Teaching pack: Prevention & Risk

HPV and HBV vaccination, hereditary cancer syndrome testing (BRCA, Lynch), chemoprevention (tamoxifen, aspirin in Lynch), risk-reducing surgery, and population-level tobacco and alcohol control. The most cost-effective section of oncology and the least glamorous.

• Alcohol reduction, pricing and cancer warning labels: Alcohol causes at least seven cancers and there is no safe threshold. Price, availability and cancer warning labels are the tools that work; most people still do not know alcohol causes cancer.
• Aspirin for cancer prevention and adjuvant therapy: Daily low-dose aspirin lowers bowel cancer risk in people with Lynch syndrome and appears to cut recurrence in bowel cancers with a particular mutation. In healthy older people it caused more harm than good.
• Bariatric surgery and cancer incidence: People with severe obesity who have weight-loss surgery develop about a third fewer cancers over the following decade, especially womb and other hormone-related cancers, than similar people who do not.
• Cancer interception vaccines: Vaccinating people who do not have cancer yet but are very likely to get it, against the antigens their future tumour will carry.
• Cancer registries and population surveillance: The public systems that count every cancer diagnosis and death in a country, which tell us whether incidence and survival are improving.
• Chemoprevention & risk-reducing surgery: Drugs or surgery for people at high inherited risk, before any cancer appears.
• Coffee and tea intake: Coffee does not cause cancer and is probably protective against liver and womb cancer. Very hot drinks of any kind may raise oesophageal cancer risk.
• Exercise & lifestyle oncology: Structured exercise during and after treatment, which the CHALLENGE trial showed improves survival in colon cancer.
• Germline (hereditary) testing: A test of the DNA you were born with, to find inherited risk genes such as BRCA or Lynch syndrome.
• Global oncology and access in low- and middle-income countries: Seventy percent of cancer deaths occur in low- and middle-income countries, where radiotherapy machines, pathologists, essential medicines and palliative care are scarce. Global oncology works on affordable, adapted care and the systems to deliver it.

• Paths to cures: interception, eradication, control · What already prevents cancer (historic)
• Paths to cures: interception, eradication, control · Vaccinating and monitoring people who do not yet have cancer (emerging)
• Paths to cures: interception, eradication, control · Removing every cell, and knowing that you did (current)
• Paths to cures: interception, eradication, control · Killing the last cell, wherever it is hiding (emerging)
• Paths to cures: interception, eradication, control · Living with cancer as a chronic disease (current)
• Paths to cures: interception, eradication, control · Steering resistance instead of waiting for it (emerging)

• KEN SHE (single-dose HPV vaccine) (phase 3, n=2,275): Vaccine efficacy against persistent HPV16/18 infection: 97.5%
• ALASCCA (phase 3, n=626): Time to recurrence at 3 years, group A (PIK3CA exon 9/20): 7.7% vs 14.1%, HR 0.49
• CHALLENGE (CCTG CO.21) (phase 3, n=889): Disease-free survival at 5 years: 80.3% vs 73.9%, HR 0.72
• RTOG 0129 (HPV analysis) (phase 3, n=743): Overall survival at 3 years by HPV status: 82.4% vs 57.1%
• PREHAB: multimodal prehabilitation before colorectal cancer surgery (phase 3, n=251): Fewer severe complications and faster recovery with prehabilitation; surgery not delayed.
• POLO (phase 3, n=154): Progression-free survival: 7.4 months vs 3.8 months, HR 0.53

1. What single change would most improve outcomes across all cancers, and what evidence supports it?
   Answer

   Prevention and early detection: HPV vaccination has driven cervical cancer toward elimination in vaccinated cohorts, tobacco control and screening (mammography, colonoscopy, low-dose CT) have proven mortality benefits, and early-stage disease is where surgery cures; MCED blood tests aim to extend this but are unproven.
2. What questions should someone newly diagnosed with triple-negative breast cancer ask before surgery?
   Answer

   Whether chemo-immunotherapy before surgery (KEYNOTE-522) is planned and why; germline BRCA testing; PD-L1 and HER2-low status; TIL score; clinical trial options; fertility preservation; breast-conserving versus mastectomy and sentinel node approach; what response (pCR/RCB) will mean for treatment afterwards.
3. Who should have germline genetic testing when diagnosed with cancer?
   Answer

   All patients with TNBC, ovarian, pancreatic, or metastatic prostate cancer, increasingly all breast cancer, and anyone with suggestive family history; results change surgery, drug choice (PARP inhibitors), and family screening.
4. What is exercise oncology and is there real evidence?
   Answer

   Structured exercise during and after treatment; the CHALLENGE trial (2025) randomised colon cancer survivors and showed improved disease-free and overall survival, the first level-1 evidence, plus less fatigue and neuropathy.