Population-Based Cancer Prevention Education Intervention Through mHealth: A Randomized Controlled Trial.

Despite the high potential of mHealth-related educational interventions to reach large segments of the population, implementation and adoption of such interventions may be challenging. The objective of this study was to gather knowledge on the feasibility of a future cancer prevention education intervention based on the European Code Against Cancer (ECAC), using a population-based mHealth implementation strategy. A type-2 hybrid effectiveness-implementation study was conducted in a sample of the Spanish general population to assess adoption, fidelity, appropriateness, and acceptability of an intervention to disseminate cancer prevention messages, and willingness to consult further digital information. Participation rates, sociodemographic data, mHealth use patterns and implementation outcomes were calculated. Receiving cancer prevention messages through mHealth is acceptable, appropriate (frequency, timing, understandability and perceived usefulness) and feasible. mHealth users reported high access to the Internet through different devices, high ability and confidence to browse a website, and high willingness to receive cancer prevention messages in the phone, despite low participation rates in comparison to the initial positive response rates. Although adoption of the intervention was high, post-intervention fidelity was seriously hampered by the disruptions caused by the Covid-19 pandemic, which may have affected recall bias. In the context of the Europe's Beating Cancer Plan to increase knowledge about cancer prevention across the European Union, this study contributes to inform the design of future interventions using mHealth at large scale, to ensure a broad coverage and adoption of cancer prevention messages as those promoted by the ECAC.Trial Registration: ClinicalTrials.gov from the U.S. National Library of Medicine, NCT05992792. Registered 15 August 2023 - Retrospectively registered https://clinicaltrials.gov/study/NCT05992792?cond=Cancer&term=NCT05992792&rank=1 .

Mapping the European cancer prevention research landscape: A case for more prevention research funding.

Despite the strong evidence of prevention as a prime defence against the disease, the majority of cancer research investment continues to be made in basic science and clinical translational research. Little quantitative data is available to guide decisions on the choice of research priorities or the allocation of research resources. The primary aim of the mapping of the European cancer prevention research landscape presented in this paper is to provide the evidence-base to inform future investments in cancer research. Using bibliometric data to identify funders that are active in prevention research in Europe and in the world, we have identified that 14% of cancer research papers had a focus on prevention research and those were funded by 16% of all the European cancer research funders. An important finding of our study is the lack of research on primary prevention with primary prevention funders accounting for 25% of European cancer prevention funders, meaning that less than 4% of all European cancer research funders identified show an interest in primary prevention. An additional analysis revealed that 7% of European cancer prevention research papers are categorised as implementation projects, meaning that only 1% of all cancer research publications are implementation research in cancer prevention. This paper highlights that the narrow focus on biology and treatment in Europe needs to be widened to include such areas as primary prevention and secondary prevention and a larger concentration on implementation research. These data can help support a more policy-focused cancer research agenda for individual European governments and charitable and philanthropic organisations and stimulate joining efforts across Europe to create a more systematic and structured approach to cancer prevention.

Latin America and the Caribbean Code Against cancer 1st edition: Environment, occupation, and cancer.

Within the framework of the Latin America and Caribbean region (LAC) Code Against Cancer 1st edition, the current work presents recommendations to reduce exposure to environmental and occupational carcinogenic agents relevant for LAC. Using the methodology established by the International Agency for Research on Cancer (IARC) in the World Code Against Cancer Framework and experience from developing the European Code Against Cancer 4th edition, a working group of LAC cancer-prevention experts reviewed the list of Group I IARC carcinogenic agents, identified prevalent environmental and occupational exposures in the region, and proposed evidence-based cancer prevention recommendations suited to the epidemiological, socioeconomic, and cultural conditions of LAC countries. Two sets of recommendations were drafted: those targeting the general public and a second set for policymakers. Outdoor and indoor air pollution, ultra-violet radiation and occupational exposures to silica dust, asbestos, benzene, diesel, and welding fumes were identified as prevalent carcinogens in LAC and as agents that could be reduced or eliminated to prevent cancers. Recommendations for additional risk factors were not included due to insufficient data of their attributable burden in LAC (sunbeds, radon, aflatoxin), or lack of a clear preventive action to be taken by the individual (arsenic in drinking water, medical radiation), or lack of evidence of carcinogenicity effect (bisphenol A, phthalates, and pesticides). A broad consensus was reached on environmental and occupational carcinogenic exposures present throughout the LAC region and on individual-level and public policy-level recommendations to reduce or eliminate these exposures. Key educational content for the dissemination of these recommendations was also developed as part of LAC Code Against Cancer 1st Edition.

Latin America and the Caribbean Code Against Cancer 1st Edition: 17 cancer prevention recommendations to the public and to policy-makers (World Code Against Cancer Framework).

Preventable risk factors are responsible of at least 40% of cases and almost 45% of all cancer deaths worldwide. Cancer is already the leading cause of death in almost half of the Latin American and the Caribbean countries constituting a public health problem. Cost-effective measures to reduce exposures through primary prevention and screening of certain types of cancers are critical in the fight against cancer but need to be tailored to the local needs and scenarios. The Latin America and the Caribbean (LAC) Code Against Cancer, 1st edition, consists of 17 evidence-based recommendations for the general public, based on the most recent solid evidence on lifestyle, environmental, occupational, and infectious risk factors, and medical interventions. Each recommendation is accompanied by recommendations for policymakers to guide governments establishing the infrastructure needed to enable the public adopting the recommendations. The LAC Code Against Cancer has been developed in a collaborative effort by a large number of experts from the region, under the umbrella strategy and authoritative methodology of the World Code Against Cancer Framework. The Code is a structured instrument ideal for cancer prevention and control that aims to raise awareness and educate the public, while building capacity and competencies to policymakers, health professionals, stakeholders, to contribute to reduce the burden of cancer in LAC.

Latin America and the Caribbean Code Against Cancer 1st edition: Building capacity on cancer prevention to primary healthcare professionals.

INTRODUCTION: Every year 1.5 million new cancer cases are diagnosed in Latin America and the Caribbean (LAC). Of these, about 40 % could be prevented. Health illiteracy has been identified as a main barrier for cancer prevention. Primary healthcare professionals (HCP) are key in cancer prevention as they are the first entry point of the population into the healthcare system. The LAC Code Against Cancer 1st edition aims to improve health literacy and awareness of cancer prevention in the LAC population, through building capacity of primary HCP. METHODS: The definition and development of the learning objectives, curriculum, structure, and evaluation of an online learning program for primary HCP was led by a dedicated group of experts from the LAC Code Against Cancer project. A pedagogical guideline and a template to ensure harmonization across topics were produced to guide the program development. Two rounds of internal revisions and an editorial process were performed. RESULTS: An online competency-based microlearning program for primary HCP was produced, taking the LAC Code Against Cancer as a basis. The competences addressed in the curriculum are core knowledge, communication skills, decision-making and applying knowledge to real-world situations. A comprehensive evaluation to assess acquisition of these competences, based on the Miller's Pyramid, was designed with three data collection points: a) immediately before, to assess baseline knowledge and skills; b) immediately after, to determine acquired competences; and c) at 3-6 months follow-up, to assess performance in daily practice. The e-learning will be freely available in the Virtual Campus for Public Health of the Pan American Health Organization in Spanish, English, and Portuguese. CONCLUSION: Primary HCP, perceived as trustworthy sources of information, are key actors to increase the population's awareness and literacy on cancer prevention. Building capacity of these professionals has the potential to increase dissemination and impact of the LAC Code Against Cancer by prompting communication with the public and offering personalized actionable preventive messages through counselling.

Latin America and the Caribbean Code Against Cancer 1st edition: Tobacco and nicotine-related products, secondhand smoke, and alcohol and cancer.

Tobacco, secondhand smoke (SHS), and alcohol, all carcinogens, are leading preventable cancer risk factors in Latin America and the Caribbean (LAC). Since 2000, smoking and SHS exposure have significantly decreased in the region. Yet alcohol consumption remains high. The entry of nicotine-related products such as electronic cigarettes (e-cigs) threatens achievements made in tobacco control and chronic diseases prevention, including cancer. E-cigs use is likely associated with smoking initiation among adolescents who had never smoked and dual use with combustible tobacco products. Therefore, the LAC Code Against Cancer recommends to the public actions they can take to reduce their risk of cancer: 1. Don't smoke or use any type of tobacco. If you do, quitting is possible, with professional help if needed. Don't use e-cigarettes either, as they lead to tobacco use. 2. Make your home a smoke-free place. Respect and promote laws that ensure smoke-free spaces to protect our health. and 3. Avoid drinking alcoholic beverages. This helps prevent several types of cancer. The Code recommends to policymakers a package of cost-effective policies based on the MPOWER and SAFER to prevent cancer at the population level. It also recommends that primary care health professionals: 1. Ask all their patients and their families whether they smoke or vape, inform them about the harms of smoking and vaping, and promote tobacco and nicotine related products cessation strategies among users. 2. Inform about the harms of exposure to SHS, especially among children, and promote smoke-free environments, and 3. Prevent alcohol use by their patients and their families, use tools to assess use, intensity, and frequency, and apply brief counseling intervention to support alcohol abstinence in primary care.

Latin America and the Caribbean Code Against Cancer 1st Edition: Medical interventions including hormone replacement therapy and cancer screening.

Prostate, breast, colorectal, cervical, and lung cancers are the leading cause of cancer in Latin America and the Caribbean (LAC) accounting for nearly 50% of cancer cases and cancer deaths in the region. Following the IARC Code Against Cancer methodology, a group of Latin American experts evaluated the evidence on several medical interventions to reduce cancer incidence and mortality considering the cancer burden in the region. A recommendation to limit the use of HRT was issued based on the risk associated to develop breast, endometrial, and ovarian cancer and on growing concerns related to the over-the-counter and without prescription sales, which in turn bias estimations on current use in LAC. In alignment with WHO breast and cervical cancer initiatives, biennial screening by clinical breast examination (performed by trained health professionals) from the age of 40 years and biennial screening by mammography from the age of 50 years to 74, as well as cervical screening by HPV testing (either self-sampling or provider-sampling) every 5-10 years for women aged 30-64 years, were recommended. The steadily increasing rates of colorectal cancer in LAC also led to recommend colorectal screening by occult blood testing every two years or by endoscopic examination of the colorectum every 10 years for both men and women aged 50-74 years. After evaluating the evidence, the experts decided not to issue recommendations for prostate and lung cancer screening; while there was insufficient evidence on prostate cancer mortality reduction by prostate-specific antigen (PSA) testing, there was evidence of mortality reduction by low-dose computed tomography (LDCT) targeting high-risk individuals (mainly heavy and/or long-term smokers) but not individuals with average risk to whom recommendations of this Code are directed. Finally, the group of experts adapted the gathered evidence to develop a competency-based online microlearning program for building cancer prevention capacity of primary care health professionals.

Latin America and the Caribbean Code Against Cancer 1st edition: Formative research on the comprehension and persuasiveness of the recommendations by the general population.

BACKGROUND: Cancer prevention is the most efficient and cost-effective strategy in cancer control. One prevention strategy is giving credible, clear, and evidence-based recommendations to the individual; however, it is key that these messages are accepted and understood properly by the public. This study aimed to pilot the draft recommendations developed as part of the Latin America and the Caribbean (LAC) Code Against Cancer 1st edition, in terms of comprehension and persuasion of each message. METHODS: A mixed method two-wave study, in which two versions of the messages were presented to the general population in five LAC countries. We used an ad-hoc questionnaire and interviews that followed the cognitive-pretesting methodology. RESULTS: Findings suggest that the messages were generally well understood, especially in Spanish speaking countries, and that the messages were generally more understandable than persuasive. We adapted and revised the recommendations based on the findings of the first Wave and held a second iteration in the Spanish speaking countries. We observed a better understanding of most messages in Wave 2. CONCLUSION: The LAC Code Against Cancer is a valuable tool of well understood messages for the public, with concrete actions everyone can take to prevent cancer. Further research should assess particularities of the region for further efficient dissemination of these important health messages, identify key messages for certain population groups and future interventions that strengthen health literacy in rural and less educated populations to increase behavior change.

Latin American and the Caribbean Code Against Cancer 1st edition: Infections and cancer.

About 13% of all cancers around the world are associated with infectious agents, particularly in low-resource settings. The main infectious agents associated with cancer are Helicobacter pylori (H. pylori), that causes gastric cancer, human papillomavirus (HPV) that causes cervical, vulvar, vaginal, penile, anal, and oropharyngeal cancer, hepatitis B and C viruses that cause liver cancer, and human immunodeficiency virus (HIV), associated with cancers of the cervix, Kaposi sarcoma (KS) and non-Hodgkin´s lymphoma. In Latin America and the Caribbean (LAC), about 150,000 cancer cases are caused annually by infections. The LAC Cancer Code Against Cancer consists of a set of 17 evidence-based and individual-level cancer prevention recommendations targeted to the general population, suited to the epidemiological, socioeconomic, and cultural conditions of the region, and tailored to the availability and accessibility of health-care systems. The recommendations with respect to infection-driven malignancies include testing and treating for H. pylori in the context of specific public health programs, vaccination against HPV and Hepatitis B Virus (HBV) and detection and treatment of chronic infections with HBV, Hepatitis C virus (HCV) and HIV, in addition to the promotion of safe sex and use of condoms to prevent sexually transmitted infections (STI). Countries, policy makers, health care systems and individuals should consider the adoption of these recommendations to help reduce the incidence and mortality of infection-related cancers in LAC, to improve quality of life of individuals and reduce the costs of cancer care in the region.

Latin American and the Caribbean Code Against Cancer 1st edition: Weight, physical activity, diet, breastfeeding, and cancer.

In Latin America and the Caribbean a considerable proportion of the population have excess body weight, do not meet the recommendations of physical activity and healthy diet, and have suboptimal rates of breastfeeding. Excess body weight is associated with at least 15 cancer sites, physical activity protects against three cancers, with some evidence suggesting a protective effect for eight more cancer sites, and sedentary behavior probably increases the risk of five cancer sites. Fiber and wholegrains protect against colorectal cancer, high intake of fruits and vegetables could reduce the risk of aerodigestive cancers; processed and red meat increase the risk of colorectal cancer; and very hot beverages are associated with esophageal cancer. Moreover, sugar-sweetened beverages and ultra-processed foods are a convincing cause for excess body weight, increasing cancer risk through this pathway, with some emerging evidence suggesting also direct pathways. Breastfeeding protects against breast cancer, and could protect against ovarian cancer. Taking this evidence into account, the Latin America and the Caribbean Code Against Cancer recommends the general public to maintain a healthy body weight, be physically active and limit sedentary behavior, eat a healthy diet (eat plenty of vegetables, fruits, wholegrains and legumes; avoid sugar-sweetened beverages and processed meat; and limit ultra-processed foods, red meat and very hot beverages), and breastfeed. Moreover, the Latin America and the Caribbean Code Against Cancer also includes a set of public policy recommendations for cancer prevention to inform policy makers and civil society about the need of policies to shape healthy environments and create opportunities to facilitate the adoption of the recommendations directed to the public.

Why Am I Ill? Beliefs in Supernatural and Natural Causes of Ill Health at the Time of Diagnostic Workup of Patients With Esophageal Cancer in Tanzania.

PURPOSE: An understanding of the cultural and context-specific perceptions of the causes of cancer is an important prerequisite for designing effective primary health prevention and early detection strategies. We aimed to use the Murdock Ill Health Theoretical Model to conceptualize views on illness causation among dysphagia-suffering patients undergoing diagnostic workup for esophageal cancer (EC) in Tanzania. METHODS: At the end of a structured interview on lifestyle habits, patients with suspected EC were asked about beliefs on the reasons behind their illness through (1) a set of questions with fixed binary answers, whose determinants were analyzed using logistic regression, and (2) a single question with free-text answers. Responses were coded using a hierarchy of natural and supernatural (godly and social constructs) causes. RESULTS: Among 322 patients interviewed between November 2015 and December 2019, we found complex and varied views about the origins of their illness. Overall, 49% of patients attributed illness to natural causes and 39% to supernatural causes. Natural causes ranged from infection, use of alcohol and tobacco, other ailments, and the environment. The supernatural causes included attributing illness to God, curses, and spells from personal acquaintances. Belief in supernatural causes was more common in the less educated and those who sought help first via a traditional healer. CONCLUSION: The results underscore the need for increased community awareness of biomedical causes of ill health and patient-based participatory research to inform prevention programs. The results also highlight the importance of building health systems that support a series of health-seeking behaviors that acknowledge both biomedical and local traditional healing belief systems.

Digital interventions to moderate physical inactivity and/or nutrition in young people: a Cancer Prevention Europe overview of systematic reviews.

Background: Strategies to increase physical activity (PA) and improve nutrition would contribute to substantial health benefits in the population, including reducing the risk of several types of cancers. The increasing accessibility of digital technologies mean that these tools could potentially facilitate the improvement of health behaviours among young people. Objective: We conducted a review of systematic reviews to assess the available evidence on digital interventions aimed at increasing physical activity and good nutrition in sub-populations of young people (school-aged children, college/university students, young adults only (over 18 years) and both adolescent and young adults (<25 years)). Methods: Searches for systematic reviews were conducted across relevant databases including KSR Evidence (www.ksrevidence.com), Cochrane Database of Systematic Reviews (CDSR) and Database of Abstracts of Reviews of Effects (DARE; CRD). Records were independently screened by title and abstract by two reviewers and those deemed eligible were obtained for full text screening. Risk of bias (RoB) was assessed with the Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) tool. We employed a narrative analysis and developed evidence gap maps. Results: Twenty-four reviews were included with at least one for each sub-population and employing a range of digital interventions. The quality of evidence was limited with only one of the 24 of reviews overall judged as low RoB. Definitions of "digital intervention" greatly varied across systematic reviews with some reported interventions fitting into more than one category (i.e., an internet intervention could also be a mobile phone or computer intervention), however definitions as reported in the relevant reviews were used. No reviews reported cancer incidence or related outcomes. Available evidence was limited both by sub-population and type of intervention, but evidence was most pronounced in school-aged children. In school-aged children eHealth interventions, defined as school-based programmes delivered by the internet, computers, tablets, mobile technology, or tele-health methods, improved outcomes. Accelerometer-measured (Standardised Mean Difference [SMD] 0.33, 95% Confidence Interval [CI]: 0.05 to 0.61) and self-reported (SMD: 0.14, 95% CI: 0.05 to 0.23) PA increased, as did fruit and vegetable intake (SMD: 0.11, 95% CI: 0.03 to 0.19) (review rated as low RoB, minimal to considerable heterogeneity across results). No difference was reported for consumption of fat post-intervention (SMD: -0.06, 95% CI: -0.15 to 0.03) or sugar sweetened beverages(SSB) and snack consumption combined post-intervention (SMD: -0.02, 95% CI:-0.10 to 0.06),or at the follow up (studies reported 2 weeks to 36 months follow-up) after the intervention (SMD:-0.06, 95% CI: -0.15 to 0.03) (review rated low ROB, minimal to substantial heterogeneity across results). Smartphone based interventions utilising Short Messaging Service (SMS), app or combined approaches also improved PA measured using objective and subjective methods (SMD: 0.44, 95% CI: 0.11 to 0.77) when compared to controls, with increases in total PA [weighted mean difference (WMD) 32.35 min per day, 95% CI: 10.36 to 54.33] and in daily steps (WMD: 1,185, 95% CI: 303 to 2,068) (review rated as high RoB, moderate to substantial heterogeneity across results). For all results, interpretation has limitations in terms of RoB and presence of unexplained heterogeneity. Conclusions: This review of reviews has identified limited evidence that suggests some potential for digital interventions to increase PA and, to lesser extent, improve nutrition in school-aged children. However, effects can be small and based on less robust evidence. The body of evidence is characterised by a considerable level of heterogeneity, unclear/overlapping populations and intervention definitions, and a low methodological quality of systematic reviews. The heterogeneity across studies is further complicated when the age (older vs. more recent), interactivity (feedback/survey vs. no/less feedback/surveys), and accessibility (type of device) of the digital intervention is considered. This underscores the difficulty in synthesising evidence in a field with rapidly evolving technology and the resulting challenges in recommending the use of digital technology in public health. There is an urgent need for further research using contemporary technology and appropriate methods.

Digital interventions to moderate alcohol consumption in young people: a Cancer Prevention Europe overview of systematic reviews.

Background: Strategies to reduce alcohol consumption would contribute to substantial health benefits in the population, including reducing cancer risk. The increasing accessibility and applicability of digital technologies make these powerful tools suitable to facilitate changes in behaviour in young people which could then translate into both immediate and long-term improvements to public health. Objective: We conducted a review of systematic reviews to assess the available evidence on digital interventions aimed at reducing alcohol consumption in sub-populations of young people [school-aged children, college/university students, young adults only (over 18 years) and both adolescent and young adults (<25 years)]. Methods: Searches were conducted across relevant databases including KSR Evidence, Cochrane Database of Systematic Reviews (CDSR) and Database of Abstracts of Reviews of Effects (DARE). Records were independently screened by title and abstract and those that met inclusion criteria were obtained for full text screening by two reviewers. Risk of bias (RoB) was assessed with the ROBIS checklist. We employed a narrative analysis. Results: Twenty-seven systematic reviews were included that addressed relevant interventions in one or more of the sub-populations, but those reviews were mostly assessed as low quality. Definitions of "digital intervention" greatly varied across systematic reviews. Available evidence was limited both by sub-population and type of intervention. No reviews reported cancer incidence or influence on cancer related outcomes. In school-aged children eHealth multiple health behaviour change interventions delivered through a variety of digital methods were not effective in preventing or reducing alcohol consumption with no effect on the prevalence of alcohol use [Odds Ratio (OR) = 1.13, 95% CI: 0.95-1.36, review rated low RoB, minimal heterogeneity]. While in adolescents and/or young adults who were identified as risky drinkers, the use of computer or mobile device-based interventions resulted in reduced alcohol consumption when comparing the digital intervention with no/minimal intervention (-13.4 g/week, 95% CI: -19.3 to -7.6, review rated low RoB, moderate to substantial heterogeneity).In University/College students, a range of E-interventions reduced the number of drinks consumed per week compared to assessment only controls although the overall effect was small [standardised mean difference (SMD): -0.15, 95% CI: -0.21 to -0.09]. Web-based personalised feedback interventions demonstrated a small to medium effect on alcohol consumption (SMD: -0.19, 95% CI: -0.27 to -0.11) (review rated high RoB, minimal heterogeneity). In risky drinkers, stand-alone Computerized interventions reduced short (SMD: -0.17, 95% CI: -0.27 to -0.08) and long term (SMD: -0.17, 95% CI: -0.30 to -0.04) alcohol consumption compared to no intervention, while a small effect (SMD: -0.15, 95% CI: -0.25 to -0.06) in favour of computerised assessment and feedback vs. assessment only was observed. No short-term (SMD: -0.10, 95% CI: -0.30 to 0.11) or long-term effect (SMD: -0.11, 95% CI: -0.53 to 0.32) was demonstrated for computerised brief interventions when compared to counsellor based interventions (review rated low RoB, minimal to considerable heterogeneity). In young adults and adolescents, SMS-based interventions did not significantly reduce the quantity of drinks per occasion from baseline (SMD: 0.28, 95% CI: -0.02 to 0.58) or the average number of standard glasses per week (SMD: -0.05, 95% CI: -0.15 to 0.05) but increased the risk of binge drinking episodes (OR = 2.45, 95% CI: 1.32-4.53, review rated high RoB; minimal to substantial heterogeneity). For all results, interpretation has limitations in terms of risk of bias and heterogeneity. Conclusions: Limited evidence suggests some potential for digital interventions, particularly those with feedback, in reducing alcohol consumption in certain sub-populations of younger people. However, this effect is often small, inconsistent or diminishes when only methodologically robust evidence is considered. There is no systematic review evidence that digital interventions reduce cancer incidence through alcohol moderation in young people. To reduce alcohol consumption, a major cancer risk factor, further methodologically robust research is warranted to explore the full potential of digital interventions and to form the basis of evidence based public health initiatives.

The patient, diagnostic, and treatment intervals in adult patients with cancer from high- and lower-income countries: A systematic review and meta-analysis.

BACKGROUND: Longer time intervals to diagnosis and treatment are associated with worse survival for various types of cancer. The patient, diagnostic, and treatment intervals are considered core indicators for early diagnosis and treatment. This review estimated the median duration of these intervals for various types of cancer and compared it across high- and lower-income countries. METHODS AND FINDINGS: We conducted a systematic review with meta-analysis (prospectively registered protocol CRD42020200752). Three databases (MEDLINE, Embase, and Web of Science) and information sources including grey literature (Google Scholar, OpenGrey, EThOS, ProQuest Dissertations & Theses) were searched. Eligible articles were published during 2009 to 2022 and reported the duration of the following intervals in adult patients diagnosed with primary symptomatic cancer: patient interval (from the onset of symptoms to first presentation to a healthcare professional), diagnostic interval (from first presentation to diagnosis), and treatment interval (from diagnosis to treatment start). Interval duration was recorded in days and study medians were combined in a pooled estimate with 95% confidence intervals (CIs). The methodological quality of studies was assessed using the Aarhus checklist. A total of 410 articles representing 68 countries and reporting on 5,537,594 patients were included. The majority of articles reported data from high-income countries (n = 294, 72%), with 116 (28%) reporting data from lower-income countries. Pooled meta-analytic estimates were possible for 38 types of cancer. The majority of studies were conducted on patients with breast, lung, colorectal, and head and neck cancer. In studies from high-income countries, pooled median patient intervals generally did not exceed a month for most cancers. However, in studies from lower-income countries, patient intervals were consistently 1.5 to 4 times longer for almost all cancer sites. The majority of data on the diagnostic and treatment intervals came from high-income countries. Across both high- and lower-income countries, the longest diagnostic intervals were observed for hematological (71 days [95% CI 52 to 85], e.g., myelomas (83 days [47 to 145])), genitourinary (58 days [50 to 77], e.g., prostate (85 days [57 to 112])), and digestive/gastrointestinal (57 days [45 to 67], e.g., colorectal (63 days [48 to 78])) cancers. Similarly, the longest treatment intervals were observed for genitourinary (57 days [45 to 66], e.g., prostate (75 days [61 to 87])) and gynecological (46 days [38 to 54], e.g., cervical (69 days [45 to 108]) cancers. In studies from high-income countries, the implementation of cancer-directed policies was associated with shorter patient and diagnostic intervals for several cancers. This review included a large number of studies conducted worldwide but is limited by survivor bias and the inherent complexity and many possible biases in the measurement of time points and intervals in the cancer treatment pathway. In addition, the subintervals that compose the diagnostic interval (e.g., primary care interval, referral to diagnosis interval) were not considered. CONCLUSIONS: These results identify the cancers where diagnosis and treatment initiation may take the longest and reveal the extent of global disparities in early diagnosis and treatment. Efforts should be made to reduce help-seeking times for cancer symptoms in lower-income countries. Estimates for the diagnostic and treatment intervals came mostly from high-income countries that have powerful health information systems in place to record such information.

Acceptability, appropriateness and feasibility of the Latin American and Caribbean Code against Cancer: perceptions of decision-makers and health professionals in Argentina.

Background: Cancer is an important public health problem. In Latin America and the Caribbean, there were approximately 1,500,000 new cases of cancer and 700,000 deaths due to cancer in 2020. These figures will increase by 78% by 2040 to more than 2.5 million people diagnosed with cancer each year, who will require medical attention, care and support. However, it is estimated that at least 40% of cancers could be prevented by adopting a healthier lifestyle, reducing risky behaviours and implementing recommended health interventions. Objective: To evaluate the perceptions of health decision-makers and professionals regarding the Latin American and Caribbean Code against Cancer (CLCC) as a support tool for designing and implementing public policies for cancer prevention and control (acceptability, appropriateness and feasibility) in Argentina. Methods: A qualitative study was conducted using individual, semi-structured interviews with health decision-makers and professionals (n = 30). The questions and thematic analysis of the information gathered have been guided by the principles of the Consolidated Framework for Implementation Research: intervention characteristics, outer setting, inner setting and characteristics of individuals. Results: Health professionals and health decision-makers broadly accepted the proposal of the CLCC as a tool for supporting the design and implementation of public policies for cancer prevention and control, and considered it to be appropriate. Additionally, from the interviewees' perspective, factors should be ensured to guarantee the implementation of the CLCC as a viable public health policy. They also felt it was right to take the CECC as a model and to adapt its content to the specific characteristics of the Latin American population, customs, lifestyle habits, epidemiological characteristics and, in particular, the Argentinian socio-economic context. Interviewees perceived the CLCC as a health intervention whose complexity varied depending on the recommendation, although most of them were feasible. The broad consensus among the interviewees was that the development of the CLCC could yield numerous advantages in improving cancer prevention and control policy, and responding to the needs of the population. It was also considered to be an opportunity to introduce fundamental changes. With regard to the implementation of the CLCC, interviewees reported a favourable institutional climate, since they perceived that it would receive a priority equal to or greater than the ongoing prevention measures, and that it would have the commitment of the health authorities. They also felt that the implementation of the CLCC in their work environment would not be very complicated, and that the decision-makers and professionals had the necessary capacity to implement it. Finally, they felt that the implementation would be facilitated by the participation and consensus of health decision-makers at the primary care level, and negotiation with industrial and environmental sectors. Conclusions: Our study shows that health professionals and decision-makers consider the CLCC to be highly acceptable, appropriate and feasible. This would facilitate its implementation as a tool that could enhance current cancer prevention and control policies in Argentina. The results of the study indicate the necessity for the CLCC to be adapted to the socio-economic context of Argentina, and highlight that population adherence to the CLCC recommendations will depend on complex and diverse factors, especially those involving changing unhealthy behaviours linked to cancer risk.

Coverage and Acceptability of Mobile Phone Messages for Cancer Prevention: a Population-Based Study in a Latin American Country.

Mobile health (m-health) has shown positive effects on disease prevention; however, several factors might influence its effectiveness, particularly in low- and middle-income countries. Randomized trials provide data with high internal validity but no major information on population impact. We conducted a pilot population-based study to assess the feasibility of cancer prevention through m-health in a Latin American population. A sample of affiliates to a health insurance company in Colombia was randomly selected and assigned to receive a short message service (SMS) or voice messages (VMS) during 4 weeks; weekly frequencies 2 and 7. Baseline and post-intervention surveys were conducted. Overall, 797 affiliates were contacted (SMS 393, VMS 404) but only 15.3% and 24.8% enrolled, respectively. Over 80% acceptability was observed among participants for all items evaluated (usefulness, understandability, timing, and frequency); however, 2-VMS per week was the only frequency consistent with the declared number of messages received and listened. Other frequencies resulted in high reception recall but low willingness to read/listen the messages. The willingness to be part of future programs was 20.0%. The gap between declared acceptability and practice, low participation rates, and low willingness to read/listen messages indicate m-health should be part of multicomponent interventions and should not be conceived as the sole intervention.

Sustainability and monitoring of the European Code Against Cancer: Recommendations.

INTRODUCTION: As part of the third European Commission's Joint Action on Cancer (Innovative Partnership for Action Against Cancer, iPAAC), the International Agency for Research on Cancer (IARC) was commissioned to produce a report on recommendations to sustain and monitor future updates of the European Code Against Cancer (ECAC). MATERIALS AND METHODS: A co-creational consultation process, including a virtual workshop, was carried out. More than 100 experts in cancer prevention, public health, communication and representatives of European authorities provided input on the scope of future editions of the ECAC, including updating the scientific evidence and its maintenance, and on strategies for its implementation and dissemination across Europe. RESULTS AND DISCUSSION: Overwhelming support for the need of the ECAC and its continuous updating, optimization and wider dissemination was expressed by all the stakeholders. Eight recommendations and four research needs summarise the assessment and pave the way for the future of the ECAC.