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About four in ten cancers could be prevented with tools that already exist: vaccines against the viruses that cause them, tobacco and alcohol control, weight, aspirin for the right people, and finding the families who carry a high-risk gene. The roadmap is mostly about deployment, with interception vaccines as the long-range bet.
Prevention has the strongest evidence and the weakest deployment in oncology. Tobacco control has prevented more cancer deaths than any drug. Hepatitis B vaccination cut liver cancer in the countries that adopted it early, and HPV vaccination is eliminating cervical cancer where coverage is high; a single dose proved almost fully protective (KEN SHE, 2021) and the WHO endorsed one-dose schedules, which makes elimination affordable everywhere. Germline testing finds the BRCA and Lynch carriers who benefit from risk-reducing surgery, aspirin and intensive screening. Tamoxifen prevents breast cancer in high-risk women.
The present decade is adding precision to prevention: aspirin after bowel cancer surgery works in tumours with PIK3CA mutations (ALASCCA) and is being tested in four cancers in Add-Aspirin, while ASPREE showed it does not help everyone; low-dose tamoxifen keeps the benefit with fewer side-effects; salpingectomy during any pelvic operation prevents ovarian cancer; polygenic scores could set when screening starts; population germline screening would find the carriers who do not know. GLP-1 agonists and bariatric surgery may prevent obesity-related cancers and need a randomised trial to prove it.
The frontier is interception: vaccinating people who carry a high-risk gene against the cancers they are likely to develop, with the Lynch syndrome frameshift vaccine as the first candidate for a randomised trial. The pace is set by the adoption gap, by funding that follows treatment rather than prevention, and by the politics of alcohol, tobacco and food.
The link between smoking and lung cancer, established in the 1950s, produced the taxes, advertising bans and smoke-free laws that have prevented more cancer deaths than any treatment. Universal infant hepatitis B vaccination, begun in Taiwan in the 1980s, cut liver cancer in the vaccinated generation. Helicobacter pylori was identified as the cause of most stomach cancer. Tamoxifen was shown to prevent breast cancer in high-risk women in 1998, the first drug proven to stop a cancer before it starts.
The first HPV vaccine (2006) and the nine-valent version that prevents about nine in ten cervical cancers turned an infection into a preventable one; HPV DNA testing replaced the smear and one round of it in rural India cut cervical cancer deaths (Osmanabad). Germline testing made BRCA and Lynch carriers findable, and risk-reducing surgery, aspirin (CAPP2) and intensive surveillance gave them options. In 2020 the WHO adopted a strategy to eliminate cervical cancer as a public health problem: vaccinate, screen, treat.
KEN SHE showed in 2021 that a single dose of HPV vaccine is almost fully protective against the two most dangerous types, confirming what an interrupted Indian trial had suggested; the WHO endorsed one-dose schedules in 2022, halving the cost of elimination. India's Serum Institute launched its own vaccine, Cervavac. Self-collected HPV swabs and same-day thermal ablation of precancer are letting nurses run cervical programmes without colposcopy. Catch-up vaccination for men, to prevent the throat cancers that now outnumber cervical cancers in some countries, is the next policy step.
ASPREE showed that daily aspirin does not help healthy older people and can harm them; ALASCCA showed that three years of low-dose aspirin roughly halves recurrence in bowel cancers carrying PIK3CA mutations; Add-Aspirin is testing it in 11,000 patients across four cancers. The lesson is that chemoprevention needs a biomarker or a defined high-risk group. Low-dose tamoxifen keeps the preventive benefit with fewer side-effects and could be prescribed by pharmacists and nurses; removing the fallopian tubes during any pelvic operation, once childbearing is finished, prevents most ovarian cancers at no extra operation.
People on GLP-1 agonists have lower rates of obesity-related cancers in observational data and bariatric surgery patients develop fewer cancers; a randomised trial with cancer as the primary outcome is the most important prevention study this decade could run. Smoke-free generation laws are being enacted and need built-in evaluation; cytisine, a cheap plant-based quit-smoking pill, belongs on every essential medicines list; cancer warning labels on alcohol are a natural experiment waiting to be measured. Treating everyone with chronic hepatitis B, curing hepatitis C and family-based H. pylori test-and-treat would remove most of the remaining infection-caused cancers.
Most people who carry a high-risk cancer gene find out when they or a relative get cancer. The proposals: reflex germline testing for every cancer where it changes care, letting clinics contact relatives directly when a gene is found, offering everyone at 30 a test for the genes that matter, and polygenic risk scores that set when screening starts, built to work in every ancestry before they are deployed anywhere. UK Biobank is the cohort where most of these scores are being validated.
Lynch syndrome tumours share frameshift neoantigens, which makes a shared vaccine possible; a randomised prevention trial in carriers would be the first preventive cancer vaccine that is not against a virus. A bone drug (denosumab) may prevent BRCA1 breast cancers by hitting the cells they grow from. A master protocol for chemoprevention across many precancers, and regulators accepting shrinkage of precancer as an endpoint, would make prevention drugs developable at all. The bar is high: healthy people accept risk today for a probabilistic benefit years later.
Around four in ten cancers are preventable with tools we already own, and the gap is deployment, not discovery. Prevention has no product to sell, so funding follows treatment; the commercial determinants of alcohol, tobacco and food are politically defended; and screening brings overdiagnosis that has to be managed rather than ignored. Community pharmacies as prevention hubs and social impact bonds repaid from avoided treatment costs are two ways to pay for what is already proven.
Every era's records, trial outcomes and papers, and every watch item, as JSON.
Probability ranges are named estimates that the claim is borne out on roughly a five-year horizon. They are meant to be argued with: propose a revision with your name and reasoning via a pull request to src/data/confidence.ts.
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One roadmap page on OnCo cites this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing page listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
The single most quotable number in tobacco control: quitting at 30 avoids almost all the risk, quitting at 50 avoids half of it, and it is never not worth stopping. It is also the argument for putting cessation support inside a lung screening appointment rather than beside it.
Supplements are drugs, and drugs have to be tested. A plausible mechanism, a consistent observational signal and a safe-sounding intervention still produced measurable harm in the people it was meant to protect.
The methodological ancestor of modern cancer epidemiology. Cohort design, exposure recorded before outcome, and a dose-response relationship measured rather than asserted: this is the template every later study of a cancer risk factor follows.
Half of the evidence base on which every tobacco control policy in the world rests. Lung cancer was a rare disease at the start of the twentieth century and the commonest cause of cancer death by its end; this paper and Doll and Hill's are where the cause was named.
Shares Mandatory radon testing when homes are sold, with subsidised mitigation, Community pharmacies as one-stop cancer prevention hubs, Family-based H. pylori test-and-treat to prevent stomach cancer, Put cytisine, a cheap plant-based quit-smoking pill, on every essential medicines list.
Shares Build polygenic scores that work in every ancestry before deploying any, Let clinics contact relatives directly when a cancer gene is found, A bone drug to prevent breast cancer in BRCA1 carriers, Get every Lynch syndrome carrier onto the right dose of aspirin.
Shares Community-tailored HPV vaccine confidence campaigns with school-based delivery, Switch every country to single-dose HPV vaccination and add catch-up to age 26, Single-dose HPV vaccination plus HPV self-sampling to reach WHO elimination in low-income countries, HPV DNA testing and self-sampling.
Shares Cancer interception vaccines for high-risk carriers, A frameshift neoantigen vaccine for Lynch syndrome carriers as the first preventive cancer vaccine approval, A randomised trial of a shared-antigen vaccine to prevent Lynch syndrome cancers, Cancer interception vaccines.
Shares Smoke-free generation laws with a built-in evaluation across countries, The mortality of doctors in relation to their smoking habits; a preliminary report, Tobacco smoking as a possible etiologic factor in bronchiogenic carcinoma; a study of 684 proved cases, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch.
Shares Smoke-free generation laws with a built-in evaluation across countries, Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national statistics with two case-control studies, The mortality of doctors in relation to their smoking habits; a preliminary report, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch.
Shares KEN SHE (single-dose HPV vaccine), CERVAVAC (quadrivalent HPV vaccine, India), IARC India HPV vaccine dose study (one, two or three doses), Nonavalent HPV vaccine.
Shares Offer everyone at 30 a test for the cancer genes that matter, A bone drug to prevent breast cancer in BRCA1 carriers, Population germline screening for hereditary cancer genes with cascade testing, Inherited risk is mostly unidentified.