research in cancer epidemiology

Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries

Affiliations.

• 1 Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia.
• 2 Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France.
• PMID: 33538338
• DOI: 10.3322/caac.21660

This article provides an update on the global cancer burden using the GLOBOCAN 2020 estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer. Worldwide, an estimated 19.3 million new cancer cases (18.1 million excluding nonmelanoma skin cancer) and almost 10.0 million cancer deaths (9.9 million excluding nonmelanoma skin cancer) occurred in 2020. Female breast cancer has surpassed lung cancer as the most commonly diagnosed cancer, with an estimated 2.3 million new cases (11.7%), followed by lung (11.4%), colorectal (10.0 %), prostate (7.3%), and stomach (5.6%) cancers. Lung cancer remained the leading cause of cancer death, with an estimated 1.8 million deaths (18%), followed by colorectal (9.4%), liver (8.3%), stomach (7.7%), and female breast (6.9%) cancers. Overall incidence was from 2-fold to 3-fold higher in transitioned versus transitioning countries for both sexes, whereas mortality varied <2-fold for men and little for women. Death rates for female breast and cervical cancers, however, were considerably higher in transitioning versus transitioned countries (15.0 vs 12.8 per 100,000 and 12.4 vs 5.2 per 100,000, respectively). The global cancer burden is expected to be 28.4 million cases in 2040, a 47% rise from 2020, with a larger increase in transitioning (64% to 95%) versus transitioned (32% to 56%) countries due to demographic changes, although this may be further exacerbated by increasing risk factors associated with globalization and a growing economy. Efforts to build a sustainable infrastructure for the dissemination of cancer prevention measures and provision of cancer care in transitioning countries is critical for global cancer control.

Keywords: burden; cancer; epidemiology; incidence; mortality.

© 2021 American Cancer Society.

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Circulating microRNA signature predicts cancer incidence in Lynch syndrome – a pilot study

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Tero Sievänen , Tiina Jokela , Matti Hyvärinen , Tia-Marje Korhonen , Kirsi Pylvänäinen , Jukka-Pekka Mecklin , Juha Karvanen , Elina Sillanpää , Toni T. Seppälä , Eija K. Laakkonen; Circulating microRNA signature predicts cancer incidence in Lynch syndrome – a pilot study. Cancer Prev Res (Phila) 2024; https://doi.org/10.1158/1940-6207.CAPR-23-0368

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Lynch syndrome (LS) is the most common autosomal dominant cancer syndrome and is characterized by high genetic cancer risk modified by lifestyle factors. This study explored whether a circulating microRNA (c-miR) signature predicts LS cancer incidence within a 4-year prospective surveillance period. To gain insight how lifestyle behavior could affect LS cancer risk, we investigated whether the cancer-predicting c-miR signature correlates with known risk-reducing factors such as physical activity, body mass index (BMI), dietary fiber or non-steroidal anti-inflammatory drug usage. The study included 110 c-miR samples from LS carriers, 18 of whom were diagnosed with cancer during a 4-year prospective surveillance period. Lasso regression was utilized to find c-miRs associated with cancer risk. Individual risk sum derived from the chosen c-miRs was used to develop a model to predict LS cancer incidence. This model was validated using 5-fold cross-validation. Correlation and pathway analyses were applied to inspect biological functions of c-miRs. Pearson correlation was used to examine the associations of c-miR risk sum and lifestyle factors. Hsa-miR-10b-5p, hsa-miR-125b-5p, hsa-miR-200a-3p, hsa-miR-3613-5p and hsa-miR-3615 were identified as cancer predictors by Lasso, and their risk sum score associated with higher likelihood of cancer incidence (HR 2.72, 95% CI 1.64-4.52, C-index=0.72). In cross-validation, the model indicated good concordance with the average C-index of 0.75 (0.6-1.0). Co-regulated hsa-miR-10b-5p, hsa-miR-125b-5p and hsa-miR-200a-3p targeted genes involved in cancer-associated biological pathways. The c-miR risk sum score correlated with BMI (r=0.23, p<0.01). In summary, BMI-associated c-miRs predict LS cancer incidence within four years, although further validation is required.

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Supplementary data.

Figure S1: Schoenfeld residuals of the c-miR risk prediction models. A, Unadjusted c-miR risk sum score prediction model. B, Sex and MMR-variant adjusted c-miR risk sum score prediction model.

Figure S2: STRING database complete gene node map. Edges represent gene-gene associations. Thickness of edges indicates association confidence (www.string-db.org).

Table S1: Missing values for cancer and cancer-free groups.

Table S2: Cancer characteristics.

Table S3: Differentially expressed c-miRs between cancer-free LS carriers and healthy non-carrier controls. Lasso-selected c- miRs used for computing c-miR risk sum score are bolded. SE = standard error, Wald = Wald-test statistic, FDR = False discovery rate.

Table S4: C-miR full model. HR = hazard ratio, 95% CI = 95% confidence interval, b= regression coefficient, SE = standard error, df = degrees of freedom. P significant at 0.05 level.

Table S5: 5-fold cross-validation of c-miR risk sum score models.

Table S6: Model fits in the full MLH1 sample. b = regression coefficient; HR = hazard ratio; 95% CI = 95% confidence interval; P-value = P-value significant at <0.05 level; Full model C-index = Harrel’s concordance (C) index. N = 74 of whom 14 developed cancers during the surveillance.

Table S7: C-miR risk sum score of hsa-let-7e-5p, hsa-miR-10b-5p and hsa-miR-3613-5p in MLH1 sample. Unadjusted and sex- adjusted models. b = regression coefficient; HR = hazard ratio; 95% CI = 95% confidence interval; P-value = P-value significant at <0.05 level; Full model C-index = Harrel’s concordance (C) index. N = 74 of whom 14 developed cancers during the surveillance

Table S8: 5-fold cross-validated MLH1 c-miR risk sum score model.

Table S9: Model fits in the full CRC sample. b = regression coefficient; HR = hazard ratio; 95% CI = 95% confidence interval; P- value = P-value significant at <0.05 level; Full model C-index = Harrel’s concordance (C) index. N = 101 of whom 9 developed CRC during the surveillance.

Table S10: C-miR risk sum score in CRC samples. Unadjusted and sex and MMR-variant adjusted models. b = regression coefficient; HR = hazard ratio; 95% CI = 95% confidence interval; P-value = P-value significant at <0.05 level; Full model C- index = Harrel’s concordance (C) index. N = 74 of whom 14 developed cancers during the surveillance.

Table S11: 5-fold cross-validated CRC c-miR risk sum score model.

Table S12: The experimentally verified c-miR risk sum target genes from miRTarBase.

Table S13: The significantly enriched Reactome pathways. FDR = False discovery rate.

Table S14: Pearson correlations of c-miR risk sum score and physical activity, BMI, dietary fiber consumption, NSAID usage and age in the complete-case analysis. Lifestyle data was collected in 2017 or 2020 with a questionnaire. Blood sample was taken at regular colonoscopy visit between 2018 and 2020. The average time-period between lifestyle data collection and blood sample was 2.0 (0.3-3.9) years.

Methods S1: This code supplementary file was used to perform the differential expression analysis as well as to develop the c-miR cancer risk prediction model described in the manuscript.

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• Review Article
• Published: 28 March 2024

Global epidemiology of epithelial ovarian cancer

• Penelope M. Webb   ORCID: orcid.org/0000-0003-0733-5930 1 , 2 &
• Susan J. Jordan   ORCID: orcid.org/0000-0002-4566-1414 2  

Nature Reviews Clinical Oncology ( 2024 ) Cite this article

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• Epidemiology
• Ovarian cancer
• Risk factors

Globally, ovarian cancer is the eighth most common cancer in women, accounting for an estimated 3.7% of cases and 4.7% of cancer deaths in 2020. Until the early 2000s, age-standardized incidence was highest in northern Europe and North America, but this trend has changed; incidence is now declining in these regions and increasing in parts of eastern Europe and Asia. Ovarian cancer is a very heterogeneous disease and, even among the most common type, namely epithelial ovarian cancer, five major clinically and genetically distinct histotypes exist. Most high-grade serous ovarian carcinomas are now recognized to originate in the fimbrial ends of the fallopian tube. This knowledge has led to more cancers being coded as fallopian tube in origin, which probably explains some of the apparent declines in ovarian cancer incidence, particularly in high-income countries; however, it also suggests that opportunistic salpingectomy offers an important opportunity for prevention. The five histotypes share several reproductive and hormonal risk factors, although differences also exist. In this Review, we summarize the epidemiology of this complex disease, comparing the different histotypes, and consider the potential for prevention. We also discuss how changes in the prevalence of risk and protective factors might have contributed to the observed changes in incidence and what this might mean for incidence in the future.

The disease we call ‘ovarian’ cancer encompasses a wide range of tumour types, including cancers that arise in the fallopian tube; changes in coding and reporting make incidence trends over the past decade difficult to interpret.

Between 1920 and 1960, successive birth cohorts had lower risk of developing ovarian cancer, although incidence might be increasing again in women born after about 1970.

With the recognition that high-grade serous cancers originate in the fallopian tube, salpingectomy (opportunistic or targeted) offers the opportunity for prevention and could delay the need for oophorectomy among women with a high genetic risk.

Hormonally related factors, including pregnancy, oral contraceptive use and breastfeeding, reduce the risk of ovarian cancer, particularly the endometrioid and clear cell histotypes; the benefits of newer contraceptive formulations are less clear.

Lifestyle exposures, including smoking, obesity and, potentially, sedentary behaviour or inactivity, all increase the risk of a woman developing the less common histotypes but do not appear to affect the risk of developing the most common high-grade serous cancers.

If current trends continue, the incidence of ovarian cancer might start to increase, although widespread uptake of salpingectomy and expanded identification and interventions targeting BRCA mutation carriers have the potential to reduce incidence.

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IARC Publications – Cancer Epidemiology: Principles and Methods

Published in section: IARC News

Publication date: 18 May, 2009, 0:00

Direct link: https://www.iarc.who.int/news-events/iarc-publications-cancer-epidemiology-principles-and-methods/

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25 year trends in cancer incidence and mortality among adults aged 35-69 years in the UK, 1993-2018: retrospective secondary analysis

Linked editorial.

Cancer trends in the UK

• Related content
• Peer review
• Jon Shelton , head of cancer intelligence 1 ,
• Ewa Zotow , visiting lecturer (statistics) 2 ,
• Lesley Smith , senior research fellow 3 ,
• Shane A Johnson , senior data and research analyst 1 ,
• Catherine S Thomson , service manager (cancer and adult screening) 4 ,
• Amar Ahmad , principal statistician 1 ,
• Lars Murdock , data analysis and research manager 1 ,
• Diana Nagarwalla , data analysis and research manager 1 ,
• David Forman , visiting professor of epidemiology 5
• 1 Cancer Research UK, London, UK
• 2 University College London, London, UK
• 3 Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
• 4 Public Health Scotland, Edinburgh, UK
• 5 Faculty of Medicine and Health, University of Leeds, Leeds, UK
• Correspondence to: J Shelton jon.shelton{at}cancer.org.uk
• Accepted 19 January 2024

Objective To examine and interpret trends in UK cancer incidence and mortality for all cancers combined and for the most common cancer sites in adults aged 35-69 years.

Design Retrospective secondary data analysis.

Data sources Cancer registration data, cancer mortality and national population data from the Office for National Statistics, Public Health Wales, Public Health Scotland, Northern Ireland Cancer Registry, NHS England, and the General Register Office for Northern Ireland.

Setting 23 cancer sites were included in the analysis in the UK.

Participants Men and women aged 35-69 years diagnosed with or who died from cancer between 1993 to 2018.

Main outcome measures Change in cancer incidence and mortality age standardised rates over time.

Results The number of cancer cases in this age range rose by 57% for men (from 55 014 cases registered in 1993 to 86 297 in 2018) and by 48% for women (60 187 to 88 970) with age standardised rates showing average annual increases of 0.8% in both sexes. The increase in incidence was predominantly driven by increases in prostate (male) and breast (female) cancers. Without these two sites, all cancer trends in age standardised incidence rates were relatively stable. Trends for a small number of less common cancers showed concerning increases in incidence rates, for example, in melanoma skin, liver, oral, and kidney cancers. The number of cancer deaths decreased over the 25 year period, by 20% in men (from 32 878 to 26 322) and 17% in women (28 516 to 23 719); age standardised mortality rates reduced for all cancers combined by 37% in men (−2.0% per year) and 33% in women (−1.6% per year). The largest decreases in mortality were noted for stomach, mesothelioma, and bladder cancers in men and stomach and cervical cancers and non-Hodgkin lymphoma in women. Most incidence and mortality changes were statistically significant even when the size of change was relatively small.

Conclusions Cancer mortality had a substantial reduction during the past 25 years in both men and women aged 35-69 years. This decline is likely a reflection of the successes in cancer prevention (eg, smoking prevention policies and cessation programmes), earlier detection (eg, screening programmes) and improved diagnostic tests, and more effective treatment. By contrast, increased prevalence of non-smoking risk factors are the likely cause of the observed increased incidence for a small number of specific cancers. This analysis also provides a benchmark for the following decade, which will include the impact of covid-19 on cancer incidence and outcomes.

Introduction

The availability of comprehensive cancer registration data across the UK since 1993 makes comparison of cancer incidence and mortality trends over 25 years possible. We examined UK trends in cancer incidence and mortality for men and women, aged 35-69 years, for all cancers combined and for the most common sites (or site groups) of cancer between 1993 and 2018.

This study focuses on the 35-69 years age group because cancer trend data are more reliable and easier to interpret in this age range. 1 Diagnostic accuracy is better in this age range than in older patients who have a greater proportion of clinical and uncertain diagnoses, as evidenced by the relatively low proportion of microscopically verified tumours, 2 especially in the earlier part of the period analysed. By the age of 35 years, the pattern of cancer broadly represents the usual adult profiles because specific cancers that are observed in childhood, adolescence, and young people would not impact on the overall pattern. Trends in the 35-69 years age group are also reflective of causal factors in the more recent and medium term past rather than in the longer term and, therefore, will be more indicative of future patterns of cancer in the older populations.

This time period has also seen the introduction of three population screening programmes across the UK, which have affected trends by diagnosing some cancers at an earlier stage, preventing cancers, but also had the potential for diagnosing some cancers that would not have otherwise caused harm to the individual, particularly breast cancer. 3 4 Cervical smear tests have been used since the 1960s and the national screening programme was introduced in 1988, with over 85% coverage of the target population (women and people with a cervix aged 25-64 years) in the UK by 1994. 5 The breast screening programme was introduced in 1988 and covered all UK countries by the mid-1990s, with women aged 50-70 years being invited. 6 The bowel screening programme was introduced from 2006 and took a number of years to reach full roll-out. Currently, people aged 60-74 across England, Wales, and Northern Ireland, and 50-74 for Scotland are eligible. Prostate specific antigen testing is not part of the national screening programme. Anyone older than 50 years with a prostate can request a prostate specific antigen test from their family doctor (general practitioner).

The past 25 years have seen differing trends in cancer risk factors, with the two most important risk factors displaying trends in opposing directions. In one direction, smoking prevalence is reducing due to introductions of tax rises on tobacco products, further advertising bans, and smokefree policies, including education and encouraging quitting, and, in the other direction, the proportion of the population classified as overweight or obese is increasing, of which diet and exercise contribute to, as well as being independent risk factors for cancer. 7

Cancer registration data are currently collected by four national registries in the UK. These organisations collect detailed information on newly diagnosed primary tumours, referred to as registrations. Prior to 2013, cancer registrations in England were collected by eight regional registries and compiled by the Office for National Statistics, 8 with these regional registries producing complete population coverage for England since 1971. 9 Cancer Research UK aggregate these data from the UK registries, with incidence, mortality, and corresponding national population data provided by the Office for National Statistics, Public Health Wales, 10 Public Health Scotland, 11 the Northern Ireland Cancer Registry, 12 NHS England, 13 and the General Register Office for Northern Ireland. 14 Coding of cancer registrations is consistent between countries of the UK, using internationally accepted codes from the International Classification of Diseases 10th revision (ICD-10) and collaboration through the UK and Ireland Association of Cancer Registries. 15

Cancer sites (for single sites) or site groups (with multiple sites, such as oral) included in these analyses were selected as the most common causes of cancer incidence or death. These cancer sites are: all cancers combined (excluding non-melanoma skin cancer for incidence) (C00-C97, excluding C44); bladder (C67); bowel (C18-C20); brain and central nervous system (C70-C72, C75.1-C75.3, D32-D33, D35.2-D35.4, D42-D43, D44.3-D44.5); breast (women only) (C50); cervix (C53); Hodgkin lymphoma (C81); kidney (C64-C66, C68); larynx (C32); leukaemia (C91-C95); liver (C22); lung (C33-C34); melanoma skin(C43); mesothelioma (C45); myeloma (C90); non-Hodgkin lymphoma (C82-C86); oesophagus (C15); lip, oral cavity, and pharynx (oral) (C00-C06, C09-C10, C12-C14); ovary (C56-C57.4); pancreas (C25); prostate (C61); stomach (C16); testis (C62); and uterus (C54-C55). In addition, sex specific all cancer groups are also presented without breast and prostate cancers to inspect the overall trends in the absence of the most common cancer site for each sex. Sex is reported as recorded by the cancer registries at the time of registration. Mesothelioma was a new specific code introduced in ICD-10 and no reliable mortality data are available for this site before 2001, hence, we have not included this type of cancer prior to then. Non-malignant brain and central nervous system codes (ICD-10 D codes) are included despite their benign nature because they can cause mortality due to their location in the cranial cavity. The codes included for the brain and central nervous system have been chosen following clinical engagement and discussion with cancer registries across the UK. Non-melanoma skin cancer is excluded for incidence data because of the lack of completeness in the recording of these cancers and therefore unreliability of the data; this process is standard practice among UK cancer registries. 16 A proportion of non-melanoma skin cancer cases can be diagnosed and treated within primary care and have not consistently been captured within cancer registration data. 17

To overcome yearly variation for sites with low numbers of cases, we calculated three-year rolling average age standardised rates per 100 000 population. 18 These rates were based on the European standard population 2013 for men and women separately for each cancer site or site group for both incidence and mortality, restricted to the 35-69 years age group. 19

The estimated annual percentage change is commonly computed using a generalised linear regression model with Gaussian or Poisson link function. 18 20 In this analysis, a generalised linear model was performed with quasi-Poisson link function as overdispersion is very common when modelling rates and count data. 21 The outcome was the age standardised cancer (incidence or mortality) rate per 100 000 and the independent variable was the period variable, which was defined as the three year period for each data point, starting from 1993-95 and ending with 2016-18. Estimated annual percentage change was estimated as (exp (β^−1)' 100, where β^ is the estimated slope of the period variable, with corresponding 95% confidence interval, which is derived from the fitted quasi-Poisson regression model. 22 The determination of trends was based on the following criteria: firstly, an increasing trend was identified when the estimated annual percentage change value and its 95% confidence interval were greater than zero. This value suggests a statistically significant increase in the age standardised rate over time. Secondly, a decreasing trend was indicated when both the estimated annual percentage change value and its 95% confidence interval were less than zero, signifying a statistically significant decline in the age standardised rate over the period considered. Finally, in cases where these conditions were not met, the age standardised rate was concluded to have remained relatively stable. This designation means that no significant change in the age standardised rate over the period examined was noted. These criteria ensure a thorough and precise interpretation of the estimated annual percentage change values and their corresponding trends. These analyses were carried out for each sex and site or site group separately. Statistical analysis was performed using R version 4.0.2. 23

Patient and public involvement

This work uses aggregated and non-identifiable routine data that have been provided by patients and collected by the health services of the UK as part of their care and support. Given the aggregated nature of the data, attempts to identify or involve any of the patients whose data are included is not possible nor permitted. Although patients and the public were not involved in the design and conduct of this research, the aim of this research is to provide an assessment of trends in cancer incidence and mortality and the impacts of treatment and policy changes to improve outcomes for cancer patients across the UK. Dissemination to the public will include a press release and a summary published online, written using layman’s terms, and a webinar to discuss the results.

Table 1 and table 2 show the percentage of all newly diagnosed cancer cases and deaths by age group in 1993 and 2018. For male registrations, around 43% of all registrations were in the 35-69 years age group in 1993 and 2018, while for female registrations, between 47% and 48% of all registrations were in this age group in 1993 and 2018, respectively. For mortality, around 40% of male cancer deaths occurred in the 35-69 years age group in 1993 and this value was lower at 30% in 2018. For female cancer deaths, a slightly smaller reduction was noted, from 38% in the 35-69 years age group in 1993 to 31% in 2018.

Number of newly diagnosed cancer cases (% of total) in the UK for all cancers, excluding non-melanoma skin cancer, (ICD-10 C00-C97 excluding C44) by sex and age group in 1993 and 2018

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Number of deaths (% of total) in the UK for all cancers, (ICD-10 C00-C97) by sex and age group in 1993 and 2018

Figure 1 shows the number of newly diagnosed cancer cases and deaths in the 35-69 years age group between 1993 and 2018 by sex. Across the UK, of cancer registrations in 2018, 83% were from England, and 5.1% from Wales, 9.2% from Scotland, and 2.7% from Northern Ireland; for deaths in 2018, 81.4%, 5.3%, 10.4%, and 2.9% were from England, Wales, Scotland, and Northern Ireland, respectively. These proportions remained relatively stable over the study period. For men, the number of cancer registrations increased by 57% from 55 014 cases registered in 1993 to 86 297 cases registered in 2018, while for women, cases increased by 48% from 60 187 in 1993 to 88 970 in 2018. The rate of increase in the number of cases of cancer was more marked between 2003 and 2013 for both sexes than in other time periods in the study.

Number of newly diagnosed cancer cases and deaths in the UK for all cancers, excluding non-melanoma skin cancer for incidence (International Classification of Diseases (10th revision) codes C00-C97 (excluding C44 for incidence)), men and women, 35-69 years, 1993 to 2018. An interactive version of this graphic is available at https://bit.ly/4acPDjP

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The number of cancer deaths in men and women aged 35-69 years decreased: by 20% in men from 32 878 in 1993 to 26 322 deaths in 2018 and by 17% in women from 28 516 in 1993 to 23 719 deaths in 2018. The main decrease in the number of deaths per year occurred before the year 2000 ( fig 1 ) with a decrease of 14% in males and 11% in females between 1993 and 2000. Since 2000, the number of deaths each year in both men and women has remained fairly constant ( fig 1 ).

Table 3 , table 4 , figure 2 and figure 3 , and figure 4 and figure 5 show the trends over time in both incidence and mortality rates by sex and cancer site or site group. The tables only include specific age standardised incidence and mortality rates for the first (1993-95) and last (2016-18) period to give an indication of the change over the 25 year period. The trends in incidence and mortality age standardised rates for all years are shown in the figures. Figure 6 and figure 7 show the age adjusted average annual percentage change in the rates. Between 1993-95 and 2016-18, the age standardised incidence rate for all cancers (excluding non-melanoma skin cancer) increased slightly in men and women with age adjusted annual increases of 0.8% for both sexes. The trends in prostate and breast cancer, as the two largest cancer sites in men and women, respectively, substantially contribute to the overall all sites trends for cancer incidence. Figure 3 shows the trends for each sex without the largest cancer site. In contrast to the male age standardised incidence rate for all cancers, which showed a general increase, the incidence trend for men for all cancers excluding non-melanoma skin and prostate cancer, showed a decrease before 2000, but very little change in the following period. For women, an increase in age standardised incidence rates for all cancers excluding non-melanoma skin and breast cancer is still observed but the rate of increase is lower, at 0.7% per annum on average, over the 25 year period. Over the same period reductions in age standardised mortality for all cancers, including non-melanoma skin cancer, were −2.0% per year in men and −1.6% in women. Exclusion of prostate cancer from the mortality trends for men had a negligible effect on the average annual percentage change. For women, the exclusion of breast cancer from mortality trends led to a smaller decrease in mortality of −1.3% per annum.

Age standardised* incidence and mortality rates in 1993-95 and 2016-18 and percentage change by cancer type, men aged 35-69 years, UK

Age standardised* incidence and mortality rates in 1993-95 and 2016-18 and percentage change by cancer type, women aged 35-69 years, UK

European 2013 population age standardised incidence and mortality rates in the UK for all cancers, 19 excluding non-melanoma skin cancer for incidence (International Classification of Diseases (10th revision) codes C00-C97 excluding C44 for incidence), men and women, 35-69 years, 1993-95 to 2016-18. An interactive version of this graphic is available at https://bit.ly/4a484aE

European 2013 population age standardised incidence and mortality rates in the UK for all cancers in men and women aged 35-69 years during 1993-95 to 2016-18, 19 excluding non-melanoma skin cancer for incidence, and breast cancer in women and prostate cancer in men were excluded for incidence and mortality (International Classification of Diseases (10th revision) codes C00-C97 excluding C44 for incidence, C50, C61). An interactive version of this graphic is available at https://bit.ly/3vakQoX

European 2013 age standardised incidence and mortality rates by year, 19 in the UK, for men and women aged 35-69 years from 1993-95 to 2016-18, by cancer site. An interactive version of this graphic is available at https://bit.ly/49a6ovn

Relative European 2013 age standardised incidence and mortality rates by year, 19 in the UK, for men and women aged 35-69 years from 1993-95 to 2016-18 (the reference year is 1993-95=100), by cancer site. CNS=central nervous system. An interactive version of this graphic is available at https://bit.ly/3PiKGOk

Average annual percentage change in incidence and mortality rates, in the UK, for men aged 35-69 years from 1993-95 to 2016-18 by cancer site. An interactive version of this graphic is available at https://bit.ly/3wMR6yU

Average annual percentage change in incidence and mortality rates, in the UK, for women aged 35-69 years, from 1993-95 to 2016-18, by cancer site. An interactive version of this graphic is available at https://bit.ly/3v0QdT7

Incidence rates varied over time across the different cancer sites and site groups. The largest average annual percentage increases over time for cancer incidence rates for men aged 35-69 years were for cancers of the liver (4.7%), prostate (4.2%), and melanoma skin cancer (4.2%). Increases of 1% or more per annum were also seen for oral cancer (3.4%), kidney cancer (2.7%), myeloma (1.6%), Hodgkin lymphoma (1.5%), testicular cancer (1.3%), non-Hodgkin lymphoma (1.0%), and leukaemia (1.0%). The largest annual decreases over the two decades were seen for stomach (−4.2%), bladder (−4.1%), and lung cancers (−2.1%), with decreases of more than 1% per annum also observed for mesothelioma (−1.9% from 2001 onwards) and laryngeal cancer (−1.5%).

For women, the largest average annual percentage increases in incidence rates were noted for liver (3.9%), melanoma skin (3.5%), and oral (3.3%) cancers with increases in incidence of more than 1% per annum also observed for kidney (2.9%), uterus (1.9%), brain and central nervous system cancers (1.8%), Hodgkin lymphoma (1.6%), myeloma (1.1%), and non-Hodgkin lymphoma (1.0%). The largest annual decreases were reported for bladder (−3.6%) and stomach (−3.1%) cancers while the only other site showing a decrease of more than 1% per annum was cervical cancer (−1.3%). Although breast cancer represents the largest individual cancer site for women and therefore plays a large part in all cancer trends, the average annual increase was only 0.9%. All the incidence changes mentioned, for both men and women, and most incidence changes shown in table 3 and table 4 and in figure 6 and figure 7 were statistically significant (P<0.05) even when the size of change was relatively small.

Mortality rates mainly decreased over time in both sexes. For men, the cancer sites that showed average annual percentage reductions in mortality rates of more than 1% per annum were stomach (−5.1%), mesothelioma (–4.2% from 2001), bladder (–3.2%), lung (–3.1%), non-Hodgkin lymphoma (–2.9%), testis (–2.8%), Hodgkin lymphoma (–2.6%), bowel (–2.5%), larynx (–2.5%), prostate (–1.8%), myeloma (–1.7%), and leukaemia (–1.6%). Only liver (3.0%) and oral (1.1%) cancers showed an average annual increase in mortality of 1% or more with melanoma skin cancer (0.3%) the only other site showing an increase. For women, the cancer sites with average annual decreases in mortality per year of 1% or more were stomach (–4.2%), cervix (–3.6%), non-Hodgkin lymphoma (–3.2%), breast (–2.8%), Hodgkin lymphoma (–2.8%), ovary (–2.8%), myeloma (–2.3%), bowel (–2.2%), leukaemia (–2.1%), larynx (–2.0%), mesothelioma (–2.0% since 2001), bladder (–1.6%), oesophagus (–1.2%), and kidney (1.0%). As with men, liver (2.7%) and oral (1.2%) cancers showed average annual increases of more than 1%, in addition to uterine cancer (1.1%). For both men and women, the mortality changes mentioned previously and most mortality changes shown in table 3 and table 4 and in figure 6 and figure 7 were statistically significant (P<0.05), even when the size of change was relatively small.

Principal findings

The most striking finding in this analysis of UK cancer trends among the 35-69 years age group is the substantial decline in cancer mortality rates observed in both sexes (37% decline in men and 33% decline in women) across the period examined. A decrease in mortality was reported across nearly all the specific types of cancer examined (23 in total), with only liver, oral, and uterine cancers showing an increase together with melanoma skin cancer in men and pancreatic cancer in women, both showing small increases. By contrast, the incidence trends in this age group showed varying patterns with some sites increasing, some decreasing and some remaining relatively constant. Over all sites, a modest increase was noted in cancer incidence rates of around 0.8% per annum in both sexes, amounting to an increase of 15% in men and 16% in women over the 25 year time frame.

The increase in prostate cancer incidence over this period, especially in the 35-69 years age group considered here, is very likely to be a direct result of the uptake of prostate specific antigen testing, which results in the detection of early stage disease and, to an unknown extent, indolent disease that may otherwise never have been regarded as clinically significant. 24 25 The results do, however, affect people diagnosed and represent a large increase in workload for clinical staff. The fact that the overall mortality trends for men show no difference whether prostate cancer is included or excluded in the analysis indicates that the incidence increase for this cancer has largely been of non-fatal disease. That the specific mortality rates for prostate cancer showed an appreciable rate of decline during this time (–1.8% per annum) also indicates improved clinical treatment of the disease or an increase in the proportion of men diagnosed with a favourable prognosis, or both. 24 26 However, the increase in prostate cancer incidence still results in thousands of men each year dealing with the concerns of a cancer diagnosis and the impact this may have on their lives.

Breast cancer comprehensively dominated incidence and mortality trends in female cancer. Even though the average annual incidence increase of breast cancer over this period (0.9%) was modest in comparison to the prostate cancer increase in men (4.2%), breast cancer incidence rates remained substantially higher than those for any other cancer site in either sex. Inspection of figure 4 shows that breast cancer incidence rates (age standardised) increased at a faster rate until around 2003-05 (from 194.7 in 1993-95 to 229.9 in 2003-05), a slower rate from then until 2013-15 (240.8) but have levelled off in the most recent years analysed (238.0 in 2016-18). These changes in the incidence trend likely reflect a reduced effect of the initial incidence increases brought about by mammography screening in the UK introduced from the late 1980s or a possible effect of a decline in usage of hormone replacement treatment. 27 28 However, the effect of hormone replacement treatment on breast cancer risk is small in comparison to other risk factors, 7 and trends in this treatment has varied over time, such as changes in preferred formulations, doses, and treatment durations, 29 30 31 which may impact breast cancer risk levels. 32 33 As has been reported elsewhere, 34 35 36 mortality for breast cancer has declined substantially despite the incidence increase, which is indicative of improvements in early detection (including through screening 37 ) and improved treatment.

The other two major sites of cancer in men apart from prostate cancer, namely lung and bowel cancers, showed substantial reductions in mortality. These results are likely from primary prevention (historical reduction in smoking rates) 38 39 40 41 for lung cancer and earlier detection (including screening) and improved treatment for bowel cancer. 42 43 44 While lung cancer incidence substantially decreased, the incidence rates of bowel cancer remained unchanged. However, closer inspection of the bowel cancer incidence trends over the full period shows an increase from the point the bowel screening programme was first introduced from 2006 in the UK. This rate, however, has now decreased back to the observed level prior to the introduction of the screening programme. As others have shown, the introduction of bowel screening leads to an initial short-term increase in cancer incidence due to detection of as-yet undiagnosed cancer cases, followed by a decrease because of removal of adenomas. 42 45 46 Therefore, bowel cancer incidence trends can reasonably be assumed to decrease further over the coming years, unless other preventable risk factors for bowel cancer affect the trend.

Similarly, lung and bowel were the other two major cancer sites for women (alongside breast cancer), and both showed reductions in mortality. The decline in lung cancer mortality was, however, not as extensive as that for men (–0.5% compared with –3.1% per annum) likely reflecting the different demographic pattern in smoking rates that led to peak smoking prevalence in women occurring around 30 years later than men, albeit at around half the peak prevalence observed in men. 40 47 Smoking prevalence in women has always been lower than in men. 39 48 The lung cancer incidence trends showed a significant increase in women of 0.8% per annum as opposed to the –2.1% per annum decrease in men. That the incidence rate in 2016-18 was still higher in men than in women again is almost certainly a reflection of historical differences in smoking patterns. 39 49 50 Bowel cancer incidence in women followed a similar pattern to men and is equally reflective of the introduction of the bowel screening programme. Bowel cancer mortality in women has declined at a similar rate to men (–2.2% compared with –2.5% per annum), indicative of the same improvements in early detection and improved treatment.

These reductions in mortality across the most common cancers in both sexes are likely a representation of considerable success in cancer prevention, diagnosis, and treatment. Further improvements are likely to be realised from the continued reduction in smoking prevalence, of which smoking prevention policies continue to contribute, 51 alongside the recent move to faecal immunochemical testing in the bowel screening programme adopted throughout the UK during 2019. 52 The recommended rollout of targeted lung screening is expected to further help with the earlier diagnosis of lung cancer where surgery is a viable treatment option and outcomes are vastly improved. 53 54

Although four major sites influenced the overall pattern of cancer incidence and mortality, increases in rates among some of the less common sites do raise concerns. Four cancers showed substantial increases in incidence (more than 2% per annum) in both sexes: liver, melanoma skin, oral, and kidney cancers. All have strong associations with established risk factors: alcohol consumption, smoking, and HPV for oral cancer; 7 55 56 overweight and obesity, smoking, alcohol, and hepatitis B and C for liver cancer; 7 57 58 ultraviolet light for melanoma; 59 60 and obesity and smoking for kidney cancer. 61 62 63 Increases in liver cancer incidence and mortality for both men and women are very concerning, with nearly one in two attributable to modifiable risk factors. 7 With high prevalence of overweight and obesity and diabetes in the general population, other studies expect the rates to remain high. 64 For oral and kidney cancer, despite the association with smoking, incidence rates have not followed the decrease seen for lung cancer incidence in men. This is likely to be due to the smaller proportion of cases attributable to smoking in these two sites. Whilst smoking accounts for around 17% of oral cancers, over one in three are attributed to alcohol consumption. 7 For kidney cancer, smoking is attributable to 13% of cases whereas obesity causes around 25%, however, increasing trends in kidney mortality are shown for this age group and period. 7 Therefore, the increasing incidence trends could potentially have been worse, especially in men, if the reduction in smoking prevalence had not occurred. The increased incidence of melanoma skin cancer is likely to be caused by the increased sunlight and ultraviolet exposure caused by the availability of cheaper air travel to countries with a warmer climate and insufficient regulation of tanning beds until 2010. 65 66

In women, uterine cancer incidence increased by 1.9% per annum; although, this increase was predominantly seen over the period 1993-2007 and since then incidence trends have increased at a slower rate. One of the main risk factors for uterine cancer is the use of oestrogen-based hormone replacement therapy, 67 68 and since around 2000, use has substantially declined. 27 Around a third of uterine cancers in the UK are also attributed to overweight and obesity, but the increase in incidence is also likely to be caused by a decrease in the number of women undergoing hysterectomies for menorrhagia, in favour of endometrial ablation. 69

Other cancers that showed increases in incidence were cancers of the pancreas, brain, and central nervous system, together with Hodgkin and non-Hodgkin lymphoma, myeloma, and leukaemia in both sexes, and oesophageal and testicular cancers in men. With the exception of pancreatic cancer, which only decreased in women, all these cancers also showed a reduction in mortality in both sexes, indicating improving treatment or earlier detection, or both. Generally, the causes of these cancers are not well understood although obesity is associated with the adenocarcinoma histological subtype of oesophageal cancer, 70 especially in men, 7 while a combination of smoking and alcohol is implicated in the squamous cell carcinoma subtype. 71 The considerable male excess in oesophageal adenocarcinoma in comparison with squamous cell carcinoma rates, 72 possibly underlined by the higher incidence of gastroesophageal reflux disease in men 73 and the protective effect of oestrogen, 74 75 may explain the differing trends now observed between men and women.

Several cancer sites showed decreases in both incidence and mortality rates over the time period, notably stomach, larynx, and bladder cancer in both sexes, as well as cervical and ovarian cancers in women and mesothelioma in men. The changes in stomach cancer rates were of a similar magnitude and represented the largest percentage mortality decline in both sexes. This decline can probably be attributed to a combination of a reduction in the prevalence of Helicobacter pylori infection and an increase over time in fruit and vegetable consumption reducing the dependency on preserved foods. 76 77 Challenges in coding of stomach and oesophageal cancer before 2000 may also have had a role in shaping these trends. Laryngeal cancer is associated with tobacco use and alcohol consumption as well as occupational exposures, 56 78 79 and the decline in rates is most likely to be related to the decrease in smoking prevalence as well as decreases in occupational exposure. 80 The refinement of understanding pathology for bladder cancer during this period, in which previously diagnosed malignant disease is now categorised as benign, 81 is likely to have resulted in an artificial decline in incidence rates. 82 83 This artefact should not, however, have affected the decline in mortality rates given the benign nature of these tumours that do not cause death. 81 This decline in mortality, although not as marked as that for incidence, remained appreciable. The changes in cervical cancer rates, which showed the largest percentage mortality decline amongst gynaecological cancers, are almost certainly attributed to the success of the cytological screening programme during the whole of the time period considered. 84 85 With the introduction of the HPV vaccination programme for girls in 2008 86 and the subsequent expansion to boys in 2019, 87 rates of cervical cancer are expected to fall substantially over the following decades as the first cohort of vaccinated women reaches the peak age for cervical cancer incidence (aged 30-34 years). A reduction has already been shown for women aged 20-24. 88 The absolute incidence rates of mesothelioma in women were small in magnitude in 1993-95 (0.8 per 100 000 per annum) and remained similar over time (0.7 per 100 000 per annum in 2016-18). The incidence rates of mesothelioma in men were considerably greater, especially in 1993-95 (around 6.3 per 100 000 per annum), due largely to occupational asbestos exposure, 89 but a significant decrease was noted over time (to 3.6 per 100 000 per annum in 2016-18) resulting from both the decline in asbestos exposure and the decline in heavy industries, such as coal mining. Mortality decreased substantially in both sexes over the period for which data are available (2001-03 to 2016-18).

The conclusions that can be drawn from this analysis are, overall, positive and reassuring. Within the 35-69 year age group, cancer mortality rates have shown a substantial overall decline during the last quarter of a century in both men and women. The most probable causes are a combination of changes in the underlying risk of disease for some cancers (notably lung and stomach), in increased levels of early detection (notably breast 37 and cervix 90 ) and improved treatment (notably breast and bowel) for others. The specific circumstances leading to the increased incidence of breast cancer, of which risk factors are complex, need to be better understood and controlled. Similar results have been shown for incidence within Great Britain and mortality in the UK for some cancer sites. 91 Speculated overdiagnosis, where tumours are detected that would not have caused the patient any harm during their lifetimes, has been thought to increase rates for breast and prostate cancers in particular, of which prostate is especially affected by the widespread use of prostate specific antigen testing. 4 92 However, given the decreases in mortality across the wide set of cancer sites analysed here, improvements in early diagnosis, treatment, or both are having a positive effect for most cancer patients, although cancer mortality in this age group still needs reducing.

After accounting for the major two sites in men and women, the increase in overall incidence rates disappeared in men while it remained significant in women. This difference between sexes is due to a decrease in cancers with substantially higher initial incidence rates in men, such as lung, stomach, and bladder, resulting in a higher overall impact on male incidence, combined with an increase in incidence in uterine cancer, one of the most common cancers in women.

Strengths and limitations

This study benefits from high quality cancer registry data collected by all four cancer registries in each country across the UK, which allows for the inspection of a wide range of cancer sites over 25 years. ICD-10 coding changes have been minimal, only affecting trends in cancer incidence for bladder and ovarian cancers and cancer mortality for mesothelioma, whereas challenges in coding stomach and oesophageal cancer may have affected trends for these sites. Changes in registration practice may well have had a small effect on certain cancer sites. By focusing only on the 35-69 age range, we present a clear and reliable comparative picture of cancer incidence across 25 years within the UK, which provides a reliable indicator regarding future cancer incidence trends. Understanding cancer in older people and changes in the trends of different cancers is also of interest, but subject to a different study given the increasing life expectancy over this period, impact of comorbidities, and differing interaction with health services in this age group.

Limitations include the absence of staging data to substantiate any improvements in earlier diagnosis. Due to the number of sites analysed, we also have not broken down sites by histological type, which could be beneficial in certain sites to understand the trends within cancer sites—eg, small cell and non-small cell lung cancer or oestrogen receptor-positive and oestrogen receptor-negative breast cancer. In focusing on the age group selected, we are excluding older ages where rates of cancer are higher. Although this exclusion reduces the number of cases included, providing a smaller cohort for each year, the age group selected provides a more reliable comparator for future trends given the accuracy of incidence recording and also focuses on the cancers that lead to a larger number of years of life lost. The age range included in this study has been well defined; however, other studies are indicating potentially different trends worldwide in young adults with potential increases in risk factors such as dietary risk factors playing a role. 93 94 The data captured across the UK registries provides a basis for further understanding to see whether different trends are observed across younger age groups and whether the causes of this can be determined. Additionally, although we have included a broad range of cancer sites, cancers that have not been included in this study could well be showing different trends, such as a more recent increase in thyroid cancer in the UK. 95

This study also provides a baseline covering a 25 year period uninterrupted by covid-19. Trends in cancer incidence and mortality beyond these years will be affected and therefore understanding the causes of trends will be more complicated. Having a 25 year baseline provides the observed trend for which expected cases can be assessed against observed. This benchmark will present a comparison for the following decade as the presentation, diagnosis, and treatment of cancer have been hugely affected by rules and regulations affecting public and health service staff. Mortality trends will also be impacted with decision making regarding coding of deaths with covid-19 likely to be the underlying cause of death for people with cancer if that has directly led to the patient dying, rather than their cancer.

This study focuses on the overall sex specific trends for cancer incidence and mortality in the specified age group to observe and understand trends over the 25 year period across the entire UK. Further breakdowns have not been possible. Paucity of numbers for less common cancers precluded separate analyses for the individual UK nations while data limitations precluded analyses by other demographic characteristics, for example, ethnic group and deprivation. The main obstacle to analysing data by ethnic group is the completeness of recordings in hospitals. In England, completeness improved substantially in 2012, but prior to this, the proportion of cases with unknown ethnic group renders results over time to be incomparable. In other UK countries, completeness of ethnic group recording is still not good enough to conduct country-wide cancer incidence or mortality analyses by ethnicity. For deprivation, the measures currently available are derived within each UK nation, and a specific validated UK-wide deprivation measure does not yet exist. Given the obvious importance of looking at variation in UK trends within ethnic groups and deprivation categories, such analyses represent a priority for further research and highlights the importance of data collection across all UK nations.

Conclusions

Overall, these results substantiate the view that in this age group there is no generalised increase in cancer incidence, while there is a substantial decrease in cancer mortality in the UK over the 25 year study period. Specific concerns about individual cancer sites identified were raised, of which the most important numerically, apart from the increases in breast and prostate cancer incidence, was the need to accelerate the decrease in female lung cancer. After which, concerns about oral cancer, liver cancer, kidney cancer, uterine cancer, and melanoma skin cancer present the most pressing issues. There are also several cancer sites that showed decreases in both incidence and mortality, notably, stomach, larynx, bladder, and cervical.

What is already known on this topic

No recent studies have investigated cancer incidence and mortality rates over such a long time frame within the 35-69 year age group in the UK

Short term trends for specific cancer sites are related to known risk factors, screening programmes, and improved treatment

Trends in the 35-69 years age group can be indicative of future patterns of cancer in older people

What this study adds

Decreased rates of many cancers, including lung and laryngeal, is positive, and likely to be driven by the decrease in smoking prevalence across the UK

An increase in rates of other cancer sites, including uterine and kidney, was noted, which may be a result of the increasing prevalence of overweight/obesity and other risk factors

Organised population screening programmes have led to an increase in cancer incidence but also look to have contributed to a reduction in cancer mortality across the UK

Ethics statements

Ethical approval.

Ethics approval for this work was not required as the study used publicly available data.

Data availability statement

Data sharing may be possible for additional analyses. All code used for analyses in this paper are also available from the Cancer Research UK website and GitHub. Information on how to access the data used in this analysis are available from the Cancer Research UK website.

Acknowledgments

This work uses data that has been provided by patients and collected by the health services as part of their care and support. The data is collated, maintained, and quality assured by NHS England, Public Health Wales, Public Health Scotland, and the Northern Ireland Cancer Registry.

Contributors: All authors participated in study conception and design, and/or the analysis and interpretation of results. Conception and design: DF, LS, and CT. Analysis and interpretation: all authors. Writing manuscript: all authors. Supervision and guarantor: JS and DF. All authors critically reviewed drafts of the manuscript, read and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

The manuscript’s guarantor (DF) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported, that no important aspects of the study have been omitted and that any discrepancies from the study as planned have been explained.

Dissemination to participants and related and public communities: study results will be disseminated to the public and health professionals by a press release written using layman’s terms; findings will also be shared through mass media communications and social media postings. A webinar produced alongside a patient advocacy group is also planned to accompany the publication of this study, a recording of which will be made available on the Cancer Research UK website. Since the study analyses cancer registry data collected during routine care, and provided in aggregated form, we are unable to specifically disseminate results to study participants beyond the usual channels of publication.

Provenance and peer review: Not commissioned; externally peer reviewed.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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• v.32(6); 2020 Dec 31

Cervical cancer: Epidemiology, risk factors and screening

Shaokai zhang.

1 Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou 450008, China

Luyao Zhang

Youlin qiao.

2 Department of Epidemiology, National Cancer Center, Chinese Academy of Medical Sciences, School of Population Medicine and Public Health, Peking Union Medical College, Beijing 100021, China

Cervical cancer is one of the leading causes of cancer death among females worldwide and its behavior epidemiologically likes a venereal disease of low infectiousness. Early age at first intercourse and multiple sexual partners have been shown to exert strong effects on risk. The wide differences in the incidence among different countries also influenced by the introduction of screening. Although the general picture remains one of decreasing incidence and mortality, there are signs of an increasing cervical cancer risk probably due to changes in sexual behavior. Smoking and human papillomavirus (HPV) 16/18 are currently important issues in a concept of multifactorial, stepwise carcinogenesis at the cervix uteri. Therefore, society-based preventive and control measures, screening activities and HPV vaccination are recommended. Cervical cancer screening methods have evolved from cell morphology observation to molecular testing. High-risk HPV genotyping and liquid-based cytology are common methods which have been widely recommended and used worldwide. In future, accurate, cheap, fast and easy-to-use methods would be more popular. Artificial intelligence also shows to be promising in cervical cancer screening by integrating image recognition with big data technology. Meanwhile, China has achieved numerous breakthroughs in cervical cancer prevention and control which could be a great demonstration for other developing and resource-limited areas. In conclusion, although cervical cancer threatens female health, it could be the first cancer that would be eliminated by human beings with comprehensive preventive and control strategy.

Introduction

Cervical cancer is the second common female malignant tumor globally which seriously threatens female’s health. Persistent infection of high-risk human papillomavirus (HPV) has been clarified to be the necessary cause of cervical cancer ( 1 , 2 ). The clear etiology accelerated the establishment and implementation of comprehensive prevention and control system of cervical cancer. In May 2018, the World Health Organization (WHO) issued a call for the elimination of cervical cancer globally, and more than 70 countries and international academic societies acted positively immediately ( 3 - 6 ). Thereafter, in November 17, 2020, WHO released the global strategy to accelerate the elimination of cervical cancer as a public health problem to light the road of cervical cancer prevention and control in future which mean that 194 countries promise together to eliminate cervical cancer for the first time ( 7 ). At this milestone time point, we reviewed the update progress of cervical cancer prevention and control in epidemiology, risk factors and screening, in order to pave the way of cervical cancer elimination.

Epidemiology for cervical cancer

Cervical cancer is one of the leading causes of cancer death among women ( 8 ). Over the past 30 years, the increasing proportion of young women affected by cervical cancer has ranged from 10% to 40% ( 9 ). According to the WHO and International Agency for Research on Cancer (IARC) estimates, the year 2008 saw 529,000 new cases of cervical cancer globally. In developing countries, the number of new cases of cervical cancer was 452,000 and ranked second among malignancies in female patients ( 10 ). Conversely, the number of new cases of cervical cancer was 77,000 in developed countries and ranked tenth among female malignancies.

In 2018 worldwide with an estimated 570,000 cases and 311,000 deaths, cervical cancer ranks as the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women ( 11 ). However, approximately 85% of the worldwide deaths from cervical cancer occur in underdeveloped or developing countries, and the death rate is 18 times higher in low-income and middle-income countries compared with wealthier countries ( 12 ). Cervical cancer ranks second in incidence and mortality behind breast cancer in lower Human Development Index (HDI) settings; however, it is the most commonly diagnosed cancer in 28 countries and the leading cause of cancer death in 42 countries, the vast majority of which are in Sub-Saharan Africa and South Eastern Asia ( 13 ). The highest regional incidence and mortality rates are seen in Africa ( 14 ). In relative terms, the rates are 7−10 times lower in North America, Australia/New Zealand, and Western Asia (Saudi Arabia and Iraq) ( 15 ).

In China, cervical cancer is the second largest female malignant tumor ( 11 ). According to the data from National Cancer Center in 2015, there were 98,900 new cases and 30,500 deaths of cervical cancer ( 16 ). In the past 20 years, the incidence and mortality of cervical cancer have been increasing gradually in China ( 17 ).

Between 2004 and 2007, the Chinese scientific research team, cooperated with WHO/IARC and the Cleveland Medical Center in the United States in 8 rural and urban areas (Xiangyuan county of Shanxi Province, Yangcheng county of Shanxi Province, Xinmi county of Henan Province, Hotan Prefecture of Xinjiang Uygur Autonomous Region, Shanghai City, Beijing City, Shenzhen City of Guangdong Province, and Shenyang City of Liaoning Province), carried out a population-based multicenter HPV type distribution study among females aged 15−59 years old, clarifying the dominant HPV types of rural and urban populations in China, as well as female HPV infection status and age distribution ( 18 ). Studies have confirmed that persistent infection of high-risk HPV is closely related to the occurrence of cervical cancer. There are 14 types of high-risk HPV, namely HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68 and 73. A multi-center cross-sectional survey study showed that the infection rate of high-risk HPV in China is about 14.3%, and the dominant types are HPV16 (2.9%), HPV52 (1.7%), HPV58 (1.5%), HPV33 (1%) and HPV18 (0.8%), and showed double peaks during adolescence and perimenopause ( 19 ). Globally, HPV16 has the highest infection rate, HPV18 is the second most common type, while HPV 33 is common in Asia, and HPV52 and HPV58 have relatively low infection rates. This shows that compared with the global HPV epidemiology, HPV epidemiology in China has both similarities and differences.

Subsequently, the Chinese scientific research team conducted a cross-sectional multi-center cervical cancer and precancerous HPV genotyping study based on 19 hospitals in 7 geographic regions (Northeast China, North China, Northwest China, Central China, East China, Southwest, and South China). Through the pathological laboratory procedures of strict quality control, it was found that the dominant HPV types in cervical cancer tissue were HPV16, 18, 31, 52 and 58, respectively, and that HPV16 and 18 were the most carcinogenic, which could cause more than 84.5% of cervical cancer ( 20 ). The above research on HPV dominant types from different perspectives provides solid scientific evidence and support for the future research and application of preventive HPV vaccine and in vitro diagnostic technology, epidemiological research and health economics research in the Chinese population.

Risk factors for cervical cancer

A number of risk factors for cervical cancer are linked to exposure to the HPV ( 21 , 22 ). Invasive cancer development process could prolong up to 20 years from the precursor lesion caused by sexually transmitted HPV ( 23 ). However, there are also other numerous risk factors (such as reproductive and sexual factors, behavioral factors, etc) for cervical cancers which include sexual intercourse at a young age (<16 years old), multiple sexual partners, smoking, high parity and low socio-economic level ( 24 , 25 ).

Sexually transmitted infections (STI)

The primary cause of pre-cancerous and cancerous cervical lesions is infection with a high-risk or oncogenic HPV types. Most cases of cervical cancer occur as a result of infection with HPV16 and 18. High-risk types, especially HPV16, are found to be highly prevalent in human populations ( 22 ). The infection is usually transmitted by sexual contact, causing squamous intraepithelial lesions. Most lesions disappear after 6−12 months due to immunological intervention. However, a small percentage of these lesions remain and can cause cancer.

The results of a meta-analysis showed that the highest prevalence of HPV occurs at the age of 25 years, which could be related to changes in sexual behavior ( 26 ). In a meta-analysis study, the bimodal distribution of cervical cancer in some regions has been studied. In this distribution, immediately after sexual intercourse, an outbreak of HPV can be observed, which is followed by a plateau at adult age; the second peak again is observed after 45 years old ( 27 ). Permanent infection with one of the high-risk types of HPV over time leads to the development of cervical intraepithelial neoplasia (CIN). The major mechanisms through which HPV contributes to carcinogenesis involve the activity of two viral oncoproteins, E6 and E7, which interfere with major tumor suppressor genes, P53 and retinoblastoma. In addition, E6 and E7 are associated with changes in host DNA and virus DNA methylation. Interactions of E6 and E7 with cellular proteins and DNA methylation modifications are associated with changes in key cellular pathways that regulate genetic integrity, cell adhesion, immune response, apoptosis, and cellular control ( 28 ).

Human immunodeficiency virus (HIV)

The risk of developing infection from high-risk HPV types is higher in women with HIV ( 29 ). The results of the studies on the relationship between HIV and cervical cancer suggested a higher rate of persistent HPV infection with multiple oncogene viruses, more abnormal Papanicolau (Pap) smears, and higher incidence of CIN and invasive cervix carcinoma among people with HIV ( 23 ). Women infected with HIV are at increased risk of HPV infection at an early age (13−18 years) and are at high risk of cervical cancer. Compared with non-infected women, HIV positive patients with cervical cancer are diagnosed at an earlier age (15−49 years old) ( 30 ).

Reproductive and sexual factors

Sexual partners.

Factors relating to sexual behavior have also been linked to cervical cancer. One study found that an increased risk of cervical cancer is observed in people with multiple sexual partners ( 31 ). Moreover, many studies have also suggested that women with multiple sexual partners are at high risk for HPV acquisition and cervical cancer ( 32 , 33 ). From the meta-analysis, a significant increased risk of cervical diseases was observed in individuals with multiple sexual partners compared to individuals with few partners, both in non-malignant cervical disease and in cervical cancer ( 34 ). The association remained exist even after controlling for the status of HPV infection, which is a major cause of cervical cancer. Also, early age at first intercourse is a risk factor for cervical cancer ( 35 ).

Oral contraceptive (OC) pills

OC pills are known to be a risk factor for cervical cancer. In an international collaborative epidemiological study of cervical cancer, the relative risk in current users increased with an increase in the duration of OC use. It has been reported that the use of OC for 5 years or more can double the risk of cancer ( 36 ). And in a multi-center case-control study, among women who tested positive for HPV DNA, the risk of cervical cancer increased by 3 times if they have used OC pills for 5 years or more ( 37 ). In addition, a recent systematic review & meta-analysis also suggested that OC pills use had a definite associated risk for developing cervical cancer especially for adenocarcinoma. This study concluded that use of OC pills is an independent risk factor in causing cervical cancer ( 38 ).

Cervical cancer screening

With the background of cervical cancer elimination worldwide, cervical cancer screening plays an increased role in the comprehensive prevention and control besides HPV vaccination, especially those methods that demonstrated excellent clinical performance.

Overview of cervical cancer screening methods

The screening methods for cervical cancer are mainly as following: traditional Pap smear, visual inspection with acetic acid & Lugol’s iodine (VIA/VILI), liquid-based cytology (LBC) and HPV testing. The disease burden of cervical cancer has been significantly reduced in developed countries by Pap smear, mainly in the United States, since 1950s. However, the accuracy of traditional Pap smear could be easily affected by following factors: the level of cytological room, professional technicians, sampling method, slide quality, dyeing skills, and cytological personnel experience. In developed countries with high standard experimental conditions and technical level, the sensitivity of cytology is as high as 80%−90%, in contrast, in resource-limited regions, it could be as low as 30%−40%. To overcome the limitations of traditional Pap smear in cervical cancer screening, LBC was developed and approved by Food and Drug Administration (FDA) in 1996 for clinical-use purpose. Compared with the traditional Pap smear, the sensitivity of LBC was significantly improved. Meanwhile, organized and practicable LBC screening program has also been established in developed countries which could ensure cervical cancer screening strategy is carried out continuously and effectively.

Cervical cancer screening has been facilitated since the cause clarified. HPV-based testing is a pivotal part for cervical cancer screening besides cytology-based tests.

The detection of high-risk HPV in cervical lesion biopsies and exfoliated cells has evolved from restriction endonuclease cleavage patterns and hybridization techniques to polymerase chain reaction (PCR)-based system ( 39 ) and most recently next-generation sequencing (NGS) assays ( 40 ). Currently, HPV genotyping is primarily based on the detection of individual types by various methods that utilizing the highly conserved L1 gene and PCR-based methods. These PCR methods employed consensus primers that could target and amplify different sized fragments such as 455 bp with the MY09/11|PGMY system ( 41 ), 150 bp with the GP5+/6+ system ( 42 ), or <100 bp with SPF10 ( 43 ). And another point that is worth noting is that all these techniques remained the most validated methodology to identify and characterize clinically relevant HPV ( 44 - 46 ).

Additionally, the type-specific probes are always to be used to achieve HPV genotyping, besides DNA sequencing ( 46 , 47 ). Other types of assays may be type-specific with immediate discrimination and quantitation of specific HPV types in an “onetube” assay. These methods employ real-time (RT)-PCR techniques, coupled with beta-globin detection for internal quality control utilizing specialized detection systems ( 48 ).

Cervical cancer malignant pathways are tightly correlated to the viral E6 and E7 oncoprotein activities which could also contribute to the accumulation of cellular genomic mutations and viral integration ( 47 ). Therefore, identification of HPV E6/E7 mRNA has been shown to be promising in cervical cancer screening. And most of the assays utilized reverse transcriptase PCR or nucleic acid sequence-based amplification to identify E6/E7 genome fragments ( 49 ).

Recently, the correlation between increased HPV CpG site methylation levels and high-grade cervical lesions has also been demonstrated in numerous studies and has facilitated the development of quantitative assays targeted CpG methylation ( 50 , 51 ). . Studies indicate that NGS assays can provide single-molecule CpG methylation levels to help unravel the mechanism of methylation in cervical cancer development ( 39 , 50 ).

The application of HPV detection has accelerated the transition of cervical cancer screening from morphology to molecular biology. HPV testing was initially used as a triage method for the reflex triage of population with atypical squamous cells of undetermined significance (ASC-US). In 2014, FDA approved HPV detection for the use in cervical screening. Thereafter, HPV detection plays an increasingly important role in the practice of cervical cancer screening. At present, more than 425 HPV testing has been developed worldwide, of which more than 150 is from China. To restrict and standardize HPV testing market, China released guidelines for the clinical performance evaluation for HPV testing against clinical endpoints in 2015. In other countries, it is also necessary to set similar regulations in consideration that 59.7% of HPV tests on the global market without a single peer-reviewed publication ( 49 ). To improve the coverage of cervical cancer screening, HPV testing that is rapid, simple, inexpensive could be more popular and can further promote the application in practice. In 2008, care HPV was developed in China, which demonstrated excellent performance in screening, although it was easy to use, cheap, fast and friendly to the laboratory requirements ( 52 , 53 ). In 2018, the care HPV achieved the pre-qualification certification issued by WHO, which was expected to benefit more people in developing countries and resource-poor areas such as Africa and Southeast Asia ( 54 ). In addition, the cost-effective reflex triage, referral of women, and management strategies appropriate to various resource level areas were also in evaluation ( 55 - 58 ).

In recent years, with the rapid development of science and technology, the application of artificial intelligence (AI) based products is booming. In cervical cancer prevention and control, AI also showed to be promising in cytology-based screening and colposcopy examination based on the image pattern recognition ( 59 , 60 ). These AI-based technology or system can intelligently identify lesions and assist medical staff in clinical examination and diagnosis which could alleviate difficulties in diagnosis in primary clinics.

Screening practice in China

In China, cervical cancer screening started since 1990s, although late compared with Western countries, China still achieved great breakthroughs. Common screening methods were introduced into China for the first time after clinical performance evaluation in high-risk areas which included HPV DNA detection (Hybrid Capture II, HC2), LBC and visual inspection with VIA/VILI ( 61 - 63 ). At the same time, these studies also further made it clear that “one or more HPV tests in a lifetime for cervical cancer screening could be feasible in developing countries” which had important impact on the clinical practice of cervical cancer screening in China and even in the world.

In July 2019, the State Council issued the “Healthy China Action (2019−2030)” plan, emphasizing the need to move forward the diagnosis and treatment and optimize the allocation of medical resources, from the treatment-centered to the health-centered, and to improve health level of the whole people. The program also clearly points out that cervical cancer screening coverage rate needs to reach more than 80% by 2030 ( 64 ), indicating the importance and severity of cervical cancer prevention and control.

Finally, the achievements of scientific research should be able to be developed into products and applied in practice. Based on the experience and study findings, two “National Demonstration Base for Early Diagnosis and Treatment of Cervical Cancer” were set up in Shenzhen Maternal and Child Health Hospital (City type) and Xiangyuan Maternal and Child Health Hospital (Rural type) in Shanxi Province in February 2005 ( 65 ). Thereafter, National Health and Family Planning Commission of China and China Women’s Federation launched cervical cancer and breast cancer screening program for women aged 35−64 years old in rural areas in 2009 ( 66 ), which was also one of the major public health service projects in China organized by national government. Different screening and management strategies have been set up for various resource-level regions. Up to 2017, the project has offered cervical cancer screening for 73.99 million women. Currently, the project has covered 1,501 counties ( 67 ). Meanwhile, China has developed effective cervical cancer prevention and control network which covered screening, diagnosis to treatment, follow-up and rehabilitation step by integrating government support and leadership, multi-sectors’ cooperation, professional personnel support and whole society participation. In 2017, Chinese Preventive Medicine Association released the “Guideline for Comprehensive Prevention and Control of Cervical Cancer” to further promote the standardized and development of cervical cancer prevention and control in China ( 68 ).

The priority of public health measures for cancer prevention and control reflects the government and society’s attention to public’s health, especially in resource-limited areas, and also reflects the civilization and progress of a country and society.

A large number of studies around the world have confirmed that cervical cancer could be prevented and controlled well by screening and early treatment. And it has been widely recognized if only considering the effect of cancer screening. However, the screening methods or solutions with the best effect may be not the best one. In the case of limited health resources, it is necessary to analyze and compare the input and output of different programs from the perspective of health economics which included how to scientifically determine the initial age of screening and time interval, select appropriate screening programs according to local health resources, and focus on cancer intervention in order to maximize the use of limited health resources. And then, we could determine the screening solution that not only has a good effect of disease prevention and control, but also is in line with the principle of cost-effectiveness.

Conclusions

The disease burden of cervical cancer has decreased significantly in developed countries and regions in last decades, however it is still serious in less developed countries and regions, and effective preventive measures in these areas still face serious challenges. At present, there are various available prevention and control measures that are cost-effective and scientific evidence-based to meet the needs of areas with different economic levels. It is gratifying to note that the globe has achieved a strategic consensus on the elimination of cervical cancer and also has developed and released the global strategy to accelerate the elimination of cervical cancer. Although the global elimination of cervical cancer has a long way to go, it is believed that through large-scale continuous promotion and widely use of existing effective prevention and control measures, cervical cancer will become the first cancer eliminated by human beings.

Acknowledgements

This study was supported by grants from the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (No. 2017-I2M-B&R-03 and No. 2016-I2M-1-019).

Conflicts of Interest : The authors have no conflicts of interest to declare.

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Cancer deaths plummet in middle-aged people

14 March 2024

Fewer middle-aged people are dying from cancer in the UK than at any point over the last 25 years, a new study from Cancer Research UK has revealed. *    

Published today in the British Medical Journal , this is the first major study to examine trends in cancer incidence and mortality amongst middle-aged adults (35-69 yrs.) in the UK between 1993 to 2018.   

Researchers said that analysing trends in this age group helps to understand the impact of different risk factors on the population as well as the likely future patterns of cancer in older patients.  

“This study helps us to see the progress we’ve made in beating cancer and where challenges clearly remain,” said Jon Shelton, Cancer Research UK’s head of cancer intelligence and lead author of the study.  

“This research is a useful benchmarking tool for the next 25 years and beyond so that we can take action to save more lives from cancer. We must continue to prevent as many cancer cases as possible, diagnose cancers sooner and develop kinder treatments.”  

The good news

The study showed that overall, mortality rates had dropped by 37% in men and by 33% in women.   

In examining data for 23 cancer groups or types, it also found that cervical cancer mortality rates decreased by 54.3%, showing how cervical screening has already helped to prevent cancer and stop the disease in its tracks, with HPV vaccination set to make a further huge impact on reducing the disease.  

The study also revealed that lung cancer mortality rates decreased by 53.2% in men and by 20.7% in women, linked to reduced smoking rates in recent decades.   

Deaths in breast and bowel cancers have also dropped, showing how screening programme s help to save lives by preventing bowel cancers and by diagnosing both cancers earlier leading to more treatment options.  

Despite progress, challenges remain

Although rates in premature cancer deaths fell by over a third in this period, the data also exposed challenges across the UK’s health system.  

T he charity warned that cancer cases are on the rise overall . The data highlights that cancer cases rose by 57% in men and 48% in women over the 25 years, largely due to a growing and ageing population as well as some lifestyle factors impacting people’s cancer risk.  

Researchers also found concerning increases in rates of melanoma, liver, oral and kidney cancers.  

In addition, death rates for liver, oral and uterine cancers – all linked to risk factors including UV exposure, alcohol, overweight and obesity, and smoking – were all increasing, following the increase in rates for these cancers.  

Cancer Research UK said there is an immense challenge ahead to maintain progress, with all UK nations failing to meet their cancer waiting times targets and NHS staff under extreme pressure.  

“With cancer cases and mortality for some sites on the rise and improvements in survival slowing, it’s vital that the UK Government takes bold action to keep momentum up,” added Shelton. “Now is the time to go further and faster, building on the successes of decades of research and improvements in healthcare.”  

We need to take action

The findings of this research highlight where the UK Government can focus its efforts to help to save more lives from cancer, as well as the steps people can take to reduce their risk of the disease.  

Cancer Research UK is urging political leaders to deliver long-term cancer strategies in all UK nations, including a National Cancer Council in England to drive cross-government action on cancer.  

If bold action is taken against smoking, overweight and obesity and alcohol, nearly 37,000 cancer cases could be prevented by 2040 in the UK and tens of thousands more in future years. ** Preventing ill health not only benefits cancer patients and their families, it also leads to huge gains for the economy and the NHS.  

Cancer Research UK is also calling on the Government to diagnose more cancers earlier. Bowel cancer screening should be optimised to reduce inequalities in access and reach as many eligible people as possible.   

Targeted lung screening, which is being rolled out across England, will help to save more lives from a cancer type that takes more lives than any other. It is vital that other UK nations follow suit to reach more at-risk people.  

Anne’s story

Anne Parmenter, 68-years-old from Suffolk, was diagnosed with bowel cancer in 2015. Anne’s cancer was caught after receiving a bowel cancer testing kit in the post on her 60th birthday. She said it was screening that saved her life.  

Anne explained: “I had no symptoms before receiving the kit. I didn’t feel unwell, so I don’t think my cancer would have been caught if I didn’t take up the NHS screening offer.  

“Weeks after doing the test I was invited into hospital to have part of my bowel removed, and this was followed by chemotherapy. My story shows how early diagnosis can save lives.”  

Nine years have passed since Anne’s diagnosis. Reflecting on her experience, Anne said: “Getting diagnosed with cancer has changed how I look at life. None of us know what is around the corner, which is why it’s so important that cancer is found as soon as it can be, and that the NHS is ready to help everyone who needs treatment.”  

A defining health issue

“This major study brings to life improvements that have been made to tackle cancer in recent decades,” said Michelle Mitchell, Cancer Research UK’s chief executive.  

“If we take lung cancer, for example, we can clearly see that reducing smoking prevalence saves lives. The UK Government can build on this success by raising the age of sale of tobacco and continuing to fund a world-leading programme of measures to help people who smoke quit.   

“But c ancer is still a defining health issue in the UK that impacts nearly one in two people. P eople face long waits for vital tests and treatment and cancer cases are on the rise.   

“Cancer patients won’t feel the full benefits of advances in research breakthroughs and innovation, including new cancer treatments, without long-term plan and funding from the UK Government.”  

* Age-standardised mortality rate for males and females aged 35-69 years, between 1993-2018 in the UK  

** Longer, better lives: A manifesto for cancer research and care (cancerresearchuk.org) p.13  

this is a really poor article – there’s no link to the study and the link to the BMJ site is an internal link to cervical cancer ?

You’ve had a lot of press on this today (the reason I wanted to find out more) and tbh I would have expected a bit more diligence on this article :( really disappointed

Thanks for pointing out that the wrong link was embedded in the article, that’s now been updated to the correct one. Or, you can read the paper here

Jacob, Cancer Research UK

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At Moffitt Cancer Center, we come face-to-face with cancer every day, but we also see courage. And it inspires us to be the safest and best place for cancer care – to bring greater hope to every patient we serve. It’s why we’ve been continually named One of the Top Places to Work in the Tampa Bay Area. As the only National Cancer Institute-designated Comprehensive Cancer Center based in Florida, Moffitt employs some of the best and brightest minds from around the world. Moffitt is the leading cancer hospital in both Florida and the Southeast and has been nationally ranked by U.S. News & World Report since 1999. Because working at Moffitt is both a career and a mission: to contribute to the prevention and cure of cancer. Join a dedicated, diverse and inclusive team of over 7,000 to be a part of the Courageous future we envision.

Applied Research Scientist

The Applied Research Scientist position will support the research and research team activities of Dr. Anna Giuliano , an epidemiologist with ongoing investigations to understand infection-related cancers, particularly to develop improved methods for their prevention through screening and improved treatments. Dr. Giuliano leads multiple domestic and multinational studies, including development of early detection cancer biomarkers, clinical trials for the prevention of HPV-related cancers among people living with HIV in Latin America and the Caribbean, and research of understudied virally-associated cancers among men and women living with HIV in sub-Saharan Africa.

This position is comparable to a staff scientist role: an essential contributor to analysis, writing, and grant preparation for ongoing and future research projects under the general direction of Dr. Giuliano. This position will have ample opportunities for authorship and other documentable career-enhancing activities.

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Researchers demonstrate technique for identifying single cancer cells in blood for the first time

by Keele University

A pioneering study led by a Keele scientist has demonstrated how a single cancer cell can be identified in a sample of blood, paving the way for more personalized and targeted treatments for cancer patients.

Led by Professor of Oncology Josep Sulé-Suso, the team of academics from Keele University, the Cancer center at University Hospitals North Midlands NHS Trust, and Loughborough University (Professor Paul Roach), used a technique called Fourier Transform Infrared (FTIR) microspectroscopy, which can separate cells based on their biochemical composition using an infrared light.

Publishing their findings in the journal PLOS One , the team has shown for the first time that FTIR microspectroscopy, used together with a machine learning algorithm, is able to identify a single lung cancer cell in a sample of blood.

The advent of personalized medicine has greatly improved the treatment and management of patients with cancer, by tailoring therapies to individuals based on their specific needs and the type of cancer they have.

Professor Sulé-Suso and his colleagues believe that by identifying individual tumor cells circulating in blood using this technique, patients can be assessed more effectively during the initial tumor screening, staging, response to treatment, and follow up stages of cancer treatment.

These findings could therefore lead to improving the personalized medicine approach even further by making screening for cancer cells more robust than current processes.

Professor Sule-Suso said, "Identifying cancer cells in blood using this technique could be a game-changer in the management of patients with cancer."

The team has now had approval to expand their research with a further study, looking at blood samples from patients with different types of cancer, not just lung, to see if this technique can be replicated successfully with other cancer types.

Professor Kamaraj Karunanithi, Director of Research and Innovation at University Hospitals of North Midlands NHS Trust (UHNM), said, "The UHNM Research and Innovation Department is thrilled to back research targeting the early detection of cancer cells in the bloodstream. Detecting cancer spread early is vital for improving patient care.

"This research has the potential to establish new standards in treating cancer at various stages. The UHNM research strategy not only backs delivery of national and international research but also concentrates on identifying and developing local research in collaboration with our local universities."

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