Escolar Documentos
Profissional Documentos
Cultura Documentos
Julian Peto
Collaborating in Cancer Research Cardiff 8th March 2006
London School of Hygiene and Tropical Medicine and Institute of Cancer Research
Bradford Hill
Richard Doll
Tobacco
Elimination of tobacco would prevent one third of all cancers worldwide Increased risk for cancers of lung, pancreas, bladder, kidney, larynx, mouth, pharynx, oesophagus Recent evidence links smoking to increased risk of stomach, liver and cervical cancers
Osaka 1970-71
10
Osaka 1988-92 Hawaiian Japanese 1988-92 Hawaiian Caucasian 1968-72 Hawaiian Caucasian 1988-92
prostate
colon (m)
stomach (m)
breast (f)
Cancers linked to obesity (Calle et al., NEJM April 24 2003) Oesophagus, colon, rectum, liver, gallbladder, pancreas, kidney, nonHodgkins lymphoma, myeloma
Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease Collaborative Group on Hormonal Factors in Breast Cancer Lancet (2002) 360:187-195 Reduction in risk: 3.0% per year for earlier age at first birth 7.0% per birth 4.3% per year of breastfeeding
Predicted reduction in Western breast cancer rates if women had 6 or 7 children and breastfed each child for 2 years
Lancet (2002) 360: 187-95
Cause
Smoking Known infections Alcohol Sunlight Air pollution Occupation Lack of exercise Diet Overweight (BMI>25kg m 2) Other dietary factors Presently unavoidable
Current smokers
60 2 0.4 0.4 0.4 0.4 0.4 4
Nonsmokers
5 1 1 1 1 1 10
Biology
Better screening
Epidemiology, genetics and biology Clinical research Evaluation of treatment, screening and prevention
Pre-molecular cancer epidemiology 1950s and 1960s: Cancer rates in adults suggest a series of rate-limiting heritable steps in multi-stage carcinogenesis.
Armitage and Doll (1954) Br J Cancer 8: 1-12 The age distribution of cancer and a multi-stage theory of carcinogenesis Reprinted in Int J Epid (2004) 33: 1174-79
The tumour suppressor gene hypothesis for polyposis coli and familial retinoblastoma Cancers in apparently autosomal dominant syndromes such as polyposis coli and familial retinoblastoma appear as a result of subsequent somatic mutations in which individual cells become homozygous for a recessive neoplasm-causing gene. DeMars 1969
Colon cancer incidence is proportional to the cube of age in familial polyposis coli, and to the fifth power of age in the general population
Ashley (1969)
J Med Genet 6,378
Denmark
Iceland
350 300 250 200 150 100 50 0 20 40 60 80
100 80 60 40 20 0 20
Japan (Osaka)
40
60
80
Menarche
10
20
30
40
50
60
70
Age
1. The immortal strand. When a stem cell divides, the original DNA stays in the stem cell daughter, and the new copy (containing copying errors) goes into the differentiating daughter and is discarded within a week or two. Copied DNA in differentiating daughter
Stem cell mechanisms to prevent mutation 2. DNA damage causes stem cell death rather than error-prone repair 3. Mutant stem cells cannot escape from the stem cell niche.
Stem cell mechanisms to prevent mutation 4. Stem cell hierarchy. With four successive layers of stem cells that divide 12 times and then die, the maximum number of divisions in any cells ancestry is reduced from ~20,000 to 48 in a human lifespan
Lung cancer mortality in continuing smokers and ex-smokers. Halpern et al (1993) JNCI 85, 457
7
Death rate per 1000
6 5 4 3 2 1 0 40 45 50 55 60 65 70 75
Age stopped 60-64 55-59 50-54 40-49
Age
Are stem cell proliferation (hormones, childhood cancers) and chromosomal damage (Blooms syndrome, asbestos) more important causes of most cancers than point mutation (XP)?
Cairns (1998) Genetics 148: 1433-40
British cervical cancer mortality before screening began (1920 birth cohort)
25
Annual death rate per 100,000.
20
15 10
Cumulative lifetime cancer mortality for general population, unilateral sporadic retinoblastoma survivors and genetic retinoblastoma survivors.
Fletcher et al. (2004) J Natl Cancer Inst 96:357-63
80 70
60 50 40 30 20 10 0 15 25 35 45 55
Genetic Rb
Sporadic Rb
General population
65 75 85
Age (years)
Apart from adrenocortical carcinoma in p53 carriers and retinoblastoma in Rb1 carriers, the same early onset cancers are associated with germline p53 or Rb1 mutation (osteosarcoma, soft tissue sarcomas, breast cancer and brain cancer). Most of the adult-onset cancers in Rb1 carriers are caused by DNA-damaging agents
Breast cancer and percent mammographic density. Boyd et al. (1995). Adjusted odds ratio 1.0 1.2 2.2 2.4 3.4 5.3
Cases 10 29 65 94 90 66
Controls 25 61 73 97 67 31
Cumulative breast cancer risks for first degree relatives of CHEK2*1100delC heterozygotes with bilateral breast cancer, first degree relatives of CHEK2 wild types with bilateral breast cancer, and the expected rate in the general population
In the late 1980s Ian Kennedy told a Select Committee that HIV testing of the anonymised discarded residue of blood samples from pregnant women was unethical because a test must confer some benefit on the patient. This illogical assertion was accepted by the Select Committee and delayed the introduction of HIV monitoring, despite the pleas of many eminent scientists including Black, Cox, Doll, Bodmer, Hoffenberg and Weiss. Black et al. (1987) Lancet ii 1277
Data can be used for any medical research purpose under the [Data Protection] Act, without the need for the consent of individuals. So Professor Julian Peto is simply wrong when he states that the Data Protection Act is preventing data from being passed to medical researchers. (Lord Falconer. Letter to The Times, May 17th 2001.)
The increasing bureaucratic burden imposed by ethicists causes harm to patients and does enormous damage to British cancer research. Legislation is needed to restore the following principle: 'Consent is not required for access to medical records for non-commercial medical research that has no effect on the individuals being studied and has been approved by an accredited research ethics committee. 93% of the audience voted for this proposed law at a Parliamentary Group on Cancer public meeting (Nov 5th 2002)
Olivia Fletcher Nikki Johnson Clare Palles Maribel Almonte Isabel dos Santos Silva
John Cairns Richard Doll