Teaching pack: Prevention & Risk

Prevention & Risk is the section about stopping cancer before it starts, through vaccines, germline testing, lifestyle change, and preventive drugs or surgery. Its subjects include HPV and HBV vaccination, testing for hereditary cancer syndromes such as BRCA and Lynch, chemoprevention with tamoxifen or with aspirin in Lynch syndrome, risk-reducing surgery, and population-level control of tobacco and alcohol. It is described here as the most cost-effective part of oncology and the least glamorous. Technologies filed under it include HPV & HBV vaccination, Germline (hereditary) testing, Chemoprevention & risk-reducing surgery, Cancer interception vaccines, Exercise & lifestyle oncology and Systematic drug repurposing, and the people linked to it are Harald zur Hausen and Semir Beyaz.

• 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: Cancer interception vaccines immunise people who do not yet have cancer but carry a high inherited risk, such as Lynch syndrome carriers, against the antigens their future tumour is predicted to express, so memory T cells remove transformed cells early. Because healthy people accept risk for a probabilistic benefit, the safety bar is far higher and trials take years.
• 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: IARC downgraded it in 2016, and cohort studies link two to three cups a day with lower rates of liver and womb cancer. Drinks of any kind served above 65 C are classed as a probable cause of oesophageal cancer, so the temperature, not the coffee, is the 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.

• Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers · Tobacco, hepatitis B and the first chemoprevention (historic)
• Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers · HPV vaccines, hereditary testing and the elimination goal (historic)
• Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers · One dose, self-sampling and vaccines made where they are needed (current)
• Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers · Aspirin and tamoxifen for the right people (current)
• Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers · Weight, alcohol, tobacco and infection at population scale (emerging)
• Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers · Inherited risk found before the cancer (emerging)
• Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation · A cancer with a visible precursor, and the first proof that finding it early saves lives (historic)
• Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation · Total mesorectal excision, and radiotherapy before the operation (historic)
• Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation · Chemotherapy after the operation, and how small the benefit is when the nodes are clear (historic)
• Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation · The screening programmes, and the discovery that uptake is the whole game (current)
• Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation · Antibodies, and the two things that decide whether they work (current)
• Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation · The genome, the subtypes and the hypermutated sixth (historic)
• Gallbladder cancer roadmap: from a chance finding at gallstone surgery to a disease with its own trials · Surgery arrives, and the cancer is found by accident (historic)
• Gallbladder cancer roadmap: from a chance finding at gallstone surgery to a disease with its own trials · Staging by depth, then by side (historic)
• Gallbladder cancer roadmap: from a chance finding at gallstone surgery to a disease with its own trials · The incidental cancer pathway: re-resect from T1b, but who, when and how much (current)
• Gallbladder cancer roadmap: from a chance finding at gallstone surgery to a disease with its own trials · A borrowed chemotherapy standard (historic)
• Gallbladder cancer roadmap: from a chance finding at gallstone surgery to a disease with its own trials · Adjuvant capecitabine and second-line FOLFOX, from UK trials (current)
• Gallbladder cancer roadmap: from a chance finding at gallstone surgery to a disease with its own trials · Radiotherapy: one single-arm trial and a nomogram (historic)
• 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 · The cause is named, and cancer epidemiology is invented to name it (historic)
• 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 · Cytotoxic chemotherapy, and the ceiling it hit (historic)
• 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 · EGFR, ALK, and the invention of precision oncology in solid tumours (historic)
• 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 · Low-dose computed tomography earns its place, and chest radiography loses its (historic)
• 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 · Immunotherapy, and the trouble with PD-L1 as a gate (historic)
• 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 · Stage III, and treatment moving to either side of the operation (current)
• Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting · Two viruses, found because lymphoma is the cancer you can get hold of (historic)
• Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting · How little is enough: the Hodgkin de-escalation programme begins (historic)
• Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting · Reading the genes, and the twenty years it took to make that useful (historic)
• Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting · Everything that failed to beat R-CHOP, and the one thing that did (current)
• Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting · The scan after two cycles, and what it is good for (current)
• Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting · Indolent lymphoma: how long to treat, and the two-year mark that splits the disease (current)
• 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)

• PATRICIA (phase 3, n=18,644): Vaccine efficacy against CIN2+ associated with HPV-16 or HPV-18 (according-to-protocol cohort for efficacy, primary analysis): 92.9%
• 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
• Funen faecal occult blood screening trial (phase 3, n=61,933): Colorectal cancer mortality: 0.82 mortality ratio vs 1 mortality ratio
• CHALLENGE (CCTG CO.21) (phase 3, n=889): Disease-free survival at 5 years: 80.3% vs 73.9%, HR 0.72
• TUMORAPA (switching from a calcineurin inhibitor to sirolimus after a transplant skin cancer) (phase 3, n=120): New cutaneous squamous cell carcinoma: 22% vs 39%
• BWEL (Breast Cancer Weight Loss, Alliance A011401) (phase 3, n=3,181): Invasive disease-free survival: Event-driven primary analysis not yet published; ClinicalTrials.gov lists primary completion in 2030. Only weight and quality-of-life secondary analyses have been reported (2025-2026).

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.

• NCI: Cancer causes and prevention: https://www.cancer.gov/about-cancer/causes-prevention