Primary Prevention

The most obvious ways to prevent people dying from cancer are either to find cures for the different forms of the disease or to find ways to stop the development of clinical cancer in the first instance. At the present time, cancer prevention involves determining the causes of cancer (risk determinants) among those factors shown to be associated with the development of the disease by epidemiological studies (risk factors). Avoiding a changing exposure to risk determinants would result in a reduction in cancer risk.

The evidence that cancer is preventable is compelling. Different populations around the world experience different levels of different forms of cancer[4], and these levels change with time in orderly and predictable manners[5]. Groups of migrants quickly leave behind the cancer levels of their original home and acquire the cancer pattern of their new residence sometimes within one generation[6-7]. Thus those Japanese who left Japan for California left behind the high levels of gastric cancer in their homeland and exchanged it for the high levels of breast and colorectal cancer present among inhabitants of their new home. Furthermore, groups whose lifestyle habits differentiate themselves from other members of the same community frequently have different cancer risks (c.f. Seventh Day Adventist and Mormons[8]).

For reasons such as these, it is estimated that upwards of 80 per cent, or even 90 per cent, of cancers in western populations may be attributable to environmental causes[9] defining "environment" in its broadest sense to include a wide range of ill-defined, dietary, social and cultural practices. Although all of these avoidable causes have not yet been clearly identified, it is thought that risk determinants exist for about one half of cancers. Thus, primary prevention in the context of cancer is an important area of Public Health.

Secondary Prevention

It is very frequently the case that the probability of successful treatment of cancer is increased, sometimes very substantially, if the cancer can be diagnosed at an early stage. Awareness of the significance of signs and symptoms is important, but all too frequently cancers which exhibit symptoms are at an advanced stage. Screening is a term frequently applied to the situation where tests are used to indicate whether an (generally asymptomatic) individual is at a high or low chance of having a cancer. Detecting cancers at an early, asymptomatic stage could lead to decreases in the mortality rate for certain cancers.

Tertiary Prevention

An obvious way to prevent cancer death is to cure those cancers which develop. However, there have been few major breakthroughs in cancer treatment in the sense of turning a fatal tumour into a curable one. Notably successes have been in Testicular Teratoma[10], Hodgkin's Disease[11], Children's Leukaemia, Wilm's Tumour and choriocarcinoma. Progress in survival of the major cancers has been very much less than hoped. Adjuvant chemotherapy and Tamoxifen have improved survival in breast cancer[12], adjuvant chemotherapy has also contributed to improvements in prognosis of ovarian cancer and colorectal cancer[13] and there have been some other progress which could be attributed specifically to certain treatments.

General progress in medical science has led to modern anaesthesia making more patients to be candidates for surgery and surgery safer, better control of infection and bacterial diseases, better imaging has improved tumour localisation and staging, and better devices are available to deliver the appropriate doses of radiation and drugs. Thus, more patients can get better and more appropriate therapy and, hence, have a better prognosis.

The quality-of-life issue has not been neglected with breast conservation therapy now almost supplanting traditional, radical mastectomy in the majority of women; more plastic breast reconstruction; less amputation of limbs for bone and soft-tissue sarcomas; and better colostomies, being some important advances.

Against this background of Cancer as an important Public Health problem which is one of the commonest causes of premature and avoidable death in Europe, the European Code Against Cancer was introduced to be a series of recommendations which, if followed, could lead in many instances to a reduction in cancer incidence and also to reductions in cancer mortality.

The European Code Against Cancer was originally drawn-up and was subsequently endorsed by the European Commission high-level Committee of Cancer Experts in 1987. In 1994, the European Commission invited the European School of Oncology to assemble a group of international experts to examine and consider revision of the scientific aspects of the recommendations given in the current Code. This exercise took place and a new version was adopted by the Cancer Experts Committee at its meeting of November 1994[1].

This publication constitutes the second revision, producing the third version of the European Code Against Cancer. The project was funded by the Europe Against Cancer programme of the European Commission. An Executive Committee was formed to guide the project and the Committee involved Public Health specialists, Oncologists as well as representatives of the Cancer Leagues and the Prevention Departments of Ministries of Health in Europe. A Scientific Committee was established comprising several independent experts and nominated Chairmen of the sub-Committees established to review recommendations on specific topics. Below the scientific rationale for each recommended point of the European Code Against Cancer is outlined as well as discussion of other factors which were considered but not included in the Code.