There are still 1.1 billion smokers worldwide

and tobacco causes more preventable
cancer deaths than any other risk factor.

02 RISK FACTORS MAP 2.1
Infectious agents can cause a wide range of FIGURE 2.2 Proportion (%) of
OVERVIEW
cancer types. FIGURE 2.1 However, there is large Prevalence (%) of human papillomavirus (HPV) cancer deaths caused
3% or less 3.1–6% 6.1–9% 9.1% or more No data
variation across countries in the proportion of infection (all ages) and HPV vaccination by alcohol drinking
cancers caused by infectious agents, ranging from (ages 10–20 years) among females by continent in men ages 15 years
around 4% in many very high-income countries or older, 2016
Vaccination prevalence
OF RISK
to more than 50% in several sub-Saharan African
Overall HPV prevalence
countries. As such, in many low-income countries
infection-related cancers are a leading cause of
Figure 1
HPV vaccination is suboptimal globally,
cancer deaths (see 04, Infection). FIGURE 2.2
Unhealthy diet, excess body weight, and
Prevalence of human in
particularly papillomavirus
Africa, where HPV
FACTORS
physical inactivity cause multiple types of cancer
infection (all ages) and
infection vaccination
rates (ages 10-
are highest.
20 years) among females by continent
(see 05, Diet and Nutrition) and are emerging risk
factors for cancer worldwide. The cancer burden
Africa 1% vs. 21%
associated with these risk factors is expected to
grow in most parts of the world, particularly in
parts of the Middle East and several other low- and Asia
middle-income countries in parts of Asia and

Latin America &
Many of the known risk
Oceania because of the obesity epidemic. Further,
Caribbean
alcohol drinking is responsible for 4.2% of all
factors for cancer can cancer deaths globally, with marked variation
across countries. MAP 2.1
Europe
be prevented. Other risk factors known to cause cancer

include excessive exposure to ultraviolet radiation Northern America
from the sun and indoor tanning, which cause skin
Tobacco use, infectious agents, unhealthy diet, cancer (see 06, UV Radiation); some reproductive and 0 10 20 30 40
excess body weight, physical inactivity, and alcohol hormonal factors (see 07, Reproductive and Hormonal Overall HPV prevalence (all ages)
consumption account for the majority of cancer Factors); and occupational exposures to hazardous Vaccination prevalence (ages 10-20) An inexpensive intervention to
deaths caused by known risk factors. substances and environmental pollutants such as air FIGURE 2.3 improve storage of groundnuts
CANCERATLAS.CANCER.ORG
among subsistence farmers
Smoking causes multiple cancer types (see 03, pollution, arsenic, and aflatoxin. FIGURE 2.3, 2.4 (see 08, Distribution (%) of global aflatoxin-related liver
cancer by WHO region in Guinea reduced aflatoxin Potentially modifiable risk
Tobacco), and smokeless tobacco causes cancers of Environmental Pollutants and Occupational Exposures)
the oral cavity, esophagus, and pancreas. In 2017, The risk factors for cancer, however, are not limited
exposure by more than 50%. factors cause about one-half
Africa
smoking was responsible for an estimated to the above; for example, medical radiation and
South-East Asia AFLATOXIN is a toxin of cancer deaths globally.
2.3 million cancer deaths globally (24% of all cancer radiation from naturally-occurring high radon levels produced by a fungus
Western Pacific P e r c e n t
deaths), with an additional 190,000 cancer deaths in residential places can cause cancer. that infests grains,
Figure 3
12
Eastern Mediterranean peanuts, soybeans, and 3 . 0 % o r l e 3s . s1 - 6 % 6 . 1 - 9 % 9 . 1 % o r m o Nr eo d a t a
due to smokeless tobacco and secondhand smoke. Americas
Infectious agents such as H. pylori, corn that have been Proportion of lung cancers caused by select
FIGURE 2.4
HPV, and hepatitis B and C viruses are
Europe* stored in warm, moist
conditions.
environmental and occupational factors worldwide
Proportion (%) of lung cancers caused by select THE Ways To
responsible for a substantial proportion Reduce
FIGURE 2.1 Types of cancer caused by infectious agents
of cases for some cancer sites.
20 environmental and occupational factors other EUROPEAN
Figure 2 than tobacco use worldwide
Distribution of global aflatoxin-related liver cancer by WHO region CODE Your
INFECTIOUS AGENT CANCER TYPE
10
3 17% AGAINST Cancer
Helicobacter pylori Stomach
4
More than half of CANCER Risk
0
15 these lung cancers
14%
Human papillomavirus (HPV) Genital organs (cervix, vulva, vagina, occur in low- and ECAC is an initiative 1 Do not smoke or use any 6 Limit alcohol consumption. 10 For women:
penis), anus, oral cavity, oropharynx, tonsil middle-income of the European form of tobacco. Not drinking is better for ‑If you can, breastfeed

cancer prevention. your baby.

Hepatitis B virus (HBV)
countries in the Commission, developed 2 Make your home smoke
20
Hepatocellular carcinoma (liver) ‑Limit use of hormone

Western Pacific by the World Health free. Support smoke-free 7 Avoid too much sun. Use
replacement therapy.
10 region. Organization’s policies in your workplace. sun protection. Do not
Hepatitis C virus (HCV) Hepatocellular carcinoma (liver),
non-Hodgkin lymphoma International Agency use sunbeds. 11 Ensure your children take
3 Take action to be a
for Research on Cancer part in vaccination
healthy body weight. 8 In the workplace,
Epstein-Barr virus (EBV) Nasopharynx, some types of lymphoma 7% 7% (IARC). The ECAC aims follow health and safety
programs for hepatitis
27 4 Be physically active. Limit

B virus and human
to inform people about instructions to protect
Kaposi sarcoma herpes virus (KSHV) Kaposi sarcoma, primary effusion lymphoma the time you spend sitting. papillomavirus.
actions they can take yourself from harmful
5
for themselves or their 5 Have a healthy diet: substances. 12 Take part in organized
Schistosoma haematobium Urinary bladder Similar to other environmental ‑Eat
plenty of whole cancer screening
families to reduce their 9 Know if you are exposed

pollutants, the cancer burden grains, pulses, vegetables programs for cancers of
Clonorchis sinensis, Opisthorchis viverrini Cholangiocarcinoma (bile ducts) risk of cancer. to radiation from naturally
associated with aflatoxin is and fruits. the bowel, female breast,
high radon levels in your
Human T-cell lymphotropic virus, type 1 Adult T-cell leukemia (blood) and lymphoma greater in low- and middle-income ‑Limitfoods high in sugar
home. Take action to
and cervix.
or fat (high-calorie) and
countries. 0
avoid sugary drinks. reduce high radon levels.
Human immunodeficiency virus (HIV)* Kaposi sarcoma, lymphoma, cervix, anus, Household air Ambient air Residential Occupational
pollution pollution radon risks ‑Avoid processed meat;
conjunctiva of the eye limit red meat and foods
*Due to increased replication of oncogenic viruses (e.g., EBV and KSHV), mainly through immunosuppression. *Zero percent of aflatoxin-related liver cancer in Europe
%Note:
ofDoes
lungnotcancers caused by risk factor
include tobacco use. Some cancers may be attributable to two or more risk factors. high in salt.
18 canceratlas . cancer . org canceratlas . cancer . org CANCERATLAS.CANCER.ORG 19

include pipes, cigars, bidi, hookah, and/or kreteks; FIGURE 3.1 Prevalence (%) of
RISKS OF
smokeless products include snuff, chewing tobacco, Cigarette and e-cigarette use (%) among daily smoking for
10% or less 10.1–20% 20.1–30% 30.1–40% 40.1% or more No data
and betel. Novel tobacco products, especially high schoolers, United States, 2011–2018 men and women
recently redesigned e-cigarettes, increasingly
E-cigarettes
dominate tobacco use among youth in some
Cigarettes
TOBACCO
high-income countries (HIC). FIGURE 3.1
Eighty percent of the world’s smokers live in
low and middle income countries (LMIC). The 25 E-cigarette use has
“
enormous global health and economic burden from overtaken cigarette use
tobacco use is increasingly borne by LMIC, due among US high schoolers.
to population aging and the massive numbers of
20.8%
people who continue to smoke. Although smoking We know what works to
prevalence and per-capita consumption are 20 reduce tobacco use and
Tobacco use is the decreasing worldwide, the rate of decrease is slower

in LMIC than in HIC, and among women than
tobacco-related cancers.
Our responsibility now is to
leading preventable men in HIC.

implement it.
cause of cancer
All smoked and traditional smokeless tobacco — Dr. Michael Thun
products cause cancer. Although lung cancer is the 15
worldwide. Fortunately,
most common cancer caused by cigarette smoking,
at least 19 other cancer sites or subsites are
reductions in smoking
designated as causally related to smoking. FIGURE 3.2
Even this list may be incomplete, as it does not
10
yield large reductions
include breast cancer or advanced prostate cancer,
8.1%
Some of the
two sites for which the evidence has been labeled
countries with the
in cancer incidence suggestive but not conclusive. Cigar and pipe
smoking cause cancers of the lung and upper highest male smoking
and mortality. aerodigestive tract, including the oral cavity,
oropharynx, hypopharynx, larynx and esophagus;
5 prevalence, such
secondhand smoke causes lung cancer. Smoked as China, Russia, and
An estimated 1.3 billion people use tobacco prod- tobacco products cause even more deaths from Indonesia, are also MALE
ucts worldwide. The majority (about 1.1 billion) use vascular and respiratory conditions than from
among the world’s
smoked tobacco products, chiefly as manufactured cancer. Cessation of smoking dramatically reduces 0
most populous. FEMALE
or hand-rolled cigarettes. Other smoked products risks compared to continued smoking. 2012 2014 2016 2018
P r e v a l e n c e ( % )
FIGURE 3.2 1 0 % o r l e s1 s0 . 1 - 2 0 %
2 0 . 1 - 3 0 %
3 0 . 1 - 4 0 %
4 0 . 1 % o r m N
o ro e d a t a
Annual smoking-attributable cancer deaths by Access to smoking cessation

type, 2010–2014, United States aids such as counseling,
telephone quit lines, and
Cervix % BY TYPE IN MEN % BY TYPE IN WOMEN # BY TYPE IN MEN # BY TYPE IN MEN pharmacotherapy can help
Pancreas people quit smoking. Even
Colorectum
brief counseling encounters
have been shown to
Kidney, other urinary tract
increase quit rates, and a
Acute myeloid leukemia
combination of counseling and
Stomach pharmacotherapy can further
Liver Although lung cancer dominates, increase success.
Bladder smoking also causes substantial
Lip, oral cavity, pharynx numbers of deaths
Esophagus from other types of cancer.
Larynx
Lung, bronchus, trachea
72.1%
93.4% 2,125
730
83.2% 72,164
76.4% 53,635
75 50 25 0 25 50 75 100 60K 40K 20K 0 20K 40K

04 RISK FACTORS
is a necessary cause of cervical cancer, which is the MAP 4.1
INFECTION
leading cause of cancer death among women in
Proportion of cancers attributable to 5.0% or less 5.1–15% 15.1–25% 25.1–40% 40.1% or more No data
many less-developed regions of the world because
infections (%), by country
of lack of screening. HPV infection is also
“
responsible for a proportion of vulvar (25%),
vaginal (78%), anal (88%), penile (50%),
oropharyngeal (31% on average, but much higher
in North America and Northern Europe), oral
Infections are an cavity (2.2%) and laryngeal cancer (2.4%). FIGURE 4.3 One woman dies of cervical cancer
every two minutes, making it
Worldwide, HBV and HCV infections
one of the greatest threats
important cause account for 56% and 20% of liver cancer deaths,
respectively. However, these proportions
Iceland
Sweden
Russia to women’s health…But it doesn’t
have to be this way.
of many cancers
Norway Finland
substantially vary by region, with HBV the Cervical cancer is one of the
Canada Estonia
predominant cause of liver cancer in less United
most preventable and treatable
worldwide, especially
Kingdom Denmark Latvia
Lithuania
developed countries (2/3 of cases) and HCV in Netherlands Russia— forms of cancer.
Ireland | Belarus
more developed settings (44%). Other infections Germany Poland
in economically
Belgium
Czechia — Dr Tedros Adhanom Ghebreyesus,
that cause cancer include Epstein-Barr virus Lux.—
Slovakia Ukraine
Mongolia WHO Director-General, Call to action
Austria Hungary Kazakhstan
Swit.
(120,000 cases, estimated conservatively), Kaposi Moldova
transitioning countries.
Slovenia— Croatia for global elimination
France Romania
Bos. & Herz.
sarcoma-associated herpesvirus (HHV-8; 40,000 Uzbekistan DPR of cervical cancer, May 2018.
Montenegro— Serbia Bulgaria Georgia Kyrgyzstan Korea Japan
cases, mainly in sub-Saharan Africa), human T-cell United States of America Albania N. Macedonia
Armenia—
Azerbaijan
Portugal Spain Turkmenistan
Turkey Tajikistan
Italy
lymphotropic virus, liver flukes, and schistosomal Greece Rep. Korea
—Malta China
Infectious agents are responsible for an estimated infections. Human immunodeficiency virus (HIV) Tunisia
Cyprus—
Lebanon—
Syria ACCESS CREATES PROGRESS
Iran Afghanistan
Iraq
15% of all new cancer cases annually worldwide, of infection also indirectly causes infection-related Palestine— Jordan
Morocco —Israel Pakistan HPV infection causes virtually
which two-thirds occur in less developed countries cancers through immunodepression. In the US, Kuwait— Nepal
Algeria Bahrain— Bhutan all cervical cancers. HPV vaccines

(where they account for up to one quarter of all for instance, the proportion of infection-associated —Bahamas Western Libya Egypt
—Qatar
Sahara UAE
Bangladesh can protect against the types
cancer). FIGURE 4.1 The four most important cancer- cancer in people with HIV (40%) is 10 times larger Mexico Cuba Puerto Rico
|
Saudi Arabia India Myanmar Lao
of HPV that cause about
causing infections worldwide are Helicobacter pylori than in the general US population (4%). Haiti PDR
90% of all cervical cancers.
Jamaica— —Guadeloupe
—Belize | Cabo Verde Mauritania
(770,000 cases globally in 2012), human Powerful prevention tools exist for infection- Honduras Dominican —Martinique | Mali
Niger
Oman
Rep. Senegal Eritrea Thailand Philippines
—St. Lucia Yemen Viet Nam —Guam
papillomavirus (HPV) (640,000), hepatitis B virus related cancer, including HPV and HBV vaccines, Guatemala
| —Barbados Chad Sudan
Nicaragua Gambia— Burkina
El Salvador —Djibouti
(HBV) (420,000), and hepatitis C virus (HCV) screening for HPV-driven cervical precancer, and —Trin. & Tob.
Guinea-Bissau Guinea
Faso Cambodia
Benin
Costa Rica
(170,000), which together account for more than drugs to treat HBV, HCV, Helicobacter pylori, Venezuela Côte Nigeria
Ethiopia Sri Lanka
Panama Guyana Sierra Leone d’Ivoire Ghana Central South
90% of all infection-related cancers. FIGURE 4.2 and HIV infections. French Guiana
Liberia
|
Togo
African Rep. Sudan
Brunei Dar.—
Colombia Suriname Cameroon Maldives—
Helicobacter pylori causes 90% of stomach cancers, Equatorial Guinea— Malaysia
Uganda Singapore—
half of which occur in China alone. HPV infection Gabon
Congo
Kenya Somalia
Rwanda— Papua New Guinea
Ecuador
—Burundi
DR Congo Indonesia
1 in 3 cancers
Tanzania
FIGURE 4.2 FIGURE 4.3 Solomon Is.
Peru —Timor-Leste |
Leading cancer-causing infections
worldwide, by sex (%)
Most common infection-attributable
cancers worldwide FIGURE 3
Brazil Angola Malawi
—Comoros
in sub-Saharan Africa
are caused by infections.
Zambia Madagascar
Samoa—
Human papillomavirus Human papillomavirus, Stomach Bolivia

Vanuatu—
Zimbabwe
Helicobacter pylori Helicobacter pylori, Liver Namibia Mozambique — Mauritius
Fiji—
and Hepatitis B and C viruses
—
Hepatitis B virus Cervix 100 Paraguay
Botswana
Réunion New Caledonia
Hepatitis C virus account for the majority of Head and neck —Eswatini
|
French
35
infection-related cancers
Polynesia—
Other agents FIGURE 2 Other anogenital Australia
worldwide. FIGURE 4.1 S. Africa —Lesotho
31%
Proportion of cancers worldwide attributable to infections, by sex Other 35% Argentina Infections account for
Proportion of cancers 30
a large percentage of cancers
Uruguay attributable to infections (%),
11
6 6 54 in transitioning countries.
5 by agent and region 25
46 Chile
The main
27%

20
11
10
infection-related New Zealand
cancers are stomach,

liver, and cervix. 15
Other agents
MALE FEMALE
Human herpes virus-8
24% Epstein-Barr virus 10
Hepatitis C virus
25
Hepatitis B virus 5
27
5%
P e 4%r c e n t Helicobacter pylori
5% Human papillomavirus
0 0
Sub-Saharan Eastern Asia Central Asia Pacific Latin America North Africa & Europe North Australia/ WORLD
5 . 0 % o r l e 5s . s1 - 1 5 %1 5 . 1 - 2 5 %
2 5 . 1Africa - 4(incl. China)
0 % 4 (incl.
0 India)
. 1 Islands
% o r m West Asia N
o ro e d a t aAmerica New Zealand
canceratlas.cancer.org canceratlas.cancer.org canceratlas.cancer.org
“
39% of men and 40% of women aged 18 years and International
BODY WEIGHT,
older, and 27% of boys and 24% of girls aged 5–18 variation in the
years, were obese. MAP 5.1 High amounts of sugar- prevalence of
sweetened beverages, and sedentary behaviors, Movement is a medicine for creating obesity by sex, 2016
change in a person’s physical, emotional,
PHYSICAL
including screen-time, increase risk of excess body
and mental states.
weight, whereas aerobic physical activity, including
walking, reduces risk. FIGURE 5.1 — Carol Welch, biosomatics instructor.
ACTIVITY, DIET
Alcohol consumption is known to cause cancers
of the oral cavity, pharynx, larynx, esophagus, liver,
FIGURE 5.2
colon, rectum, and female breast. Worldwide, in
FIGURE
Proportion of cancer 2 attributable
deaths
& ALCOHOL
2016, 4.2% of cancer deaths were attributed to
alcohol consumption. FIGURE 5.2
Cancer deaths
to alcohol (%) byattributable
site, 2016 to alcohol (%) by
site, 2016
Independent of effects on body weight, a
healthy dietary pattern rich in plant foods,
Pharynx (excluding
including fruits, non-starchy vegetables, whole
nasopharynx) 31% The obesity epidemic
Excess body weight, grains, and legumes (e.g., beans), and low in
red and processed meats, reduces risk of certain
affects most countries
in the world.
alcohol consumption, cancers, particularly colorectal cancer. Lip and oral cavity
Independent of effects on body weight, physical
unhealthy diet and activity reduces risk of some types of cancer,

specifically colon, and among women, breast and
Larynx
physical inactivity are endometrial cancer. Globally, 23% of adults did

not meet World Health Organization physical Esophagus
important modifiable activity guidelines in 2010, and more than 80% of

adolescents were insufficiently physically active.
cancer risk factors. Reversing the obesity epidemic, limiting

alcohol consumption (among those who drink),
Colon and rectum
and increasing the prevalence of healthy eating

Liver
Excess body weight (i.e., overweight and obesity) and active living hold considerable potential for
increases risk of 13 types of cancer, and in 2012 reducing cancer incidence and mortality, which MALE
accounted for 3.6% of all new cancer cases among will require a comprehensive approach involving Breast
adults worldwide. The global prevalence of excess actions by institutions and individuals at all levels
FEMALE
body weight has increased: in 2016 an estimated from national to local communities. 0 20 40 60 80 100
P r e v a l e n c e ( % )
% of deaths
canceratlas.cancer.org
1 0 % o r l e s1 s0 . 1 - 2 0 %
2 0 . 1 - 3 0 %
3 0 . 1 - 4 0 %
4 0 . 1 % o r m N
o ro e d a t a
FIGURE 5.1
Cancer Prevention Recommendations of the The International Agency
World Cancer Research Fund/American
Institute for Cancer Research
for Research on Cancer
has concluded that alcoholic
beverage consumption
causes at least
Limit consumption
of red and Limit consumption seven types of cancer.
processed meat of sugar
Limit consumption of sweetened drinks
‘fast foods’ and other
processed foods high in Limit alcohol
fat, starches or sugars consumption
Eat a diet rich in Do not use supplements

whole grains, vegetables, for cancer prevention
fruit and beans
10 CANCER PREVENTION
RECOMMENDATIONS
For mothers: breastfeed
Be physically While following each individual recommendation your baby if you can
active protects against cancer, the greatest benefit
is gained by following all recommendations
together. Not smoking and avoiding other
exposure to tobacco and excess sun are also After a cancer diagnosis: follow WCRF/AICR
Be a healthy weight important in reducing cancer risk. recommendations, if you can
canceratlas . cancer . org canceratlas . cancer . org 25

When the UV Index is 3+, skin can be protected FIGURE 6.1 Melanoma skin
ULTRAVIOLET
by avoiding outdoor activities in the middle of the Direct costs of melanoma skin cancers and cancer incidence,
2.0 or less 2.1–5.6 5.7–10.1 10.2–21.6 21.7 or more No data
day; providing effective shade outdoors; wearing squamous cell carcinomas and basal cell age-standardized
hats, clothing cover and sunglasses; and applying carcinomas combined, 2013 Euros (millions) rate (world) per
100,000, both sexes,
RADIATION
sunscreen of Sun Protection Factor 15+ or higher.
Melanoma 2018
In contrast to many European countries, Australia
Squamous and basal cell carcinomas
began implementing UV protection campaigns in
the 1980s, and rates of melanoma are now
decreasing in younger generations. FIGURE 6.3
€ 613.2 M
Skin cancers are United States
“
caused by ultraviolet
radiation and can There is no such thing as
€ 422.6 M
Australia
be prevented by sun a healthy tan.
protection and
— World Health Organization
€ 235.8 M
banning sunbeds. Germany
A majority of skin cancers are caused by ultraviolet FIGURE 6.3

(UV) radiation. Keratinocyte skin cancers (basal Age-standardized incidence rates (world) per € 149.1 M
cell and cutaneous squamous cell carcinomas) are 100,000, invasive melanoma, persons aged <25 United Kingdom
the most common human cancers with over 13 years by sex in Australia and England, 1990–2010 FIGURE 6.2
million cases estimated each year worldwide.
Australia Sunbed prevalence (%) among females
While rarely fatal, keratinocyte cancers cause
England and males across different countries by
substantial burdens of morbidity and cosmetic € 75.5 M
concern (most occur on the face). Melanoma is a Females Brazil
year of survey since 2009
Over 90% of skin cancers
more fatal form of skin cancer with about 69,000 Males Female could be prevented by use
deaths and 350,000 cases annually worldwide. In Male
many countries skin cancers pose a significant
of sun protection.
R a t e p e r 1 0 0 , 0 0 0
economic burden due to their sheer numbers and
€ 66.0 M 2 . 0 o r l e s2s . 1 - 5 . 6 5 . 7 - 1 0 . 11 0 . 2 - 2 1 .2 6 1 . 7 o r m o Nr eo d a t a
the high cost of treatment for metastatic ACCESS CREATES PROGRESS Sweden 60
melanoma. FIGURE 6.1
UV radiation comes from the sun, filtered by Rates of melanoma
are decreasing in young 61.5%
stratospheric ozone. The UV Index measures the
intensity of sunburn-causing UV reaching the
people in Australia.
€ 54.7 M 50
Earth’s surface on a scale of 1 (low) to 11+ (extreme) Canada
and varies with latitude, altitude, time of day and
year, cloud cover, and air pollution. In summer, the 6
Sunbed use remains common
UV Index averages around 12 in Bangkok, Thailand 40 in many countries.
(14°N); 9 in Sydney, Australia (34°S); 8 in New York,
5 € 34.0 M
USA (41°N); 7 in Berlin, Germany (52°N) and 5 in Denmark
St Petersburg, Russia (60° N). Cosmetic tanning
devices also emit UV radiation, often stronger than 4 30
summer sun, and are classified as human
carcinogens; however, their use remains high,
particularly in Europe and North America. 3 € 32.1 M
New Zealand 20
FIGURE 6.2 Banning these devices brings potentially
high savings of lives and costs. 2
Inherited risk factors for skin cancer, such as
light skin and red hair, and having freckles and Skin cancers create a
1 10
moles, influence the effects of ambient UV and substantial economic burden
occupational and recreational sun exposure. Skin in many countries.
cancer is rare in people with innately dark skin. 0 7.5%
Risk is higher with high UV exposure in childhood. 1990 1995 2000 2005 2010
0
Year of diagnosis 2009 2010 2011 2012 2013 2014 2015 2016 2017

07 RISK FACTORS MAP & FIGURE 7.1
Reproductive patterns and exposure to of exogenous hormones for contraception, Percent (%) of
children who receive
REPRODUCTIVE
reproductive hormones play a role in the reproductive assistance, and menopausal
development of some cancers in women. symptoms. Hormonal contraceptive users have any breast milk
Economic, political and societal shifts in the a slight, transient increase in the risk of breast at 12 months of age
& HORMONAL
last century have been marked by profound cancer, but a moderate and long-term reduction
changes in sexual maturation and reproductive in the risk of some types of ovarian cancer and
patterns. These changes have led to increased endometrial cancer. FIGURE 7.3 Although use of
FACTORS
lifetime number of monthly menstrual cycles, fertility drugs is a relatively recent exposure,
which is associated with higher risk of breast, early studies indicate that use of these powerful
endometrial and ovarian cancers. Although not hormones does not increase cancer risk. Global breast cancer
fully understood, one mechanism that could Menopausal hormone therapy increases risk of deaths averted
underlie these relationships is increased exposure breast and endometrial cancer dependent on through current
breastfeeding rates,
The magnitude of the
to endogenous estrogen and progesterone levels. formulation, timing of use, and body size, but
Other aspects of menses may play a role in the may be associated with a decreased risk of by region
associations of
development of some types of ovarian cancers. colorectal cancer.
ANNUAL DEATHS AVERTED
Longer-term breastfeeding MAP & FIGURE 7.1 lowers
reproductive factors with Increasing breastfeeding

risk of most types of breast cancer, likely through Central &
417
Eastern Europe
cessation of the menstrual cycle, changes to the
duration from present levels
cancer risk is relatively
hormonal milieu, and profound cellular changes to Middle East &
853
the breast tissue. to 12 months per child in North Africa
small. However, these While shifting patterns of reproductive factors,

such as decreasing age at menarche, increasing
high-income countries and Eastern &
Southern Africa
1,452
2 years per child in
factors affect all women. age at first birth, and fewer births per woman,
continue in many developing countries—and may low- and middle-income
West &
Central Africa
1,264
Therefore, they have have contributed to increases in incidence rates

for hormone-related cancers—these trends have
countries could avert Latin America &
1,266
a large impact at the

Caribbean
plateaued in many developed countries. MAP 7.2, 22,000 breast cancer
FIGURE 7.2 In addition, many women in higher-
deaths per year. High-income
2,602
population level.
countries
income counties are exposed to sustained use
While breastfeeding up to and beyond 12 months
East Asia &
Pacific
2,990 is common in many low- and middle-income
countries, fewer children in high-income countries
FIGURE 7.3 South Asia 8,651 are breastfed to this point.
Associations of reproductive and hormonal risk factors with the ten most common cancers among women worldwide P e r c e n t
Lung,
2 0 . 0 % o r l e
2 s0 s. 1 - 4 0 %
4 0 . 1 - 6 0 %
6 0 . 1 - 8 0 %
8 0 . 1 % o r m N
o ro e d a t a
Colon bronchus
FIGURE 7.2 MAP 7.2
Breast Endometrium Ovary Cervix uteri Liver Thyroid NHL & rectum & trachea Stomach
Mean number of births per woman in representative Average births per 2.0 or fewer 2.1–3 3.1–4 4.1–5 5.1 or more No data
High endogenous estradiol levels
(vs. low)     countries by level of Human Development Index (HDI) woman, 2010–2015
Increased from 1950–2100
Older age at menarche Risk Association
(vs. youngest)     X X X
Low HDI
: > 1.95
: 1.57 – 1.95 Medium HDI
Ever hormonal oral contraceptive use
(vs. never)     X X   X
: 1.26 – 1.56 High HDI
: 1:05 – 1.25 Very High HDI

Parous
(vs. nulliparous)     X X X X
No Risk Association Average number of births
X Strong Evidence per woman is converging around
Older age at first birth
  X  X  X X Moderate Evidence 10 2 in countries of all HDI levels.
(vs. younger)
Breastfeeding for long duration Decreased

(vs. no breastfeeding)  X  X   X
Risk Association
8
: 0.80 – 0.95
Late age at menopause : 0.64 – 0.81 6
(vs. early)    X X   
: 0.51 – 0.63
Current use of estrogen alone : < 0.51
    X   4
menopausal hormone therapy (vs. never)
Evidence Strength
Current use of combination  Strong Evidence 2
menopausal hormone therapy (vs. never)     X X    The number of births per woman
 Moderate Evidence
has decreased to 2 or fewer
h in
s most higher-HDI countries.
Removal of any reproductive organs 0
(vs. retention)     X X
1950 1975 2000 2025 2050 2075 2100
N u m b e r o f b i r t
2 . 0 o r f e w 2e . r1 - 3 3 . 1 - 4 4 . 1 - 5 5 . 1 o r m o r Ne o d a t a

outdoor air pollution:

ENVIRONMENTAL POLLUTANTS primarily from radon gas entering homes from the
ENVIRONMENTAL
Average annual
Outdoor air pollution causes between 6 and 8 soil, exposure to high levels of radon can also occur 15.0 or less 15.1–30.0 30.1–45.0 45.1–75.0 75.1 or more No data
population-weighted
million premature deaths from lung cancer and when the gas is trapped in underground mines.
concentrations of
other diseases each year. The International Agency Populations consuming high levels of arsenic
PM2.5 (particulate
& OCCUPATIONAL
for Research on Cancer (IARC) has classified in drinking water have excess risks of skin, lung, PM2.5 (µg/m3)
matter of 2.5 μm
outdoor air pollution and the particulate matter in and bladder cancer. High levels of arsenic in
diameter or less),
outdoor air pollution as known human drinking water have been found in parts of China,
measured in μg/m3, Exposure to outdoor
EXPOSURES
carcinogens. Outdoor air pollution levels are Bangladesh, and some countries in Central and
particularly high in rapidly-growing cities in South America. Some predominantly occupational
2017 air pollution causes
low- and middle-income countries. MAP 8.1 Diesel exposures, such as asbestos and asbestiform fibers, over half a million
exhaust, also classified as a lung carcinogen by benzene, and polychlorinated biphenyls (PCBs),
lung cancer deaths
IARC, contributes to outdoor air pollution and is may also occur in the general population, albeit at
each year.
Limiting carcinogenic
also an occupational lung carcinogen. lower levels.
Indoor air pollution from use of solid fuel (e.g.
“
exposures in the wood, other biomass, and coal) is estimated to
cause about 3.8 million deaths, including about
OCCUPATIONAL EXPOSURES
Numerous substances are known to cause cancer Outdoor air pollution levels
environment and in the 285,000 lung cancer deaths, each year in low- and
middle-income countries. Globally, the number of
in workers. FIGURE 8.2 Due to the intensity and/or
duration of these exposures, the cancer burden can The air we breathe has become
are highest in economically
transitioning countries.
workplace provides an people cooking with solid fuels has declined, but
populations in less-developed countries continue
be relatively high among those workers exposed.
Exposure to occupational carcinogens remains
polluted with a mixture of
cancer-causing substances.
opportunity to reduce to be exposed to high levels of household air
pollution. MAP 8.2, FIGURE 8.1 IARC classifies indoor
a concern in low- and middle-income countries,
where exposures are likely to be higher than in
We now know that outdoor air
pollution is not only a major risk to
the cancer burden, smoke emissions from coal as a known human

carcinogen, and from other types of solid fuels as
high-income countries, and regulations and
enforcement are often less strict.
health in general, but also a leading
environmental cause of
particularly for workers probable carcinogens.

Exposure to radon is probably the second-
Asbestos is an important cause of occupational
cancer deaths.
lung cancer and the unique cause of malignant

with unacceptably
— Dr. Kurt Straif, former Head of the
leading cause of lung cancer in the United mesothelioma, and remains an occupational and IARC Monographs Section
high exposures.
States and Europe. Radon gas forms from the environmental hazard in many countries. However,
radioactive decay of uranium, found at differing there are many other causes of occupational
MAP 8.2
concentrations in soil and rock throughout the cancer, and asbestos accounts for less than one-
world. While the general population is exposed third of occupational cancers globally. indoor air pollution : P M 2 . 5 ( µ m / m 3 )
Proportion (%) of
6.5% or less
1 5 . 0 o r l 6.6–22.0%
e 1s 5s . 1 - 3 0 .3 0 0 22.1–47.0%
. 1 - 4 5 .4 0 5 . 1 -47.1%–76.0%
7 5 .7 0 5 . 1 o r m 76.1% oro more
o Nr e d a t a No data
population using
FIGURE 8.1 FIGURE 8.2 nds ic solid fuels in 2017
pou an
Occupational
n
)
om org
l
ms
tio
Proportion (%) of population using
nds
no
n
-ra and
nic
tio
carcinogens and
dia
phe
c c d in
for
nds I)
pou
e
pou um (V
solid fuels, 1990–2017
itch
dia
rga
hyd
t ra
ino ,
ma tion
(all
ong ists
eni an
loro
associated cancer
com
t
ium
rp
dus
iole
lde
ars nic
os
gamradia
str id m
ne
com omi
ach
e
l-ta
Sub-Saharan Africa sites*
dan
est
ton
ma
kel
e
nze
rav
od
Ars
t
Ac
Ch
Coa
Pen
Soo
X-
Asb
Nic
For
Lin
Plu
Wo
Ult
Be
South Asia
Southeast Asia, East Asia & Oceania Lung        
FigureLatin
2 America & Caribbean Haematolymphatic system      
North Africa & Middle East Skin     
Indoor air pollution: proportion (%) of
Central Europe, Eastern Europe & Central Asia Nasal cavity & paranasal sinus    
population using solid fuels in 2017
Leukemia   
100 Non-Hodgkin Lymphoma   
Larynx  
Bone  
Urinary bladder  
75 Liver 
Nasopharynx   Indoor air pollution
Eye  from use of solid fuel
Mesothelioma  is estimated to cause
50 Ovary  about 3.8 million
Salivary gland  deaths, including about
Stomach  285,000 lung cancer
Thyroid  Approximately 3–6% of all cancers deaths, each year in
25 worldwide are caused by exposures to low- and middle-income
Breast 
Brain & nervous system  carcinogens in the workplace. countries.
Colon 
Esophagus 
0
1993 1997 2001 2005 2009 2013 2017
Kidney  *limited to agents with occupational exposure linked to two or more cancer sites
Sub-Saharan Africa
30 canceratlas . cancer . org canceratlas . cancer . org P e r c e n t 31
South Asia
Southeast Asia East Asia and Oceania
09 RISK FACTORS 6
Hematopoietic Azathioprine Formaldehyde Pentachlorophenol
program, notably genetic traits, reproductive FIGURE 9.2 1
System Benzene Helicobacter pylori Phosphorus-32, as phosphate
Busulfan Hepatitis C virus Rubber production industry
HUMAN
status, and some nutritional factors. Other factors, Carcinogenic agents associated with five or more
2 1,3-Butadiene HIV type 1 Semustine [1-(2-Chloroeth-
such as weight control or physical activity, have cancer sites as listed here
Chlorambucil Human T-cell lymphotropic virus yl)-3-(4-methylcyclohexyl)-1-
been evaluated by the IARC Handbooks for their type 1 nitrosourea, or methyl-CCNU]
Human immunodeficiency virus type 1 Cyclophosphamide
CARCINOGENS
preventive effects. 3 Kaposi sarcoma herpes virus Thiotepa
Alcoholic beverages Cyclosporine
The main figure shows, for each organ or group Lindane Thorium-232 and its decay products
Human papillomavirus type 16 Epstein-Barr virus
of organs in the human body, which agent(s) can Melphalan Tobacco smoking
X-radiation, gamma-radiation Etoposide with cisplatin and
cause an increased risk of cancer at a given site. bleomycin MOPP (vincristine-prednisone- Treosulfan
Tobacco smoking
5 nitrogen mustard-procarbazine X-radiation, gamma-radiation
FIGURE 9.1 Over 40 agents have more than one target Fission products, including
organ site, with up to 17 sites for tobacco smoking 17 Strontium-90 mixture)
Identified by the IARC and 14 sites for X-radiation and gamma-radiation. 4

6
7
Skin MELANOMA OTHER MALIGNANT NEOPLASMS Methoxsalen plus ultraviolet A
Monographs Program
FIGURE 9.2 Some agents have been classified in Group 1 Solar radiation Arsenic and inorganic arsenic Mineral oils, untreated or mildly
with less than sufficient evidence from epidemiolog- 5 7
Polychlorinated biphenyls compounds treated
ical studies, often on the basis of sufficient evidence Ultraviolet-emitting tanning devices Azathioprine Shale oils
of carcinogenicity in experimental animals and
7 Coal-tar distillation Solar radiation
The International Agency for Research on Cancer 9 Coal-tar pitch Soot
(IARC) Monographs (www.monographs.iarc.fr)
strong evidence in exposed humans that the agent
acts through a relevant mechanism of carcinogenicity.
7 8
Cyclosporine X-radiation, gamma-radiation
identify environmental and occupational causes
of human cancer. Sometimes called the WHO
It is noteworthy that a few agents have been shown to 14 8
Bone Plutonium Radium-226 and its decay products X-radiation, gamma-radiation
cause cancer in the offspring of the person exposed.
Radium-224 and its decay products Radium-228 and its decay products
“Encyclopedia of Carcinogens,” the IARC
Monographs are critical reviews and evaluations 9
Breast Alcoholic beverages Estrogen-progestogen X-radiation, gamma-radiation
FIGURE 9.1
of the weight of the evidence that an agent can 10 Diethylstilbestrol contraceptives
Group 1 carcinogenic agents by target site
increase the risk of cancer in humans. Since the To date, IARC has classified Estrogen-progestogen
menopausal therapy
program’s inception in 1971, over 1000 agents have
120 agents as carcinogenic
been evaluated, including individual chemicals, 1
Brain and Central X-radiation, gamma-radiation
10
Digestive System ESOPHAGUS LIVER (ANGIOSARCOMA) BILIARY TRACT
complex mixtures, physical agents, biological agents, Nervous System to humans. Acetaldehyde associated with Vinyl chloride Chlonorchis sinensis
personal habits, and occupational exposures. consumption of alcoholic beverages 1,2-Dichloropropane
LIVER (HEPATOCELLULAR
2
Eye Human immunodeficiency virus Ultraviolet-emitting tanning devices Welding Alcoholic beverages CARCINOMA) Opisthorchis viverrini
The agents are classified as “carcinogenic to
type 1 (HIV) Betel quid with tobacco Aflatoxins
humans” (Group 1), “probably carcinogenic to PANCREAS
Betel quid without tobacco Alcoholic beverages
humans” (Group 2A), “possibly carcinogenic 3
Oral Cavity and ORAL CAVITY PHARYNX (ORO-, HYPO- AND/ NASOPHARYNX Smokeless tobacco
Smokeless tobacco Estrogen-progestogen
to humans” (Group 2B), “not classifiable as to Pharynx Alcoholic beverages OR NOT OTHERWISE SPECIFIED) Epstein-Barr virus 11 Tobacco smoking
Tobacco smoking contraceptives
their carcinogenicity to humans” (Group 3), or as Betel quid with tobacco Alcoholic beverages Formaldehyde COLON AND RECTUM
X-radiation, gamma-radiation Hepatitis B virus
“probably not carcinogenic to humans” (Group 4). Betel quid without tobacco Betel quid with tobacco Salted fish, Chinese-style Alcoholic beverages
UPPER AERODIGESTIVE TRACT Hepatitis C virus
Human papillomavirus type 16 12 Processed meat (consumption of)
This classification, based on all published scientific Human papillomavirus type 16 Wood dust Plutonium
Tobacco smoking Acetaldehyde associated with
literature, reflects the strength of the evidence Smokeless tobacco TONSIL Tobacco smoking
consumption of alcoholic beverages Thorium-232 and its decay products
derived from epidemiological studies in humans, Tobacco smoking SALIVARY GLAND Human papillomavirus type 16 X-radiation, gamma-radiation
STOMACH Tobacco smoking (in smokers and
cancer bioassays in experimental animals, and X-radiation, gamma-radiation in smokers’ children) ANUS
Helicobacter pylori
in-vivo and in-vitro studies on the mechanisms of Multiple Sites Cyclosporine
Rubber production industry GALLBLADDER HIV type 1
4
Respiratory NASAL CAVITY AND Aluminium production MOPP (vincristine-prednisone-
(Partly Unspecified) Fission products, including Human papillomavirus type 16
carcinogenicity. Evidence from studies in humans nitrogen mustard-procarbazine Tobacco smoking Thorium-232 and its decay
System PARANASAL SINUS Arsenic and inorganic Strontium-90
mixture) products
and animals is considered to be sufficient, limited, Isopropyl alcohol manufacture arsenic compounds X-radiation, gamma-radiation
X-radiation, gamma-radiation
using strong acids Asbestos (all forms) Nickel compounds
inadequate, or suggesting lack of carcinogenicity. (exposure in utero)
Data from mechanistic studies are considered as
Leather dust Beryllium and beryllium compounds Outdoor air pollution 11
Urinary System KIDNEY URINARY BLADDER Rubber production industry
Nickel compounds Bis(chloromethyl)ether; chloromethyl Outdoor air pollution, All Cancers 2,3,7,8-Tetrachlorodibenzo- Tobacco smoking Aluminum production Schistosoma haematobium
providing strong, moderate, or weak evidence for particulate matter in
Radium-226 and its decay products methyl ether (technical grade) Combined para-dioxin Trichloroethylene 4-Aminobiphenyl Tobacco smoking
a given mechanism. To date, 120 agents have been Painter (occupational exposure as)
Radium-228 and its decay products Cadmium and X-radiation, gamma-radiation Arsenic and inorganic arsenic ortho-Toluidine
classified in Group 1, the vast majority on the basis cadmium compounds Plutonium compounds
Tobacco smoking Endothelium HIV type 1 RENAL PELVIS X-radiation, gamma-radiation
of sufficient evidence from epidemiological studies Chromium (VI) compounds Radon-222 and its decay products (Kaposi Sarcoma) Kaposi sarcoma herpes virus Auramine production
Wood dust Aristolochic acid, plants containing URETER
that the agent can cause cancer at one or several Coal, indoor emissions from Rubber production industry Benzidine
LARYNX household combustion Phenacetin Aristolochic acid, plants containing
sites in humans. Some important risk factors
Acid mists, strong inorganic
Silica dust, crystalline Less Than Sufficient N'-Nitrosonornicotine, (NNN) and
Phenacetin, analgesic mixtures
Chlornaphazine
Phenacetin
Coal gasification 4-(N-nitro-methyl-amino-1-(3-
known to cause cancer in humans have however Alcoholic beverages
Soot Evidence in Humans* pyridyl)-1-but none (NNK) containing Cyclophosphamide
Coal-tar pitch Phenacetin, analgesic mixtures
not been covered in the IARC Monographs Sulfur mustard 2,3,4,5,8-Pentachlorodibenzofuran Tobacco smoking Magenta production containing
Asbestos (all forms) Coke production Tobacco smoke, secondhand 3,4,5,3',4'-Pentachlorobiphenyl 2-Naphthylamine Tobacco smoking
Tobacco smoking Diesel engine exhausts Areca nut
Tobacco smoking (PCB-126) Painter (occupational exposure as)
LUNG Aristolochic Acid
HAZARD VS. RISK Hematite mining (underground) X-radiation, gamma-radiation Polychlorinated biphenyls dioxin
Acheson process (occupational Benzidine, dyes metabolized to like, with a Toxic Equivalent Factor
The classification indicates the the level of risk associated Iron and steel founding Welding fumes
12
Genital System UTERINE CERVIX ENDOMETRIUM Tobacco smoking
strength of the evidence that a exposures associated with) Benzo[a]pyrene according to WHO (PCBs 77, 81,
with exposure. The cancer risk Diethylstilbestrol (exposure in utero) Estrogen menopausal therapy
Ethanol in alcoholic beverages 105, 114, 118, 123, 126, 156, VAGINA
substance or agent causes cancer. associated with substances 167, 169, 189) Estrogen-progestogen Estrogen-progestogen
Mesothelium Asbestos (all forms) Fluoro-edenite Ethylene oxide Diethylstilbestrol (exposure in utero)
The Monographs Programme or agents assigned the same Radionuclides, alpha-particle contraceptives menopausal therapy
seeks to identify cancer hazards. classification may be very Erionite Painter (occupational exposure as) Etoposide emitting, internally deposited Human papillomavirus type 16
HIV type 1 Tamoxifen
An agent is considered a cancer different, depending on factors Ionizing radiation (all types) Radionuclides, beta-particle VULVA
Human papilllomavirus type OVARY
hazard if it is capable of causing such as the type and extent of 5
Thyroid Radioiodines, including iodine-131 X-radiation, gamma-radiation 4,4'-Methylenebis (1-chloroani- emitting, internally deposited 16, 18, 31, 33, 35, 39, 45, 51, Human papillomavirus type 16
cancer under some circumstances. exposure and the strength of the (exposure during childhood and line) (MOCA) Ultraviolet radiation 52, 56, 58, 59 Asbestos (all forms)
adolescence) PENIS
However, it does not indicate effect of the agent. Neutron radiation *Mechanistic upgrades to Group 1
Tobacco smoking Estrogen menopausal therapy
Human papillomavirus type 16
XX SECTION TITLE
THE BURDEN
This section describes the global cancer burden in terms of
incidence, mortality, prevalence, and survival for each major
world region as well as by Human Development Index.
ACCESS
CREATES
PROGRESS
With interventions to improve
early diagnosis and
adherence to appropriate
treatment, childhood cancer
survival can be increased to
60% in lower-income countries,
saving almost 1 million
children’s lives over
Each year, about 270,000 cancer cases a decade.
are diagnosed in children. Today, five-year
survival from childhood cancer in
high income countries is greater than
80%, but it can be as low as 20% in
lower-income countries.

10 THE BURDEN MAP 10.1
Worldwide, there were an estimated 18.1 million cancer overall (2.1 million, 12%) but the fifth The ranking of
THE BURDEN
cases and 9.6 million cancer deaths in 2018 leading cause of cancer death (627,000, 7%) cancer as a leading
1st 2nd 3rd–4th 5th + No data
(including non-melanoma skin cancers), with one because of its relatively favorable prognosis. As cause of premature
in four men and one in five women developing the such, it is the most prevalent cancer worldwide death in 2016
(ages 30–69)
OF CANCER
disease, and one in eight men and one in eleven (6.9 million women living within 5 years of their
women dying from it. FIGURE 10.1 In addition, there breast cancer diagnosis). Colorectal cancer is the
were 43.8 million persons living with cancer in 2018 third most frequently-diagnosed cancer globally,
who were diagnosed within the last 5 years. but second only to lung cancer in terms of
Half of the new cancer cases and cancer deaths mortality (1.8 million cases and 881,000 deaths).
in the world occur in Asia. FIGURE 10.2 China, with Prostate cancer is the fourth most frequently
Cancer is a major public the largest population size in the region and diagnosed cancer, while stomach and liver cancer
health and economic

worldwide—1.4 billion inhabitants, representing remain major causes of cancer death in 2018.
19% of the global population in 2018—has the Based on projected population aging and
issue and its burden

greatest global proportion of new cases (4.3 million growth, the global burden of cancer is set to
cases, 24% of the total) and deaths (2.9 million increase by more than 60% by 2040, from
is set to spiral. With

deaths, 30%). Northern America is second in terms 18.1 million new cases in 2018 to a predicted
of new cases (2.4 million, 13%), and fourth for 29.4 million cases in the year 2040. FIGURE 10.4
over 18 million cases

cancer deaths (0.7 million, 7%). Close to one fourth More broadly, cancer has become a leading
of all new cases globally (4.2 million) and one fifth cause of death over the last few decades. In terms
in 2018, we can expect of deaths (1.9 million) occur in Europe, despite

the region representing less than one tenth of the
of premature mortality (defined as death in ages
30–69 years), in the year 2016, cancer was the
29 million cases by global population. leading cause of death in 55 (largely high-income)
“
For both sexes combined worldwide, lung countries, but second (mainly to cardiovascular
2040 due to the cancer continues to be the most commonly

diagnosed cancer (2.1 million, 12% of the total)
disease) in an additional 79 countries. MAP 10.1 With
rates of cardiovascular mortality in decline in many
aging and growth of FIGURE 10.3 and the leading cause of cancer death
(1.8 million, 18%) because of its poor prognosis.
countries due to highly successful prevention and
treatment, cancer is set to become the leading
An inclusive and coordinated
large-scale global response to fight
the population. Female breast cancer is the second most common barrier to increasing life expectancy in this century. cancer is overdue. Further delays will
mean needless deaths, worsening
inequities, and a failure to realise health,
FIGURE 10.1 FIGURE 10.2 economic, and societal benefits.
Percentage (%) of males and females Cancer incidence, mortality and
developing and dying from cancer survivors diagnosed within the
Cancer ranks as the first — Rifat Atun, global health systems expert,
and Franco Cavalli, medical oncologist
R a n k i n g o f c a n c e r a s l e a d i n g c a u s e o f d e a t h , 3 0 - 6 9 y e a r s o f a
worldwide in 2018* past 5 years worldwide in 2018* or second leading cause of
premature death (among
1 s t 2 n d 3 r d - 4 t h5 t h + N o d a t a
Developing cancer Asia
Dying from cancer Europe
those 30–69 years of age) FIGURE 10.3 FIGURE 10.4
Americas
Africa in 134 countries of Cancer incidence, mortality and survivors diagnosed within the past Number of new cancer cases in 2018 vs. 2040: impact
5 years: top 5 cancer sites in 2018 worldwide for both sexes combined* of demographic projections by 2040
MALE FEMALE Oceania the world.
Top 5 cancers New cases 2018
All other cancers New cases 2040 (+ demographic changes)
Lung cancer is the most
The global cancer burden is Lung commonly diagnosed cancer 0.5 M people
dominated by Europe, China, Breast and the leading cause of
and Northern America. Colorectum cancer death worldwide.
Prostate
Stomach
Liver
6 1 7 0.7 4 2 12 5
48 Thyroid 18
57 40

16
14
21
12
26
7
2018 2040
54 46 49 51 55 45
18.1 M 29.4 M
11

21% of males 18% of females
10

9
worldwide develop cancer worldwide develop cancer
20
during their lifetime 23 Based on population growth and
8
during their lifetime 8
7
5
28 6 8 aging, the global cancer burden will
13% of males 9% of females INCIDENCE MORTALITY PREVALENCE INCIDENCE MORTALITY PREVALENCE grow to 29.4 million cases annually
worldwide die from the disease worldwide die from the disease 18.1 M 9.6 M 43.8 M 18.1M 9.6 M 43.8 M in 2040 (assuming global rates in
2018 remain unchanged).
canceratlas.cancer.org *Total includes non-melanoma skin cancers

11 THE BURDEN FIGURE 11.1 MAP 11.1
Lung cancer incidence and mortality rates, 2018 Lung cancer
decline, however, with rates among women often
LUNG
remaining low. incidence by sex,
INCIDENCE MORTALITY 4.6 or less 4.7–12.6 12.7–26.3 26.4–40.3 40.4 or more No data
In most parts of the world, tobacco use is the age-standardized
Polynesia
Polynesia
main cause of lung cancer, although other causes Micronesia rate (world) per
North America
North America 100,000, 2018
can be particularly important in selected countries. Eastern Asia
Western Europe
Western Europe
CANCER
FIGURE 11.5 Other established risk factors include
Northern Europe
secondhand smoke, air pollution, radon, and Southern
Central Europe
& Eastern Europe
several occupational agents (see 08, Environmental Australia & New Zealand
Australia andWestern
New Z… Asia
Pollutants and Occupational Exposures). However, WORLD
World
Caribbean
reducing tobacco smoking alone could prevent the
majority of lung cancers. Screening for detection of
South-Eastern Asia
South-Eastern Asia
Southern Africa
Tobacco smoking
the disease at an earlier stage for long-term heavy South America
South America
Melanesia causes about
current and former smokers is available, but wide
two-thirds of all
Lung cancer remains
Northern
Northern Africa
Africa
dissemination of the procedure is unlikely in the South-Central Asia
short term, even in high-income countries, because

Central
Central America
America
lung cancer deaths
the most commonly
Middle Africa
of the need for a more advanced and coordinated Eastern
Eastern Africa
Africa
Western Africa worldwide.
diagnosed cancer and
healthcare system.
40 30 20 10 0 10 20 30 40
FIGURE 11.2 Age-standardized rate (world) per 100,000
the leading cause of Smoking and lung cancer mortality rate trends The tobacco epidemic is characterized
cancer death worldwide

in men and women, United States by an increase in uptake of smoking
Cigarettes per capita Lung cancer (men) followed by an increase in lung cancer
because of inadequate Lung cancer (women) mortality rates a few decades later.
tobacco control policies.
Lung cancer death rate per 100,000 persons

Number of cigarettes per capita
4k 80
Globally, there were an estimated 2.1 million

lung cancer cases and 1.8 million deaths in 2018.
Incidence and mortality rates vary 20-fold between MALE
2k 40
regions. FIGURE 11.1 The variation is similarly large
across countries. The highest incidence rates FEMALE
among men are in Europe, particularly in Eastern A g e - s t a n d a r d i z e d r a t e ( w o r l d ) p e r 1 0 0 , 0 0 0
Since the United States
European countries such as Hungary (77 cases L e s s t h a n 44 .. 77 - 1 2 . 61 2 . 7 - 2 6 .2 3 6 . 4 - 4 0 .4 3 0 . 4 o r m o Nr eo d a t a Surgeon General’s Report
per 100,000 male population) as well as Western 0 0 on Smoking and Health
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010
Asia (particularly in the former Soviet Union) in 1964, smoking
and in certain countries in Asia such as Turkey prevalence among adults
and China. MAP 11.1 Among women, lung cancer FIGURE 11.3 FIGURE 11.4 in the United States has
incidence rates are highest in Hungary (38 cases Converging lung cancer mortality UK Lung cancer mortality rates among Japan decreased by half.
rates among males and females, US males and females, select countries FIGURE 11.5
per 100,000 female population), followed by other S. Africa
European countries, Northern America, Australia, select high-income countries, Denmark Figure
in Asia, 4
Africa, and Latin America, Brazil Lung cancers related
1952–2013, age-standardized rate 1950–2013, age-standardized rate to tobacco smoking
and New Zealand. In general, the geographic Male Male Figure 5
(world) per 100,000, all ages Female (world) per 100,000, all ages Female and air pollution in
patterns of lung cancer mortality are quite similar
China and France
to those of incidence due to the relatively poor
75 75
prognosis of the disease after diagnosis. Air pollution
Historically, lung cancer mortality rates have 100 Tobacco smoking
been higher among males than females due to
an earlier uptake of smoking in large numbers. 4%
80 14%
FIGURE 11.2 More recently, reports have noted a 50 50
convergence in incidence and mortality rates
between young men and women in Europe, North 60
America, and Australia, due to a larger decrease 70% 81%
in rates in men and a substantial rise (or slower
40
decline) in women who acquired the smoking habit 25 25
later than men. FIGURE 11.3 In Asia, Latin America,
and Africa, however, the lung cancer burden 20
Although tobacco remains the most
among men still largely exceeds that of women at
important risk factor for lung cancer,
all ages. FIGURE 11.4 In the last few decades, mortality
0 0 0 other factors such as air pollution are
rates among men in these regions have started to
1950 1960 1970 1980 1990 2000 2010 1950 1960 1970 1980 1990 2000 2010 China France significant in some countries.
canceratlas.cancer.org A g e - s t a n d a r d i z e d r a t e ( w o r l d ) p e r 1 0 0 , 0 0 0
breast cancer is high, there has been a decline or Countries where
BREAST “
stabilization of rates, while in countries where breast cancer is the
Breast Other No data
rates have historically been low, rates have been most frequently
markedly increasing, probably related to improved diagnosed cancer in
diagnosis (i.e., detection of asymptomatic cancers) women, 2018
In lower-resource settings, breast and
CANCER
in combination with socio-cultural changes linked cervical cancer disproportionately affect
to an increase in westernized lifestyle. FIGURE 12.3 women in the prime of life, resulting
Declines in breast cancer mortality rates have been in significant economic and societal Breast cancer
reported in many high-income countries, with impact. A woman’s country… should not
large decreases in European and North American be allowed to influence the likelihood of is the most
countries and in Australia and New Zealand,
dying from these cancers. common cancer
whereas countries in transition continue to show — Dr. Ophira Ginsburg, medical oncologist in women in
a slight increase in mortality from breast cancer,
Breast cancer though this appears to be slowing. FIGURE 12.4 The almost
favorable trends in mortality may result from all countries
accounts for almost a the combined effects of earlier detection (screening
worldwide.
quarter of new cancer
and increased breast cancer awareness) and a
Lifetime risk of breast cancer
range of improvements in treatment.
among females in high-income
cases among women. FIGURE 12.1

countries can be up to
three times that in
Cumulative risk of being diagnosed with female low-income countries.
breast cancer by age 75 years, globally and
Breast cancer is the leading cancer type in females
in select countries
in most countries in the world in 2018. MAP 12.1 ACCESS CREATES PROGRESS
About one in twenty females will be diagnosed
with breast cancer over the course of their lifetime, Although enormously challenging,
resource stratified approaches
although this number varies significantly by
to detect and treat breast cancers
country. FIGURE 12.1 There are large variations in can substantially decrease breast
estimated incidence rates worldwide, with an cancer mortality worldwide.
almost fourfold difference between the highest- 3% 4% 5% 9% 10% 5%
India Zimbabwe Colombia United States United Kingdom WORLD
and lowest-ranked regions. FIGURE 12.2 Incidence
rates are elevated in Australia/New Zealand,
FIGURE 12.3 FIGURE 12.4
Europe and North America, notably in Belgium
Although female breast cancer incidence Female breast cancer incidence
M rates,
o s tallcages,
o m m o n l y d USA: g n o s e Female
i a White d c abreast
n c cancer
e r amortality
m o n rates,
g walloages,
m e n UK
(113 cases per 100,000 female population) and FIGURE 12.2
rates are lowest in less developed 1978–2012, age-standardized rate (world) USA: Black 1950–2013, age-standardized rate (world) USA
Luxembourg (109) in Europe, and in Australia Female breast cancer incidence and mortality O t h e r B r e a s t N o d a t a
regions, mortality rates in these areas per 100,000 UK per 100,000 Australia
(94). In contrast, incidence rates in sub-Saharan rates, 2018
are comparable to most of the more Australia Japan
African regions, particularly in Eastern (30 cases Incidence Figure 3 Figure 4
developed regions due to lack of access Japan Ecuador
per 100,000 female population) and Middle Africa Mortality Female breast cancer incidence rates, all ages, 1978–2012, age- Female breast cancer mortality rates, all ages, 1950–2013,Thailand
age-
to early detection and treatment. Turkey
(28), as well as South Central Asia (26), were standardized rate (world) per 100,000 Ecuador standardized rate (world) per 100,000
considerably lower. Geographic variation is less Australia and New Zealand Thailand
pronounced for mortality rates, with the highest Western Europe 100 100
Northern Europe
rates seen in Melanesia (26 deaths per 100,000
North America
female population) and Polynesia (22), as well as in
Southern Europe
Northern and Western Africa (18). Notably, some Polynesia
countries in Europe, North America, and Oceania South America
75 75
have among the lowest mortality rates despite their Central and Eastern Europe
high incidence rates. Caribbean
Melanesia
The variations observed in breast cancer
Northern Africa
incidence across countries can likely be at least
WORLD
partly attributed to differences in the prevalence Southern Africa 50 50
and distribution of the major risk factors (e.g. Western Asia
reproductive factors, obesity) and partly to the Micronesia
degree of early detection and screening activities in Eastern Asia
Central America
operation. Breast cancer screening detects breast
South-Eastern Asia 25 25
cancer at earlier stages, but also captures cases Western Africa
that would have never been diagnosed otherwise. Eastern Africa
As such, incidence rates are often higher in Middle Africa
countries that implement breast cancer screening South-Central Asia
programs. In countries where the incidence of 100 80 60 40 20 0 20 0 0
Age-standardized rate (world) per 100,000 1980 1985 1990 1995 2000 2005 2010 1950 1960 1970 1980 1990 2000 2010

Sympathetic
nervous system
0 20 40 60 0 80 20 40 60 0 8020 40 0 60 2080 400 6020 8040 60 80
13 THE BURDEN FIGURE 13.2

Central nervous Sympathetic Soft tissue Other
BY REGION Leukemia Lymphomas system tumors nervous system sarcomas neoplasms
Age-standardized
CANCER IN
Sub-Saharan Africa
FIGURE 13.1 Epithelial tumours
cancer incidence North Africa Lymphomas
Leukemia & melanoma
Percentage (%) of the population in which frequency of cancer is measured on each rates (world) per South Asia (India only)
Leukemia
continent in children (age 0–14 years) and adolescents (age 15–19 years) million population, East Asia Central nervous
2001–2010 Southeast Asia system tumors Central nervous
EUROPE
CHILDREN
West Asia Lymphomas system tumors
Children Adolescents
Latin America Other neoplasms
66.4 46.1 North America 0 20 40 0 60 20 80 40 60 80 0 20 40 0 60 20 80 40 60 80
Europe Soft tissue
Oceania FIGURE 4
Sympathetic sarcomas
NORTH AMERICA nervous system
ASIA Age-standardized cancer
0 20incidence
40 rates
60 (world)
80 0 per
20 million
40 population by
60 0 80 20 region,
40 children
60 0 age
8020 40 0 60 2080 400 6020 8040 60 80
Children Adolescents Children Adolescents
0-14 years, 2001-2010
BY ETHNIC GROUP (US)
The childhood cancer 97.2 98.1 6.3 5.3 Native American

Epithelial tumours Occurrence of childhood cancer
burden is strongly
Asian & Pacific Islander
Leukemia Lymphomas
AFRICA Black
& melanoma varies by region,
Germ cell &
with the tumours
highest incidence in more
related to level of
Children Adolescents White Hispanic gonadal
Central nervous developed regions.
White Non-Hispanic Central nervous
5.3 2.6 CHILDREN AGE system tumors
development, with LATIN AMERICA
Children Adolescents
OCEANIA 0–14 YEARS
Lymphomas
0 20 40 60 80 100 120
system tumors
140 160 180 200 220 240
high incidence in high-

Other neoplasms Soft tissue sarcoma Sympathetic nervous system Other neoplasms
Children Adolescents CNS tumours 0 20
Lymphomas 40 60 0 80 20 Leukaemia
40 0 60 20 80 40 60 80 0 20 40 0 60 20 80 40 60 80
15.7 9.2 15–19 YEARS Central nervous Epithelial tumors Germ cell & Other
59.5 64.7 canceratlas.cancer.org
income countries but BY REGION Leukemia Lymphomas system tumors Soft tissue
& melanoma gonadal tumors neoplasms
Sub-Saharan Africa nervous system
higher mortality in low-

The true burden of FIGURE 13.3
North Africa 0 20 40 60 80 0 20 40 60 0 80 20 40 600 8020 40 0 60 20 80 40 60 80
cancer in children is unknown in most Age-standardized
South Asia (India only)
income countries.
low-income countries. cancer incidence
East Asia
rates (world) per Southeast Asia Epithelial tumours
million population, Leukemia
West Asia Lymphomas & melanoma
2001–2010 Germ cell &
FIGURE 6 Latin America
Cancers occurring in childhood and adolescence The incidence of cancer in children and FIGURE 13.4 gonadal tumours
North America Other neoplasms
differ markedly from cancers in adults in their adolescents has been increasing by 0.5 to 1 percent Five-year age-standardized net survival
Five-year age-standardized net survival
Central nervous
Central nervous
(%) in children aged 0-14 years system Europe
tumors
incidence and tumor characteristics. Worldwide, per year in the high-income countries with (%) observed in the available cohorts of cases system tumors
diagnosed with lymphoid leukaemia Oceania FIGURE 5
the average annual incidence in children aged less established cancer registries over the past few diagnosed with lymphoid leukemia
than 15 years is 140 new cases per million children, decades. Although the increase may in part reflect
Age-standardized cancer
0 20incidence
40 0 rates
60 20(world)
80 40 per60
million population by region,
Other children age
neoplasms
0 80 20 40 0 60 20 80 40 60 80 0 20 40 0 60 20 80 40 60 80
Western Europe 15-19 years, 2001-2010
although there are threefold variations between more frequent diagnosis facilitated by advanced BY ETHNIC GROUP (US) Soft tissue
world regions and ethnic groups. FIGURE 13.2 imaging techniques, other factors may have also Native American Sympathetic sarcomas
Oceania
The low rates recorded by population-based cancer contributed. Exposures to high doses of ionizing nervous system
Asian & Pacific Islander 0 60 0 80 20 40 600 8020
registries in some low-income countries are radiation, high birth weight and certain genetic North America 11,014 88% 20 40 60 80 0 20 40 40 The60 80
distribution of cancer in
children survival Black
thought to result from under-diagnosis. FIGURE 13.1 syndromes have been consistently associated with adolescents differs from that of
White Hispanic children and adults.
The most common cancers in children are increased risk of cancer in children. The role of Northern Europe
White Non-Hispanic FIGURE
Epithelial 7
tumours
leukemia and lymphoma, while the major cancers other risk factors, such as air pollutants, tobacco or
Lymphomas
among adults, such as carcinoma of the lung, breast pesticide use, older parental age, or fewer children Southern Europe 5-year age-standardised
0 20 40 net60 80 &(%)
survival melanoma
for children
100 120 aged
140 0–14
160 years 180 diagnosed
200 220 240
Germ cell &
or colon, are rare in children. The incidence of per family is debated. Potentially protective effects with acute lymphoid
Other neoplasms leukemia,
Germ select
ASR
cell & gonadal per countries
tumoursmillion 1995-2009
Epithelial
gonadal tumours tumours & melanoma
Eastern Europe Central nervous system tumors Lymphomas Leukemia Other neoplasms
carcinomas increases progressively with age, and of breastfeeding and folate supplementation are Central
FIGURE 13.5 Colombia, Cali 41%nervous 52% Periods of diagnosis
together with lymphomas or germ cell tumors they being investigated. system tumors
East Asia Changes in 5-year age- 1995–1999 ACCESS CREATES PROGRESS
become the most common cancers in adolescents More than 80% of childhood cancer patients in Thai registries
standardized net survival Other neoplasms 2005–2009
aged 15–19 years, with the overall incidence rate high-income countries survive 5 years after their West Asia 0 20 40 0 60
Bulgaria 20 80 40 60 0 80 20
(%) for children aged 0–14 40 0 60 20 80 40 60 80 Burkitt
0 lymphoma
20 40 is the
60 most80common
rising to 185 per million. In contrast, the incidence diagnosis. In many low-income countries, in
years diagnosed with acute Turkey, Izmir pediatric cancer in many parts of
of embryonal tumors, such as neuroblastoma, contrast, the outlook is much less favorable because Soft tissue
Latin America lymphoid leukemia, select sub-Saharan Africa. While about
retinoblastoma, and nephroblastoma is very low in of suboptimal access to care, late diagnosis, countries 1995–2009 nervous system South Korea 90% of children with Burkitt lymphoma
adolescents. FIGURE 13.3 treatment abandonment, inadequacy of therapy, Southeast Asia 0 20 40 60 80 0 20 40 60 0 80 20 40 60 80 in high-income countries
Belarus
and the financial burden. Survival of childhood can be cured with timely treatment including
cancer patients has been assessed in only a few Africa 78 43% UK high-intensity chemotherapy and supportive
children
More than half of long-term
survival
low-income countries. FIGURE 13.4 Epithelial tumours
care infrastructure, about
Australia 50% of children with the disease
survivors of childhood cancer As survival of cancer patients improves over 20 40
5-year survival (%) circle size
60
indicates
80 100 & melanoma
Germ cell & USA in resource-constrained settings
time FIGURE 13.5, many survivors experience chronic 5-year survival (%) number of cases
experience chronic health conditions later in life as a consequence of
gonadal tumours
Other neoplasms
where such treatment is not feasible
Survival from
canceratlas.cancer.org Central nervous France 82% 89% can be cured with a simplified protocol.
health conditions. their cancer or the anti-cancer therapy. lymphoid leukemia is over 80% system tumors
in more developed regions. 40 50 60 70 80 90 100
Other neoplasms
0 20 40 0 60 20 80
42 canceratlas . cancer . org canceratlas . cancer . org 40 net60
5-year 0 80
survival (%) 20 40 60 20 80 40
0canceratlas.cancer.org 60 80 43
Soft tissue
14 THE BURDEN MAP & FIGURE 14.1
Over the last century, reductions in mortality In South Africa, for example, infectious and HDI and the top
five cancers in
HUMAN
from infectious disease, childhood and parasitic diseases account for 45% of premature
Low Medium High Very High No data
maternal conditions, and changes in fertility deaths, while cancer and cardiovascular disease males and females,
have led to rapid population growth and aging, each account for only 10%. cases in thousands,
2018
DEVELOPMENT
and consequently an increasing burden of The profiles of cancer substantially vary by
noncommunicable diseases, including cancer. The HDI, reflecting differences in lifestyle factors,
LOW Male
unsurpassed scale of the cancer problem worldwide entrenchment of tobacco marketing, the built Colorectum HUMAN DEVELOPMENT INDEX
Female
INDEX
continues to evolve as countries undergo major environment, and the availability of detection and (HDI) is a measure of
Breast
diagnostic services that are associated with social development that considers
transitions, as measured by human development Cervix uteri
not only standard of living
index (HDI). MAP & FIGURE 14.1 and economic development. Among the top 5 most Prostate (gross national income per
TRANSITIONS
Cancer is a major cause of premature death commonly diagnosed cancers and 5 leading causes Liver capita), but also health (life
(at ages <70) linked to socioeconomic transitions. of cancer death by HDI, and separately for India expectancy) and education
MEDIUM
MAP 14.2 It is the leading cause of premature death and China, there are 16 different cancer types that (average years of schooling).
Lung These scores are used to
in 48 (predominantly very high-HDI) countries, rank within the top five even within these six broad
Colorectum create a composite measure
where cancer has surpassed the first position from “regions.” FIGURE 14.3 that can be grouped into
Breast
Understanding the
cardiovascular disease. In Japan, cancer now The rising cancer burden will hit the lower levels: low, medium, high, and
Cervix uteri
represents 45% of all premature deaths, compared HDI countries the hardest. Low- and medium-HDI very high.
Lip oral cavity
transition from
with 21% due to cardiovascular disease. FIGURE 14.2 countries, many of which are ill-equipped to deal
HIGH
In a further 43 countries, cancer is the second- with the present situation, are projected to have
Lung
infection-related
leading cause of premature death following the greatest percentage increase in the burden of
Colorectum
cardiovascular disease, while both diseases rank cancer in the coming decades. FIGURE 14.4
Breast
cancers to lifestyle- lower in most low- and medium-HDI countries.
Stomach
Liver
related cancers in FIGURE 14.2 VERY HIGH
many low- and middle- Leading causes of premature mortality (%) While infectious causes of death dominate Lung
“
Figure 1
(ages <70 years) in South Africa and Japan in South Africa, cancer is the most common Colorectum
income countries
Leading causes of premature mortality (%) (ages <70 years) in South Africa and Japan
cause of death in Japan. Breast
Infectious and parasitic diseases Prostate
is vital for planning

Malignant neoplasms Bladder Economic growth without investment in human

Cardiovascular diseases 45 17 4
4 development is unsustainable—and unethical.
0 250 500 750 1000
5
tailored cancer control
Intentional injuries
— Amartya Sen,
Respiratory infectious diseases
By 2040,
5
awarded the Nobel Prize in Economics.
Males Females
programs to reduce
Digestive diseases v e r y h i g h i g h m e d i u m l o w
SOUTH JAPAN the cancer burden will
5
Unintentional injuries
AFRICA canceratlas.cancer.org
double in low-HDI countries,
5
the future deaths

Other causes
MAP 14.2
which are least equipped
8
Ranking of cancer 1st 2nd 3rd–4th 5th–10th No data
6
and suffering from 10

21
to deal with the pending as a leading cause
of premature death
the disease. cancer epidemic.
10
(ages <70)
Numbers may not sum to 100 due to rounding.
Infectious and parasitic diseases Malignant neoplasms Cardiovascular diseases Respiratory infectious diseases
Figure 2 Incidence, Males Unintentional injuries Figure 2
Other causes Malignant neoplasms Cardiovascular diseases FIGURE 14.4
Intentional injuries Digestive diseases Unintentional injuries Other causes
Incidence, Females Figure 3 millions of new cancer cases in 2018
canceratlas.cancer.orgEstimated
FIGURE 14.3 0 20 40 60 80 100 and the projected increase by 2040 by four-tier HDI
MALE FEMALE Estimated number of new cancer cases in
Most commonly diagnosed cancers and leading level, assuming only a demographic effect
Low Low 2018 and the projected increase by 2040 by
causes of cancer death (%) by four-tier HDI plus
Medium Medium
India and China* 12M
High High 2040 +62% +32%
Lung Prostate Breast Very High Very High 2018
Colorectum Esophagus Cervix China China 10M
Stomach Kaposi sarcoma Uterus India India
Liver Bladder Ovary Figure 2 Figure 20 8M
INCIDENCE 20 40 60 80 100
Pancreas Thyroid
NHL
Mortality, Males Mortality, Females
MORTALITY 6M +75%
Lip, oral cavity
Other Low Low
Medium Medium 4M
High canceratlas.cancer.org High canceratlas.cancer.org
Very High Very High +100%

2M
China China Cancer is a leading cause of death in
India India North and South America, Europe,
0
RAustralia,
a n k i n g North
o f c aAfrica,
n c e r and
a m parts ofr Asia.
o n g p e m a t u r e m o r t a l i t y ( 0 - 6
*India and China are not included in HDI categories 0 20 40 60 80 100 0 20 40 60 80 100 Low HDI Medium HDI High HDI Very High HDI
1 s t 2 n d 3 r d - 4 t h 5 t h - 1 0 t hN o d a t a
2018 2040
There are more than 370 million Indigenous populations have not benefited equally from Indigenous peoples
CANCER IN
people spanning at least 70 countries worldwide. advances in early detection and treatment. as percent of total
Indigenous peoples generally face disadvantage Comprehensive, sustained efforts centered population, 2010 or
and have worse health than non-Indigenous around indigenous leadership and participation most recent data year
INDIGENOUS
people. Data related to cancer in these are needed to improve cancer outcomes for
populations tend to be absent or of poor quality Indigenous peoples. Cancer control planning
Greenland
making many Indigenous peoples statistically by and for Indigenous peoples is progressing in
POPULATIONS
invisible, with the majority of data that exist some jurisdictions. Russia
Sweden
coming from a few high-income countries. There Norway
is under-reporting of cancer incidence and Canada

Russia—
mortality in many jurisdictions. Indigenous
peoples often have higher incidence and mortality
Higher prevalence
rates of cancers related to exposure to tobacco, United States of America
China
alcohol, poor diet, physical inactivity, high BMI,
of risk factors, poor

and diabetes mellitus than non-Indigenous Pakistan Nepal
Mexico Bhutan
people living in the same countries, although
India Myanmar
outcomes, and
cancer patterns vary from country to country. THE WORLD HEALTH ORGANIZATION HAS CALLED FOR THE
ELIMINATION OF CERVICAL CANCER. Honduras Thailand
FIGURE 15.1 Cancer-causing infections such as Guatemala | Nicaragua
While disease burden is highest in lower- and middle-income
under-reporting are
El Salvador
Nigeria
Helicobacter pylori and hepatitis B virus, which are Costa Rica Venezuela
countries, significant disparities exist in high-income countries. Panama
Cameroon
related to poverty and overcrowding, tend to be In Australia, cervical cancer incidence in Indigenous women is Colombia
among the cancer

Kenya
higher in Indigenous populations, particularly double that of non-Indigenous women, with mortality rates over Ecuador
in regions where vaccination for hepatitis B is not three times higher. Strategies and actions needed to accelerate
control challenges for occurring. FIGURE 15.2 Further, survival after cervical cancer elimination for Indigenous women globally must Peru Brazil
be led by Indigenous women and form part of the draft global
diagnosis is lower, and its improvement is slower Bolivia
strategy tabled at the 2020 World Health Assembly.
Indigenous peoples. in Indigenous populations, suggesting Indigenous Paraguay
Australia
Argentina
FIGURE 15.1 Stomach Prostate Chile

Relative risk of cancer-specific mortality for Indigenous compared with non-Indigenous peoples by country and site* Lung Breast New Zealand
Colorectum Uterus ACCESS CREATES PROGRESS
10 Cervix NEW ZEALAND
MALE New Zealand is P e r c e n t
INDIGENOUS MĀORI PEOPLE
the only country in the 5 % o r l e s 5s . 1

Hei Ahuru Mowai, Aotearoa/
- 1 0New% 1Zealand’s
0 . 1 Indigenous
- 1 5 % 1 5 . 1 - 2 5 % M o r e t h a n 2 N5 o% d a t a
world that routinely Māori cancer leadership group, aims to influence national
records and reports cancer policy by ensuring participation and engagement with
Māori from policy development to implementation across the
1 national-level cancer cancer control continuum. The group has representatives on
most of the country’s cancer groups and also partnered with
Alaska USA Canada (Métis) Canada Australia New Zealand statistics for its the Ministry of Health on a Cancer and Racism seminar which
1999-2009 2012-2016 1991-2001 (Registered Indian)
1991-2001
2012-2016 2006-2011
Indigenous population. will inform a new national cancer strategy. Hei Ahuru Mowai
is currently working with the National Bowel Screening
Programme to ensure equity is addressed in its national
roll-out.
Cancer mortality rates FIGURE 15.2
0.1 in Indigenous people
Prevalence (%) of H. pylori among Indigenous
Alaska US can be
Canada many times
(Métis) higher
Canada than
(Registered Indian) Australia NZ
10 FEMALE peoples, select studies*
those of non-Indigenous people
in some countries.
Alaskan Natives
Canada
Brazil Indigenous peoples in many

countries have a high prevalence of
1 Greenland H. pylori, an infection which causes
Western Australia (Urban)
stomach cancer.
Alaska USA Canada (Métis) Canada Australia New Zealand
1999-2009 2012-2016 1991-2001 (Registered Indian) 2012-2016 2006-2011
1991-2001 Western Australia (Isolated)
New Zealand
0 25 50 75 100
0.1 *Source varies by country. See Sources and Methods, page 116
Alaska US Canada (Métis) Canada (Registered Indian) Australia NZ

There are striking geographic differences in the and the average prognosis of the major cancers The most common
OVERVIEW OF
incidence and mortality of different cancer types in observed. MAP 16.1 , 16.2 Certain cancers dominate the cancer cases and
Breast Cervix Lung Liver Thyroid Colorectum Stomach No data
different world regions. This global diversity global landscape, particularly in women: female deaths in women
reflects both the presence of local risk factors for breast cancer is the most frequent cancer in four- in 185 countries in
2018
GEOGRAPHIC
specific cancers, and the extent to which effective fifths of the world’s nations, with cervical cancer
cancer control measures have been implemented. ranking most frequent in the majority of remaining
Much of the observed variation in recorded countries, particularly in sub-Saharan Africa. The
WOMEN
DIVERSITY
incidence rates of different cancer types in different mortality profile among women is slightly more
registry populations can be ascribed to lifestyle and heterogeneous, with lung cancer also a leading
environmental factors. FIGURE 16.1 Such marked cause of death.
international variability supports the critical role of Among men, there is considerable international
cancer prevention as a means to reduce the future diversity in the leading cancer types, with around
The diversity in cancer

cancer burden. Although specific causes remain 10 different cancers as the most commonly
unknown for many cancers, where measured, diagnosed cancer or leading cause of cancer death.
profiles in different
about two-fifths of cancers diagnosed today are Prostate, lung, and liver cancer are major cancers
potentially avoidable. Prevention measures include in men, although other cancers dominate in some
world areas signifies

eliminating exposure to known lifestyle and regions (lip and oral cavity in South Asia and
environmental risk factors, including tobacco and Kaposi sarcoma in Eastern Africa). Nevertheless,
that both regional

alcohol, dietary factors, excess body weight, and lung cancer is the leading cause of cancer death
UV radiation, and increasing resistance to infection among men in over half of the world’s countries.
cooperation and by vaccination. However, the proportion of cancer

cases avoidable—overall and for specific risk CASES DEATHS
local, evidence-based
“
factors—substantially varies by region. For
example, infection accounts for 30–50% of all cases Breast and cervical cancer are the most
interventions are frequently diagnosed cancers and

M o s tleading
c o m causes
m o n c a u s e o f c a n c e r d e a t h i n f e m a l e
in sub-Saharan Africa, whereas this proportion is
M o s t c o m m o n l y d i a g n o s e d c aofncancer
c e r ideath
n f e in
m many
a l e countries
s B r e a in
s t women.
C e r v i x u t C
e ro i l o r e c t uL m
i v e r L u n g S t o m a c h
only 3–5% in Europe and North America.
needed in the fight

Cancer varies between different populations, B r e a s t C e r v i x u t Le ir vi e r L u n g T h y r o i d N Lung
o d a tcancer
a is also a leading cause of cancer N o d a t a
The most frequently diagnosed cancers and
and every type is rare in some part of the world. death in many countries.
leading causes of cancer death at the national level
against cancer.
Many specific causes are now known
reflect the major risk factors in the population (to explain these differences), but a large
MAP 16.2
proportion of global variation for common
cancers remains unexplained. The most common
FIGURE 16.1 cancer cases and
— Prof. Julian Peto, Nature, 2001 Prostate Lung Liver Colorectum Stomach Lip, Leukemia Kaposi Non-Hodgkin Esophagus No data
GeoDiv
Relative Overview-
and absolute Fig1
global variations in incidence rates of registry populations included deaths in men in
oral cavity sarcoma lymphoma
in CI5 Relative
Volume XI (circa 2008–12); rates shown areinthose within the 10th rates
and 90th percentiles in males 185 countries in
and absolute global variations age-standardised (world) of registry populations included in CI5 Volume XI (circa 2008-12); rates shown are those
2018
within the 10th and 90th percentiles in males.
RELATIVE MAGNITUDE* ABSOLUTE VARIATIONS Considering both sexes
8.1 Nasopharynx Germany, Lower Saxony Thailand, Khon Kaen together, either female MEN
2.9 Gallbladder Jordan (Jordanians) Czech Republic
breast, prostate, or
7.5 Hodgkin lymphoma China, Anshan City Spain, Basque Country
2.5 Brain, nervous system Japan, Yamagata Prefecture Poland, Lublin cervical cancer is the
5.3 Thyroid China, Haimen County Turkey, Trabzon most commonly diagnosed
8.3 Other pharynx
cancer in over
Peru, Lima USA, North Carolina (Black)
6.2 Multiple myeloma China, Jiashan County Italy, Modena
4.1 Larynx Argentina, Tierra del Fuego USA, North Carolina (Black) 70% of countries.
3.9 Lip, oral cavity China, Hefei Russia, Arkhangelsk
13.3 Testis India, Chennai UK, Wales
2.5 Leukemia Costa Rica Australian Capital Territory
3.5 Pancreas Ecuador, Quito USA, Michigan, Detroit
5.3 Esophagus Turkey, Bursa France, Calvados
3.2 NHL India, Chennai USA, Michigan
6.3 Kidney Seychelles USA, Virginia (Black)
5.4 Liver UK, England, East Midlands China, Linzhou County Site-specific cancer incidence rates
51.8 Melanoma of skin Qatar (Qataris) USA, Georgia vary up to 50-fold
5.7 Stomach USA, Oklahoma Turkey, Trabzon between geographic areas. CASES DEATHS
6.1 Bladder Malaysia, Penang Switzerland, Geneva
3.1 Colorectum Ecuador, Loja Italy, Trento
M o s t c o m m o n l y d i a g n o s e d c a n c e r i n m a l e s M o s t c o m m o n c a u s e o f c a n c e r d e a t h i n m a l e s
3.6 Lung Qatar (Qataris) Russia, Chelyabinsk
C o l o r e c t uK m
While prostate cancer
a p o s i s a r cL oi pm , ao r a l c aL vu i nt yg
is the most commonly
P r o s t a t eN o d a t a
diagnosed
C o l o r e c t uK m
cancer
a p o s i s a r cL oi pm , ao r a l c aL vu i nt yg O t h e r s p e c i f i Se tdo sm
15.3 Prostate China, Maanshan France, Limousin
E s o p h a g L
u es u k e m i a L i v e r
among men
N o n - H o d g k i n l Sy m
in 106 countries
t o pm h ao cmh a
worldwide,
E s o p h a g L u es u k e m i a L i v e r N o n - H o d g k i n l Py m
r o ps ht ao tme a N o d
0 20 40 60 80 100 120 140 lung cancer dominates as the leading cause

*Relative magnitude is the rate in the 90th percentile divided by the rate in the 10th percentile. ASR (World) per 100,000 of cancer death in 93 countries.
48 asr1 canceratlas . cancer . org canceratlas . cancer . org 49
The most common cancers in men are prostate suggest poor outcomes and substantial case-fatality The most common
(69,000 cases, or 23% of all cancers) and liver from cancers. Yet primary prevention remains key cancer cases and
Regional Diversity cancers (24,000 cases, or 8% of all cancers) as well in sub-Saharan Africa, where there is a need to deaths in sub-
Saharan Africa, both
Breast Cervix Prostate Liver Kaposi sarcoma Lung Esophagus Stomach
as Kaposi sarcoma (20,000 cancers, 7%). Breast prioritize the most cost-effective means of reducing
(115,000 cases, 25% of all cancers) and cervical the cancer burden. Improved access to diagnosis sexes combined, 2018
“
SUB-SAHARAN
cancers (112,000 cases, 24%) are the most and treatment, including palliative care, is also
frequently diagnosed cancers in women. essential to improve survival and limit suffering CASES DEATHS
FIGURE 17.1, 17.2 from the disease in the region.
AFRICA
Incidence rates have been increasing for several Opportunities for
major cancer sites. For example, cervical cancer reducing suffering and
rates increased by 80% in Zimbabwe and 36% in death from cancer in
South Africa, although they have risen and Africa exist across all
declined recently in Uganda. FIGURE 17.3 Major FIGURE 17.2 stages of the cancer
Up to 50% of the Incidence and mortality rates of the most common control spectrum.
increases have been seen for breast as well as for
prostate cancers where they have been measured, cancers in sub-Saharan Africa in males and — Max Parkin,
cancers diagnosed doubling in Zimbabwe (breast) and South Africa

(both cancers) over the last 15 years. While the
females, 2018
INCIDENCE MORTALITY
cancer epidemiologist
in some countries cause of elevated rates for certain cancers such as

esophagus is still largely unknown, a westerniza-
Prostate
in Eastern Africa are tion of lifestyle (e.g. dietary habits, fertility, excess
body weight, and physical inactivity) has been
Liver
Over one-third of
still related to related to observed increases in breast cancer, and
Colorectum
all cervical cancer deaths
is expected to give rise to increases in rates of other Esophagus
globally occur in
infection, and these cancers such as colorectum. An improved aware-
Lung
sub-Saharan Africa,
are largely preventable.
ness and increased capacity to perform
prostatectomies on older men has been suggested NHL though the region
to be linked to the increase in prostate cancer rates.
There is a large opportunity for cancer
Kaposi sarcoma represents only
An estimated 752,000 new cancer cases (4% of the prevention and control programs to improve health Stomach 14% of the world
global total) and 506,000 cancer deaths occurred in outcomes in the region. Comparing incidence and Leukemia female population.
sub-Saharan Africa in 2018. Although the overall mortality rates of all cancers combined across
cancer burden in the region is dominated by breast, countries, large disparities in terms of incidence-to- Bladder
cervical, and prostate cancers, the cancer profile in mortality ratios are apparent. FIGURE 17.4 Large 40 32 24 16 8 0 8 16 24 32 FIGURE 17.3 FIGURE 17.4
sub-Saharan Africa is quite diverse. MAP 17.1 differences between incidence and mortality ASR (World) per 100,000 Trends in incidence rates in selected countries Incidence and mortality rates in selected
in sub-Saharan Africa countries in sub-Saharan Africa, 2018
FIGURE 17.1 1998–2002 Incidence A relatively low incidence to mortality ratio

MALE Rates for several major
Estimated number* of new cancer cases vs. deaths Sub-Saharan Africa has a unique mix 2003–2007
cancers are increasing.
Mortality can indicate poorer cancer outcomes.
and distribution (%) by type, both sexes, 2018 of common cancers including several 2008–2012 Figure 4 While the ratio between cancer incidence and
infection-related cancers.
Figure 2 FEMALE
Breast Figure 1 mortalityrates
Incidence and mortality is 2.3
in in Mauritius,
selected one of
countries inthe wealthiest
sub-Saharan Africa,
Incidence and mortality rates of most 90
2018 countries in the region, it is 1.4 in Uganda.
Cervix Estimated numbers of new cancer cases and deaths, both sexes, 2018 common cancers in females, 2018
Prostate 80
Colorectum INCIDENCE MORTALITY France, La Réunion
Liver 70
15 15 Cervix canceratlas.cancer.org
42 45 South Africa
NHL
Breast 60
Kaposi sarcoma Zimbabwe
ASR (World) per 100,000

Esophagus Colorectum 50

Other cancers Kenya

11
Ovary 40
15
Malawi
Liver
CASES DEATHS

30

Mauritius
Esophagus
20
7
Uganda
Stomach
10 Cabo Verde

NHL
9
Uterus 0 Burundi
4 6 6 CERVIX BREAST (F) PROSTATE KAPOSI SARCOMA ESOPHAGUS (M)
4 5 4 5
Lung Rwanda
Uganda
Uganda
Uganda
Uganda
Uganda
S. Africa
S. Africa
S. Africa
S. Africa
S. Africa
Zimbabwe
Zimbabwe
Zimbabwe
Zimbabwe
Zimbabwe
Total estimated Total estimated 40 32 24 16 8 0 8 16 24 32 0 25 50 75 100 125 150 175 200 225
*Excludes non-melanoma skin cancer. 752,000 506,000 ASR (World) per 100,000 ASR (World) per 100,000
50 canceratlas . cancer . org

canceratlas.cancer.org canceratlas . cancer . org 51
Incidence and mortality rates for all cancers mortality trends for major cancers in the region, Leading cause of
combined (except non-melanoma skin) reveal the except colorectal cancer, for which rates are rising cancer death in
Regional Diversity extent of variation between countries, with in many countries. While lung cancer mortality Latin America and
the Caribbean,
Lung Stomach Colorectum Liver Prostate Gallbladder Cervix
incidence rates varying (in both sexes) from 263 rates in men are decreasing in many countries,
(per 100,000) in Uruguay to 105 in Guyana, and they are still increasing in women. Bolivia and both sexes, 2018
LATIN AMERICA &

mortality from 130 in Uruguay to 61 in Mexico. Chile exhibit the highest incidence rates of
FIGURE 18.2 The lifetime risk of being diagnosed with gallbladder cancer worldwide (14 and 9 per —Bahamas
Mexico Puerto Rico
cancer ranges from 26% (1 in 4 persons) in 100,000, respectively), possibly related to specific
THE CARIBBEAN
|
—Guadeloupe
Uruguay to 11% (1 in 10 persons) in Guyana. The types of indigenous ancestry. Jamaica— | —Martinique
Belize Dominican Rep. —St. Lucia
corresponding cancer mortality risk ranges from Honduras —Barbados
FIGURE 18.2 Guatemala
Nicaragua
14% (1 in 7 persons) in Uruguay to 7% (1 in 15 El Salvador —Trin. & Tob.
persons) in Mexico. There are marked variations All cancer sites combined incidence and mortality Costa Rica Venezuela Suriname
Panama
rates in Latin America and the Caribbean, both Guyana
in the incidence and mortality rates of specific Colombia
French Guiana
Prostate, breast and

sexes, all ages, 2018
cancers across countries: for example, cervical Ecuador
cancer varies six-fold for incidence, from 39 per Incidence
colorectal cancer are 100,000 in Bolivia to 7 in Guadeloupe, and a Mortality

Brazil
striking 15-fold for mortality, from 19 in Jamaica to
Bolivia and Chile have the
Peru
the main cancers in 1 in Martinique. While the highest prostate cancer

Figure 2 Incidence rates vary more highest gallbladder cancer Bolivia
incidence rates are seen in the Caribbean, with than twofold between
the region. 189 per 100,000 in Guadeloupe, the lowest are
estimated in Honduras (25). In Bolivia, the most
Estimated incidence and mortality rates in 2018,
countries of this region.
all cancers, both sexes, all ages
rates in the world. Paraguay
common cause of cancer death is gallbladder Uruguay

About 1.3 million new cancer cases and 666,000 cancer. MAP 18.1 Uruguay
France, Guadeloupe Gallbladder is the leading cause of Argentina
cancer deaths were estimated to have occurred in In some countries with longstanding cancer
Puerto Rico cancer death in Bolivia.
2018 in Latin America and the Caribbean. The five registries, there is evidence of moderate increases Chile
France, Martinique
most common cancers in 2018 were female breast in all-cancer incidence rates; this is mainly due to
(200,000 new cases, 15% of all cancer cases), an upwards trend in incidence rates of the most Barbados
prostate (190,000, 14%), colorectal (128,000, 9%), common cancer types, including female breast, French Guyana
lung (90,000, 7%) and stomach cancer (67,000, colorectal and prostate cancer—coinciding with Argentina
5%). Lung cancer is the leading cause of death marked declines in stomach and cervical cancer. Brazil Incidence rates of prostate and breast
(81,000, 12%), followed by colorectal (65,000 10%), FIGURE 18.3, 18.4 In contrast, overall cancer mortality cancer are increasing, while rates of
Cuba
prostate (54,000, 8%), female breast (53,000, 8%) rates are stabilizing or in decline in most countries
Jamaica stomach and cervical cancer, both
and stomach (52,000, 8%). FIGURE 18.1 during the most recent decade, driven by favorable
FIGURE 18.3 FIGURE 18.4 related to infection, are decreasing.
Costa Rica
Figure 3
Incidence trends in selected countries in Latin America,
Figure 4
Incidence trends in selected countries in Latin America,
Chile
prostate and breast cancer, all ages, 1982–2012 stomach and cervical cancer, all ages, 1982–2012
FIGURE 18.1 Peru
Estimated number* of new cancer cases vs. deaths Infection-related cancers Venezuela PROSTATE STOMACH (MALE)
and distribution (%) by type, both sexes, 2018 including stomach, cervix, and liver Colombia, Cali 80 Chile, Valdivia 80
Bahamas
still rank among the leading Colombia
Chile, Valdivia Costa Rica
Breast
Figure 1 cancers in this region. Ecuador, Quito 60 Colombia, Cali 60

Prostate Trinidad & Tobago
Estimated numbers of new cancer cases and deaths, both sexes, 2018 Costa Rica Ecuador, Quito
Colorectum Paraguay
Lung 40 40
Panama
Stomach
15 12 Suriname
Cervix 42 44 20 20
Thyroid Dominican Republic
Liver Saint Lucia Figure 3
0 0
Pancreas
10
1984 1988 1992 1996 2000 2004 2008 2012 1984 1988 1992 1996 2000 2004 2008 2012

Ecuador
Other cancers
Bolivia BREAST Chile Valdivia Colombia Cali Costa Rica CERVIX Chile Valdivia Colombia Cali Costa Rica
14
Mexico Colombia, Cali 80Ecuador Quito Colombia, Cali 80Ecuador Quito

CASES DEATHS

Haiti Costa Rica Ecuador, Quito

canceratlas.cancer.org canceratlas.cancer.org
8
El Salvador Ecuador, Quito 60 Chile, Valdivia 60

Chile, Valdivia Costa Rica
Nicaragua
40 40

Honduras
8
9
Belize
4 7 8 Guatemala 20 20
4 5 5 5
Guyana
0 0
Total estimated Total estimated 0 40 80 120 160 200 240 1984 1988 1992 1996 2000 2004 2008 2012 1984 1988 1992 1996 2000 2004 2008 2012
*Excludes non-melanoma skin cancer. 1,344,000 666,000 ASR (World) per 100,000
Chile Valdivia Colombia Cali Costa Rica Chile Valdivia Colombia Cali Costa Rica
canceratlas.cancer.org canceratlas . cancer . org Ecuador Quito Ecuador Quito 53
canceratlas.cancer.org canceratlas.cancer.org
19 THE BURDEN MAP & FIGURE 19.1
Patterns in cancer occurrence are similar in the Colorectal cancer

USA and Canada, reflecting the shared prevalence incidence in
“
Regional Diversity of behaviors associated with disease risk. Northern America,
age-standardized
19.9–22.4 22.5–25.6 25.7–30.1 30.2–39.5 39.6–55.1 No data
Incidence is relatively low for infection-related

cancers, and high for cancers associated with rate (world) per
NORTHERN
lifestyle “westernization”. For example, Northern The crisis is obesity. It’s the fastest-growing 100,000, both sexes,
cause of disease and death in America. 2011–2015
America has among the highest incidence of
And it’s completely preventable.
colorectal cancer worldwide. However, because this
There are wide differences in progress
AMERICA
cancer is amenable to primary prevention and — Dr. Richard H. Carmona,
Trends in colorectal Alaska against colorectal cancer incidence and
treatment, there is substantial socioeconomic and US Surgeon General
cancer mortality mortality in Northern America.
geographic variation in incidence and mortality
in Massachusetts
within the region. MAP & FIGURE 19.1 For instance,
and Mississippi,
Northwest
incidence rates of colorectal cancer are two-fold
Three in five endometrial 1970–2016 Territories
Lung cancer remains higher among residents of the North and Atlantic
regions of Canada than among residents in the cancers in the USA
Geographic variation in colorectal
cancer mortality trends in the US,
Massachusetts
the leading cause Western US, largely because of differences in risk

factor exposures and access to screening.
are caused by excess
1970-2016
Mississippi
British
Columbia
Newfoundland
body weight.
& Labrador
of cancer death
25 Alberta
Cancer trends in the two countries are likewise Hawaii Manitoba
comparable, with mortality rates declining contin-

in Northern America,
Saskatchewan
Ontario
uously for more than two decades because of 20 New Brunswick—
Washington
improvements in prevention, early detection,
despite decades North Vermont
Montana | Maine
FIGURE 19.3

and treatment. Progress against tobacco-related Oregon
Dakota
New —New Hampshire
15
of declines in
Idaho
diseases as a result of reductions in smoking is Lung cancer incidence trends by sex in the South
Dakota
Wisconsin
Michigan York —Massachussetts
—Rhode Island
Wyoming —Conn.
reflected in declines for lung cancer, which are United States and Canada, 1975–2015 Iowa
Pennsylvania
—New Jersey
Nebraska
Indiana Ohio
smoking prevalence.
slower and more prolonged among women than Utah Illinois West —Delaware
US Male California Colorado Virginia
men because of later uptake of smoking and slower 10 Missouri
—Virginia
Kentucky
Canada Female
—North Carolina
cessation. FIGURE 19.3 Colorectal cancer incidence Arizona New Oklahoma Arkansas Tennessee
Mexico —South Carolina
Cancer is the leading cause of death in Canada and rates have decreased by almost 40% since 2000 in Mississippi
5 Alabama —Georgia
the second-leading cause, after heart disease, in adults 50 and older, largely because of increased Progress in lung cancer incidence Texas
the USA. About 1.9 million new cancer cases and screening, which allows for removal of precancerous in Northern America is the result |
—Florida
polyps. FIGURE 19.4 In contrast, rates are rising in Figure 3 Louisiana

693,000 cancer deaths were estimated to have of declines in smoking that began 0
occurred in Northern America in 2018. The most young adults for cancers associated with excess Trends in lung cancer incidence earlier.
decades by sex, age- 1968 1984 2000 2016 Puerto Rico
commonly diagnosed cancers are prostate in males body weight, such as colorectal and endometrial standardized rate (world), 1975–2015
and breast in females, while lung cancer remains cancers, foreshadowing the health effects of the
80
the most common cause of cancer death in both obesity epidemic. FIGURE 19.5 FIGURE 19.4 FIGURE 19.5
sexes. FIGURE 19.2 Colorectal cancer incidence trends among adults Uterine corpus and colorectal (both sexes US colorectum
≥50 years of age in the United States and Canada, 1975–2015 combined) cancer incidence trends, age <50 years, Canada colorectum
70
in the United States and Canada, 1975–2015 US uterine corpus
FIGURE 19.2 US
FigureCanada
4 7 Canada uterine corpus
Estimated number* of new cancer cases vs. deaths While breast cancer is the
and distribution (%) by1 type, both sexes, 2018 most commonly diagnosed cancer Colorectal cancer incidence trends among adults ≥50 years of age in the
Figure 60
in Northern America, lung cancer is by far United States and Canada, 1975–2015
Breast Estimated numbers of new cancer cases and deaths, both sexes, 2018 6
the leading cause of cancer death.
Lung 200
Prostate 50
Colorectum 14 5
38 38 25
Bladder
160
NHL 40

Melanoma of skin 4

Pancreas

13
Liver 30 120
Leukemia 3
CASES DEATHS

Other cancers

20 80
2
9
Decreases in colorectal cancer incidence

12
Recent rapid increases in uterine

since 2000 are largely due to
4 4 7 10 40 1 corpus cancer incidence are likely
increases in screening, allowing removal
4 due to the obesity epidemic.
5
10 5
5 7 of precancerous polyps.
Total estimated Total estimated 0 0 0
*Excludes non-melanoma skin cancer. 1,896,000 693,000 1980 1990 2000 2010 1980 1990 2000 2010 1980 1990 2000 2010
54 US males US females canceratlas . cancer . org canceratlas . cancer . org 55

Canada males Canada females
canceratlas.cancer.org US colorectum Canada colorectum US uterine Canada uterine
Southern, Eastern, and South-Eastern Asia is a cancer profiles are observed among males according All cancer sites
diverse, densely populated region with 4.2 billion to subregion. For example, cancer of the oral cavity combined incidence
Regional Diversity inhabitants, making up 55% of the world is a common cancer in much of South and South- rates in Southern,
Eastern, and South-
84.3–100.2 100.3–130.9 131.0–163.3 163.4–248.9 249.0–313.5
population. In 2018, 8.2 million new cancer cases East Asia, and a number of countries in this region
and 5.2 million cancer deaths were estimated in the (India, Sri Lanka) exhibit among the highest rates in Eastern Asia,
SOUTHERN,
age-standardized
region, corresponding to around half of the cancer the world, FIGURE 20.2 largely as a result of the high
rate (world) per
burden worldwide. China alone accounts for 52% usage of smokeless tobacco products. In South-
100,000, both sexes
of new cancer cases (4.3 million) and 55% of cancer Eastern and Eastern Asia, two infection-related
EASTERN &
combined, 2018
deaths (2.9 million) in the region. Overall, cancers cancers (liver and stomach cancers) continue to be
of the lung (1,166,200 new cases, 15% of all cases), among the most commonly diagnosed cancers and Mongolia
colorectum (914,200, 11%) and female breast leading causes of cancer death among males.
SOUTH-EASTERN
(845,400, 10%) are the most common cancers. FIGURE 20.3
FIGURE 20.1 Lung cancer remains the leading cause of DPR
Korea
death (1,013,100 deaths, 21% of all deaths), followed FIGURE 20.2
ASIA
China
by stomach (560,500, 11%) and liver cancer Highest lip and oral cavity cancer incidence Afghanistan
Japan
Iran
(554,000, 11%). rates in Southern, Eastern, and South-Eastern Rep. Korea
This region contributes

Pakistan
Cancer rates in the region vary widely, with Asia, males, 2018
Nepal
nearly a fourfold difference across countries. Bhutan
about half of new cancer
“
MAP 20.1 Incidence rates are higher in South-Eastern India
Lung, breast, and
Bangladesh
Asia, and highest in the overall region in the Due to the high use of smokeless Myanmar
Lao
cases and cancer deaths
tobacco products, rates of lip and
Republic of Korea (314 cases per 100,000
worldwide.
PDR
colorectal cancers are

Figure 2
population). In contrast, lower rates are seen in oral cavity cancers in some countries Thailand
Highest lip and oral cavity Accurate population-based cancer
many countries in South Asia, including Bhutan, in this region are upcancer incidence
to three times Philippines
common in this region,

Viet Nam
rates inhigher
Southern, Eastern, and South-Eastern data are a first step to planning Cambodia
Sri Lanka, and India (fewer than 90 cases per than the global average.
prevention, treatment and supportive Sri Lanka
Asia, age-standardized rate (world), males, The Republic of Korea has
in addition to liver and
100,000). Mortality rates followed a similar pattern care programs in countries with an Brunei Dar.
2018 Maldives— |
some of the highest cancer
by subregion: Mongolia (170 per 100,000) and increasing cancer burden like Myanmar.
Malaysia
Indonesia rates not only in the region
stomach cancers,
China (130) had the highest mortality rates, Singapore—
— Dr. Kyaw Kan Kaung,
whereas Sri Lanka (51) and India (61) had the
but also worldwide.
Non-communicable Disease
which are associated

lowest rates. Pakistan 16.3 Director, Department of Public
While female breast cancer is the most com- Health, Ministry of Health and
—Timor-Leste
Sports, Myanmar Government
with infection.
monly diagnosed cancer in nearly all countries
among women in Asia, marked differences in the
India 13.9

Estimated number* of new cancer cases vs. deaths Incidence and mortality rates for the Mortality rates are highest for
and distribution (%) by type, both sexes, 2018 Bangladesh 12.4
Figure
most 3
common cancers in Southern, lung cancer in bothFigure 3 and
males
Incidence
Eastern, and
and mortality rates
South-Eastern the most common cancers, age-females in this
for2018
Asia, region. and mortality rates for the most common cancers, age-
Incidence
Lung
MALE
standaridzed rate (world) per 100,000, Males, 2018 FEMALE2018
standaridzed rate (world) per 100,000, Females,
Colorectum Stomach and liver cancer, both related
Breast Figure 1 to infection, are the second- and INCIDENCE MORTALITY INCIDENCE MORTALITY
Sri Lanka 12.3
Stomach third-leading
Estimated numbers of new cancer causes
cases and deaths of cancer
in Southern, death
Eastern, and South-eastern Asia, both sexes, 2018 Lung Breast
Liver in this region after lung cancer.
Esophagus Colorectum Lung
Thyroid 14
40 34 20 Afghanistan 9.3
Stomach
Pancreas Colorectum
Other cancers
Liver Cervix

11
Myanmar 6.9 Esophagus Thyroid
Prostate Stomach
CASES DEATHS
11

Lip, oral cavity Liver

Nepal 5.9
10
Bladder Ovary

11
4
Leukemia Uterus
4 9 6 WORLD 5.8
5 8 8 NHL Esophagus
7
32 24 16 8 0 8 16 24 32 32 24 16 8 0 8 16 24 32
Total estimated Total estimated 0 5 10 15 20
Percentages may not sum to 100 due to rounding.
*Excludes non-melanoma skin cancer. 8,208,000 5,179,000 ASR (World) per 100,000 ASR (World) per 100,000 ASR (World) per 100,000

21 THE BURDEN
There were an estimated 3.9 million new cancer Incidence trends for all cancer sites combined MAP 21.1 Most commonly diagnosed cancers in Europe among males and females, 2018
cases and 1.9 million cancer deaths in Europe in have continued to rise in many countries, although Europeans represent about
Regional Diversity 2018. Cancers of the female breast (523,000 new at a slower pace in recent years. This slower
Lung Prostate Colorectum Breast one-tenth of the global
cases, 13% of all cancer cases), colorectum increase partly results from a stabilization or
(500,000, 13%), lung (470,000, 12%), and prostate decline in breast and prostate cancers, countered
population, yet one in four
male female
of all cancer diagnoses
EUROPE
(450,000, 12%) were the most common cancers on by an increase in colorectal cancer. FIGURE 21.3 On the
the continent, and combined they represented other hand, overall cancer death rates are steadily
occur in this region.
almost half of the overall cancer burden. FIGURE 21.1 decreasing in Europe, mainly due to decreasing
For men, prostate cancer was the most commonly death rates from breast and prostate cancers as well
diagnosed cancer in almost all northern and as lung (male only, particularly in Northern and
Breast, prostate, lung, western European countries, and lung cancer was Western Europe). In Central and Eastern
In many European countries, one in
three people will be diagnosed with
the most commonly diagnosed in most Eastern European men, lung cancer incidence and
and colorectal cancers European countries. For women, breast cancer is mortality rates are beginning to stabilize or decline.
cancer by the age of 75.
represent over half of

the most commonly diagnosed cancer in all But in women across Europe, who for the most part
European countries. MAP 21.1 These cancers were acquired the smoking habit several decades after Figure 2
FIGURE 21.2
all cancer diagnoses

also the leading causes of cancer death in Europe: men, lung cancer rates are still rising, though
Lifetime
Lifetime risk (%)(%)
risk of aofcancer diagnosis
a cancer in European
diagnosis countries,
in European countries, by sex
lung (388,000 deaths, 20%), colorectum (242,000, there are early signs of stabilization in recent years
by sex
in Europe.
13%), female breast (138,000, 7%), and pancreas in some countries, notably in the highest-risk
(128,000, 7%). countries of Northern Europe. MALE FEMALE
Substantial variation in incidence and mortality
Hungary
rates are observed at the national level, where France (metropolitan)
“
cancer incidence rates in males vary from 430 per FIGURE 21.3 Ireland
100,000 in Ireland to 239 in Montenegro. The Trends in all cancer sites combined* in Denmark Estonia
lifetime risk of a cancer diagnosis ranges from 35% and the United Kingdom**, 1960–2014 Latvia
in Ireland—indicating that 1 in 3 persons in Ireland Slovenia
The diverging health trends (including Denmark Incidence, Male
cancer) in Europe are a testimony to will be diagnosed with cancer over the course of Slovakia
UK Incidence, Female
both the successes and failures of health their lifetime—to 25%, or 1 in 4 persons, in Norway
Mortality, Male
policy in Europe. Montenegro. FIGURE 21.2 Similarly, a twofold Czech Republic
Mortality, Female
difference in rates is seen for mortality, with the Denmark
— Johan Mackenbach, Professor of Public Health
highest and lowest mortality rates observed in Belgium
at Erasmus MC, and Martin McKee, Professor of
Hungary and Sweden, respectively. The risk of Although all-cancer incidence Serbia
European Public Health at the London School
of Hygiene and Tropical Medicine dying from cancer in men varied from 22% in the
400 rates have increased, Lithuania
Republic of Moldova to 10% in Iceland, and in

mortality rates have declined. Croatia
MALE Greece
women from 13% in Hungary to 7% in Spain.
350 Belarus
FEMALE Spain
FIGURE 21.1 The Netherlands
Estimated number* of new cancer cases vs. deaths Moldova
300 Luxembourg
and distribution (%) by type, both sexes, 2018
Cancers of the breast, lung, and
Germany
Breast Figure 1 colorectum are the most frequent in
United Kingdom
Colorectum this
Estimated numbers of new cancer cases and deaths, region.
both sexes, 2018 250 Sweden
Lung
Portugal
Prostate
Italy
Bladder 13
38 39 Poland
Melanoma of skin 20 200
Bulgaria
Kidney
Switzerland
Pancreas
Romania

Stomach
13
150 Russian Federation

Liver
Lung and prostate Ukraine
Other cancers
CASES DEATHS cancers are the most Finland

frequent cancers Bosnia Herzegovina

13
100
in most European Macedonia
countries among men, Cyprus
12
while breast cancer Austria

50 ranks first in all Iceland

7
3 4 European countries Malta

4 12 7
5 5 5 in women. Montenegro
Albania
0
Total estimated Total estimated 1960 1970 1980 1990 2000 2010 40 30 20 10 0 10 20 30
*Excludes non-melanoma skin cancer. 3,911,000 1,930,000 **Incidence is UK, England only Cumulative Risk

canceratlas.cancer.org Males Females
Northern Africa and Central and Western Asia world (40 cases per 100,000 in men), while rates Most commonly
is a large and diverse region characterised by low in Israel, Syria, and Turkey also exceed 20 per diagnosed cancer in
Regional Diversity but increasing cancer incidence rates. The overall 100,000 in men. Western Asia also includes the Northern Africa and
West and Central
Breast Lung Liver Stomach No data
number of cases estimated for 2018 in the region Gulf countries, with specific cancer profiles
was around 745,000, with this number predicted to corresponding to their high national levels of HDI, Asia, both sexes, 2018
NORTHERN
increase to 1.4 million cases annually by 2040. high prevalence of obesity, and varying levels of
However, each of the three sub-regions have smoking uptake, but low alcohol consumption. MAP 22.2
Cancer cases are predicted to
distinct cancer profiles. MAP 22.1
double in this region by 2040—
AFRICA, WEST &
CENTRAL ASIA
NORTHERN AFRICA Cancer incidence rates in Central Asia are
the largest increase of any
In Northern Africa, cancer incidence rates are relatively low but increasing. Cancer profiles are Kazakhstan
world region.
CENTRAL ASIA
typically about one-third to half of the consistent with low- to medium-HDI countries,
corresponding rates in Western countries, with with a high incidence of infection-related cancers
incidence rates for all cancer sites combined such as stomach (11% of all cancer cases) and Georgia—
Uzbekistan
ranging from less than 90 cases per 100,000 cervical cancer (6% of all cancer cases). The region Breast cancer is the most Armenia— Azerbaijan Kyrgyzstan
Turkey
population in Sudan to more than 160 in Egypt forms part of the so-called esophageal cancer commonly diagnosed Turkmenistan
In this diverse region in men, and less than 100 in Libya and Sudan to belt, which includes Turkmenistan, Tajikistan, cancer in many countries
of this region.
Syrian
Arab Rep.
Tajikistan
more than 140 in Algeria and Morocco in women. Uzbekistan, Kazakhstan, Afghanistan and the
with countries at
Tunisia Lebanon—
Iraq
FIGURE 22.1 Liver cancer is the second most common eastern part of Turkey, with some of the highest Israel—
Morocco
differing stages of
cancer in both sexes combined, with incidence incidence rates worldwide, particularly in men. —Jordan
—Kuwait
Algeria
rates in Egypt estimated to be the second-highest Libya
—Bahrain
Egypt
the cancer transition,

worldwide in both men and women. FIGURE 22.2 —Qatar
Saudi Arabia
UAE
WESTERN ASIA FIGURE 22.1 Oman
cancers associated Western Asia is a large region, with close to All-sites* cancer incidence and mortality rates
in Northern Africa and West and Central Asia,
with infection,
Sudan
400,000 estimated cancer cases annually, but Yemen
high-quality cancer registry data are available for both sexes combined, 2018
smoking, and excess

only few countries, partly due to large numbers of Incidence
displaced persons and ongoing conflicts. Some Mortality
body weight are of the countries in the region have very high
bladder cancer incidence rates; Lebanon notably Lebanon
MAP 22.2
Proportion (%)
all common. has the highest estimated incidence rate in the Israel
of cancer cases
Turkey 1.3–2.6% 2.7–3.8% B r e a 3.9–4.9%
s t L i v e r L u n 5.0–5.5%
g S t o m a c hN 5.6–7.2%
o d a t a No data
attributable to
Armenia
excess body weight
Kazakhstan
FIGURE 22.2 Figure 2 in Northern Africa
Gaza Strip & West Bank and West and
Estimated number* NORTHERN AFRICA WESTERN ASIA CENTRAL ASIA
Estimated numbers of new cancer cases and deaths in Northern Africa and West and Central
Jordan Asia by subregion, both sexes, 2018 Central Asia, 2012
of new cancer cases Figure 2 1 13 Egypt
vs. deaths and 19 4
41 0 2
distribution (%) by
Estimated numbers of new 4cancer cases and deaths in4 Northern Africa and West and Central Georgia Asia by subregion, both sexes, 2018
Morocco
11
type, both sexes, 2018 Several countries in the region,

13
Algeria
Total estimated Total estimated Total estimated particularly in Western Asia,
10
Bladder Kyrgyzstan
Brain, nervous system
279,000 391,000 75,000 have a high proportion of Kazakhstan
11
Kuwait cancer cases attributable to

Breast
10
Libya excess body weight.

7
Cervix 7
4 7 5 7 Turkmenistan
Colorectum 6 6 5 5 6 Georgia—
5 6 Uzbekistan
Esophagus Tunisia
Armenia—
“
Azerbaijan Kyrgyzstan
Leukemia UAE Turkey Turkmenistan
Liver
CASES Azerbaijan
Tajikistan
Syrian
Lung Iraq Tunisia
Arab Rep.
DEATHS
Lebanon—
Iraq
NHL Bahrain Morocco Israel— We need to ask ourselves: What
Pancreas Oman —Jordan legacy do we want our generation to be
—Kuwait
Prostate 15 22 14 Algeria known for? The one that watched the
41 39 39 Qatar Libya

Egypt —Bahrain
Stomach Sudan NCD epidemic destroy the lives of

—Qatar
Thyroid Saudi Arabia our children and our children’s children,
Uzbekistan UAE
14
Other cancers Oman or the generation that said

11
Total estimated Total estimated Total estimated Saudi Arabia

‘enough is enough’ and took action?
177,000 220,000 51,000 Tajikistan
9
Sudan
Yemen Yemen — HRH Princess Dina Mired, The Third
11
UN High Level Meeting on NCDs: Time

8
4 0 50 100 150 200 canceratlas.cancer.org

250 to Deliver, 27th September 2018
5 6 5 7
6 5 8 6 ASR (World) per 100,000
*Excludes non-melanoma skin cancer. 5 5 6
60 canceratlas . cancercanceratlas.cancer.org
. org canceratlas . cancer . org 61
14% of all cancers), prostate (23,500, 13%), and Cervical cancer

colorectum (22,300, 12%) are also commonly incidence in
Regional Diversity 6.0 6.1–12.6 12.7–18.7 18.8–22.6 22.7–29.1
“
diagnosed in the region. Lung cancer accounts for Oceania,
the greatest number of cancer deaths (11,800, 17%), age-standardized
followed by colorectal (8,100, 12%) and female rate (world) per
OCEANIA
breast cancer (4,800, 7%). Skin cancers (melanoma 100,000, 2018
Delivering cancer services in our small —Guam
and non-melanoma) are the most common cancers island nations is a challenge. Regional
and represent a significant public health issue, solutions built collaboratively with local
particularly in Australia and New Zealand. leaders have been shown to provide Papua New Guinea
FIGURE 23.2 Given the relatively large proportion of sustainable benefits. Australia has achieved high HPV
Geographic dispersion, the region’s inhabitants in Australia and New
Zealand, the vast majority of the region’s cancer
— Dr. Paula Vivili, Director, Public Health vaccine and cervical cancer screening
long distances, the coverage, which is predicted to reduce
Division at the Pacific Community,
|
cases and deaths (93% and 85%, respectively) occur New Caledonia Solomon Is.
cervical cancer rates to fewer than

impact of climate
in these two countries. Papua New Guinea is Samoa—
four new cases per 100,000 women by

Vanuatu—
unique among the other nations in terms of its
Fiji—
change, and a double

relatively large population and burden (8.4 million,
11,200 new cases, 7,100 deaths); most of the Pacific FIGURE 23.2
around 2028. New Caledonia
|
burden of infection- and

Island countries and territories feature small Australia French
Incidence rates of melanoma of the skin in selected Polynesia—
populations that are often spread across many regions, both sexes combined, 2018
lifestyle-related cancers Cervical cancer incidence rates in the

remote islands.
Cancer profiles vary considerably across Figure 1 region range from 6 cases per 100,000
Australia and New Zealand have
confront the nations of subregions. In Australasia and Polynesia, the
cancers with the highest incidence rates include
Melanomatheskin
combined,
cancerskin
highest
2018
incidence, both sexes
melanoma
incidence rates in the world.
female population in Australia and
New Zealand to 25 or more in Fiji
this vast region. female breast, prostate, lung, and colorectum.

FIGURE 23.3 In contrast, in Melanesia and Micronesia,
and Papua New Guinea.
breast cancer incidence rates are almost half those Australia & New
An estimated 181,000 new cancer diagnoses and of the above regions, and cervical cancer is the second- Zealand
69,000 cancer deaths occurred in 2018 in the leading cancer, with rates two to three times higher
New Zealand
subregions of Oceania, namely Australasia, than the average rate in the region. MAP 23.1 Western Europe
Melanesia, Micronesia, and Polynesia. FIGURE 23.1
Cancers of the female breast (24,600 new cases,
Northern Europe
FIGURE 23.3
FIGURE 23.1 Figure 3and mortality rates in Oceania
Incidence Figure 3
Estimated number* of new cancer cases vs. deaths North America Age-standardized
by sub-regions, top 10(world) incidence
cancers, 2018 and mortality rates in Oceania, top 10 Age-standardized (world) incidence and mortality rates in Oceania, top
and distribution (%) by type, both sexes, 2018 cancers, by sub-regions: Australia, NZ, Polynesia 10 cancers, by sub-regions: Melanesia, Micronesia
INCIDENCE MORTALITY INCIDENCE MORTALITY
Breast AUSTRALIA & NZ 6 . 0 6 . 1 - 1 2 . 61 2 MELANESIA
. 7 - 1 8 .1 7 8 . 8 - 2 2 .2 6 2 . 7 - 2 9 . 1
Southern Europe
Prostate Although lung cancer is the fifth-most Breast Breast
Colorectum commonly diagnosed cancer in the region, Prostate Prostate
Figure 1
Melanoma of skin
Central & Eastern Colorectum Cervix
it is the leading cause of cancer death. Europe
Lung Estimated numbers of new cancer cases and deaths, both sexes, 2018 Melanoma of skin Lip oral cavity
NHL Lung Colorectum
Leukemia Polynesia Uterus Lung
NHL Liver
Pancreas
35
14
4 3 17 Thyroid Uterus
Liver
Melanesia Leukemia Stomach
Other cancers
Kidney Thyroid

POLYNESIA MICRONESIA
13
South America
Breast Breast
12
CASES DEATHS Prostate Prostate

Southern Africa Lung Lung

Colorectum Cervix
Uterus Colorectum
7
12
Central America Thyroid Liver

Cervix Uterus
3
4 7 Liver Ovary
9 10 4 6 WORLD Stomach Thyroid
5
NHL Stomach
Total estimated Total estimated 0 10 20 30 100 90 80 70 60 50 40 30 20 10 0 10 20 30 40 100 90 80 70 60 50 40 30 20 10 0 10 20 30 40

*Excludes non-melanoma skin cancer. 181,000 69,000 ASR (World) per 100,000 ASR (World) per 100,000 ASR (World) per 100,000

24 THE BURDEN
improved population awareness about cancer FIGURE 24.2 FIGURE 24.3 FIGURE 24.4
CANCER
symptoms, better access to diagnostic services, and Observed survival (%) in patients with breast Figure 3
Five-year net survival (%) for women Figure
Trends in4five-year net survival (%)
adequate care are key. Universal Health Coverage is cancer since time of diagnosis in countries with
Figure 2 Five-year
diagnosed netadvanced
with survival breast
for women diagnosed
cancer in with advanced breast Trends
from in five-year
breast cancer in net
Asiasurvival (%) from breast cancer in South Asia
one strategy to achieving this. (see 40, Universal high, medium and low human development index* cancer in by
the USA in 2009–2015 therace/ethnicity
USA in 2009-2015 by race/ethnicity
Singapore
Health Coverage) The implementation of universal in sub-Saharan Africa in 2009–2014
Malaysia (Penang) Breast cancer survival has improved 100
SURVIVAL
health coverage in Thailand in 2002 may at least High HDI
125 Hispanic (any race) 31% Thailand (6 registries) in some South Asian countries.
partly account for the increase in the 5-year breast Medium HDI India (2 registries)
cancer survival proportion, from 44% for patients Low HDI
diagnosed from 1995 to 1999 to 62% for those Asian / Pacific Islander 80
diagnosed from 2010 to 2014. FIGURE 24.4 (includes Hispanic) 31%
Cancer patient survival benchmarking is an 100
important tool for advocacy to ensure equitable
cancer care. Global initiatives assessing
Non-Hispanic White 28%
Access to effective
60
international cancer survival include EUROCARE,
75
early detection and
a cross European project since 1989; the
International Cancer Benchmarking Partnership,
Black (includes Hispanic) 20%
Period of diagnosis
cancer treatment
involving high-income countries with similar 40
health systems; CONCORD, which collects and 0 50 100 1995--1999 2000--2004 2005--2009 2010--2014
can substantially
reports data from all countries worldwide; 50
and SURVCAN, which aims to improve data and
Relative Survival Rate (%)
Survival from childhood
Singapore Malaysia (Penang)Thailand (6 registries) India (2 registries)
acute lymphoblastic leukemia
improve survival for

capacity for survival estimation in Africa, Asia, FIGURE 24.1 Five-year net survival (%) in patients diagnosed with colon
and South America, including an initiative with cancer, female breast cancer, and acute lymphoblastic leukemia
varies almost twofold across
cancer patients and the African Cancer Registry Network to expand 25 (children) in 2010–2014 CONCORD-3 study worldwide
population-based survival estimates in sub- European countries.
reduce the survival Saharan Africa. Unfortunately, high-quality data
remains scarce. MAP 24.1 Improving the quality and Years since diagnosis
Figure 1 Colon Figure 1 Breast Figure 1 Leukemia
COLON BREAST (WOMEN) ACUTE LYMPHOBLASTIC
gap worldwide. availability of population-based survival data is
essential to ensuring effective monitoring of
0
1 2 3 4 5
58 HIGH 84
LEUKEMIA (CHILDREN)
Africa
Africa
progress in cancer control. *High HDI: Seychelles, Mauritius; Medium HDI: Kenya, Namibia and South Africa; 12 LOW 40
Low HDI: Benin, Côte d’Ivoire, Ethiopia, Mali, Mozambique, Uganda and Zimbabwe
High HDI Medium HDI Low HDI
Overall improvements in early detection and
Central
Central 60 87 69
treatment have greatly improved average survival canceratlas.cancer.org
& South
& South
of cancer patients worldwide over the past several MAP 24.1 America
America 48
75 50
decades, yet prognosis still varies markedly
Availability of Case samples from Regional high quality National high quality No data
depending on where a patient lives. FIGURE 24.1 registries data data Asia
Asia 72 89 89
high-quality cancer
Survival differences are also marked within
data for survival
regions. Within sub-Saharan Africa for example,
statistics, 2008–2014 58
overall (observed) survival of women diagnosed
with breast cancer is about 50% higher in patients 29 66
residing in high Human Development Index (HDI)

countries than in those residing in low-HDI Europe
Europe 68 89 95
countries. FIGURE 24.2 This is in part because breast
cancer patients in the low-HDI countries are more
likely to be diagnosed at a later stage and less likely
to receive the appropriate treatment. In addition to
variation between countries, within-country
differences have also been reported. For example,
in the United States, black cancer patients have
lower survival than non-Hispanic white patients.
FIGURE 24.3 In order to close this survival gap,
71 54
NET SURVIVAL is a measure of the OBSERVED SURVIVAL is a measure 45
probability of surviving the cancer of the probability of a person with
diagnosed that is comparable cancer surviving from all causes of
North
North 67 90 93
between countries, as it corrects death (cancer and other causes). ACCESS CREATES PROGRESS America
America 65 88 90
for differences between countries
in death from other diseases (non- T y p e o f d a t a
The number of population-based cancer registries that are able Oceania
Oceania 71 90 91
cancer mortality). Net survival 64 88 91
C
tosprovide
a s e
high-quality survival statistics is lacking but has grown
a m p l e s f r oR me gr ei og ni sa tl r hi ei gs h q Nu aa t l ii ot yn da al ht ai g h q Nu o
a ldi ta y t d
a a t a
is often age-standardized for

over the last decades, providing national and global evidence to
comparability between countries 0 50 100 0 50 100 0 50 100
with different age distributions.
improve effectiveness of health care systems.

“
problems, sexual dysfunction, relationship issues Estimated number
CANCER
and school worries are common. Late effects of cancer survivors
256 or less 257–439 440–662 663–1,011 1,012 or more No data
(occurring months or years after treatment ends) diagnosed within
may include cardiac problems, lymphedema, The challenge in overcoming cancer is not only the past five
years per 100,000
SURVIVORSHIP
impaired functional status, and second cancers. to find therapies that will prevent or arrest the
disease quickly but also to map the middle ground population, both
MAP 25.2 Combined, long-term and late effects of
of survivorship and minimize its medical and sexes, 2018
cancer may double survivors’ risk of poor mental
social hazards.
and physical health-related quality of life. FIGURE 25.1 Cancer survivors tend
Working-age cancer survivors often face — Fitzhugh Mullan, founding member, to be concentrated in
challenges in maintaining employment. They National Coalition for Cancer Survivorship higher-income countries
The growing increasingly experience medical financial where screening,
diagnosis, and effective
population of cancer
hardship, including problems paying medical bills,
FIGURE 25.2
financial distress, and delaying or forgoing care treatment are more
Suggested site-specific surveillance accessible.
survivors represents
because of cost. In the USA, as many as 60% of
recommendations for cancer survivors,
working-age cancer survivors report at least one
United Kingdom
a global challenge for

type of financial hardship.
Among older adults, most of those diagnosed
survivors and their

with cancer present with one or more co-morbid
health conditions. As the proportion of survivors
families, employers, who are older increases, rates of cancer-related

morbidity can be expected to rise as well. To reduce
healthcare systems the human cost of cancer, finding ways to screen

those at risk for and mitigating adverse effects of
and governments. treatment will be increasingly important, as will

tailored follow-up care.
National guidelines for coordinated survivor-
The number of cancer survivors is rising world- ship care are in place in some high-income BREAST CANCER (EARLY AND LOCAL STAGES)
wide, propelled by advances in early detection and countries, such as Australia, Canada, and the UK. People who have had treatment for breast
treatment and the aging of the world’s population. FIGURE 25.2 In the US, guidelines are not always cancer should have an agreed, written care
plan, which should be recorded by a named MAP 25.2
In 2018, there were approximately 43.8 million consistent. Survivorship care guidelines are less healthcare professional.
cancer survivors diagnosed within the previous common in low- and middle-income countries. Years lived with
Offer annual mammography to all people with
5 years. MAP 25.1 Developing and delivering care that addresses the disability due to P r o p o r t i o n p e r 1 0 0 , 0 0 0
breast cancer for 5 years.
49,994 or fewer 49,995–192,095 192,096–483,705 483,706–989,921 989,922 or more No data
Their growing visibility makes it increasingly long-term and late occurring effects of cancer and cancer, both sexes, 2 5 6 o r l e s2 s5 7 - 4 3 94 4 0 - 6 6 26 6 3 - 1 , 0 11 1, 0 1 2 o r m oN r oe d a t a
clear that while some cancer survivors thrive, for its treatment represent key challenges of survivor- all ages, 2017
COLORECTAL CANCER
many, life after cancer presents lasting challenges. ship worldwide.
Offer patients regular surveillance with a
Fear of recurrence, depression, pain, memory
minimum of two CTs of the chest, abdomen,
and pelvis in the first 3 years and regular
serum carcinoembryonic antigen tests (at
FIGURE 25.1 least every 6 months in the first 3 years).
Prevalence (%) of poor health-related quality of life among Years lived with
Offer a surveillance colonoscopy at 1 year
cancer survivors and adults without cancer, US, 2010 after initial treatment. If this investigation is disability due to cancer
normal consider further colonoscopic follow‑ are highest in the
Figure 1 without cancer
Adults up after 5 years. countries with both high
Cancer survivors cancer rates and large
Prevalence of poor health-related quality of life among cancer survivors and adults without cancer, US,
2010 LUNG CANCER populations, like China,
Compared with those who have not had Offer all patients an initial specialist follow-up
the US, and Russia.
30
cancer, cancer survivors are more likely appointment within 6 weeks of completing
to experience poor physical and/or treatment to discuss ongoing care. Offer
regular appointments thereafter, rather than
Many cancer
mental health. relying on patients requesting appointments
when they experience symptoms.
survivors face late
20 Offer protocol-driven follow-up led by a lung and lasting medical,
cancer clinical nurse specialist as an option for
patients with a life expectancy of more than
emotional, and social
3 months. challenges resulting in
10
7.8 million years
Guidelines for follow-up care exist lived with disability
in some high-income countries, globally in 2017.
but are uncommon in low- and
middle-income countries.
0
Poor physical health Poor mental health Poor physical and mental health

Y e a r s l i v e d w i t h d i s a b i l i t y d u e t o c a n c e r , 2 0 1 7
XX SECTION TITLE
TAKING ACTION
This section describes effective interventions across the cancer continuum, from
prevention to early detection, treatment, and palliative care. Many organizations
work in the fight against cancer through research, health promotion, and policy.
ACCESS
CREATES
PROGRESS
Effective delivery of combined
high coverage screening and
vaccination could avert over
13 million cervical cancer cases
by 2069,and eventually lead
to cervical cancer being
eliminated as a major
public health problem.
Over the next half century, an estimated

44 million cervical cancer cases will occur
if current trends continue worldwide.

26 TAKING ACTION
Evidence-based, resource appropriate Regular screening for cervical, colorectal, MAP 26.1 Figure 2 FIGURE 26.2
THE CANCER
interventions for cancer prevention and control breast, and lung cancers allows detection of early detection: Cervical No program Pilot National prevention: Cumulative probability (%)
exist across the cancer continuum in each country, these diseases at an early stage, when treatments cancer screening using of death from lung cancer by attained
from prevention of risk factors to early detection, are more successful and the chance for survival visual inspection with age and smoking status 30
Disproportionately high rates
CONTINUUM
treatment, survivorship, and end-of-life care. and cure is high. MAP 26.1 Screening for colorectal and acetic acid, as of June 2017
Current Smoker
FIGURE 26.1 Tobacco use, the cause of the largest cervical cancers also prevents cancer by detecting of cervical cancer in lower-HDI
Quit 70+
number of preventable cancers worldwide, can be precancerous lessions for removal by surgery or countries are almost entirely 25
Quit 60-69
substantially reduced through raising excise tax other forms of treatment. A heightened awareness due to lack of screening.
Quit 50-59
on tobacco products, smoke-free air laws, health of warning signs for cancer of the oral cavity, skin, 20
Quit 40-49
An Overview of
warnings on tobacco packaging, and restrictions and some other cancers may also lead to detection
Quit <40
on promotion and advertising of tobacco products. of cancers at early stage (see 30, Early Detection). Never Smoker 15
Interventions and
FIGURE 26.2 (see 28, Tobacco Control) Unhealthy diet Effective treatment modes (surgery, radiation,
and physical inactivity can be reduced through chemotherapy, hormonal therapy, immunotherapy)
Potential for Impact increased public awareness about their health have been developed for several cancers, including 10
hazards and through public policies (e.g., excise for cancers of the breast, colon and rectum, and
tax on sweetened beverages) and structural and testis and for many childhood cancers. FIGURE 26.3 5
environmental interventions (e.g., pedestrian and (see 31, Management and Treatment) For certain
Resource-appropriate, bike lanes) (see 27, Health Promotion). The hepatitis

B virus (HBV) and human papillomavirus (HPV),
cancers such as testis, treatment could lead to cure,
even for advanced-stage disease. Awareness and
0
broad application of
55-59 60-64 65-69 70-74 75-79 80-84 85+
infections that cause liver cancer (HBV) and availability of services to meet the needs of cancer 30
Attained age
cervical and other urogenital and oropharyngeal survivors are increasing worldwide FIGURE 26.4,
MALE
known interventions cancers (HPV), can be prevented through vacci- and pain associated with cancer can be controlled 25
in each country can

nation (see 29, Vaccination). Indoor and outdoor by administration of analgesic drugs. FIGURE 26.5
FEMALE
air pollution can be reduced through use of clean (see 32, Pain Control)
20
substantially reduce
stoves, cleaner fuels, and proper ventilation, and Resource-appropriate application of known
air quality guidelines and policies. Protection interventions in each country could prevent a The risk of dying
from lung cancer can be
the morbidity and
from harmful sun exposure could reduce the risk substantial proportion of cancer deaths. However, 15
of skin cancer. Cancer-causing occupational such broad interventions have not materialized in
substantially reduced
by quitting smoking
mortality associated exposures could be prevented through improved
work place safety. Addressing cancer risk
most parts of the world largely because of lack of
political commitment.
If 70% of all eligible girls were at any age. 10
vaccinated, an estimated
with cancer. factors can also have a shared impact on other
non-communicable diseases.
N a t i o n a Pl i l o t
178,000 cervical cancer deaths 5
could be avoided annually 0

FIGURE 26.1
Proportion (%) of countries with NCD plans/national cancer control plans that
worldwide. 55-59 60-64 65-69 70-74 75-79 80-84 85+
High income countries Lower middle income countries Attained age
address key components across the cancer continuum, by income level, 2018 Upper middle income countries Low income countries
FIGURE 26.3 FIGURE 26.4 FIGURE 26.5
100
treatment: Childhood cancer mortality trends, all cancer sites survivorship: Breast Health Global Initiative end-of-life care: Adult palliative care needs at the
The cancer continuum combined, males 0–19 years, 1975–2013 resource allocations for monitoring breast end of life by disease (%) worldwide, 2011
is represented in national cancer survivorship care
Cancer
non-communicable disease
Egypt Mortality from childhood Cardiovascular diseases
and cancer control plans. BASIC
75
Figure 3Colombia cancer has decreased in many Chronic obstructive pulmonary disease
Monitor for breast cancer recurrence,
Brazil high-income countries due to second primary cancers
HIV/AIDS
United States treatment advances, Diabetes mellitus
Monitor for long-term complications
Japan but similar progress is lacking in Other
7 lower-resource countries. Other diseases

7
50 LIMITED 5
6 Monitor for endocrine medication
6
adherence

5
10
MAXIMAL 66 34
25 4
Genetic testing and counseling

3 Screening for high-risk cancers
2
PREVENTION & EARLY DETECTION TREATMENT / SURVIVORSHIP / END OF LIFE POLICY & RESEARCH 38
0 1
HPV HBV Cervical Breast cancer Breast cancer WHO Radiotherapy National Pediatric Survivorship Palliative Vulnerable Cost Cancer Financial Cancer Monitoring practices for breast Cancer forms a large portion
vaccination vaccination cancer screening screening Essential treatment cancer care care care populations of the plan research resources registries cancer survivorship care can vary of end-of-life palliative care
screening (opportunistic) (population- Medicines guidelines 0
based) List 1977 1983 1989 1995 2001 2007 2013 by resource availability. needs worldwide.
Year of death
27 TAKING ACTION
The scale of the global cancer burden and its FIGURE 27.4
HEALTH
associated economic costs indicate that adoption Counseling in healthcare: Green
of healthy behaviors to reduce the risk of cancer Prescriptions (New Zealand)
is critical. However, behavior change initiatives
A Green Prescription (GRx) is the written advice
Taxes on from a health care professional to a patient to be
PROMOTION
directed at individuals are not likely to be
physically active. The program is administered
successful without addressing the many external
sugar-sweetened
factors that influence behavior. In addition to by District Health Boards, with support from the
educating and building skills that encourage beverages ACCESS CREATES PROGRESS
New Zealand Ministry of Health.
healthier behaviors, health promotion must also intended to reduce In the Netherlands, substantial
investments have been
A Population and consumption
include efforts to address the environmental,
economic, and social factors that influence an made in cycling-promoting
are an emerging infrastructure and policies, Patients receiving a GRx from their health A retrospective study of individuals who
Systems Approach
individual’s ability to engage in those behaviors. care provider are eligible for ongoing had participated in the GRx program two
resulting in 27% of trips being
For instance, the availability of sidewalks and public health made by bicycle. This physical support, delivered as monthly telephone to three years earlier found that those who
biking infrastructure affects the degree of physical
activity in a community, and the availability
strategy. activity is estimated
to avert 6,500 deaths annually
calls, face to face meetings, or group
support in a community setting. The patient’s
had completed the program reported an
additional 64 min of total physical activity
Health promotion of affordable fresh fruits and vegetables affects

healthy eating habits. This is especially important
and contribute an additional
half-year to the life expectancy
progress is reported back to the referring
health professional.
per week and were less likely to be sedentary
and more likely to meet the current physical
must address the in the context of health equity, as vulnerable

populations are most affected by environments
of Dutch people. activity guidelines of at least 150 min of
physical activity per week.
environmental, that are not conducive to healthy behaviors.

A comprehensive policy framework to create
economic, and social environments that support following cancer
FIGURE 27.3
Education and
factors that influence

prevention recommendations includes actions at
Information: The Healthy Caribbean Coalition’s
the environmental, system, and individual levels.
The Healthy
#toomuchjunk campaign educates
health behaviors.
FIGURE 27.1 While this framework was developed to
Caribbean
address diet, physical activity, breastfeeding, and
Coalition citizens about the harmful effects of poor
alcohol consumption (all factors associated with
#toomuchjunk diet and lack of physical activity and
cancer risk and/or body weight), the broad policy
Campaign asks them to call on their governments
levers are applicable to other health behaviors,
such as tobacco use and vaccination. Examples of to enact policies and legislation that
initiatives include taxation, FIGURE 27.2 information effectively combat childhood
and community mobilization, FIGURE 27.3 and overweight and obesity.
counseling in healthcare. FIGURE 27.4
“
World Cancer Research Fund/ American Fiscal policy:
HEALTHY POPULATION MEXICO USA, PHILADELPHIA UNITED KINGDOM
Institute for Cancer Research Sugar-sweetened
Health cannot be a question
(WCRF/AICR) policy framework beverage taxes
of income; it is a fundamental Action A 10% excise tax Action The city of Philadelphia implemented Action The 2018 United Kingdom (UK)
human right. increase on sugar- a tax on sugar-sweetened sugar-sweetened beverage tax utilized
sweetened beverages beverages (US $0.015 per ounce) a different strategy than other localities
Improve the — Nelson Mandela on January 1, 2014. on January 1, 2017. by introducing a tiered tax based on
Marketing food and the amount of sugar in the beverage—a
restrictions drink supply high tax for drinks with >8g of sugar
Integrate actions Result A 6% decline in Result wo months after the tax went into
T
across sectors purchases of these effect, Philadelphia residents were per 100ml; a moderate tax for drinks
beverages and a 4% 40 percent less likely to drink sugary with 5–8g/100ml; and no tax for
Labeling and Incentives in increase in purchases of soda and 60 percent less likely drinks with <5g/100ml.
packaging HEALTH ENHANCING communities SYSTEMS unsweetened beverages to drink an energy drink each day
ENVIRONMENTS CHANGE (mainly water) in the first compared with residents of nearby Result The tax has already incentivized some
year of the tax. cities. manufacturers to markedly reduce the
Create healthy – amount of sugar in their recipes, positively
and safe settings Healthy In addition, Philadelphians were 58 affecting all those who consume these
urban design percent more likely to drink bottled beverages.
water every day. –
Fiscal policies
A 2017 modelling study examining the
Inform people potential impact of product reformulation
The WCRF/AICR has introduced a A handful of communities worldwide, including Mexico, the United Kingdom,
estimated that, with reduced sugar
BEHAVIOR CHANGE content by 15–30%, the number of adults
new policy framework to address COMMUNICATION and various cities in the US, have begun implementing excise and children with obesity would fall by
Education
diet, physical activity, breastfeeding, and skills taxes on sugar-sweetened beverages and evaluating the impact on 144,000, and there would be 19,000
Counseling
consumption and/or product formulation. fewer cases of diabetes per year in the UK.
and alcohol consumption. in healthcare
72 canceratlas . cancer . org 73

28 TAKING ACTION MAP 28.1
provisions include increasing tobacco excise taxes, Parties to the
TOBACCO
creating smoke-free environments, and putting FIGURE 28.2 Framework
FCTC Party Not FCTC Party No data
strict restrictions on tobacco product marketing The benefits of tobacco taxes Convention on
and graphic warning labels on tobacco packaging. in the Philippines Tobacco Control
Taxing tobacco aggressively has proven to be (FCTC)
CONTROL
the most effective tobacco control measure. The
mechanism is simple: governments put high excise
taxes on tobacco products, tobacco companies raise
prices to protect profits, and consumers react to
higher prices by quitting, not initiating or reducing
tobacco consumption. Importantly, young and/or
lower-income people are more likely to be affected. ACCESS CREATES PROGRESS As of mid-2019, there
FIGURE 28.1 Through tobacco taxes, countries enjoy are 181 parties to the
There are many the benefits of lower consumption through higher Not only are they saving hundreds
of thousands of lives, but the
Framework Convention
productivity and lower healthcare costs, and tax on Tobacco Control.
effective measures to revenues increase. Reinvesting these revenues in
government is spending its new
“
tobacco tax revenue on…
reduce tobacco use

health can further enhance the effects. FIGURE 28.2
In 2012, Australia moved beyond the gold • Universal healthcare for
low-income persons
that can lower smoking

standard of large, graphic warning labels on tobacco
• Improving health infrastructure Sugar, rum, and tobacco are
packaging by legislating plain standardized
• Helping tobacco farming commodities which are nowhere
prevalence and prevent
packages. Gone are the logos and color themes communities necessaries of life, which are
that even young children can identify around the
become objects of almost universal
premature deaths.
world. MAP 28.2
consumption, and which are therefore
Tobacco firms’ success relies on their ability extremely proper subjects of taxation.
to present tobacco use as cool and glamorous. Graphic warning labels and
— Adam Smith, Wealth of Nations
Most recently, firms have re-doubled their efforts plain packaging on tobacco
Tobacco use is the largest preventable cancer risk to sell to young women and girls. To combat this, products can counteract tobacco
factor. While global cigarette consumption and the health community must constantly remind marketing efforts.
overall prevalence have been declining recently, people that smokers lose on average 11 years of
success has been uneven. In countries with life, and more than half of long-term smokers die MAP 28.2
F C T C p a rNt yo t F C T C p Na or t dy a t a
vigorous tobacco control policies, tobacco use prematurely from tobacco-attributable disease. Tobacco packaging
has typically declined more. Finally, it is in countries where broad restrictions: use of
In recent years, tobacco control proponents communities seeking improved social welfare— Graphic warning labels + plain packaging Graphic warning labels No graphic warning labels No data
graphic warning
have developed a proven set of tools to address the including health, human rights, and environment, labels and plain
challenges of tobacco use. These measures comprise among others—are speaking out loudly against packaging
the World Health Organization’s Framework tobacco that tobacco use is waning most.
Convention on Tobacco Control, which boasts
FIGURE 1
more than 180 Parties. MAP 28.1 The treaty’s
Cigarette Price and Smoking Prevalence in South Africa by Income Group
COUNTRIES WITH
GRAPHIC WARNING LABELS
FIGURE 28.1 AND PLAIN PACKAGING
35%
Cigarette price and smoking prevalence Australia
$9
in South Africa by income group R9.00 France
RAND Hungary
High income R8.40 PER New Zealand
PACK $8
Middle income Norway
Low income 30% United Kingdom
R7.70
Rand per pack (2000 ZAR)

Price
$7
Smoking prevalence
25%
$6
When taxes raise cigarette
prices, the poor get more
health benefits than the rich. $5
R5.00 In 2018, the World Trade
20% Organization (WTO) Dispute
R4.25
Settlement Body ruled that
$4
Australia’s plain packaging law
does not violate the country’s
commitments to the
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 WTO agreement.
Low Income Middle Income High Income Price
cervical cancers, 10.9% other anogenital, and FIGURE 29.2 Hepatitis B
VACCINES
4.6% oropharyngeal cancers. FIGURE 29.1 Two HPV Cervical cancer cases averted (millions) in vaccination
50% or less 50.1–80% 80.1–90% 90% or more No data
vaccines, a bivalent and a quadrivalent vaccine, 2020–2069 with implementation of screening coverage (% of
have been available since 2006. A third vaccine, a twice per lifetime and 80–100% female-only one-year-olds who
nonavalent vaccine, has been available since 2015. vaccine coverage with nonavalent HPV vaccine, have received three
by Human Development Index level (HDI) doses of hepatitis B
These vaccines, combined with screening, have the
vaccine), 2017
potential to avert millions of cervical cancer deaths
0.1 M cases averted
over the coming decades. FIGURE 29.2 They are given
Following infant
Highly effective as a three-dose or a two-dose series, are highly
effective and safe, and target HPV types 16 and hepatitis B
and safe vaccines 18 (which cause over 70% of all cervical cancers)
and most other cancers that are caused by HPV.
vaccinations in
1984, primary
are available to The nonavalent vaccine targets HPV types 16 and
18 as well as five additional cancer-causing HPV 5.6 M liver cancer among
prevent HBV and HPV types; these seven types cause over 90% of cervical
cancers. In most countries, the target group for
children decreased
infections and HPV vaccination is young adolescent girls; some by up to 75% in
countries also recommend vaccination for boys. 4.0 M Taiwan, China.
associated cancers. The first countries to introduce HPV vaccine
were high-income countries, due to the cost of
Many countries have
vaccines. Middle- and low-income countries started
An estimated 257 million people are living with to introduce vaccines three to six years later.
2.6 M achieved high coverage
of childhood hepatitis B
hepatitis B virus (HBV) infection globally. HBV is By 2019, over 96 countries had introduced HPV
vaccination since its
responsible for nearly 900,000 deaths annually, vaccination. MAP 29.2
introduction in 1982.
including more than 300,000 deaths from
hepatocellular carcinoma (HCC). HCC results from
chronic HBV infection, and the risk of chronic
infection is greatest if transmission occurs during Rwanda has some of the highest 0.2 M
birth or early childhood. The vaccines for HBV cervical cancer rates in the
MAP 29.2
have been available since 1982 as a three-dose world. However, this country
HDI LEVEL
series, and can prevent chronic infection and has achieved greater than 98% Countries that C o v e r a g e ( % )
sequelae including cirrhosis and HCC. As of 2017, coverage in its HPV vaccine target VERY HIGH MEDIUM LOW have introduced
population due to government HIGH Introduced M o r e t h a n 98 00 %
. 1 - 9 0 %
5 0 . 1 5 0 Not
- 8 0 % . 0 introduced
% o r l eN so s d a t a
186 countries had introduced HBV vaccination, the HPV vaccine
96 countries 98 countries
and globally 3-dose vaccination coverage among commitment, school-based by June 2019
delivery, and a strategy to reach (including partial
children reached 84%. MAP 29.1 To prevent mother-
out-of-school girls. Through a scale-up of HPV vaccination introduction)
to-child transmission, the first dose should be
and screening, millions of cervical
given within 24 hours after birth; however, only
cancer cases could be avoided in the
101 countries (55%) had introduced universal HBV
coming decades, particularly in Although the HPV vaccine
vaccine birth dose, and coverage globally was
Rwanda lower-HDI countries. has been introduced
estimated at 43%.
Human papillomavirus (HPV) is the cause into some lower-HDI
of 630,000 cancers annually, 83% of which are countries, most with
the highest burden of
cervical cancer have not
FIGURE 29.1 yet included the HPV
Cancers associated with HPV HPV is responsible for nearly all cervical vaccine in their national
and percent of cases attributable cancers and a substantial proportion of other programs.
to HPV infection anogenital and oropharyngeal cancers.
100% 88% 80% 50% 30% 25%
CERVIX UTERI ANUS VAGINA PENIS OROPHARYNX VULVA
76 canceratlas . cancer . org canceratlas . cancer . org N o t i n t r o d u c e d ( 9I n8 t cr oo du un ct re i de s( 9) 6 c o u n t r i e s ) 77

30 TAKING ACTION
many of the most common cancers including FIGURE 30.1 MAP 30.1 Breast cancer screening in the European Union (EU), 2016 MAP 30.2 Colorectal cancer screening in the EU, 2016
EARLY
breast, skin, and stomach, and in low-resource Recommended activities for early detection
settings where screening may not be feasible. Early of selected cancers
Rollout complete Rollout ongoing Piloting Programs* Rollout Rollout Piloting Planning Rollout Rollout Programs* Non-programs
diagnosis is an important component of any complete ongoing complete ongoing
 Yes
early detection program because not all adults are  No population - based programs non population - based population-based, nationwide population-based, regional non population-based
DETECTION
invited to screening or attend screening, and
SITES OF CANCER EARLY DIAGNOSIS SCREENING
screening programs fail to detect some cancers.
Population awareness, trained healthcare
Breast*  
providers, prompt referral systems, and diagnostic
Cervix   National population-based
and therapeutic infrastructure are necessary for
Colon and rectum*   colorectal cancer screening is
both screening and early diagnosis to function well.
Oral cavity   not yet widespread in Europe.
Nasopharynx  
Larynx  
Early detection Stomach

Skin melanoma




allows more effective ACCESS CREATES PROGRESS Other skin cancers

Urinary bladder




treatment when Programs to raise awareness of breast cancer
and promote clinical breast examination
Prostate  

the cancer is at an in countries where mammography screening
Retinoblastoma 
is not feasible have resulted in more breast Testis  
earlier, much more

cancers being diagnosed at an early stage. Lung  
Esophagus  
curable stage. Ovary 

*Screening for colorectal cancer or using breast mammography
is recommended in high-resource settings only.
 A majority of EU Member
States have implemented
population-based breast
FIGURE 30.2 cancer screening programs.
Detection of some cancers at an early stage
combined with prompt treatment permits less Decreases in cervical cancer incidence rates between
*A program is defined as being established in a documented public screening policy.
aggressive treatment, leading to a better quality 1960–2016, age-standardized rate (world) per 100,000
of life of the patient, and is associated with MAP 30.3
Denmark
significantly reduced mortality. There are two Sweden Cervical cancer
distinct approaches to early detection—screening
Figure 2
Norway screening using
and early diagnosis. Finland National programs Pilot programs No programs
Decreases in cervical cancer incidence rates between 1960–2016, age-standardized rate (world) per HPV DNA testing,
Screening involves systematic examination of
an apparently healthy and asymptomatic
US (SEER 9)
100,000 Cervical cancer incidence rates 2017
population at risk with a test to detect the disease 35 decreased by 50% or more in many
at an early stage. However, implementation is high-income countries following the
introduction of screening with the
quite complex and resource-intensive. Screening
may be population-based (inviting the entire 30
target population at the appropriate intervals) Pap test in the 1960s. The Netherlands
Germany
or opportunistic (at the initiation of the patient or Republic of Georgia
upon invitation at an unrelated clinical encounter). Italy |
25 United States Spain
Turkey
To date, screening of the general population is China
recommended only for cervical, colorectal, and

female breast cancer, depending on resources of Mexico
20 India
the country. MAP 30.1–3 Oral cancer screening is
—Guatemala
recommended for habitual users of tobacco or El Salvador—
—Honduras
alcohol. Lung cancer screening is recommended in |

Nicaragua
Columbia
the United States for current and former heavy 15
Uganda
smokers aged 55–74 years. In addition to detection
Rwanda
at an early stage, screening can prevent cervical
and colorectal cancers through detection and 10
Peru
removal of premalignant conditions. FIGURE 30.2
Early diagnosis is detection of a cancer at the Paraguay
earliest possible stage, usually through patient 5

awareness of the early symptoms of common
Argentina
HPV DNA testing offers many advantages
cancers, and training of healthcare workers to for countries with limited healthcare
recognize and appropriately refer patients with
0 infrastructure. More lower-resource
probable early cancer symptoms. FIGURE 30.1 While 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 countries are adopting this method of
not as effective as screening, it can be used for Year of diagnosis cervical cancer screening.
78 Denmark Norway US (SEER 9) Sweden Finland Series 6 canceratlas . cancer . org canceratlas . cancer . org 79
of nearly 100 million is served by a single

Figure 1
FIGURE 31.1 Number of
Pathologistsper
permillion
millionpopulation,
population,select
select
MANAGEMENT &
radiotherapy center. Newly implementing Pathologists radiotherapy
Zero 0.01–0.50 0.51–0.75 0.76–1.00 1.01 or more No data
radiotherapy (mostly in Africa) and scaling up countries, 2011-2013
countries, 2011–2013 machines per 1,000
coverage (in South-East Asia) will require financial cancer patients
“
TREATMENT
and human resources as well as continuous Benin
Seychelles Zero
technical support. Somalia
Systemic therapy has changed over time, from Niger
administration of chemotherapy to all patients to Madagascar
Chad The chance for a cure,
personalized approaches considering receptor
Sierra Leone Many African the chance to live, should
Existing cost-
status, RNA expression, underlying DNA South Sudan countries have no longer remain an
mutations, tumor environment and immunologic DR Congo accident of geography.
fewer than five
Cameroon
effective interventions
responses. Meanwhile, the cost of cancer drugs pathologists per
Mali — Global Task Force on
continues to rise, with over US$100,000 per Burundi million population.
Expanded Access to
such as surgery, In contrast,
treatment in many high-income countries. Still Mozambique
Zimbabwe Cancer Care and Control
there are many low-cost and effective cancer drugs the United States
in Developing Countries
radiotherapy, and
Zambia
for broad and equitable application in LMICs,
Togo
has almost
which are on the WHO essential drug list. Burkina Faso 50 per million.
access to essential FIGURE 31.2, 31.3

Political will and stewardship at the national
Rwanda
Tanzania
Some countries have no
oncologic drugs can
Angola
level, as well as greater awareness and engagement Senegal radiotherapy machines,
across stakeholders, are necessary to close the Malawi making basic
greatly improve cancer cancer divide. This also requires health system Cote d'Ivoire
Ethiopia
life-saving treatment
for many cancer
improvements critical to addressing the delays in
Radiotherapy
survival worldwide.
Congo
diagnosis and the lack of access to therapy that Uganda patients a prohibitively
lead to disparities in premature death and survival Central African Rep. costly endeavor. can prevent one
between countries. Evidence-based guidelines to Mauritania
Nigeria Figure 2 out of five deaths
Cancer management starts with obtaining a valid perform phased implementation are provided by Ghana
among cervical
diagnosis. However, lack of diagnostic imaging and the National Cancer Control Network according to Gabon
Breast cancer recurrence and mortality improvements with tamoxifen
pathologists are major barriers to receipt of high- different geographic regions. FIGURE 31.4 Kenya cancer patients.
quality oncologic care in many parts of the world.
Namibia treatment, 15 years later
Botswana
FIGURE 31.1 Indeed, 8 million people die annually due South Africa
FIGURE 31.2
to poor-quality care in low- and middle-income United States RECURRENCE MORTALITY
Breast cancer recurrence Certain cancer
countries (LMICs), including many due to cancer. 0 5 50
and mortality (%) therapeutics have
Surgery is needed for 80% of early-stage
with and without 0 m Noatamoxifen
c h i n 0e 46%
.s 0 1 - 0 . 500. 5 1 - 0 . 705. 7 6 - 1 . 0 1 0. 0 1 o r m o Nr eo d a t agreatly improved cancer
cancer patients, and as a palliative measure for a FIGURE 31.3 A substantial proportion of
canceratlas.cancer.org No tamoxifen outcomes. For example,
5 initial years of
substantial proportion of late-stage cancer patients.
Cancer therapy included on the World Health countries do not include major tamoxifen treatment, 33% tamoxifen endocrine
However, surgery is only delivered to one in four therapy for hormone
Organization essential medicines list, and the cancer therapies on 15 years after diagnosis
eligible patients globally due to infrastructure receptor-positive
proportion of countries including the medication their national essential
and workforce limitations, as well as lack of on their national essential medicines list medicine list. breast cancer patients
affordability, particularly in LMICs. Furthermore, 5 years tamoxifen treatment 33% substantially reduces
although specialized surgery performed by an MEDICINE PERCENT (OF 135 COUNTRIES) USED FOR THE FOLLOWING CANCERS 5 years tamoxifen treatment local recurrence
oncologic surgeon is crucial to patient outcomes, 24% and disease-specific
due to shortages of these specialists, cancer mortality.
Methotrexate 95% Breast, bladder, leukemia, sarcoma
patients in LMICs usually receive surgery from a
general surgeon. As surgery is a key contributor Cyclophosphamide 89 Breast, lymphoma
to improving the survival of cancer patients, the Tamoxifen 83 Breast FIGURE 31.4
inequities in LMICs must be tackled. Vincristine 82 Lymphoma, acute leukemia, sarcoma Initiatives to improve access and quality of cancer care in low- and middle-income countries
Radiotherapy is indicated for about 60% of
Fluorouracil 81 Breast, gastrointestinal
cancer patients to relieve symptoms (palliative NATIONAL CANCER CONTROL NETWORK (NCCN) DISEASE CONTROL PRIORITIES 3: CANCER LANCET JOURNAL COMMISSIONS
Doxorubicin 73 Breast, lymphoma, sarcoma, bladder
treatment), shrink tumors before surgery, or kill Resource stratified guidelines help to define appropriate treatment Disease Control Priorities provides a periodic review of the most Responding to the Cancer Crisis: Expanding Global Access to
remaining cancer cells after surgery to avoid Cisplatin 72 Lung, head & neck, ovary, osteosarcoma, cervix pathways based on available resources—Basic, Core, Enhanced, up-to-date evidence on cost-effective interventions to address the Radiotherapy: This Commission presents research that quantifies
recurrence. For example, within 5 years after a Bleomycin 70 Germ cell tumor, Hodgkin lymphoma and NCCN Guidelines®—and deliver a tool for healthcare providers burden of disease in low-resource settings. This textbook provides canceratlas.cancer.org
the worldwide coverage of radiotherapy services by country, also
diagnosis of cervical cancer, radiotherapy prevents to identify treatment options that will provide the best possible evidence for investments in cancer control, from prevention to providing evidence that investment in radiotherapy not only enables
Cytarabine 65 Acute leukemia
outcomes given specific resource constraints. treatment, worldwide. treatment of large number of cancer cases to save lives but also
recurrence in 1 in 3 patients and death in 1 in 5
Hydroxycarbamide 65 Chronic myeloid leukemia brings positive economic benefits.
patients. Radiotherapy coverage is less than Regional guidelines are targeted regional resources created as
THE NATIONAL ACADEMIES OF SCIENCES, ENGINEERING, AND MEDICINE
Mercaptopurine 64 Acute lymphocytic leukemia part of a collaborative effort to combat skyrocketing cancer rates Global Surgery: This Commission describes the role of surgical and
optimal in many LMICs, with about one-third in
and unique care circumstances. They represent both the optimal The report “Crossing the Global Quality Chasm: Improving Health anesthesia care in improving health and economic productivity.
Africa, about two-thirds in Asia Pacific, and Calcium folinate 62 Colorectum
care that low- and mid-resource countries aspire to provide, and Care Worldwide” examines the global impacts of poor-quality health It presents findings on the state of surgical care in LMICs, as well as
around 90% in Europe and Latin America. Chlorambucil 62 Chronic lymphocytic leukemia pragmatic approaches that provide effective treatment options for care and recommends measures to improve quality while expanding recommendations, indicators, and targets needed to achieve the
MAP 31.1 In Ethiopia, for example, a population resource-constrained settings. universal healthcare coverage, particularly in low-resource areas. vision of universal access to safe, affordable surgical and anesthesia
Etoposide 62 Lung, ovary, germ cell tumor
care when needed.

32 TAKING ACTION
Essential medicine lists of the World Health MAP 32.1
PAIN
Organization and many countries include opioid
Untreated deaths in pain, 2016 Zero 1–1,598 1,599–5,270 5,271–13,604 13,605 or more No data
analgesics, such as morphine. The moderate or
severe pain experienced by approximately 80% of
people with advanced cancer cannot be relieved
CONTROL
without them.
But access to opioid analgesics is limited in
low- and middle-income countries, where 85% of
the world’s population consumes just 7% of the
medicinal opioids. FIGURE 32.2 Legal and regulatory
restrictions, cultural misperceptions about pain, Iceland
Sweden
inadequate training of healthcare providers, poorly Russia
Norway Finland ACCESS CREATES PROGRESS
functioning markets, weak health systems, and
Millions of cancer
Canada Estonia
concern about addiction and non-medical use all United
Kingdom Denmark
Lithuania
Latvia The Pain-Free Hospital Initiative,
contribute to limited access, even though
patients, almost Ireland
Netherlands
|
Russia—
Belarus
a one-year hospital-based
morphine, the most effective treatment for severe Belgium
Germany Poland
health worker training initiative
Czechia
entirely in low- and

pain, is safe, effective, inexpensive, and easy to use. Lux.—
Slovakia Ukraine
Kazakhstan Mongolia designed to improve the
Austria Hungary
Meanwhile, some high-income countries are Swit.
Slovenia— Croatia
Moldova quality of pain assessment and
France Romania
treatment, resulted in a tripling
middle-income
Bos. & Herz.
dealing with a very different challenge related to Montenegro— Serbia Bulgaria Georgia Uzbekistan
Kyrgyzstan
DPR
Korea
Andorra— | Japan
pain relief, as rates of addiction continue to rise United States of America
Portugal
Monaco
Albania N. Macedonia
Armenia—
Azerbaijan of the use of essential pain
Spain Turkmenistan
Turkey Tajikistan
medications and a
countries, lack
Italy
due to harmful and non-medical use of opioids. Greece Rep. Korea
—Malta China 25% decrease in average pain
Worldwide, the number of cancer patients in Cyprus— Syria
Tunisia Lebanon— Afghanistan scores in the oncology unit after
access to essential
Iraq Iran
need of pain relief is projected to increase 48% Palestine— Jordan
Morocco —Israel Pakistan being implemented at
from 2018 to 2035, but the increase is likely to be Kuwait— Nepal
Kenyatta National Hospital
pain medicines.
Algeria Bahrain— Bhutan
considerably higher in the regions with more —Bahamas Libya Egypt
—Qatar
in Nairobi, Kenya.
Bangladesh
UAE
rapidly increasing cancer rates and with the lowest Mexico Cuba Saudi Arabia India Myanmar Lao
access to pain relief, including South-Eastern Asia Haiti —Antigua & Barbuda PDR
Jamaica—
—Belize | Cabo Verde Mauritania
(projected 54% increase in cancer cases) and Africa Honduras Dominican | | Mali
Niger
Oman
FIGURE 32.3 Rep. St. Kitts |
& Nevis Dominica —St. Lucia
Senegal Eritrea
Yemen
Thailand Viet Nam Philippines
(72% increase), where consumption of pain relief is Guatemala
| St. Vin. & Gren.— —Barbados Chad Sudan
Nicaragua Gambia—
Untreated deaths in pain by region, 2016 El Salvador —Grenada Burkina
—Djibouti
sufficient to cover less than 25% of deaths in pain. —Trin. & Tob.
Guinea-Bissau Guinea
Faso Cambodia
Benin
Costa Rica
East Asia & Pacific FIGURE 32.3 A balanced approach to access to opioids Venezuela Côte Nigeria
Ethiopia Sri Lanka |
Panama Guyana Sierra Leone d’Ivoire Ghana Central South —Palau
Micronesia
South Asia with sufficient measures to prevent harmful and Liberia
|
Togo
African Rep. Sudan
Brunei Dar.—
Colombia Suriname Cameroon Maldives—
Sub-Saharan Africa non-medical use has been achieved by many Malaysia
|
Marshall Is.
Equatorial Guinea—
Uganda Singapore—
Europe & Central Asia Western European countries and in some low- and Sao Tome & Principe— Congo
Kenya Somalia Nauru
Gabon |
Rwanda— Papua New Guinea
Latin America & Caribbean low-middle income countries. Ecuador
|
Kiribati
—Burundi — Seychelles
Middle East & North Africa DR Congo Indonesia
Tanzania
North America* Solomon Is.
Peru —Timor-Leste |
FIGURE 32.2 FIGURE 32.1 —Comoros
Brazil Angola
9 5K Malawi Tuvalu—
K Total cancer and HIV deaths in pain and Untreated deaths in
109 Zambia Madagascar
Samoa—
those treated for pain, by income level, 2016 pain due to HIV and
92 Vanuatu—
1K Bolivia
cancer, 2016 Zimbabwe Fiji— Niue—
Namibia
1K
24
Mozambique — Mauritius
Treated deaths in pain, based on opioid consumption Tonga— Cook Is.—
Botswana
700k
651,867
Total deaths in pain due to cancer or HIV, treated and untreated Paraguay
—Eswatini
Three quarters of Australia
untreated deaths in
—Lesotho
600k S. Africa
HIGH INCOME Argentina
High Income
99.9% Uruguay
pain occur in just
500k
ten countries
2,091,578 Treated deaths
2,094,499 Total deaths Chile
86% of untreated
578
High Income 400k

Middle Income deaths in pain are
K
MIDDLE INCOME in middle-income Almost all untreated deaths in pain

New Zealand
High Income countries. 300k due to cancer and HIV are in

57%
“
Middle Income
Low Income 3,022,701 Treated deaths low- and middle-income countries.
714K 5,306,664 Total deaths 200k
Middle Income
The greatest numbers of Low Income
Improved access to oral morphine is
untreated deaths in pain are in East LOW INCOME 100k
mandatory for the treatment of moderate to
Asia and the Pacific; South Asia; 17% severe cancer pain, suffered by over 80%
and sub-Saharan Africa. Low Income 76,163 Treated deaths of cancer patients in terminal phase. 0
447,538 Total deaths China India Russian Nigeria Indonesia Pakistan Bangladesh Philippines Mozambique Egypt
*Zero untreated deaths in pain in North America, 2016. — World Health Organization Federation

0 1 - 1 , 5 9 81 , 5 9 9 - 5 , 25 7, 20 7 1 - 1 3 , 16 30 , 46 0 5 o r m No or ed a t a
31 cancer registries in 28 countries. The most control programs as well as for research. As with Availability of
CANCER
recent volume (Volume XI), covering 2008–2012, cancer registry data, the availability and quality of population-based
High quality PBCR PBCR Registration activity No coverage
has data from 343 registries in 68 countries. The death certificate information varies widely, with cancer registry
Global Initiative for Cancer Registry Development many low- and middle-income countries having data, 2019
SURVEILLANCE
(http://gicr.iarc.fr) was established by the either poor quality data or a complete absence of
International Agency for Research on Cancer vital registration. MAP 33.2
(IARC) in 2011 in partnership with international In many countries, mortality data complements
and national organizations aiming to improve the the cancer registry database as a means to identify
availability of high-quality cancer registry data a patient’s status (alive or dead) to estimate
High-quality cancer
via support for within-country capacity building. cancer survival. Survival studies remain sparse
Reliable cancer Six IARC Regional Hubs and accompanying in many transitioning countries, in part due to
incidence data are
lacking in many
incidence and mortality

IARC Collaborating Centres work with local the absence or low quality of national mortality
“
countries of Latin
and regional partners to provide direct support information systems. Cancer survival is
America, Africa,
data are essential

to registries, deliver training, conduct research, nevertheless a key indicator of the effectiveness and Asia.
and develop networks. of cancer services in a country or region, and a
Population-based cancer
to cancer control. To
Cancer mortality data, predominantly collected positive measure of prognosis that can reflect the
registries are the backbone
through vital registration systems, are also prospects of clinical cure.
of national cancer control
better equip countries,
important for planning and monitoring cancer
planning. Over time, quality
cancer data drives changes in
a global strategy health services that ultimately

improve patient outcomes.
In the early 1960s, there were only 31 high quality
is underway to population-based cancer registries in 28 countries.
— Dr. Tomohiro Matsuda, Chief,
strengthen capacity
National Cancer Registry Section,
This number has increased to 343 registries in National Cancer Center, Japan;
President,International Association
in cancer surveillance, 68 countries in 2008–2012, providing essential data of Cancer Registries
for health planning and prioritization.

prioritizing support
in low- and middle- FIGURE 33.1 While population
MAP 33.2
Figure 1
income countries.
Quality of mortality
Coverage (%) of high- Oceania coverage of high-quality registration
cancer registries has High Medium Low Very low No coverage
quality population- North America worldwide, H i g h q u a l i t y PP BB CC RR R e g i s t r a t i o n N a o c it ni vf oi t ry m a t i o n
based cancer registries Europe increased in North 2007–2016
Reliable cancer data are essential for planning by period and world World America, Oceania, and
100
and monitoring the effectiveness of cancer region, as published in South America Europe, it remains low in
control programs, for examining cancer care Cancer Incidence in Asia South America, Asia,
delivery patterns, and other types of research. 5 Continents Africa and Africa.
Population-based cancer registries (PBCRs) fulfill
this requirement by systematically collecting 80
Mortality
cancer incidence data for defined populations.
registration is
This includes information on patient and tumor
largely non-existent
characteristics at diagnosis, as well as additional
in Africa and large
Total population covered (%)
information including receipt of treatment and

parts of Asia.
vital status where resources permit. 60
Cancer registry data are primarily used to
describe the scale and profile of the cancer burden CANCER INCIDENCE IN FIVE CONTINENTS
and changes in cancer patterns across time and Population-based cancer registries are represented
throughout the world by the International The Global Initiative for
geographic areas. A PBCR may cover an entire
Association of Cancer Registries (IACR) 40 Cancer Registry Development
country, but most cover smaller regions within (http://www.iacr.com.fr/), an organization founded
a country, particularly in large or resource-
(GICR) is the first strategy
in 1966 that establishes standards and provides
to support cancer surveillance
constrained countries. Registry quality varies opportunities for cancer registry professionals to
meet, exchange information, and receive training.
worldwide. Together with
widely by geographic region. MAP 33.1 its partners, the GICR aims
High-quality cancer incidence data from registries
Although there are significant disparities in the 20 to provide measurable
worldwide are published by the International
status, population coverage, and quality of cancer WORLD improvements in the quality,
Agency for Research on Cancer and IACR in Cancer
registries worldwide, the number of high-quality Incidence in Five Continents (CI5) (http://ci5.iarc.fr), availability, and use of cancer
cancer registries is increasing. FIGURE 33.1 Volume I now in its 11th volume, to enable the international registry data.
comparison of cancer incidence rates across
of the Cancer Incidence in Five Continents series,
populations and time.
covering the early 1960s, included datasets from 0
1960 1970 1980 1990 2000 2010

34 TAKING ACTION
include lack of funds, competing disease priorities, FIGURE 34.2 FIGURE 34.3
RESEARCH
weak infrastructure, and work load and protected Cancer publications (2002–2013) compared with gross domestic Percent (%) of gross domestic product (GDP)
time to do research. For example, expenditure Africa accounts product (GDP) for 31 European countries spent on research, 2016 estimates, select countries
on science and technology research represents
less than 1% of gross domestic product in many
for less than
low-income countries, compared to over 2.5% in 1% of worldwide
100k A greater percentage of
several high-income countries. FIGURE 34.3 However, research publications, GDP is spent on research in
but nearly
there is renewed commitment from private and — Germany
Figure 3higher-HDI countries.
Each country and
Netherlands
public institutions in high-income countries to help
build sustainable research capacity in low-income 15% of the |
Percent of gross domestic product spent on
locality needs cancer

research, 2016 estimates, select countries
countries through north-south partnerships. world’s population. 10k |
Spain Israel
In addition to regional variation in
research tailored publication output, there is a mismatch between

Croatia
Rep. Korea
Sweden
No. of papers (2002-2013)

cancer research output/funding and societal
to local disease
|
cancer burden. Some common cancer sites, such Japan
as pancreas and lung in the United States and 1k Austria
burdens and knowledge Europe, are under-funded and under-studied

compared to less common cancers. FIGURE 34.4
Iceland
Germany
Denmark
gaps to improve
|
Further, in many countries the bulk of research Finland
Cancer publications increase
funding is allotted to basic science, with very
population health. — Luxembourg with a country’s USA
little to cancer prevention and control research. 100
gross domestic product. Belgium
Increased cancer research tailored to local | France
disease burdens and knowledge gaps is needed Cyprus
China
For national or regional cancer control programs, for continuous improvement of population
Iceland
research is an essential component of planning, health in each country and locality. In low- and ACCESS CREATES PROGRESS
10 Netherlands
implementation, and monitoring the program’s middle-income countries, research should 10 100 1k 10k
International research collaborations such as Norway
effectiveness. In addition, research improves focus on identifying local, common risk factors GDP 2007-2008 ($ billions)
the African Research Group for Oncology, a United Kingdom
patient outcomes and creates national wealth (for example, local alcoholic brews), evaluating partnership between hospitals and universities
through innovation. However, bibliometrics reveal preventive interventions, and conducting in Nigeria, the United States, and the United Canada
a large disparity in research activities across implementation and operational research. Kingdom, can advance cancer knowledge and FIGURE 34.4 Italy
provide evidence and data for making health Brazil
countries. FIGURE 34.1, 34.2 The United States and a Research in high-income countries should also Research priorities by cancer site in number of publications, proportion of US National Cancer Institute
policy decisions.
few wealthy European countries account for the focus on implementation research as well as (NCI) funding* (2012), and disability-adjusted life years (DALYs, 2011) Portugal
Lung
majority of publications. biological markers and precision medicine. Spain
10k Breast
Barriers to development of strong, sustainable Russia
Colorectum
cancer research output in low-income countries Greece
Prostate
Liver UAE
Pancreas Croatia
FIGURE 34.1
8k Leukemia Thailand
Cancer publication trends by number of papers, 2010 vs. 2017, select countries
Brain & CNS Egypt
United States 35,870
35,870 46,701
46,701 NHL Argentina
Ovary
Breast Mexico
China 10,399
10,399 33,150
33,150 12% funding Ukraine
6k 7,833 publications Costa Rica
10% DALYs
No. of publications
Japan 8,545
8,545 10,653
10,653 Uruguay
Between 2010 and 2017,
cancer publication Chile
United Kingdom 7,427
7,427 9,800
9,800
output in China Lung Cuba
more than tripled. 6% funding Jordan
4k 5,382 publications
Brazil 1,379
1,379 2,700
2,700 Chad
24% DALYs
Georgia
“
Mexico 472
472 998
998 —Liver The cancer sites associated with Colombia
1% funding
2,924 publications
the greatest number of DALYs lost do not Oman
South Africa 217
217 509
509 2k 4% DALYs receive the greatest research funding Armenia
All nations should be producers or number of publications. Paraguay
Chile 158
158 382
382
and users of research.
Kazakhstan
— The World Health Report 2013 Peru
Nigeria 104
104 231
231 Iraq
0
0 10 20 30 0 1 2 3 4 5
Kenya 26
26 72
72
Proportion of DALYs *Total NCI budget in 2012 is $5.07 billion

k
0
5k
3k
5k
6k
5k
9k
k
.5
.5
12
.5
15
.5
18
.5
21
.5
24
.5
27
.5
30
.5
33
.5
36
.5
39
.5
42
.5
45
.5
48
.5
51
1.
4.
7.
-1
10
13
16
19
22
25
28
31
34
37
40
43
46
49
35 TAKING ACTION
Cancer results in economic burden for patients, Productivity losses due to premature deaths vary FIGURE 35.3 Economic cost of smoking-attributable diseases annually
THE ECONOMIC
healthcare systems, and countries due to in transitioning countries. FIGURE 35.2 (healthcare spending and productivity losses)*
healthcare spending, and productivity losses from Cancer treatment costs are increasing
morbidity and premature mortality. Economic worldwide, making prevention and screening Smoking results in trillions of dollars of
losses globally due to health care spending
BURDEN
analyses can inform resource allocation decisions efforts more cost-effective and sometimes
and investments in cancer control programs, cost-saving. For example, when more expensive and lost productivity each year.
including prevention, early detection, treatment, chemotherapies were considered in comparisons CANADA
US$ 28.7 B
OF CANCER
survivorship, and end-of-life care. of colorectal cancer screening to no screening,
The global economic burden of cancer is treatment savings from preventing advanced
FRANCE
unknown, although data are available in some cancer and death more than doubled in the US.
countries. In the US in 2017, estimated cancer Vaccination against human papillomavirus
UNITED STATES US$ 64.2 B TURKEY
US$ 544.3 B CHINA
healthcare spending was US$161.2 billion; infection, which is responsible for most cervical MOROCCO US$ 45.1 B US$ 124.2 B
US$ 4.9 B
The economic burden
productivity loss from morbidity, US$30.3 billion; cancers, in 73 countries supported by Gavi, the
and premature mortality, US$150.7 billion. Vaccine Alliance, could avert nearly $5.6 billion in ALGERIA INDIA
US$ 7.0 B
of cancer is substantial US$ 136.2 B
The economic burden of cancer in the US is treatment costs and productivity losses between
approximately 1.8% of gross domestic product 2001–2020. Smoking is a strong risk factor for lung
ETHIOPIA
in all countries and
(GDP). In the European Union, healthcare and other cancers. The cost of smoking globally COTE D’IVOIRE
spending was €57.3 billion, and productivity losses is nearly $2.05 trillion annually, almost 2% of the US$ 0.3 B US$ 0.2 B
reflects health care

due to morbidity and premature death were €10.6 world’s economic output. FIGURE 35.3 Most of this
“
billion and €47.9 billion, respectively. With cost is productivity losses from premature death. BRAZIL
spending as well informal care costs of €26.1 billion, total burden

rose to €141.8 billion, 1.07% of GDP. FIGURE 35.1
US$ 50.2 B
as lost productivity Requests will always exceed resources.

Doing good is imperative.
due to morbidity and FIGURE 35.1 Doing everything is impossible.
Total costs of cancer in billions of Euro The cost of cancer varies widely in
premature death from including cancer care and productivity European Union countries, reflecting
— J. Grant Howard, Balancing Life’s Demands:
A New Perspective on Priorities
losses in 2009, select European countries* differences in population size, age
cancer. As cancer distribution, healthcare delivery
systems, employment patterns and
treatment costs wages, and cancer incidence and FIGURE 35.2 Productivity losses due to premature deaths from cancer
in transitioning economies*
mortality rates.
increase, prevention
and early detection UNITED KINGDOM
SOUTH AFRICA BRAZIL INDIA CHINA
US$ 108,320 US$ 57,186 US$ 21,096 US$ 61,594

efforts become more
COST PER CANCER DEATH
€ 16.2 B
THE NETHERLANDS
cost-effective, and 0.49% 0.21% 0.36% 0.34%
TOTAL COST AS % OF GROSS DOMESTIC PRODUCT
€ 7.1 B
GERMANY
US$ 2.0 B US$ 5.0 B US$ 7.2 B US$ 30.0 B
potentially cost-saving. BELGIUM TOTAL PRODUCTIVITY LOSS
€ 39.5 B
€ 3.6 B CZECHIA
€ 1.5 B
FRANCE
The economic burden € 19.0 B Productivity losses due to cancer represent
a large economic burden in transitioning
of lost productivity due to economies. Variation reflects population size,
morbidity and premature ITALY
employment patterns, wages, and cancer ACCESS CREATES PROGRESS
death from cancer mortality rates.
€ 18.5 B
Vaccination against human
is nearly 60% of the total SPAIN papillomavirus infection in
economic burden associated € 10.1 B 73 countries supported by
Gavi, the Vaccine Alliance,
with cancer in European could avert nearly US$5.6
Union countries. billion in treatment costs and
productivity losses between
2001–2020.
*For details on inflation adjustment, see Sources and Methods, page 124.

and control. Adequately funded and staffed integration at the country level. For example, the Cervical cancer
BUILDING
National Cancer Control Plans are the best International Cancer Control Partnership was incidence, age-
1.9–9.6 9.7–17.8 17.9–29.1 29.2–45.5 45.6–75.3 No data
approach to address the cancer burden in the formed by the US National Cancer Institute and standardized
existing health context. FIGURE 36.2 the Union for International Cancer Control to rate (world) per
100,000, 2018
SYNERGIES
The growing cancer burden in low- and middle- support country development of national cancer
income countries necessitates building on existing plans or to encourage countries to include
infrastructure. MAP 36.1 & 2 In Rwanda, cervical cancer control activities within their NCD plan. Among women
cancer control has been successfully integrated into The International Cancer Control Partnership
women’s health services. In Kenya, leaders built on portal (https://www.iccp-portal.org) contains
with HIV,
the existing HIV-treatment infrastructure to screen resources for plan development, including examples 10%–40% have
Building synergies and treat women for cervical cancer. The American of plans that integrate across the health system. prevalent cervical
between diseases
Society for Clinical Oncology* trains primary care Essentially, cancer cannot be addressed alone.
physicians in countries with limited oncology It shares many common risk factors with other
precancerous
lesions, and
as well as health
infrastructure to recognize the signs and symptoms NCDs, and the health systems that work to
of cancer, and to better integrate cancer services prevent and treat NCDs as well as infectious
1.3%–1.7% are
systems improves
into existing resources. Partners who can help diseases can be leveraged to effectively incorporate
country planners see the whole health landscape, cancer control. diagnosed with
invasive
cancer prevention
including cancer, are critical in supporting this
cervical cancer.
and treatment. FIGURE 36.2
“
Countries with national cancer control and
noncommunicable disease (NCD) plans (%), 2015
In 2011, the global community adopted the Global
National cancer control plan + NCD plan
Action Plan (GAP) for the prevention and Control Figure 2 The transformed health systems
Only NCD plan
of Non-communicable Diseases (NCDs). The GAP National cancer control and noncommunicable disease plans, 2015established through investment
Only national cancer control plan
urged countries to set national targets to address in HIV programming in
No national cancer control plan or NCD plan 1 sub-Saharan Africa present a
premature death from four major NCDs (cancer, 41
17 unique opportunity for countries
cardiovascular disease, diabetes, and respiratory
to tackle the rapidly rising
disease). Built into the GAP is the opportunity to A growing number burden of NCDs. MAP 36.2
address various risk factors across NCDs that of countries have
contribute to premature mortality, known as “best national cancer TYPE OF — Wafaa M. El-Sadr, Director, International HIV prevalence
Note: skipped Cervix color #3 and used 5, 6
control plans, PLAN Center for AIDS Care and Treatment (%), both sexes,

buys”. FIGURE 36.1 In addition to focusing on these 1.0% or less 1.1–2.5% 2.6–5% 5.1–10% 10.1% or more No data
Programs; and Eric Goosby, UN Special
proven strategies, countries can turn to successful noncommunicable 2017
A g e - s t a n d a r d i z e d r a t e ( w o r l d ) p e r 1 0 0 , 0 0 0
Envoy on Tuberculosis and former
programs in maternal and child health and HIV disease plans, US Global AIDS Coordinator
or both. 1 . 9 - 9 . 6 9 . 7 - 1 7 . 81 7 . 9 - 2 9 .2 1 9 . 2 - 4 5 .4 5 5 . 6 - 7 5 . N
3 o d a t a
41
prevention and control, among others, to reach the

target population to promote cancer prevention
FIGURE 36.1
“Best buy” interventions to reduce
Addressing multiple risk factors can reduce the overall
noncommunicable diseases and contribute
noncommunicable disease
National cancer control plan burden
+ non-communicable diseaseand
plan premature mortality.
to Sustainable Development Goal 3.4

“Best buys” are a set of affordable,
Only non-communicable disease plan
Only national cancer control plan
feasible and cost-effective
intervention
No national cancer control strategies to achieve
plan or non-communicable disease plan these goals.
→ Because there are

many parallels between
GOAL 3.4 REDUCE TOBACCO USE REDUCE HARMFUL REDUCE UNHEALTHY REDUCE PHYSICAL MANAGE PREVENT AND the burdens of HIV and
USE OF ALCOHOL DIET INACTIVITY CARDIOVASCULAR MANAGE CANCER cervical cancer, and women
By 2030, reduce by ‑Tax increases
DISEASE (CVD) AND with HIV are at increased
one third premature ‑Smoke-freeindoor ‑Tax increases ‑Reduced salt intake ‑Public
awareness ‑Hepatitis B
mortality from workplaces and public ‑Restricted access in food through mass media
DIABETES
immunization to risk of cervical cancer, an
non-communicable places to retailed alcohol ‑Replacement of on physical activity ‑Counseling and prevent liver cancer opportunity exists
diseases (NCDs) ‑Health
information ‑Bans on alcohol trans fat with multi-drug therapy for ‑Screening and to integrate cervical cancer
and warnings polyunsaturated fat people with a high risk treatment of pre-
through prevention advertising screening into existing
and treatment and ‑Banson tobacco ‑Public awareness of developing heart cancerous lesions
through mass media attacks and strokes to prevent cervical HIV care services.
promote mental advertising, promotion
and sponsorship on diet (including those with cancer
health and well-being. established CVD)
‑Treatmentof heart
attacks with aspirin *https://www.asco.org/international-programs/international-meetings-educational-opportunities/cancer-control-primary-care

37 TAKING ACTION
the foundation for the prevention and control of MAP 37.1 Small SIZE OF CIRCLES REPRESENTS NUMBER OF UICC ORGANIZATIONS Large
UNITING
cancer in their countries. MAP 37.1 A global network of cancer organizations
The 2017 World Health Assembly cancer 1 190
resolution entitled “Cancer prevention and control There are over
1,100 Union for
ORGANIZATIONS
in the context of an integrated approach” (WHA
70.12) aligns national cancer control with the International Cancer
growing dialogue on universal health coverage, Control (UICC)
emphasizing the links and opportunities for
members in
170 countries. GLOBAL
integration across health platforms to deliver sus- INTERNATIONAL SOCIETY OF NURSES
tainable cancer care and stronger health systems.
A cancer community
IN CANCER CARE (ISNCC)
The resolution also emphasizes the importance
Canada UNION FOR INTERNATIONAL Iceland
Finland The International Society of
Norway
united behind
of partnerships where these are fundamental to Russia
CANCER CONTROL (UICC), Sweden Nurses in Cancer Care (ISNCC)
achieving the SDGs by 2030. FIGURE 37.2 represents over 60,000 oncology nurses and
based in Geneva, is the largest Estonia
implementation of the and oldest international cancer United Latvia focuses on maximizing and promoting the role
Denmark
Kingdom Lithuania of nurses in improving cancer care.
organization dedicated to Netherlands Belarus
Ireland
commitments from
|
Germany Poland
taking the lead in convening, Belgium
Czechia
capacity building, and advocacy Lux.—
—Slovakia Ukraine Kazakhstan Mongolia
MEXICO Austria Hungary
the World Health

initiatives that unite and support Swit.
Slovenia— Romania
JUNTOS CONTRA EL CÁNCER France Croatia
the cancer community to Serbia
“
Bulgaria
United States Italy Georgia Kyrgyzstan
Assembly 2017 cancer More than 50 civil society of America reduce the global cancer Spain
N. Macedonia
Azerbaijan Japan
Portugal Turkey Tajikistan Rep. Korea
organizations from Mexico burden, promote greater equity, Greece |
Armenia China
resolution will harness

have created the “Juntos and ensure cancer control Malta
Cyprus— Syria
Afghanistan
Tunisia
Contra el Cáncer” (Together Against Cancer) continues to be a priority in Lebanon— Iraq Iran We unite and support the cancer community
Morocco Israel— Jordan
coalition to position cancer in the national the world health and
the political drive for
Pakistan
Kuwait Nepal to reduce the global cancer burden, to
health agenda and be the voice of patients in development agenda. Algeria
Egypt
Bahrain— promote greater equity, and to ensure that
the country. Bahamas —Qatar
Mexico
real national impact.
Saudi Arabia UAE
Bangladesh cancer control continues to be a priority in the
India
Cuba
Puerto Rico
|
Myanmar world health and development agenda.
Oman Lao
Haiti Mauritania PDR
Jamaica— —Guadeloupe
|
—Belize Dominican —Martinique Mali Niger Viet Nam — HRH Princess Dina Mired, President,
Guatemala Rep.
Honduras Chad
Sudan Yemen Thailand Union for International Cancer Control
Senegal
Now is the time to drive national action to FIGURE 37.1 Treatment for All, an advocacy | Nicaragua Barbados
Burkina Cambodia
El Salvador Philippines
Faso —Djibouti
reduce cancer deaths. Governments are following campaign run by UICC Costa Rica —Trin. & Tob. Guinea Benin
Panama Nigeria Ethiopia
up on major global commitments including Venezuela
Sierra Leone Côte Ghana
d’Ivoire |
Togo
the Sustainable Development Goals (SDGs), the Guyana Cameroon
Maldives
Colombia
United Nations (UN) Political Declaration on TREATMENT FOR ALL |
Suriname
Malaysia
Uganda Singapore—
Kenya
the Prevention and Control of non-communicable Ecuador
Gabon— Congo
Rwanda—
Indonesia
diseases (NCDs), and the 2017 World Health
Assembly cancer resolution, which outlines a clear
DR Congo —Burundi
Tanzania
National, regional,
and global collaborations
Papua New Guinea
roadmap to scale up action on cancer control, Peru
Brazil
irrespective of income level. Because cancer knows
Zambia Malawi
—Comoros
have demonstrated
no borders, cooperation is necessary to reduce the Improved cancer Access to early Timely and Supportive
the value and impact of
Samoa
data for public detection and accurate and palliative Bolivia Mozambique
burden of cancer nationally and internationally. Zimbabwe
health use diagnosis treatment care
multisectoral engagement
Madagascar
Fiji
FIGURE 37.3 Working in partnership has benefits Mauritius
Namibia Botswana
such as amplifying cancer control initiatives and
Treatment for All aims to decrease the 4.3 million premature deaths from
Paraguay
in cancer control.
bringing them to the attention of key decision- cancer worldwide through a global campaign engaging a growing network of
S. Africa Australia
makers, expanding the reach and scale-up of motivated national cancer organizations intent on helping governments fulfill
interventions, stimulating idea generation and FIGURE 37.2
their obligations to deliver a 25% reduction in premature deaths through Uruguay
peer-to-peer support, and shaping cancer policies cancer and other NCDs by 2025. UICC is working with its members in Argentina Multisectoral collaboration in cancer control
that can leave a long-lasting footprint around the countries to help them develop an advocacy plan to address a specific priority Chile
related to one of the four levers for change on cancer treatment and care.
CITY CANCER CHALLENGE (C/CAN) is building a collective movement THE NCD ALLIANCE unites over 2,000 civil society organizations
world. The global cancer community—including
of cities, bringing together civil society, private companies, professional to raise the profile of non-communicable diseases (NCDs) as a
the UN, WHO, Ministries of Health, national associations, and government. City Cancer Challenge is engaging all development priority. ncdalliance.org
cancer institutes, cancer societies, research and city stakeholders in the design, planning, and implementation of cancer
FIGURE 37.3 treatment solutions. citycancerchallenge.org UICC, NGOS, AND UN AGENCIES are uniting behind WHOs ambitious New Zealand
treatment centers, academia, patient support
call to eliminate cervical cancer. The challenge is high coverage
groups, appropriate private sector, and survivors at Creative opportunities INTERNATIONAL CANCER CONTROL PARTNERSHIP (ICCP) is helping of HPV vaccination, high coverage of screening, and access to
the local, national and global levels—is collaborating to convene stakeholders governments to develop and implement effective national cancer control diagnosis, treatment, and care of invasive cancers for all. who.int/
on a broad spectrum of activities that support within and beyond the plans. iccp-portal.org reproductivehealth/call-to-action-elimination-cervical-cancer/en/ These innovative and strategic
cancer surveillance, early detection, treatment cancer community This high-level policy The biennial World Cancer World Cancer Day
FRAMEWORK CONVENTION ALLIANCE is supporting global tobacco eHOSPICE is a palliative care advocacy network that includes
partnerships are working to
and care, and the delivery of palliative care.
meeting is an opportunity
to reach key decision-
N u m
Congress provides a
forum for cancer control
b e r o f U
(February 4) unites the
entire world in the global
I C C m e m b e r o r g a n
control efforts through the WHO Framework Convention on Tobacco i care
palliative z organizations
a t from i ocountries
n around
s the world working achieve the SDG target of reducing
FIGURE 37.1 Many of these organizations work on the makers, and identify new experts, practitioners, and
Control. (FCTC). fctc.org to position palliative care and pain relief within Universal Health premature deaths from cancer and
fight against cancer,
development, implementation, and monitoring of and innovative solutions advocates to share best raising general awareness THE MCCABE CENTRE FOR LAW AND CANCER is building capacity for the Coverage (UHC) policy and programs. ehospice.com other NCDs.
0 - 4 5 - 1 5 1 6 - 4 2 4 3
effective use of law in cancer control. mccabecentre.org - 7 4
National Cancer Control Plans (NCCPs) that are with thought-leaders in the practice and the latest around the disease.
7 5 - 1 9 2
cancer field. advances in cancer control. r l e - 1 0 . 2 0 - 3 0 - 4 0 m o
38 TAKING ACTION
What started with one person in the USA more MAP & FIGURE 38.1
GLOBAL RELAY
than 30 years ago to raise money and awareness REGION
Global Relay For Life countries and
has become a true global movement against cancer,
numbers within continents, 2017 EUROPE stories of DENMARK
participants
uniting people in 29 countries to do what no one STINE HENRIKSEN
Relays 199
FOR LIFE
country or organization can do alone: build a world
I live in Sorø, Denmark and have ACCESS CREATES PROGRESS
free from cancer. Across the globe, Relay For Life Participants 203,029 met cancer from both sides. Ten
fosters hope, healing and inspiration in more than
5,000 communities. MAP & FIGURE 38.1
Survivors 12,269 years ago, I lost my sister to cancer.
A few years later, I was diagnosed with the same
The world’s largest fundraiser,
The American Cancer Society’s Global Relay Caregivers 1,248 type of cancer. That left me in an indefinable state Relay For Life attracted nearly
of gratitude—had it not been for my sisters’ death, I
For Life program engages global organizations to
1.3 million participants in 2017.
Global Relay For Life 197,199
Luminaria*
probably would not have survived.
empower communities and accelerate the fight
When I came across Relay For Life, it immediately
celebrates survivors,
for a world without cancer. Across the world, made sense, simply because of the solidarity that
Norway
cancer organizations are utilizing Relay For Life lies in the 24-hour event. My approach to Relay For
Canada
Life is that every single participant should go home
remembers loved ones

as a platform to deliver on their mission. With United
Kingdom Denmark
feeling part of a larger whole. In Relay For Life, we
the Danish Cancer Society, Relay extends their Netherlands
Ireland celebrate life!
lost and mobilizes

|
advocacy initiatives, engaging participants, Belgium
survivors and volunteers in anti-tobacco and Lux.—
participants in united kingdom
communities to take a
Swit.
caregiver advocacy events. The Japan Cancer
France
Society found Relay For Life has attracted more United States of America Japan
REGION
stand against cancer. students to volunteer work and “their interests
tend to shift to learning the value of life and having
Portugal
ASIA
participants in portugal
compassion for others and self.” The Cancer Relays 56
“
Society of New Zealand utilizes funds from the
event to promote, deliver and facilitate more than
—Israel Participants 45,949
19,000 rides to treatment and nearly 62,000 nights Survivors 5,798
UAE
of accommodation for patients.
When the Cancer Association
India Caregivers 31,718
This network of Relay For Life participants
Jamaica—
of South Africa was given the “gift” is bringing hope and help to millions across the Honduras
Luminaria* 46,567
of Relay For Life 13 years ago, Philippines
globe. To learn more about the Relay For Life
no one thought this event would
movement, please visit relayforlife.org/global or
unite our nation in the fight against
contact globalrelayforlife@cancer.org.
cancer—and provide such a
strong platform for advocating
against a disease that is affecting Malaysia
participants in zambia Singapore—
1 out of 4 South Africans. Kenya
Relay For Life has created
the opportunity for our cancer REGION
survivors to celebrate their lives
stories of MALAYSIA A quarter of a million cancer AFRICA
and for all of us to stand as one— participants
DALJIT SINGH survivors walked the track at
TOGETHER WE CAN!
their local Relay For Life in 2017
Relays 70 Zambia
Six years as a survivor; 9 years REGION
— Maria Scholtz, Head Sustainability,
as a caregiver to my wife, who had
Participants 39,451 AUSTRALASIA
Cancer Association of South Africa Zimbabwe
stomach cancer. I became involved in
(CANSA)
Survivors 5,029
Relay For Life in 2005 as a volunteer at the event in Relays 167
Penang Malaysia. I have been a committee member Caregivers 3,728
and chair for the Luminaria for the last three years, Australia
Participants 92,658
along with my wife who is the Co-chair for survivors
Luminaria* 42,142 S. Africa
participants in malaysia
and Malaysia
Chair for team recruitment. It has been a very
Argentina Survivors 7,457
rewarding journey altogether. REGION Uruguay stories of AUSTRALIA Caregivers 6,517
THE AMERICAS participants in south africa participants
SUE KING
Luminaria* 29,636
Relays 3,933 In 2005 I founded my team, the
“Ridgley Rascals” from my small
Participants 1,028,484 community of Ridgley, Tasmania. In
New Zealand
2012 I was diagnosed with breast cancer, which

Survivors 227,893 gave me a whole different feel for the Relay. The
Caregivers 7,009 compassion, friendship, support and love I received
from so many people at the Relay brought me to
Luminaria* 5,446 tears many times. I was experiencing the Relay
through different eyes. I finally really understood
what it was all about, and how all those survivors
and their families felt about the Relay. I love it with
a passion.
*Luminaria bags and candles are lit in remembrance of a life touched by cancer during Relay For Life.

39 TAKING ACTION
In 2011, a landmark high-level meeting of the practitioners, and protection of the rights of FIGURE 39.3
POLICIES &
United Nations General Assembly resulted in a patients, their families and carers); and life after International trade and investment litigation against tobacco control laws
commitment to address non-communicable a diagnosis (employment protection, access to
diseases (NCDs) as a major development insurance, pension funds, and loans).
LEGISLATION
challenge. In 2013, the World Health Assembly The effective use of law requires collaboration ACCESS CREATES PROGRESS
adopted the World Health Organization Global across sectors: government; civil society; academia;
© Commonwealth of Australia
Action Plan on NCDs, emphasizing whole-of- health professionals; communities; people
Australia and Uruguay have successfully defended litigation against
their tobacco packaging laws under international trade, intellectual
society approaches to reduce the major drivers of affected by cancer or NCDs, their families and
property and investment laws.
preventable NCDs. The plan also endorsed a global caregivers; and, as appropriate, the private sector.
monitoring framework including nine voluntary Collaboration across different parts of government
Policy and legislation global targets. FIGURE 39.1 In 2015, a goal to reduce is also needed, as few problems can be addressed
AUSTRALIA URUGUAY
are essential to
premature mortality from NCDs by one-third was by health ministries acting alone.
The Australian Government has Action Australia was challenged under a bilateral Uruguay was challenged under a bilateral
included in the United Nations Sustainable Addressing cancer and NCDs through law investment treaty between Australia and investment treaty between Uruguay and
successfully defended against three
address the burden
Development Goals. FIGURE 39.2 involves engaging with domestic, regional and Hong Kong by Philip Morris Asia, claiming Switzerland by Philip Morris Switzerland,
The effective use of law is critical to addressing international legal and governance frameworks, sets of legal challenges to its tobacco expropriation and a breach of obligations to claiming expropriation and a breach of
provide fair and equitable treatment (case obligations to provide fair and equitable
of cancer globally and plain packaging laws:

cancer and other NCDs. This is true across the including those dealing with health, human rights,
decided in Australia’s favor in December 2015), treatment (case decided in Uruguay’s favor
cancer and NCD continuum, including prevention international trade, intellectual property and a constitutional challenge in its and in the World Trade Organization by Cuba, in July 2016).
locally. The effective

(reducing exposure to risk factors such as tobacco, investment law, environment, and occupational Dominican Republic, Honduras, and Indonesia,
highest domestic court, an investment claiming breaches of obligations relating to
alcohol, unhealthy diet, air pollution, and health and safety. It also requires being able to
treaty claim, and a dispute in the
use of law to achieve
trade restrictiveness and intellectual property
occupational exposures); conduct of research and defend against litigation, or threats of litigation, by
protection (case decided in Australia’s favor in
collection and management of personal health corporate interests—such as the tobacco, alcohol World Trade Organization.
June 2018).
population health goals information (protection of individual privacy,

while allowing for the conduct and dissemination
and food industries—which is becoming increas-
ingly common. FIGURE 39.3 Legal capacity is an
These victories demonstrate the
power governments have to legislate Result Australia’s and Uruguay’s successes have confirmed the policy space that countries have under
requires collaboration of essential medical and public health research);

screening, diagnosis, treatment and care (access,
essential component of the cancer/NCD workforce.
for public health. international trade, intellectual property, and investment agreements to implement evidence-
based tobacco control measures. However, litigation of this nature is resource-intensive and
across sectors.
expensive to defend.
“
affordability, quality, safety, regulation of health
FIGURE 39.1 FIGURE 39.2 The safety of the people shall be

Nine voluntary global targets endorsed by Targets related to non-communicable diseases in GOAL 3 the highest law.
governments in the World Health Organization UN Sustainable Development Goal 3: Ensure healthy
THE ROLE OF LAW IN NCD PREVENTION BEST BUYS — Cicero
(WHO) Global Action Plan on NCDs lives and promote well-being for all at all ages
• Implement excise taxes and prices on tobacco products

Law is essential to implement a number of the • Implement plain/standardized packaging and/or large
globally agreed ‘best buys’ for NCDs—the evidence-based
↖
graphic health warnings on all tobacco packages
• Enact and enforce comprehensive bans on tobacco
interventions considered the most cost-effective advertising, promotion and sponsorship
and feasible for implementation in • Eliminate exposure to second-hand tobacco smoke in all
low- and lower middle-income countries. indoor workplaces, public places, public transport
HOW TO ACHIEVE TARGETS HEALTH TARGETS
→
Mortality & morbidity • Reduce salt intake through the reformulation of food
National systems response products to contain less salt and the setting of target 3.A 3.B 3.C 3.4 3.5 3.8
Risk factors for NCDs levels for the amount of salt in foods and meals
25% • Reduce salt intake through the implementation of
reduction of raised front-of-pack labeling
0% blood pressure 30%
increase of reduction of
diabetes/obesity tobacco use
30%
50% reduction of salt/ • Increase excise taxes on alcoholic beverages
coverage for drug therapy sodium intake • Enact and enforce bans or comprehensive restrictions
and counseling on exposure to alcohol advertising (across multiple
types of media) Strengthen the Support the research Substantially increase By 2030, reduce by Strengthen the Achieve universal health
• Enact and enforce restrictions on the physical implementation of and development of health financing and one third premature prevention and coverage, including
80% 10% availability of retailed alcohol (via reduced the WHO Framework vaccines and medicines the recruitment, mortality from non- treatment of substance financial risk protection,
hours of sale) development, training access to quality
reduction of harmful Convention on Tobacco for the communicable communicable diseases abuse, including
coverage for essential NCD
use of alcohol Control in all countries, and non-communicable and retention of the through prevention and narcotic drug abuse and essential health-care
medicines and technologies
as appropriate. diseases that primarily health workforce in treatment and promote harmful use of alcohol. services and access to
affect developing developing countries, mental health and safe, effective, quality
9 VOLUNTARY GLOBAL NCD countries, provide access especially in least well-being. and affordable essential
25% TARGETS FOR 2025 10% to affordable essential

medicines and vaccines…
developed countries
and small island
medicines and vaccines
for all.
reduction of premature reduction of
To support the primary goal of reducing physical inactivity and, in particular, provide developing States.
mortality from NCDs
premature mortality from NCDs, targets address access to medicines
risk factors and national systems responses for all.

40 TAKING ACTION
with cancer, high out-of-pocket payments and the FIGURE 40.3 FIGURE 40.4
UNIVERSAL
indirect costs of treatment often result in financial Percentage of countries with generally available SE Asia The percentage of the cancer population who pays
hardship, impoverishment, loss of income due to cancer diagnosis and treatment services in the more than 30% of total household income for healthcare
limitations in or inability to work, and worsened public sector, by WHO region and World Bank costs, select countries in Asia
health for that individual and their family. FIGURE 40.4 income group Cancer patients in lower-income
countries are the least likely to have
HEALTH
To realize UHC, cancer services must be included
in benefit packages and sustainably financed
Pathology services access to cancer care services
FigureCancer
3 surgery Figure 3 in the public sector. In many countries, a substantial
through domestic public resources, and cancer
Cancer centers or cancer depts at tertiary level proportion of cancer patients face
patients must be protected against financial ruin. Percentage of countries with generally
Subsidized chemotherapy
availableofcancer
Percentage diagnosis
countries and treatment
with generally available cancer diagnosis and treatment financial catastrophe due to the costs
Each country may utilize a different approach services in the public sector, by WHO
Radiotherapy
region in
services andtheWorld Bank
public income
sector, group
by WHO region and World Bank income group of cancer treatment.
COVERAGE
to attain UHC. Yet, there are critical implemen-
tation principles. First, multi-sectoral dialogue BY WHO REGION BY WORLD BANK INCOME GROUP
is important to set priorities and define a health IRAN
benefits package based on health needs, health 68%

100 100
system capacity, budget envelope, equity, and other
guiding principles. Second, investing in health CHINA
system capacity and equitable models for delivering 21%
80 80
Universal health
services promotes access, particularly for vulnerable 75%
Pathology MYANMAR
communities. Finally, utilizing sustainable financ- VIET NAM
50% PHILIPPINES
coverage improves
services
ing mechanisms based on public and compulsory
60 60
68% 56%
funding sources ensures financial protection. By 58%
cancer outcomes including comprehensive cancer services as part of Radiotherapy THAILAND

UHC, countries can achieve better overall outcomes, 24% INDONESIA
equitably and
40 40
more efficiently and with greater equity. 44%
MALAYSIA
promotes financial ACCESS CREATES PROGRESS 20 20

45%
protection as well. The creation of Seguro Popular in Mexico,

making universal health coverage mandatory
through a system of social protection, has 0 0
Universal health coverage (UHC) means that all improved access to care and survival from AFR WPR SEAR EMR AMR EUR Low Lower Upper High Low WORLD
income middle middle income
Lower Upper High
income middle middle income
WORLD
Making basic services and financial
breast and childhood cancers.
people have access to the healthcare services they income income income income protection available to all results
need, and that the services are of high quality
without resulting in financial hardship for patients canceratlas.cancer.org canceratlas.cancer.org
in major improvements in outcomes.
FIGURE 40.1 Considerations for progressing towards universal health coverage FIGURE 40.2 The universal healthcare coverage approach to cancer care
and their families. UHC has become an important
policy goal in many countries, and plays a key role
MODEL FOR UNIVERSAL UHC comprises three dimensions: the proportion
in the health-related United Nations Sustainable
of the population covered, the proportion of ADVANCED SERVICES Introducing advanced services, such as UHC APPROACH TO Expanding core services, such as pathology
HEALTH COVERAGE screening or targeted therapies, available and basic treatment, to entire population and
Development Goals. prepaid funds and reduced out-of-pocket APPROACH TO CANCER CARE
PROGRESSION payments, and the number of services available only to select populations results in minor ensuring financial protection of such results in
Countries should progress towards UHC CANCER CARE improvements in population outcomes. a major improvement in population outcomes.
through a process of progressive realization by to the population.
moving sequentially along 3 dimensions: (1) 2 INCREASED proportion INCREASED proportion
direct of costs covered for of costs covered for
increase the proportion of the population covered; costs
covered select services select services
(2) increase the proportion of prepaid funds and
reduce out-of-pocket payments; and (3) expand the
number of services available to the population.
“
FIGURE 40.1 As a starting point, the most effective way
Reduce
to improve cancer outcomes and achieve greater out-of-pocket
equity is to maximize the number of individuals expenditure 1 SIGNIFICANT
population INCREASE
who have access to effective services while ensuring covered in people
Increase Achieving UHC is not
financial protection before introducing new No change in receiving care
population quick or easy. It takes time, population
services. FIGURE 40.2 covered and it takes sustained coverage
Governments provide a pre-specified set of political will, and community
current
services to a distinct population using a pool pooled funds participation and ownership.
of funds as part of a “benefits package.” However, But UHC is not something
comprehensive cancer services are not covered in you achieve once. It must be
the majority of countries, and effective health constantly sustained.
promotion, prevention, early detection, treatment, Increase number No change
— Dr. Tedros Adhanom Ghebreyesus,
of services offered in services covered
and palliative and survivorship care are frequently WHO Director-General
3 MORE advanced
unavailable. FIGURE 40.3 For individuals diagnosed services
covered services covered

HISTORY OF CANCER
BCE–18 CENTURY TH
70–80 million years ago 400 BCE 1492 17th–18th centuries 1775
Evidence of cancer cells in dinosaur fossils, found GREECE EUROPE NETHERLANDS UNITED KINGDOM
in 2003. Greek physician Hippocrates (460–370 BCE), Christopher Columbus returned to Europe from the Antony van Leeuwenhoek (1632–1723) refined the Dr. Percival Pott of Saint Bartholomew’s Hospital
the “Father of Medicine,” believed illness was caused Americas with the first tobacco leaves and seeds single lens microscope and was the first to see blood in London described cancer in chimney sweeps
4.2–3.9 million years ago by imbalance of four bodily humors: yellow bile, ever seen on the continent. A crew member, Rodrigo cells and bacteria, aiding the better understanding of caused by soot collecting under the scrotum, the first
The oldest known hominid malignant tumor was black bile, blood, and phlegm. He was the first to de Jerez, was seen smoking and was imprisoned by cells, blood, and lymphatic system—major steps in indication that exposure to chemicals in the environ-
Hippocrates found in Homo erectus or Australopithecus by Louis recognize differences between benign and the Inquisition, which believed he was possessed by improving the understanding of cancer. ment could cause cancer. This research led to many
FATHER OF MEDICINE Leakey in 1932. malignant tumors. the devil. additional studies that identified other occupational
FRANCE carcinogens and thence to public health measures to
3000 BCE Circa 250 BCE 1500 Physician Le Dran (1685–1770) first recognized that reduce cancer risk.
EGYPT CHINA EUROPE breast cancer could spread to the regional auxiliary
Evidence of cancerous cells in mummies The first clinical picture of breast cancer, Autopsies were conducted more often and under-
lymph nodes, carrying a poorer prognosis. 1779
including progression, metastasis, and death, and standing of internal cancers grew. FRANCE
1900–1600 BCE prognosis approximately ten years after diagno- 1713 First cancer hospital founded in Reims. It was forced
Cancer found in remains of Bronze Age human sis, was described in The Nei Ching, or The Yellow 1595 ITALY to move from the city because people believed
female skull. Emperor’s Classic of Internal Medicine. It gave the NETHERLANDS Dr. Bernardino Ramazzini (1633–1714), cancer was contagious.
Christopher Columbus first description of tumors and five forms of therapy: a founder of occupational/industrial medicine,
Zacharias Janssen invented the
BRINGS TOBACCO FROM AMERICAS TO EUROPE 1750 BCE spiritual, pharmacological, diet, acupuncture, and compound microscope.
reported the virtual absence of cervical cancer and 18th century
Babylonian code of Hammurabi set standard fee treatment of respiratory diseases. relatively high incidence of breast cancer in nuns. UNITED KINGDOM
This observation was an important step toward
for surgical removal of tumors (ten shekels) and 17th century Scottish surgeon John Hunter (1728–93) stated
penalties for failure. 50 AD GERMANY
identifying hormonal factors such as pregnancy and
that tumors originated in the lymph system and then
ITALY infections related to sexual contact in cancer risk,
Cancer surgery techniques improved, but lack of seeded around the body. He suggested that some
1600 BCE The Romans found some tumors could be removed anesthesia and antiseptic conditions made surgery
and was the first indication that lifestyle might affect
cancers might be cured by surgery, especially those
EGYPT the development of cancer.
by surgery and cauterized, but thought medicine did a risky choice. German surgeon Wilhelm Fabricius that had not invaded nearby tissue.
The Egyptians blamed cancer on the gods. Ancient not work. They noted some tumors grew again.
Egyptian scrolls describe eight cases of breast
Hildanus (1560–1634) removed enlarged lymph 1733–1788
nodes in breast cancer operations, while
Zacharias Janssen tumors treated by cauterization. Stomach cancer 100 AD Johann Scultetus (1595–1645) performed
FRANCE
INVENTED THE COMPOUND MICROSCOPE treated with boiled barley mixed with dates; cancer ITALY Physicians and scientists performed systematic
total mastectomies.
of the uterus by a concoction of fresh dates mixed experiments on cancer, leading to oncology as a
Greek doctor Claudius Galen (129–216 AD)
medical specialty. Two French scientists—
with pig’s brain introduced into the vagina. removed some tumors surgically, but he generally 17th century physician Jean Astruc and chemist Bernard
believed that cancer was best left untreated. Galen FRANCE
1100–400 BCE believed melancholia the chief factor in causing Physician Claude Gendron (1663–1750)
Peyrilhe—were key to these new investigations.
CHINA breast cancer, and recommended special diets,
Physicians specializing in treating swellings and exorcism, and topical applications.
concluded that cancer arises locally as a hard, 1761
growing mass, untreatable with drugs, and that ITALY
ulcerations were referred to in The Rites of the it must be removed with all its “filaments.”
Zhou Dynasty. 500–1500 Giovanni Morgagni performed the first autopsies to
relate the patient’s illness to the science of disease,
Dr. John Hill
EUROPE
17th century
PUBLISHED FIRST REPORT LINKING 500 BCE Surgery and cautery were used on smaller tumors. NETHERLANDS
laying the foundation for modern pathology.
TOBACCO AND CANCER INDIA Caustic pastes, usually containing arsenic, were Professor Hermann Boerhaave (1668–1738)
Indian epic tale, the Ramayana, described used on more extensive cancers, as well as phlebot- believed inflammation could result in cancer.
1761
treatment with arsenic paste to thwart omy (blood-letting), diet, herbal medicines, powder UNITED KINGDOM
tumor growth. of crab, and symbolic charms. Dr. John Hill published “Cautions Against the
Immoderate Use of Snuff,” the first report linking
Reims, France
400 BCE 1400–1500s tobacco and cancer.
PERU ITALY
Pre-Colombian Inca mummies found to contain Leonardo da Vinci (1452–1519) dissected
lesions suggestive of malignant melanoma. cadavers for artistic and scientific purposes,
First cancer hospital adding to the knowledge of the human body.
FOUNDED 1779

HISTORY OF CANCER
19 CENTURY
TH
19th century 1851–1971 19th century
20 CENTURY
TH
By 1900
UNITED KINGDOM UNITED KINGDOM Invention and use of the modern microscope, which Hundreds of materials, both man-made and natural,
In the early 1800s, Scottish physician John Waldrop Decennial reports linked cancer death to later helped identify cancer cells. Austria
were recognized as causes of cancer (carcinogens).
proposed that “glioma of the retina,” which typically occupation and social class.
appeared within the eyes of newborns and young 19th century 1902
children and was usually lethal, might be cured via 1880 GERMANY X-ray exposure led to skin cancer on the hand
Joseph Recamier early removal of affected organs. Earlier invention of general anesthesia (chloroform, Rudolph Virchow (1821–1902), “the founder of First Cancer Society of a lab technician. Within a decade, many more
COINED THE TERM “METASTASIS” FOUNDED 1910 physicians and scientists, unaware of the dangers of
ether, nitrous oxide) became more widespread, cellular pathology,” also determined that all cells,
1829 making cancer surgery more acceptable. including cancer cells, are derived from other cells. radiation, developed a variety of cancers.
FRANCE He was the first to coin the term “leukemia” and
Gynecologist Joseph Recamier described the inva- 1881 believed that chronic inflammation was the cause 1905
sion of the bloodstream by cancer cells, coining the USA of cancer. UNITED KINGDOM
term metastasis, which came to mean the distant First practical cigarette-making machine patented by Physicians at the Royal Ophthalmology Hospital
spread of cancer from its primary site to other James Bonsack. It could produce 120,000 19th century reported the first case of “hereditary” retinal glioma,
places in the body. cigarettes a day, each machine doing the work GERMANY which presented in the child of a parent cured of
of 48 people. Production costs plummeted, Surgeon Karl Thiersch showed that cancers metas- the disease.
LEUKEMIA DESCRIBED AS A 1838 and—with the invention of the safety match a tasize through the spread of malignant cells. Marie Curie
PROLIFERATION OF BLOOD CELLS GERMANY few decades later—cigarette smoking began its AWARDED NOBEL PRIZE IN RECOGNITION 1907
by John Hughes Bennett OF HER WORK IN RADIOACTIVITY
Pathologist Johannes Müller demonstrated that can- explosive growth. 19th century USA
cer is made up of cells and not lymph. His student, UNITED KINGDOM Epidemiological study found that meat-eating
Rudolph Virchow (1821–1902), later proposed 1886 Surgeon Stephen Paget (1855–1926) first Germans, Irish, and Scandinavians living in Chicago
that chronic inflammation—the site of a wound that BRAZIL deduced that cancer cells spread to all organs had higher rates of cancer than did Italians and
never heals—was the cause of cancer. Hereditary basis for cancer first suggested after of the body by the bloodstream, but only grow Chinese, who ate considerably less meat.
Professor Hilario de Gouvea of the Medical School in the organ (“soil”) they find compatible. This laid the
1842 in Rio de Janeiro reported a family with increased groundwork for the true understanding 1910
ITALY susceptibility to retinoblastoma. of metastasis. AUSTRIA
Domenico Antonio Rigoni-Stern undertook the first First national cancer society founded: Austrian
William Stewart Halsted
DEVELOPED THE RADICAL major statistical analysis of cancer incidence and 1890s 1895 American Cancer Society
FOUNDED 1913 Cancer Society.
MASTECTOMY FOR BREAST CANCER mortality using 1760–1839 data from Verona. USA UNITED KINGDOM
This showed that more women than men died from Professor William Stewart Halsted at Johns Dr. Thomas Beatson discovered that the breasts of 1911
tumors, and that the most common female cancers Hopkins University developed the radical rabbits stopped producing milk after he removed the FRANCE
were breast and uterine (each accounting for a mastectomy for breast cancer, removing breast, ovaries. This control of one organ over another led Marie Curie was awarded a second Nobel Prize,
third of total deaths). He found cancer death rates underlying muscles, and lymph nodes under Beatson to test what would happen if the ovaries this time in chemistry, in recognition of her work
for both sexes were rising, and concluded that the arm. were removed in patients suffering from advanced in radioactivity.
incidence of cancer increases with age, that cancer breast cancer, and he found that oophorectomy
is found less in the country than in the city, and that 1895 often resulted in improvement. He thus discovered 1900–1950
unmarried people are more likely to contract the GERMANY the stimulating effect of estrogen on breast tumors Radiotherapy—the use of radiation to kill cancer
disease. Janet Lane-Claypon
Physicist Wilhelm Konrad Roentgen long before the hormone was discovered. This cells or stop them dividing—was developed as
FIRST X-RAY PUBLISHED RISK FACTORS IN BREAST CANCER
Discovered by (1845–1923) discovered x-rays, used in the work provided a foundation for the modern use of a treatment.
Wilhelm Konrad Roentgen 1845 diagnosis of cancer. Within a few years, this hormones and analogs (e.g. tamoxifen, taxol) for
UNITED KINGDOM led to the use of radiation for cancer treatment. treatment and prevention of breast cancer.
1911
John Hughes Bennett, the Edinburgh USA
physician, was the first to describe leukemia 1897 Before 1900 Peyton Rous (1879–1970) proved that viruses
as an excessive proliferation of blood cells. USA
Lung cancer was extremely rare; now it is one of the
caused cancer in chickens, for which he was
most common cancers.
Walter B. Cannon (1871–1945) was still a college eventually awarded the Nobel Prize in 1966.
student when he fed bismuth and barium mixtures
to geese, outlining their gullets on an x-ray plate (the George Papanicolaou
forerunner of the barium meal examination). CONDUCTS FIRST PAP SMEAR

HISTORY OF CANCER
1913 1933 1940s–1950s 1953 1964

USA SPAIN USA UNITED KINGDOM USA
The American Cancer Society was founded as the First World Cancer Congress held in Madrid. Dr. Charles B. Huggins’ (1901–97) research on James Watson and Francis Crick described the dou- First US Surgeon General’s report on smoking
American Society for the Control of Cancer (ASCC) prostate cancer changed the way scientists regard ble helical structure of DNA, marking the beginning and health.
by 15 physicians and business leaders in New York 1930s–1950s the behavior of all cancer cells, and for the first time of the modern era of genetics.
City. In 1945, the ASCC was renamed the Classification of breast cancer introduced, enabling brought hope to the prospect of treating advanced 1965
American Cancer Society. It remains the world’s the planning of more rational treatment tailored to Gertrude Elion cancers. He showed that cancer cells were not 1954 FRANCE
largest voluntary health organization. the individual. CREATED NEW LEUKEMIA TREATMENT autonomous and self-perpetuating but were depen- USA WHO established the International Agency
dent on chemical signals such as hormones to grow First tobacco litigation against the cigarette com- for Research on Cancer (IARC), based in
1915 1934 and survive, and that depriving cancer cells of these panies, brought by a widow on behalf of her smoker Lyon, France.
JAPAN UNITED KINGDOM signals could restore the health of patients with husband, who died from cancer. The cigarette
widespread metastases. He was awarded the Nobel
Cancer was induced in laboratory animals for the Drs. W. Burton Wood and S. R. Gloyne
Prize in 1966 (shared with Peyton Rous).
companies won. 1966
first time by a chemical, coal tar, applied to rabbits’ reported the first two cases of lung cancer International Association of Cancer Registries
skin at Tokyo University. Soon many other substances linked to asbestos. 1956 (IACR) founded.
were observed to be carcinogens, including benzene, 1950 USA
USA
hydrocarbons, aniline, asbestos, and tobacco. 1937 Dr. Min Chiu Li (1919–1980) first demonstrated 1960s–1970s
USA Dr. Min Chiu Li Gertrude Elion (1918–99) created a purine chemi- clinically that chemotherapy could result in the cure Trials in several countries demonstrated the
1926 National Cancer Institute inaugurated.
FIRST DEMONSTRATED CLINICALLY cal, which she developed into 6-mercaptopurine, or of a widely metastatic malignant disease. effectiveness of mammography screening for
THAT CHEMOTHERAPY COULD CURE 6-MP. It was rapidly approved for use in childhood
UNITED KINGDOM breast cancer.
A MALIGNANT DISEASE
leukemia. She received the Nobel Prize in 1988.
Physician and epidemiologist Janet Lane-Claypon 1939 1960
(1877–1967) published results from a study that USA JAPAN 1970s
demonstrated some of the major contemporary risk 1950 Group cancer screening for stomach cancer began USA, ITALY
Drs. Alton Ochsner and Michael DeBakey first USA
factors for breast cancer among women, including with a mobile clinic in Tohoku region. Bernard Fisher in the USA and Umberto Veronesi in
reported the association of smoking and lung cancer.
not breastfeeding, being childless, and older age at The link between smoking and lung cancer was Italy both launched long-term studies as to whether
first pregnancy. confirmed. A landmark article from The Journal of
1939–1945 the American Medical Association appeared on May
1960 lumpectomy followed by radiation therapy was an
During the Second World War, the US Army discov- USA alternative to radical mastectomy in early breast
1928 ered that nitrogen mustard was effective in treating
27th, 1950: “Tobacco smoking as a possible etio-
Dr. Min Chiu Li published another important and
cancer. These studies concluded that total mastecto-
GREECE logic factor in bronchogenic carcinoma” by E.L. my offered no advantage over either lumpectomy or
cancer of the lymph nodes (lymphoma). This was the E. Cuyler Hammond and Daniel Horn original finding: the use of multiple-agent combina-
George Papanicolaou (1883–1962) identified Wynder and Evarts Graham. The same issue lumpectomy plus radiation therapy.
birth of chemotherapy—the use of drugs to treat LAUNCHED THE HAMMOND-HORN STUDY tion chemotherapy for the treatment of metastatic
malignant cells among the normal cast-off vaginal featured a full-page ad for Chesterfields with the
cancer. cancers of the testis. Twenty years later, it was
cells of women with cancer of the cervix, which led actress Gene Tierney and golfer Ben Hogan; the
demonstrated that combination chemotherapy, com- 1971
journal accepted tobacco ads until 1953.
to the Pap smear test. 1943–1945 bined with techniques for local control, had virtually USA
eliminated deaths from testicular malignancy. The National Cancer Act in President Nixon’s “War
1930
DENMARK, UNITED KINGDOM
1951 on Cancer” mandated financial support for cancer
First national cancer registries established. UNITED KINGDOM
GERMANY
Dr. Richard Doll and Prof. Austin Bradford Hill
1963 research, outlined intervention strategies, and, in
1973, established the Surveillance, Epidemiology,
Researchers in Cologne drew the first statistical 1947 conducted the first large-scale study of the link
JAPAN
and End Results (SEER) program, a network of
connection between smoking and cancer. CANADA Cancer research programs were established by the
between smoking and lung cancer. population-based cancer registries.
Dr. Norman Delarue compared 50 patients with Ministry of Health and Welfare and the Ministry of
1930s H. PYLORI BACTERIA FIRST IDENTIFIED
Education, Science, and Culture.
PUERTO RICO
lung cancer with 50 patients hospitalized with other by Barry Marshall and J. Robin Warren 1952 1973
diseases. He discovered that over 90% of the first USA USA
Dr. Cornelius Rhoads, a pathologist, allegedly group—but only half of the second—were smokers,
Epidemiologists at the American Cancer Society
1964
injected his Puerto Rican subjects with cancer and confidently predicted that by 1950 no one USA Bone marrow transplantation first performed
cells—13 people died. launched the Hammond-Horn Study, a long-term successfully on a dog in Seattle by Dr. E. Donnall
would be smoking. Physician Irving J. Selikoff (1915–92) published the
follow-up study of 188,000 men designed to examine Thomas (1920–2012). This led to human bone mar-
the association of cigarette smoking with death from results from a study linking asbestos exposure to
1933 1947 cancer and other diseases. the development of mesothelioma.
row transplantation, resulting in cures for leukemias
The Union for International Cancer Control and lymphomas. In 1990, Dr. Thomas won a Nobel
USA
(UICC) founded. Prize for his work.
Sidney Farber (1903–73), one of the founders of the
specialty of pediatric pathology, used a derivative
of folic acid, methotrexate, to inhibit acute leukemia
in children.

HISTORY OF CANCER
1970s 1980s 1994

21 CENTURY ST
2000 2013
Childhood leukemia became one of the first USA USA 53rd World Health Assembly presided over by Dr. The US FDA approved sofosbuvir for use in
cancers that could be cured by a combination Vincent DeVita developed a four-drug National Program of Cancer Registries Libertina Amathila (Namibia) endorsed “Global strat- combination with other agents for the treatment of
of drugs. combination to significantly raise the cure (NPCR) established. egy for non-communicable disease (NCD) prevention chronic HCV infection in adults, reducing treatment
rate of Hodgkin disease to 80%. and control,” which outlined major objectives for time and toxicity compared with earlier treatments
1970s 1995 monitoring, preventing, and managing NCDs, with and increasing cure rates to more than 80%.
USA MID-1980s Gene therapy, immune system modulation, HUMAN GENOME special emphasis on major NCDs with common risk
Discovery of the first cancer gene (the oncogene, Human Genome Project was initiated to pinpoint and genetically engineered antibodies used to IS MAPPED factors and determinants—cardiovascular disease, 2015
which in certain circumstances can transform a cell location and function of estimated 50,000–100,000 treat cancer. cancer, diabetes, and chronic respiratory disease. A goal to reduce premature mortality from NCDs
into a tumor cell). genes that make up the inherited set of “instructions” including cancer by one-third by 2030 was added
for functions and behavior of human beings. 1999 2000 to the United Nations Development Programme’s
1970s onwards NETHERLANDS, USA
The entire human genome is mapped. Sustainable Development Goals.
WHO, UICC, and others promoted national 1980s Jan Walboomers of the Free University of
cancer planning for nations to prioritize and focus WHO Program on Cancer Control established. Amsterdam and Michele Manos of Johns Hopkins
2000 2015
their cancer control activities. Charter of Paris against Cancer is signed. Achievement of universal health coverage, including
University provided evidence that the human
1988 papillomavirus (HPV) is present in 99.7% of all
financial risk protection, access to quality essential
1981 First WHO World No Tobacco Day, subsequently an cases of cervical cancer. FIRST HPV VACCINE
2001 health-care services and access to safe, effective,
JAPAN annual event. LUXEMBOURG quality and affordable essential medicines and
vaccines for all, was added to the United Nations
Professor Takeshi Hirayama (1923–95) published 1999 International Childhood Cancer Day was launched,
Sustainable Development Goals.
the first report linking passive smoking and lung can- 1989 The Bill & Melinda Gates Foundation awarded a five- its aim to raise awareness of the 250,000 children
cer in the non-smoking wives of men who smoked. European Network of Cancer Registries year, $50 million grant to the Alliance for Cervical worldwide who get cancer every year. Some 80% of
(ENCR) established. Cancer Prevention (ACCP), a group of five interna- these children have little or no access to treatment. 2017
The US FDA approved the first adoptive cell immu-
1981 tional organizations with a shared goal of working to The first annual event in 2002 was supported in
notherapy, also known as chimeric antigen receptor
ITALY 1989 prevent cervical cancer in developing countries. 30 countries around the world and raised over
(CAR) T-cell therapy.
USA US$100,000 for parent organizations to help
Dr. G. Bonnadona in Milan performed the first study
children in their own countries.
National Institutes of Health researchers
of adjuvant chemotherapy for breast cancer using
performed the first approved gene therapy,
CT SCAN SCREENING 2018
cyclophosphamide, methotrexate, and 5-fluoroura- FOR LUNG CANCER
cil, resulting in reduction of cancer relapse. Adjuvant inserting foreign genes to track tumor-killing 2004 World Health Organization Director General Dr.
SWITZERLAND Tedros Adhanom Ghebreyesus calls for coordinated
chemotherapy is now standard treatment for lung, cells in cancer patients. This project proved
global action for the elimination of cervical cancer.
breast, colon, stomach, and ovary cancers. the safety of gene therapy. WHO cancer prevention and control resolution
approved by World Health Assembly.
1991 2018
1980s The World Health Organization announces the
USA Evidence linking specific environmental 2005 Global Initiative for Childhood Cancer with the aim
carcinogens to telltale DNA damage emerged, WHO Framework Convention on Tobacco Control
Kaposi’s sarcoma and T-cell lymphoma linked of reaching at least a 60% survival rate for children
e.g. sun radiation was found to produce change came into force, using international law to further
to AIDS. with cancer by 2030, representing a doubling of the
in tumor suppressor genes in skin cells, aflatoxin (a public health and prevent cancer.
global cure rate for children with cancer.
fungus poison) or hepatitis B virus to cause a muta-
1982 tion in the liver, and chemicals in cigarette smoke to 2006
USA
switch on a gene that makes lung cells vulnerable to USA
Nobel Laureate Baruch S. Blumberg was instrumen- the chemicals’ cancer-causing properties. The US Food and Drug Administration (FDA)
tal in developing a reliable and safe vaccine against
approved the first HPV vaccine to prevent infections
hepatitis B (which causes primary liver cancer).
1994 that cause cervical cancer.
USA, CANADA, UNITED KINGDOM,
1980s FRANCE, JAPAN 2011
AUSTRALIA
Scientists collaborated and discovered Lung cancer deaths reduced by low-dose computed
Barry Marshall and J. Robin Warren identified bacte- BRCA1, the first known breast and ovarian cancer tomography (CT) scanning of people at high risk.
rium H. pylori, noting it caused duodenal and gastric predisposing gene.
ulcers and increased the risk of gastric cancer.
2011
First UN High Level Meeting on Non-communicable
Diseases in New York, USA.

GLOSSARY
Aflatoxin: be effectively treated. Programs usually have: 1) an Direct costs: Hepatocellular carcinoma: Incidence: Melanoma:
A harmful, cancer-causing chemical made by certain explicit policy; 2) a team responsible for organizing Expenditures for medical procedures and services The most common type of cancer originating in The number of new cases arising in a given period in A cancerous (malignant) tumor that begins in the
types of Aspergillus mold that may be found on the screening and delivering appropriate healthcare; associated with the treatment and care of people the liver. a specified population. This information, collected cells that produce the skin coloring (melanocytes).
poorly stored grains and nuts. Consumption of foods and 3) a structure for assuring quality screening and with cancer. routinely by cancer registries, can be expressed as Melanoma is almost always curable in its early
contaminated with aflatoxin is an important risk follow-up of abnormal screening tests. High-/middle-/low-income country: an absolute number of cases per year or as a rate stages. However, it is likely to spread, and once it
factor for hepatocellular (liver) cancer. Disability-adjusted life year (DALY): For the 2020 fiscal year, according to the World per 100,000 persons per year. has spread to other parts of the body the likelihood
Carcinogen: A measurement of the years of healthy life lost due Bank, a high-income country has a gross national of cure decreases.
Age-specific rate: Any agent —chemical, physical or biological— that to disease in a population. DALYs are the sum of two income (GNI) per capita of more than US$12,375; Kaposi sarcoma:
A rate for a specified age group, in which the numer- causes cancer. Examples include tobacco smoke, components: the years of life lost due to premature a middle-income country between US$1026 and A type of cancer characterized by the abnormal Menarche:
ator and denominator refer to the same age group. asbestos, human papillomavirus (HPV), and ultravio- death, and the years of life lost due to disability. US$12,375; and a low-income country less than growth of blood vessels that develop into lesions on The first menstrual period, usually occurring
let (UV) radiation. US$1025. the skin, lymph nodes, lining of the mouth, nose, and during puberty.
Age-standardization: E-cigarette: throat, and other tissues of the body. It is caused by
A technique that allows comparison of incidence (or Carcinoma: A device that contains a solution of nicotine, flavor- Hormone replacement therapy (HRT): Menopause:
human herpesvirus-8 (HHV-8). The risk of devel-
mortality) rates between populations, adjusting for A cancerous tumor that begins in the lining layer (ep- ings, and other chemicals that turns into a mist that Hormones (estrogen, progesterone, or other types) oping Kaposi sarcoma in a person who has HHV-8 The time period marked by the permanent cessation
any differences in their respective age distributions. ithelial cells) of organs. At least 80% of all cancers can be inhaled into the lungs. Also called electronic given to women after menopause to replace the increases significantly if the person is also infected of menstruation, usually occurring between the ages
are carcinomas. cigarette. hormones no longer produced by the ovaries. HRT with human immunodeficiency virus (HIV). of 45 and 55 years.
Asbestos:
can be a risk factor for cancers of the endometrium
A natural material that is made of tiny fibers and Chemotherapy: Endometrial cancer: Keratinocyte (nonmelanoma) skin cancer: Mesothelioma:
and breast.
used in insulation and as a fire retardant. Asbestos Treatment with a drug or drugs to destroy cancer Cancer of the layer of tissue that lines the uterus. Also known as basal or squamous cell skin cancer. A benign (not cancer) or malignant (cancer) tumor
exposure is an important risk factor for cancer, es- cells. Chemotherapy may be used, either alone or in Human development index (HDI): A cancer that occurs in keratinocyte cells, which are affecting the lining of the chest or abdomen. Expo-
pecially mesothelioma (lining of the chest, abdomen combination with surgery or radiation treatment, to Epidemic: sure to asbestos particles in the air increases the
A measure of health, education and income at located in the epidermis (top layer of skin) and are
and heart) and also lung cancer. treat cancer when it is at an early stage, when the Occurrence of an illness, condition, or behavior that risk of developing malignant mesothelioma, which is
the country level produced by the United Nations responsible for producing keratin. Keratinocytes are
cancer has spread, when the cancer has come back affects many people in the same region during a extremely lethal.
Development Programme as an alternative to purely divided into squamous cells on the surface of the
Benign tumor: (recurred), or when there is a strong chance that the specified period of time. To constitute an epidemic,
economic assessments of national progress, such epidermis and basal cells located within the deeper
An abnormal growth that is not cancer and does not cancer could recur. this occurrence must exceed normal occurrence of Metastasis:
as GDP growth. basal layer of the epidermis.
spread to other areas of the body. the disease in the region. The distant spread of cancer from its primary site to
Colonoscopy: Human herpesvirus 8 (HHV-8): Leukemia: other places in the body.
Body mass index (BMI): Examination of the large bowel with a long, flexible, Estradiol:
A type of virus that causes Kaposi sarcoma. Pa- A cancer of the blood or blood-forming organs.
A measure of a person’s weight in relation to his or lighted tube called a colonoscope. The physician A form of the hormone estrogen. Morbidity:
tients with acquired immunodeficiency syndrome
her height, calculated as weight in kilograms divided looks for polyps or early cancers during the exam, Lumpectomy: Any departure from physiological or psychological
Fecal occult blood test (FOBT): frequently suffer from HHV-8-associated diseases.
by height in meters squared. and removes them using a wire passed through the Surgery to remove a breast lump or tumor and a well-being. Measures of morbidity for people living
Infection with HHV-8 can also cause certain types
colonoscope. A test used to screen for large bowel cancer. It looks with cancer may include disability, pain, time away
of lymphoma and severe lymph node enlargement, small amount of surrounding normal tissue.
Cancer: for blood in the stools, the presence of which may be from work, or days spent in the hospital.
known as Castleman’s disease. HHV-8 is also known
A disease in which abnormal cells divide uncontrol- Computerized tomography (CT): a sign of cancer. Lymphoma:
as Kaposi sarcoma-associated herpesvirus, or Mortality:
lably. Cancer cells can invade nearby tissues and A series of detailed pictures of areas inside the body A cancer of the lymphatic system. The lymphatic
Helicobacter pylori (H. pylori): KSHV. The number of deaths occurring in a given period
spread through the bloodstream and lymphatic taken from different angles; the pictures are created system is a network of thin vessels and nodes
system to other parts of the body. by a computer linked to an x-ray machine. Also A type of bacterium that causes inflammation and in a specified population. It can be expressed as an
Human immunodeficiency virus (HIV): throughout the body. The two main types of
called computerized axial tomography (CAT) scan. A ulcers in the stomach or small intestine. People with absolute number of deaths per year or as a rate per
The virus that causes acquired immune deficiency lymphoma are Hodgkin lymphoma (or disease) and
Cancer registry: H. pylori infections may be more likely to develop 100,000 persons per year.
special kind of CT machine, the spiral CT, has been syndrome (AIDS). It is transmitted through blood non-Hodgkin lymphoma.
An institution that performs the systematic cancer in the stomach.
used to look for early lung cancer. and other body fluids, and infants born to infected
collection and maintenance of a file or register of Malignant tumor: Neoplasm:
Hematopoietic system: mothers may also become infected. Infection with An abnormal growth (tumor) that starts from a single
all cancer cases occurring in a defined population. Diagnosis: A mass of cancer cells that may invade surrounding
Organs and tissues involved in the production of both HIV and HHV-8 increases the risk of developing altered cell; a neoplasm may be benign or malignant.
Registries continuously and systematically collect The process of identifying a disease by its signs tissues or spread (metastasize) to distant areas of
blood, including the bone marrow, lymph nodes, Kaposi sarcoma. Cancer is a malignant neoplasm.
information from various data sources on the and symptoms, as well as medical tests and tissue the body. Synonymous with cancer.
personal characteristics of cancer patients (e.g. sampling and examination as needed. spleen, and tonsils.
Human papillomavirus (HPV): Neuroblastoma:
age, sex, and race) and the clinical and pathological Mammography:
Hepatitis B and C viruses (HBV and HCV): A type of virus that can cause abnormal tissue Cancer that arises in immature nerve cells; affects
characteristics (e.g. stage, histologic classification) Dioxins: A breast cancer screening method using an x-ray of
Viruses that cause hepatitis, a condition that is growth (for example, warts) and other changes to mostly infants and children.
of the cancers. Organic chemical byproducts of industrial process- the breast.
characterized by inflammation of the liver. Long- cells. Long-term infection with certain types of
es; considered highly toxic environmental pollutants
Cancer screening programs: term infection may lead to cirrhosis (scarring of the human papillomavirus (e.g., types 16 and 18) can Mastectomy: Overweight/obese:
due to their effects on the immune and endocrine
liver) and liver cancer. Persons infected with HCV cause cervical cancer. HPV is also a risk factor Persons who are considered overweight have a body
Programs organized at a national or regional level systems and on encouraging tumor growth. Surgery to remove the entire breast. There are dif-
may also have an increased risk for certain types of for anal, vaginal, vulvar, penile, oropharyngeal, mass index (BMI) greater than 25; a BMI greater
that aim to decrease the incidence and mortality of a ferent types of mastectomy that differ in the amount
non-Hodgkin lymphoma. and squamous cell skin cancers. It is transmitted than 30 is considered obese.
specific type of cancer by identifying precancerous of tissue and lymph nodes removed.
through sexual contact.
lesions or tumors at an early stage, when they can

GLOSSARY
Particulate matter: Sigmoidoscopy: Years of life lost (YLL):

SOURCES & METHODS
A note about maps in this edition of Foreword Text:
Microscopic solid or liquid particles associated with An examination to help find cancer or polyps within A statistic that measures the burden of premature The Cancer Atlas: Many maps throughout the Bouvard V, Baan R, Straif K, et al. A review of human
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Ferlay J, Ervik M, Lam F, Plummer M, Vignat J, et
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RISK FACTORS
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Systemic therapy: monitoring tobacco use and prevention policies.
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bangkok-thailand

INDEX
activity, physical. See physical activity bladder cancer costs of, 88–89, 92, 99 in South, East, and Southeast Asia, 57 screening for, 55, 70, 78, 79 European Code Against Cancer, 19
acute lymphoblastic leukemia, survival from, in Europe, arsenic and, 30 dying in pain from, 82, 83 cancer registries, 42, 64, 84, 85 in South, East, and Southeast Asia, 56 European Union
65 early detection of, 78 early detection of, 64–65, 78–79 Cancer Resolution 70.12 (WHA), 10 survivors of, surveillance recommendations for, 66 breast cancer screening in, 79
adult T-cell leukemia, 18 infections and, 18 early diagnosis of, 78 Cancer Society of New Zealand, 94 See also colon cancer cancer’s cost in, 88
aflatoxin projections for, 15 early treatment of, 64–65 carcinogens, human, 30, 32–33 community mobilization, 72 colorectal cancer screening in, 79
exposure to, reduced, 19 in Western Asia, 60 economic burden of, 88–89 Caribbean co-morbidity, 66 See also Europe
liver cancer related to, 18 See also gallbladder cancer equitable care for, 64 cancer in, 52–53 CONCORD, 64, 65 eye, carcinogenic agents for, 32
Africa blood, cancer of, 18 essential medicines for, 80 Healthy Caribbean Coalition #toomuchjunk Campaign, core services, expansion of, 99
Relay For Life in, 95 body weight, excess, 18, 19, 24–25 follow-up care guidelines for, 66 72, 73 Cowal, Sally, 15 FCTC. See Framework Convention on Tobacco Control
research publications in, 86 cancer and, in Northern Africa, West Asia, and Central global burden of, 37 Cavalli, Franco, 37 “Crossing the Global Quality Chasm: Improving Health fertility drugs, cancer risk of, 28
See also Northern Africa; sub-Saharan Africa Asia, 61 growing burden of, for low- and middle-income C/CAN. See City Cancer Challenge Care Worldwide” (National Academies of Sciences, folate supplementation, childhood cancer and, 42
African Cancer Registry Network, 64 endometrial cancer and, in the US, 54 countries, 9, 10, 11 Central Asia, cancer in, 60–61 Engineering, and Medicine), 81 Framework Convention Alliance, 93
African Research Group for Oncology, 86 uterine corpus cancer and, in North America, 55 household healthcare expenditures for, 99 central nervous system cutaneous squamous cell carcinomas, direct costs Framework Convention on Tobacco Control (WHO), 74,
AICR. See American Institute for Cancer Research See also obesity interventions for, 9 carcinogenic agents for, 32 of, 26 75, 93, 97
air pollution, 38 bone, carcinogenic agents for, 33 as leading cause of death, 36 tumors of, in children, 43
childhood cancer and, 42 bowel, cancer of, 19 lifetime risk of, in Europe, 59 cervical cancer, 19, 22, 76 DALYs. See disability-adjusted life years gallbladder cancer, in Latin America and the Caribbean,
indoor, 30, 31 brain system, carcinogenic agents for, 32 management and treatment of, 80–81 in Central Asia, 60 Danish Cancer Society, 94 52
lung cancer and, 19, 39 breast cancer (female), 19, 24, 40–41 mortality data for, 84 decline in, 9 death certificates, information on, 84 GAP. See Global Action Plan
outdoor, 30, 31 awareness programs for, 78 mortality from, 11 early detection of, 78 deaths, premature, cancer and, 36, 37, 44, 92 Gavi, the Vaccine Alliance, 88, 89
reduction of, 70 breastfeeding and, 28, 29 mortality rate decline of, in the US, 9 elimination of, WHO’s call for, 93 productivity lost to, 88, 89 genetic syndromes, childhood cancer and, 42
alcohol, 18, 19, 24–25 carcinogenic agents for, 33 national control plans for, 70, 90 HIV and, 91 deaths in pain, untreated, 82, 83 genitals, cancer of, 18
cancer deaths from, 19 clinical examination for, 78 organizations uniting to address, 92–93 incidence of, 91 diagnosis, top cancer sites for, 37, 38 agents for, 33
cancers caused by, 24 diagnosis for, cumulative risk of, 40 palliative care and, 71 in Indigenous women, 46 diet, 24–25 geographic diversity, cancer and, 48–49
American Cancer Society, 94 early detection of, 78 percentage of deaths from, 36 infections and, 22, 23 healthy, 19 germ cell tumors, in children, 43
Cancer Action Network, 9 early diagnosis of, 78 policies and legislation on, 96–97 in Latin America and the Caribbean, 52, 53 unhealthy, 18, 70 Ghebreyesus, Tedros Adhanom, 23, 98
partners with, 9 in East and Southeast Asia, 56 premature deaths from, 45, 92 in Oceania, 62, 63 digestive system, carcinogenic agents for, 33 GICR. See Global Initiative for Cancer Registry Development
American Institute for Cancer Research, 24, 72 in Europe, 58, 59 prevention of, 11, 24, 48, 72 Pap tests and, 78 disability, living with, due to cancer, 67 Ginsburg, Ophira, 40
American Society for Clinical Oncology, 90 HDI and, 64 progress fighting, 9 prevalence of, 48, 49 disability-adjusted life years, 87 Global Action Plan for the Prevention and Control of
Americas, Relay For Life in, 94 incidence and mortality rates of, 40–41 as public health and economic issue, 36–37 projections for, 15, 68 Disease Control Priorities, 81 Non-Communicable Diseases (WHO), 10, 90, 96
anogenital cancers, 76 in Latin America and the Caribbean, 52, 53 public-sector diagnosis and treatment services radiotherapy and, 80, 81 Global Initiative for Cancer Registry Development, 84, 85
infections and, 22 lifetime risk of, 40 for, 98–99 screening for, 69, 70, 71, 78, 79 Eastern Asia, cancer in, 56–57 Global Task Force on Expanded Access to Cancer Care
See also anus, cancer of; genitals, cancer of menopausal hormone therapy and, 28 reducing risk of, methods for, 19 in sub-Saharan Africa, 50, 51 eating, healthy habits for, encouragement of, 72 and Control in Developing Countries, 81
anus, cancer of, 18, 76 in North America, 54 research on, 86–87 vaccination and, 69 ECAC. See European Code Against Cancer gonadal tumors, in children, 43
arsenic, consumption of, 30 in Northern Africa, West Asia, and Central Asia, 60, 61 screening for, 9, 63, 69, 70, 99 cervix uteri cancer. See cervical cancer e-cigarettes, 20 Goosby, Eric, 90
asbestiform fibers, 30 in Oceania, 62 site-specific surveillance recommendations for survivors childhood cancer, 42–43 El-Sadr, Wafaa M., 90 Green Prescription, 73
asbestos, 30 prevalence of, 36, 48, 49 of, 66 incidence of, 43 endometrial cancer, 24 gross domestic product, cancer research and, 87
Asia projections for, 15 surveillance of, 84–85 mortality trends in, 71 hormonal contraceptives and, 28 groundnuts, storage of, 19
cancer cases and deaths in, 36 risk factors for, 40 survival of, 34, 35, 42, 43, 64–67 survival from, 34, 35, 43 menopausal hormone therapy and, 28 GRx. See Green Prescription
household healthcare expenditures in, for cancer, 99 screening for, 40, 70, 78, 79 survival gap in, and HDI, 64 survivors of, chronic health conditions and, 42 endothelium, carcinogenic agents for, 33
Relay For Life in, 95 in South Asia, 56, 65 survival statistics for, availability of, 64 treatment modes for, 70 environmental exposures, 30–31 HBV. See hepatitis B virus
See also Central Asia; Eastern Asia; Southern Asia; in sub-Saharan Africa, 50, 64 sustainable development and, 11 cholangiocarcinoma, 18 epithelial tumors, in children, 43 HCC. See hepatocellular carcinoma
South-Eastern Asia; Western Asia survivors of, surveillance recommendations for, 66 targeted therapies for, 99 CI5. See Cancer Incidence in Five Continents series Epstein-Barr virus, 22 HCV. See hepatitis C virus
Atun, Rifat, 37 survivorship care for, monitoring of, 71 top sites for, 37 Cicero, 97 esophageal cancer, 18, 20, 24 HDI. See human development index
Australasia, Relay For Life in, 95 tamoxifen treatment and, 81 transitioning from infection-related to lifestyle-related, 44 City Cancer Challenge (C/CAN), 93 in Central Asia, 60 head and neck cancers, infections and, 22
treatment modes for, 70 UHC approach to, 99 colon cancer, 24 early detection of, 78 healthcare counseling, 72
basal cell carcinoma, 26 universal health coverage and, 64 worldwide burden of, 15 early detection of, 78 projections for, 15 health promotion, 72–73
behavior change initiatives, 72 breast examination, clinical, 41 Cancer Association of South Africa, 94 treatment modes for, 70 in sub-Saharan Africa, 50 Healthy Caribbean Coalition #toomuchjunk Campaign,
benzene, 30 breastfeeding, 19, 24, 28, 29 cancer control planning, national, 85 See also colorectal cancer estrogen, endogenous, exposure to, 28 72, 73
“best buys,” for reducing noncommunicable diseases, childhood cancer and, 42 See also National Cancer Control Plans colorectal cancer EUROCARE, 64 Hei Ahuru Mowai, 47
90, 96 Breast Health Global Initiative, 71 Cancer Incidence in Five Continents series, 84 in Europe, 58, 59 Europe Helicobacter pylori, 18, 22, 46, 47
bile ducts, cancer of, 18 Burkitt lymphoma, 43 cancer incidence and mortality rates, 84, 85 in Latin America and the Caribbean, 52 cancer in, 36, 58–59 hematopoietic system, carcinogenic agents for, 33
biological markers, research into, 86 in Europe, 58 menopausal hormone therapy and, 28 cancer publications in, 87 hepatitis B virus, 18, 19, 22, 46, 70
births, number of, per woman, 29 cancer geographical differences in, 48 in North America, 54, 55 Relay For Life in, 95 vaccine for, 76, 77
birth weight, childhood cancer and, 42 advances services approach to, 99 for Indigenous vs. non-Indigenous people, 46 in Oceania, 62 smoking in, 58 hepatitis C virus, 18, 22
continuum of, 70–71 in Northern Africa, West Asia, and Central Asia, 60 prevalence of, 36 See also European Union hepatocellular carcinoma, 18, 76
control measures for, implementation of, 48 in Oceania, 63 projections for, 15

INDEX
HHV-8. See Kaposi sarcoma–associated herpesvirus Japan Cancer Society, 94 Mackenbach, Johan, 58 obesity, 14, 18, 24 prostate cancer reductions in, 20
High-Level Meeting on Non-Communicable Diseases, 10 Juntos Contra el Cáncer (Together Against Cancer; mammography, 41 international variations in, 25 early detection of, 78 See also tobacco entries
High-Level Meeting on Universal Health Coverage, 10 Mexico), 92 Mandela, Nelson, 72 observed survival, 64 in Europe, 58, 59 soft-tissue sarcomas, in children, 43
HIV. See human immunodeficiency virus Matsuda, Tomohiro, 85 occupational carcinogens, cancer sites and, 30 in Latin America and the Caribbean, 52, 53 solid fuels
HLMs. See High-Level Meeting entries Kaposi sarcoma, 18 McCabe Centre for Law and Cancer, 93 occupational exposure, 18, 30–31, 38 in North America, 54 cooking with, cancer and, 30
hormonal factors, 18, 28–29 carcinogenic agents for, 33 McKee, Martin, 58 reduction of, 70 in Oceania, 62 proportion of population using, 30, 31
hormone-related cancers, reproductive factors and, 28 projections for, 15 melanoma Oceania, cancer in, 62–63 prevalence of, 36, 48, 49 Southern Asia, cancer in, 56–57
hormones, exogenous, 28 in sub-Saharan Africa, 50 in children, 43 offspring, cancer risk in, 32 projections for, 15 South-Eastern Asia, cancer in, 56–57
household healthcare expenditures, for cancer, 99 Kaposi sarcoma–associated herpesvirus, 22 direct costs of, 26 oncologic drugs, 80 in sub-Saharan Africa, 50 squamous cell carcinomas, direct costs of, 26
Howard, Grant, 89 keratinocyte skin cancers, 26 early detection of, 78 oral cancer, 18, 20, 24 publication trends, for cancer-related papers, 86, 87 stomach cancer, 18
HPV. See human papillomavirus kidney cancer, projections for, 15 incidence of, 27 carcinogenic agents for, 32 in Central Asia, 60
H. pylori. See Helicobacter pylori King, Sue, 95 invasive, 26 early detection of, 78 quality of life, cancer survivorship and, 66 early detection of, 78
Human Development Index, 14 Kyaw Kan Kaung, 57 in Oceania, 62 projections for, 15 early diagnosis of, 78
breast cancer and, 64 projections for, 15 screening for, 78 radiotherapy, 80, 81 infections and, 22
cancer profiles related to, in West and Central Asia, 60 Lancet Journal Commission on Radiotherapy, 81 men, cancer incidence and mortality in, by nation, 49 in South, East, and Southeast Asia, 56 childhood cancer and, 42 in Latin America and the Caribbean, 52, 53
HPV vaccines and, 76, 77 Latin America, cancer in, 52–53 menopausal hormone therapy, 28 oropharynx, cancer of. See pharyngeal cancer radon, 19, 30, 38 prevalence of, 36
top-five cancers and, 45 larynx, cancer of, 20, 24, 78 menses, ovarian cancer and, 28 ovarian cancer, 28 rectal cancer, 24 projections for, 15
transitions in, and cancer, 44–45 leukemia, in children, 43 mesothelioma, malignant, 30 early detection of, 78 early detection of, 78 in South, East, and Southeast Asia, 56
human immunodeficiency virus, 18, 22 lip cancer mesothelium, carcinogenic agents for, 32 hormonal contraceptives and, 28 treatment modes for, 70 Straif, Kurt, 31
cervical cancer and, 91 projections for, 15 Mired, Dina, 61, 93 projections for, 15 Relay For Life (global), 94–95 sub-Saharan Africa, cancer in, 23, 50–51
dying in pain from, 82, 83 in South, East, and Southeast Asia, 56 morbidity, productivity lost to, 88 overweight, 24. See also obesity Report on Smoking and Health (US Surgeon General), 39 sugar-sweetened beverages, taxes on, 72, 73
human papillomavirus, 18, 19, 22, 23, 70 liver cancer, 18, 24, 70 morphine, oral, 82 reproductive factors, 18, 28–29 sunbeds, 18, 19, 26
cancers associated with, 76 decrease in, after HBV vaccines, 77 mortality, pain control, 70, 82–83 research, 86–87 prevalence of, 27
DNA testing for, and cervical cancer screening, 79 infections and, 22 registration of, quality of, 85 Pain-Free Hospital Initiative, 83 gross domestic product and, 87 sun protection, 19, 26
vaccine for, 9, 63, 76, 77, 89 in Latin America and the Caribbean, 52 top cancer sites for, 37, 38 palliative care, end-of-life, by disease, 71 respiratory system, carcinogenic agents for, 32 supplements, for cancer prevention, 24
human T-cell lymphotropic virus, 22 in Northern Africa, 60 Mullan, Fitzhugh, 66 pancreatic cancer, 18 retinoblastoma, early detection of, 78 surgery, 80
hypopharynx, cancer of, 20 prevalence of, 36 in Europe, 58 risk factors, 18–19 SURVCAN, 64
See also pharynx projections for, 15 nasopharynx, cancer of, 18 projections for, 15 survival studies, 84
in South, East, and Southeast Asia, 56 early detection of, 78 understudied, 86 schistosomal infections, 22 survivorship issues, 14
IACR. See International Association of Cancer Registries in sub-Saharan Africa, 50 See also pharynx Pap tests, 78 Scholtz, Maria, 94 sustainable development, 11
IARC. See International Agency for Research on Cancer liver flukes, 22 National Academies of Sciences, Engineering, and Parkin, Max, 51 science and technology research, national expenditures Sustainable Development Goals (UN), 10, 90, 92, 93,
ICCP. See International Cancer Control Partnership local disease burdens, research tailored to, 86 Medicine, 81 pathologists, 80 on, 86 96, 97, 98
implementation research, 86 lung cancer, 19, 20 National Bowel Screening Programme, 47 PBCR. See population-based cancer registries screening, 78, 99 sympathetic nervous system, cancer of, in children, 43
inactivity, physical, interventions for, 70 arsenic and, 30 National Cancer Control Network, 80, 81 PCBs. See polychlorinated biphenyls programs for, 19 synergies, building of, between diseases and health
incidence and mortality, cancer and, disparities in asbestos and, 30 National Cancer Control Plans, 92 penis, cancer of, 76 SDGs. See Sustainable Development Goals systems, 90–91
in Latin America and the Caribbean, 52 death from, cumulative probability of, 71 National Cancer Institute (US), 10, 87, 90 pesticides, childhood cancer and, 42 secondhand smoke, 18, 20, 38
in sub-Saharan Africa, 50, 51 early detection of, 78 NCCN. See National Cancer Control Network Peto, J., 48 Seguro Popular (Mexico), 98 tanning, indoor. See sunbeds
Indigenous populations, cancer in, 46–47 in Europe, 58, 59 NCCPs. See National Cancer Control Plans pharynx Sen, Amartya, 45 targeted therapies, 99
infection-related cancers, 22 global prevalence of, 48 NCD Alliance, 93 cancer of, 18, 20, 24, 70, 76 Singh, Daljit, 94 taxation, 72
in Latin America and the Caribbean, 52 incidence and mortality rates of, 38–39 NCDs. See noncommunicable diseases carcinogenic agents for, 32 skin, carcinogenic agents for, 33 testicular cancer
in Northern Africa, West Asia, and Central Asia, 60 in Latin America and the Caribbean, 52 NCI. See National Cancer Institute See also hypopharynx; nasopharynx; oropharynx skin cancer early detection of, 78
in South, East, and Southeast Asia, 56 as most commonly diagnosed cancer, 36 net survival, 64, 65 Philip Morris Asia, 97 arsenic and, 30 treatment modes for, 70
in sub-Saharan Africa, 50 in North America, 54 New Zealand, cancer statistics in, for Indigenous Philip Morris Switzerland, 97 early detection of, 78 Thun, Michael, 21
infections, 14, 16 in Oceania, 62 people, 47 physical activity, 18, 19, 24–25, 70 early diagnosis of, 78 thyroid, carcinogenic agents for, 32
infectious agents, 18, 22–23 pollution and, 30, 31 NGOs. See nongovernmental organizations guidelines for, 24 economic burden of, 26 thyroid cancer, projections for, 15
International Agency for Research on Cancer, 10, 11, projections for, 15 noncommunicable diseases, 10 promotion of, 72 inherited factors for, 26 tobacco, 18–21
19, 24, 30, 84 risk factors for, 38 Global Action Plan for, 90 pollutants, 18. See also air pollution in Oceania, 62 childhood cancer and, 42
Global Cancer Observatory, 11 screening for, 70, 78 global targets for, voluntary, 96 polychlorinated biphenyls, 30 reduction of, 70 control of, 9
Monographs Program, 32 in South, East, and Southeast Asia, 56, 57 national plans for, 70, 90 population-based cancer registries, 84, 85 ultraviolet radiation and, 26 lung cancer deaths and, 38, 39
International Association of Cancer Registries, 84 survivors of, surveillance recommendations for, 66 nongovernmental organizations, 93 precision medicine, 86 Smith, Adam, 75 plain packaging laws for, 74, 75, 97
International Cancer Benchmarking Partnership, 64 understudied, 86 non-Hodgkin lymphoma, 18 premature death, and cancer, by country, 45 smokeless tobacco, 18, 20, 57 smoking of, 14, 16
International Cancer Control Partnership, 90, 93 lymphoid leukemia, net survival and, 42, 43 projections for, 15 prevention tools, for infection-related cancer, 22 smoking, 18 use of, 9
International Society of Nurses in Cancer Care, 93 lymphoma, 18 Northern America, cancer in, 36, 54–55 primary effusion lymphoma, 18 cessation aids for, 21 See also smokeless tobacco; smoking
interventions, 14 in children, 43 Northern Africa, cancer in, 60–61 productivity, cancer-related losses in, 88, 89 declines in, and lung cancer incidence in North tobacco control, 17, 74–75
ISNCC. See International Society of Nurses in progesterone, endogenous, exposure to, 28 America, 54
Cancer Care diseases related to, economic cost of, 89

INDEX
tobacco use
interventions for, 70
as largest preventable cancer risk, 74
and screening for oral and lung cancers, 78
tools for addressing, 74
tonsil, cancer of, 18
transitioning countries, infection-caused cancer in, 23
Treatment for All (UICC), 92
UHC. See universal health coverage

UICC. See Union for International Cancer Control
ultraviolet radiation, 18, 26–27
Union for International Cancer Control, 10, 90, 92, 93
United Nations, 96
General Assembly, 10
Political Declaration on the Prevention and Control of
Non-Communicable Diseases, 92
See also Sustainable Development Goals
universal health coverage, 64, 81, 93, 97, 98–99
urinary bladder cancer. See bladder cancer
urinary system, carcinogenic agents for, 33
urogenital cancers, 70
See also bladder cancer, kidney cancer, ovarian cancer,
prostate cancer, testicular cancer
uterine cancer
North America, 55
projections for, 15
UV Index, 26
vaccines, 19, 76–77

cervical cancer and, 69, 71
for HBV and HPV, 70
vagina, cancer of, 76
Vivili, Paula, 62
vulva, cancer of, 76
WCRF. See World Cancer Research Fund

Welch, Carol, 24
Western Asia, cancer in, 60–61
westernization, cancer incidence and, 50, 54
WHA. See World Health Assembly
WHO. See World Health Organization
women, cancer incidence and mortality in, by nation, 49
workplace, carcinogens in, 30
World Cancer Congress, 92
World Cancer Day, 92
World Cancer Leaders’ Summit, 92
World Cancer Research Fund, 24, 72
World Health Assembly, 10, 46, 92, 96
World Health Organization, 10, 11, 19, 24, 32, 46, 74,
82, 92, 93, 97
essential medicines list, 80, 82
Global Action Plan on NCDs, 96
World Health Report, 86
World Trade Organization, 97
Dispute Settlement Body, 75

“
While we face great challenges in this work, we also have the proven interventions,
dedicated global partners, and momentum we need to truly address the global cancer
burden. This Cancer Atlas, Third Edition is an important source of information to help
the global cancer community achieve our shared goal of a world without cancer.
— Gary Reedy, CEO, American Cancer Society
The Cancer Atlas, Third Edition has brought together cancer Topics Include
control experts from around the world to present useful
Risks of tobacco
and comprehensible information to aid in the fight against
cancer. This all-new edition is a comprehensive global Body weight, physical activity, diet,
overview that equally highlights the distinct patterns and and alcohol as cancer risk factors
inequities in the present cancer burden, the associated
risk factors, and the prospects for cancer prevention and Infection-related cancers
control. This edition unites these topics under the theme of
Childhood cancers
“Access Creates Progress,” drawing attention not only to
the problem at hand, but also the means of tackling the Cancer in indigenous populations
cancer burden through access to information and services.
It provides basic information on the global burden of cancer The burden of cancer by world region
in a user-friendly and accessible form for cancer control
Cancer survival and survivorship issues
advocates, government and public health agencies, and
policymakers as well as patients, survivors, and the Vaccines
general public.
Early detection
Pain control
CANCER.ORG/BOOKSTORE
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THE

Printed in the United States of America.

Library of Congress Control Number:2019949680

Managing Editor: John M. Daniel

The Cancer Atlas can be found online at www.cancer.org/canceratlas. The online

PART ONE 16 PART TWO 34

RISK FACTORS THE BURDEN

Other Freddie Bray, PhD, Section of Cancer Surveillance,

4 canceratlas . cancer . org canceratlas . cancer . org 5

6 canceratlas . cancer . org canceratlas . cancer . org 7

This much is clear:

everyone can benefit

in the fight against

cancer. As you will

see in the pages of

this Cancer Atlas,

Third Edition, progress

is not only possible,

but also achievable.

8 canceratlas . cancer . org canceratlas . cancer . org 9

CARY ADAMS of the cancer and NCD communities, a target to

10 canceratlas . cancer . org canceratlas . cancer . org 11

12 canceratlas . cancer . org canceratlas . cancer . org 13

The Cancer Atlas

14 canceratlas . cancer . org canceratlas . cancer . org 15

There are still 1.1 billion smokers worldwide

16 canceratlas . cancer . org canceratlas . cancer . org 17

middle-income countries in parts of Asia and

be prevented. Other risk factors known to cause cancer

cancer prevention. your baby.

Hepatocellular carcinoma (liver) ‑Limit use of hormone

18 canceratlas . cancer . org canceratlas . cancer . org CANCERATLAS.CANCER.ORG 19

Tobacco use is the decreasing worldwide, the rate of decrease is slower

leading preventable men in HIC.

Annual smoking-attributable cancer deaths by Access to smoking cessation

75 50 25 0 25 50 75 100 60K 40K 20K 0 20K 40K

20 canceratlas . cancer . org canceratlas . cancer . org 21

Algeria Bahrain— Bhutan all cervical cancers. HPV vaccines

Human papillomavirus Human papillomavirus, Stomach Bolivia

and Hepatitis B and C viruses

infection-related New Zealand

cancers are stomach,

unhealthy diet and activity reduces risk of some types of cancer,

physical inactivity are endometrial cancer. Globally, 23% of adults did

important modifiable activity guidelines in 2010, and more than 80% of

cancer risk factors. Reversing the obesity epidemic, limiting

and increasing the prevalence of healthy eating

Eat a diet rich in Do not use supplements

canceratlas . cancer . org canceratlas . cancer . org 25

A majority of skin cancers are caused by ultraviolet FIGURE 6.3

26 canceratlas . cancer . org canceratlas . cancer . org 27

reproductive factors with Increasing breastfeeding

small. However, these While shifting patterns of reproductive factors,

Therefore, they have have contributed to increases in incidence rates

a large impact at the

: 1:05 – 1.25 Very High HDI

Breastfeeding for long duration Decreased

28 canceratlas . cancer . org canceratlas . cancer . org 29

outdoor air pollution:

the cancer burden, smoke emissions from coal as a known human

particularly for workers probable carcinogens.

lung cancer and the unique cause of malignant

Sub-Saharan Africa sites*

Hepatocellular carcinoma (liver) ‑Limit use of hormone