How does preventing chronic disease help reduce cancer deaths?

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Gretchen Miller: Hello once more and welcome to Prevention Works, the podcast of The Australian Prevention Partnership Centre, where we talk to some of Australia’s best researchers and investigators into Australia’s problem with lifestyle-related chronic disease. I’m your host Gretchen Miller and today I’m with the CEO of Cancer Council Australia, Professor Sanchia Aranda.

Sanchia Aranda: Part of the challenge for us in our environment is if you take bowel screening, 40% of people who are invited to participate, participate. Estimates done by our colleagues at Cancer Council New South Wales show that if we could get that screening rate up to 60% we would save 84,000 lives by 2040. That’s lives, not cases of cancer. Lives.

Gretchen Miller: We all know how successful the Cancer Council has been in taking action on cancer. But why are they now interested in chronic disease prevention? The links are irrefutable. Reduce obesity and exercise more and participate in preventative testing and our cancer rates would drop dramatically.

The Cancer Council is the only cancer charity that works across all cancer types and in several ways, from prevention to research, from support to advocacy. Now they’re bringing that expertise to bear at the Prevention Centre, partnering up to reduce the number of deaths from cancer in Australia.

Sanchia Aranda: We also know that the tobacco industry is doing a whole lot of things to market, particularly to new smokers. Things like making the holes in the filters so that you feel like you’re getting more fresh air, as if that makes cigarettes safer.

Gretchen Miller: You’re rolling your eyes there.

Sanchia Aranda: I am, because it’s kind of like it might feel different but you’re still putting that terrible stuff into your lungs.

Gretchen Miller: Professor Aranda first trained as a nurse and then after postgraduate study she researched the support outcomes for people with cancer. Then she wanted to work on the system itself and work within government on cancer system improvement before coming to the Cancer Council in 2015.

There is a sizeable proportion of cancers in Australia that are potentially preventable, about 37,000 each year. Sanchia.

Sanchia Aranda: The vast majority of those relate to tobacco. Over 15,000 tobacco-related cancers every year and that’s our most important preventable factor. Then there are a significant proportion that are also related to being overweight or obese and having a high BMI and being physically inactive. Taken together those cancers are about another 8,000 cancers every year that are potentially preventable.

The most important of those is obesity, things like cancer of the colon where about 10% of those are related to obesity. Postmenopausal breast cancer, where about 8% of breast cancers are related to being overweight. Importantly, cancer of the endometrium or uterus, where about a quarter of all endometrial cancers relate to being overweight or obese.

Then there’s the factors that are related to physical inactivity and it’s, again, colon, postmenopausal breast cancer, and endometrial cancer. That’s about another 2,000 cancers.

Then there are all the dietary-related factors that link to being inactive and overweight. That includes not having enough fruit and vegetables in the diet and not having sufficient dietary fiber.

Gretchen Miller: Okay, so if we were just to look at exercise what could be avoided if you did a certain amount of exercise and what kind of exercise are we talking about?

Sanchia Aranda: To reduce your risk of the exercise or physical inactivity-related cancers, which is about 19,000 by 2025, you’d need to undertake about five hours of moderate intensity exercise every week. That’s the sort of exercise that allows you to talk but not sing. Walking’s a great one of those.

It is a fairly high level, but any amount of increased physical activity will help to reduce the risk of those cancers.

Gretchen Miller: There’ll be a kind of a payoff there even if you only manage two and a half hours. It sounds like a lot, but in actual fact you can work that into your day, can’t you?

Sanchia Aranda: You can work it into your day. It’s a little bit higher than the physical activity recommendations from the federal government for general health, which is around three hours of moderate intensity exercise. Five days a week walking for an hour isn’t actually too intensive.

Gretchen Miller: Is this a main frontier for cancer research at the moment for Cancer Council Australia?

Sanchia Aranda: Tobacco remains our number one priority. A lot of people talk about things like physical activity being the new tobacco, but actually tobacco’s the new tobacco. It’s still the number one problem. We still have poor behavior on the part of the tobacco industry in terms of trying to get people addicted to their products.

Figuring out some of the new things that we can do there is really important. Obesity, two-thirds of us are overweight. About half of us are physically inactive. That’s a rising problem, those sorts of cancers are increasing.

If we can keep on the path of reducing tobacco then, one day in our kids’ future, obesity-related cancers are likely to overtake tobacco cancers. We do need to pay attention to those as well.

Gretchen Miller: This is where your work intersects with the Prevention Centre.

Sanchia Aranda: We’re excited to have the opportunity to participate in the Prevention Centre this time around. There’s a number of reasons why I think it’s really important.

The first is to raise attention for behavioral research. We’ve got a lot of experience in the tobacco area, but we’re starting to need to take a much greater focus in hard-to-reach populations. 13% smoking rate is really down to the hardcore group and they’re much harder. We need to still see public investment in mass media campaigns and tobacco taxation, but on top of that we need new and innovative ways to think about how to change human behavior.

Then, In addition, we need new frontiers for tackling the tobacco industry where many of the product re-formulation things that are doing, such as menthol pops in the filter, give the illusion that these are safer cigarettes. When in fact that is exactly that: it’s an illusion. We need regulatory changes that the Prevention Centre can assist with doing.

Gretchen Miller: We might come to tobacco a bit further down the track in our conversation. We actually know, and this podcast series demonstrates, it’s a hugely complex issue with multiple angles to address. There’s things like health law and food affordability. You can’t do everything, although I know that Cancer Council Australia actually has a good attempt at that. You can’t do everything, so how do you see yourselves narrowing in on this?

Sanchia Aranda: One of the things that the Prevention Centre will help us do in narrowing that is really looking at what are the policy frameworks that make a difference. One of the critical things for us is that there are several state governments, five I think, involved in the Prevention Centre. They’re at the heartland of intersection with the community. We see that as a really important opportunity to traverse this really challenging federal, state environment that Australia has through thinking about what policies work at a community level as well as at a federal government level.

Gretchen Miller: That’s really interesting actually. The fact that we have three layers of government can make this quite tricky.

Sanchia Aranda: Yes, it can make it very tricky because some of the big initiatives, such as tobacco taxation and talk about things like a sugar tax, all sit with the federal government. But state governments can do other things like encouraging retailers to have out of sight sugary drinks, promoting up the healthier options. While the federal government might be looking at working with re-formulation in the food and beverage industry. Understanding where the leaders are across different levels of government is a really important contribution.

Gretchen Miller: We’re sort of getting to the crux of the matter which is a reminder that the individual can’t do everything. Yes, we can all try to lose weight. It’s harder, as many of us would know, than we think to do that. When did you realise that actually we have to take a broader overview of all this?

Sanchia Aranda: My recognition that policy environments are really important to change has been happening for a very long time. I’ve had a lot of experience globally and at the national level in Australia in really establishing plans for cancer improvement. That always sat uneasily with the kind of work that I was doing as a researcher, which was very much about the individual’s behavior and what they were doing to maintain their own health. You recognise, I think, quite quickly that you need to create the environments that individuals can make better choices within.

If you take something like junk food advertising there’s been a recent study from Cancer Council New South Wales that showed that on average kids who take public transport to school see you 4.5 advertisements for food. The vast majority of those are for junk food on the way to school.

If you ask mums and dads about that they say it’s very hard to say to children, “You can’t have that, that’s not healthy” when it’s bombarding them. You get less from bombarding if you walk to school, so that’s a good thing as well. Better for your health. But those parents would actually find it easier to make healthy choices for their kids if they weren’t being pressured around those junk food ads. I think that’s an example that shows that parents can make good choices, but they often worn down by what kids have seen and therefore demanding in their home environment.

Gretchen Miller: It’s about what influences the way a child thinks and the whole point is that while adults are supposedly self-regulating children are not. They need help and support.

Sanchia Aranda: Yes and so the adults that are responsible for those children also need … We live busy lives these days. Fast food is part of that. Being able to make better choices and have clearer information for the public must be part of what we need to understand and implement our system solution.

Gretchen Miller: Really the point is it’s the individual against the behemoth of the advertising industry. You’ve got you and then you’ve got the constant messaging. Wouldn’t it be amazing if those kids who did take public transport, who needed to take public transport, received a different message?

Sanchia Aranda: That’s exactly right. We saw that with tobacco. The taking away of public advertising of cigarettes was a major part of de-normalising tobacco smoking. If we could de-normalise junk food and put it back where it belongs as a sometimes food then that’s part of the battle to make people supported to make better choices.

We’ve also got regulatory pieces around things like our Health Star Rating system in Australia, which has amazing loopholes in it. Such as if you buy a casserole pack, one of those little salt filled pieces, they can actually get a four star because the regulation is as prepared. Once you’ve added a whole lot of pieces of chicken and some tomatoes and fresh vegetables to that preparation it gets up to a healthy rating. But the packet itself is full of salt and we could probably do without it.

Gretchen Miller: Was there any particular personal moment for you as a researcher, you began as a nurse, where you had a light bulb moment or where you just said I can do more than work with individuals?

Sanchia Aranda: I think I’ve been progressively, across my career, juxtaposing care of the individual as a nurse with trying to think about reforming the system. I guess my real light bulb moment came when we started to implement smoking cessation for people after a diagnosis with cancer when I was at Peter Mac. This was the 50th anniversary of the Surgeon General’s report on tobacco, for the first time had a chapter in it around after a cancer diagnosis.

What people don’t understand is that people who continue to smoke after a cancer diagnosis significantly increase their mortality by effective around 40% and not associated necessarily with the cancer they’ve been diagnosed with. We were battling on at the hospital to get access to free nicotine replacement therapy, access to counseling to support those patients.

Still today, so that’s a decade later, we are still trying to get the routinisation of the five As around early intervention in tobacco. Being able to ask the question of are you a smoker, there’s still a taboo about that even though you could motivate patients by saying to them do you realise you’re less likely to survive if you continue to smoke?

Being able to advise and refer people into smoking cessation support and just really providing that non-judgmental environment to allow people to be able to think about that.

There’s some great initiatives across New South Wales to embed smoking cessation across our health system, but we’ve been, for far too long as a system, tolerant of smoking in what is supposed to be at health system. Those re-normalisation of whose responsibility it is, it’s not the individual’s responsibility. It’s a supportive system that’s needed to create change.

Gretchen Miller: Because you’re battling an enormous thing, not just addiction but also the power and might of the tobacco industry as an individual.

Sanchia Aranda: That’s right and we’re going through this really strange phase of history, I think, where the tobacco industry is trying to change its image. Particularly through the promotion of e-cigarettes and vaping of nicotine when we have absolutely no idea about the long-term safety.

It’s still a process that’s about getting people addicted to nicotine. It’s not a process about making them healthier or saving any lives. We’re seeing all sorts of really strange behaviors. The division of the tobacco control community as a result of this as the sector that’s been united for decades against big tobacco is now being divided on the side of e-cigarettes vs not. When in fact that’s not the main game. Stopping addiction to nicotine in any form should be the main game.

Gretchen Miller: You’re with Prevention Works from the Australian Prevention Partnership Centre. If you would like us we’d love it if you could leave us a review on iTunes as it helps others to find us. The podcast is now also available on Spotify.

Shortly we’ll be talking about how to make public campaigns really work and guess what? It isn’t all about social media.

Sanchia, as you’ve said quite clearly, Australia’s obesity problem can’t be placed entirely on the individual’s shoulders. Just like nicotine addiction it’s up to government. That’s a clarion call. When you worked in government were you able to be so forthright?

Sanchia Aranda: Being in government is really different to being outside of government. Within government whatever you’re talking about you need to really understand whether you’re committing the government to anything as a health bureaucrat. You need to definitely be a little more measured and you’re constantly really thinking about where your voice positions your minister, because you essentially work for a minister.

Being inside government is good though because you do have a very direct opportunity to shape policy and to really consider what are the best approaches. One of my criticisms of the charity sector in the past has been that we often make policy submissions that don’t take account of how health systems are funded or how different programs within government are rolled out. Moving to the charity sector has really been about having a much greater voice for the community in thinking about this.

Governments, particularly of the Liberal persuasion, constantly label something like obesity as a problem of the individual. That means that one of the few areas where governments are prepared to work is in childhood obesity. Because it’s seen as not within their control and therefore policy environments for kids become the opportunity that you have to pressure governments to have better food and nutrition and physical activity policies. That said, kids live in environment with increasingly obese adults. Saying it’s just about child policy doesn’t really get the endemic nature of being overweight and physically inactive in our communities.

Gretchen Miller: I wanted to move now to talk about cancer prevention. As I understand it, and this is new to me as a lay person, there are two approaches to cancer prevention. Can you talk us through primary and secondary prevention and what those two things mean?

Sanchia Aranda: Primary prevention is really related to reducing the risks that you’re exposed too. Tobacco, sun, alcohol, being overweight, having a poor diet, those kinds of things are the factors that we look at primary prevention. Secondary prevention is really important because it relates to either finding precancerous lesions or finding early cancers that mean your survival is more likely in the longer term.

We have three secondary prevention programs in Australia. Cervical screening using now HPV DNA testing, colon cancer screening, and breasts screening. Part of the challenge for us in our environment is if you take bowel screening 40% of people who are invited to participate participate. Estimates done by our colleagues at Cancer Council New South Wales show that if we could get that screening rate up to 60% we would save 84,000 lives by 2040. That’s lives, not cases of cancer. Lives. A simple test that you do at home. Bowel cancer screening is interesting because it’s both finding a risk factor, so polyps, and finding early cancers. Behind lung cancer bowel cancer is our seconds biggest killer.

Ultimately over time as participation increases we’ll see an actual drop in the incidence of bowel cancer in Australia and beginning to see that already.

Gretchen Miller: Anyone over 50, as I turned last year and as my husband turned last year, will be familiar with the little happy birthday public campaign around bowel cancer to do this. How long has that been going?

Sanchia Aranda: The program’s been going around 10 years, but it’s only fully implemented this year. There’s been a really complex range of dates of your birthday for when you get to start, but by the end of this year it’ll be fully rolled out.

Gretchen Miller: Is there a gender difference in returns, because it’s slightly challenging for people, perhaps particularly for men.

Sanchia Aranda: Yes, there is a slight gender difference. 40% on average but about 43% of women and 39% of men. What we do know is that if you do it for the first time 78% of people do it the second time. Getting families to talk about these kinds of things as an issue really can encourage that participation. That yuck factor of doing a poo test is alive and well, but you get over it pretty quickly if you do it once.

Gretchen Miller: You’re supporting some research into getting people to use that happy birthday test kit. You’re supporting in kind how and why?

Sanchia Aranda: Cancer Council of Victoria have produced one of the public campaigns that was rolled out last year that showed a very significant change in take up of bowel screening. That’s led us to now have some federal government money to do a national bowel screening program this year and we’ll be able to use the insights from that work to inform the work of the Centre and be able to really refine those messages. Understand how we are changing behavior a little bit more, and really get people up there. Can you imagine if we could get to 60% in the life of TAPPC? That would be pretty good.

Gretchen Miller: I’m now thinking about Slip Slop Slap, which I grew up with, and it was so successful. It was pre-social media, TV.

Sanchia Aranda: Social media gets all the hype, but actually its penetration and reach is pretty small. If you think about something in social media like Twitter for example only 3% of Australians participate, whereas most people are exposed in some way to mass media. Television does work, it just happens to be very expensive. It’s often why people feel compelled to move to social media campaigns. Through TAPPC it would be fantastic if we understand exactly what you need to do to buy the best TV, but also how do you use those other mechanisms to supplement it and what’s actually working across those various communication channels.

One of the threads I’m particularly interested in the Partnership Centre is the communication to the public. Really understanding how you create the messages and how you best deliver them as part of shaping our prevention activity in the future.

Gretchen Miller: It’s going to be pretty exciting to see how that works out. Back to smoking, because that’s the other area of research you’re working with with TAPPC, or The Australian Prevention Partnership Centre. So much needs to be done in that field and the field is shifting. Can you talk about how plain packaging has really worked, but there’s a group that’s still smoking as we discussed earlier. It’s a bit of a battlefront still. The tobacco companies pushing back and targeting those vulnerable people.

Sanchia Aranda: Plain packaging was a really important add-on to taxation and hard hitting mass media campaigns, but we haven’t had a national mass media campaign for tobacco for about six, seven years.

Taxation remains really important. We know from our own surveying and the national tobacco survey that cost is a more important driver to reduce tobacco intake than health, which is astonishing in the context of this particular conversation.

We also know that the tobacco industry is doing a whole lot of things to market, particularly to new smokers. Things like making the holes in the filter so that you feel like you’re getting more fresh air, as if that makes cigarettes safer.

Gretchen Miller: You’re rolling your eyes there.

Sanchia Aranda: I am, because it’s kind of like it might feel different but you’re still putting that terrible stuff into your lungs. As I mentioned, the little capsules within the filter that you press and you get this hit of menthol which, again, makes it feel like it’s safer. We have things like irregular pack sizes, so that you can market to youth by having very small numbers of cigarettes that are cheaper to buy to enter the market. We need to look at what are the policy and regulatory pieces that sit around the formulation of products. We want to cut out the innovation. Ideally we’d like filters to be removed, because we shouldn’t have anything that makes the cigarettes seem more pleasant to the smoker. They are delivering combustible smoke directly into their lungs and that’s what it should feel like.

Gretchen Miller: Professor Sanchia Aranda from Cancer Council Australia there. There’s more information and a transcript on our website. Just Google Prevention Works podcast and The Australian Prevention Partnership Centre. Check out all the other conversations we’re having around tackling chronic disease. So much being brought together into space. We’d love to hear from you, so do leave us a review on iTunes and tell your friends. We’re also available on Spotify, as well as all the usual podcast apps. I’m Gretchen Miller. I’ll see you next time.

Host: Gretchen Miller

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