Cancer incidence attributable to lifestyle and environmental factors in Alberta in 2012: summary of results

Facilitators and barriers for implementing screening brief intervention and referral for health promotion in a rural hospital in Alberta: using consolidated framework for implementation research

BACKGROUND

Screening, brief intervention, and referral (SBIR) is an evidence-based, comprehensive health promotion approach commonly implemented to reduce alcohol and substance use. Implementation research on SBIR demonstrate that patients find it acceptable, reduces hospital costs, and it is effective. However, SBIR implementation in hospital settings for multiple risk factors (fruit and vegetable consumption, physical activity, alcohol and tobacco use) is still emergent. More evidence is needed to guide SBIR implementation for multiple risk factors in hospital settings.

OBJECTIVE

To explore the facilitators and barriers of SBIR implementation in a rural hospital using the Consolidated Framework for Implementation Research (CFIR).

METHODS

We conducted a descriptive qualitative investigation consisting of both inductive and deductive analyses. We conducted virtual, semi-structured interviews, guided by the CFIR framework. All interviews were audio-recorded, and transcribed verbatim. NVivo 12 Pro was used to organize and code the raw data.

RESULTS

A total of six key informant semi-structured interviews, ranging from 45 to 60 min, were carried out with members of the implementation support team and clinical implementers. Implementation support members reported that collaborating with health departments facilitated SBIR implementation by helping (a) align health promotion risk factors with existing guidelines; (b) develop training and educational resources for clinicians and patients; and (c) foster leadership buy-in. Conversely, clinical implementers reported several barriers to SBIR implementation including, increased and disrupted workflow due to SBIR-related documentation, a lack of knowledge on patients' readiness and motivation to change, as well as perceived patient stigma in relation to SBIR risk factors.

CONCLUSION

The CFIR provided a comprehensive framework to gauge facilitators and barriers relating to SBIR implementation. Our pilot investigation revealed that future SBIR implementation must address organizational, clinical implementer, and patient readiness to implement SBIR at all phases of the implementation process in a hospital.

Comparative anticancer effects of Annona muricata Linn (Annonaceae) leaves and fruits on DMBA-induced breast cancer in female rats

BACKGROUND

Numerous studies have reported the anti-cancer effects of different parts of Annona muricata Linn, however ; most of them focused on the in vitro evaluation of isolates. In vivo evidence on which part is best suited for breast cancer chemoprevention remains to be demonstrated. This is a comparative study of the effects of A. muricata fruit and leaves extracts on DMBA induced-breast cancer in rats.

METHODS

Rats exposed to DMBA (50 mg/kg, s.c.), were treated with A. muricata fruit aqueous extract at 200 mg/kg BW (3 days/week or daily) and A. muricata Linn leaves ethanolic extract at 200 mg/kg daily. Positive control group received tamoxifen at 3.3 mg/kg, while the normal and diseased controls received vehicle. After 20 weeks of treatment, the tumor incidence, tumor burden, tumor volume, histopathology, protein and CA 15 - 3 levels as well as antioxidant status, pro-inflammatory cytokines were assessed.

RESULTS

Thus, 100% of diseased rats presented cribriform ductal carcinoma of SBR grade III. A. muricata extracts (leaves and fruit) and tamoxifen significantly reduced death and tumor incidences, volume and weight of the tumors, total protein and CA15-3 levels compared to the DMBA group. They exhibited antioxidant activity, through an increase in the GSH level and SOD and catalase activities with reduced levels of MDA compared to DMBA group. TNF-α, IL-6 and INF-γ levels reduced with regards to A. muricata treatment.

CONCLUSION

These results confirm the anti-breast cancer effect of A. muricata, however, the aqueous fruit extract was more potent than the ethanolic leaves extract.

Breast cancer cell growth arrest and chemopreventive effects of Passiflora edulis Sims (Passifloraceae) ethanolic leaves extract on a rat model of mammary carcinoma

ETHNOPHARMACOLOGICAL RELEVANCE

Despite various prevention and treatment measures, the incidence and mortality due to breast cancer has been increasing globally. Passiflora edulis Sims is a plant used for the treatment of various diseases in traditional medicine, including cancers.

AIM OF THE STUDY

To assess the anti-breast cancer activity of the ethanolic extract of P. edulis leaves in vitro and in vivo.

MATERIAL AND METHODS

In vitro, the cell growth and proliferation were determined based on the MTT and BrdU assays. The flow cytometry was used to analyze the cell death mechanism while, cell migration, cell adhesion and chemotaxis were assayed for anti-metastatic potential. In vivo, 56 female Wistar rats aged 45-50 days (∼75 g) were exposed to 7,12-dimethylbenz(a)anthracene-DMBA except the normal group. Negative control group (DMBA) received solvent dilution throughout the study; standards groups (tamoxifen - 3.3 mg/kg BW and letrozole - 1 mg/kg BW) as well as P. edulis leaves ethanolic extract groups (50, 100 and 200 mg/kg) treated for 20 weeks. Tumor incidence, tumor burden and volume, CA 15-3 serum' level, antioxidant, inflammatory status and histopathology were assessed.

RESULTS

P. edulis extract showed a significant and concentration-dependent inhibition of MCF-7 and MDA-MB 231 cells growth at 100 μg/mL. It inhibited cell proliferation and clones' formation and induced apoptosis in MDA-MB 231 cells. The migration of cell into the zone freed of cells and the number of invading cells after the 48 and 72 h were significantly diminished while, it increased their adherence to collagen and fibronectin extracellular matrix as does Doxorubicin. In vivo, all rats in the DMBA group exhibited a significant (p < 0.001) increase in tumor volume, tumor burden and grade (adenocarcinoma of SBR III) and pro-inflammatory cytokine levels (TNF-α, INF-γ, IL-6 and IL-12). P. edulis extract at all tested doses significantly inhibited the DMBA-induced increase in tumor incidence, tumor burden and grade (SBR I) as well as pro-inflammatory cytokines. Moreover, it increased enzymatic and non-enzymatic antioxidants (SOD, catalase, and GSH) and decreased MDA levels although a greater effect was observed with Tamoxifen and Letrozole. P. edulis has medium content on polyphenols, flavonoids and tannins.

CONCLUSION

P. edulis has chemo-preventive effects against DMBA-induced breast cancer in rats probably through its antioxidative, anti-inflammatory and apoptosis-inducing potentials.

The Awareness of Healthy Individuals about Attributable Risk Factors of Cancer

Background and Purpose: This study aimed to determine the awareness of healthy individuals about the attributable risk factors of cancer and the reliability of their ideas. Methods: A review of relevant literature was undertaken to assemble a list of possible causes of cancer. Seventy-six healthy individuals were interviewed. Individuals were asked to declare their opinion by scoring the potential 15 cancer risk factors between 0-4. One week later, the opinions were retaken to test reliability. Results: According to the participants, smoking (94.8%) and mobile phone use (79%) had perfect consensus; being overweight (63.1%) and having a family history of cancer (92.1%) had substantial consensus; alcohol (90.8%), stress (93.5%), sunlight exposure (69.77%), plastic (84.2%), infection (57.9%), occupational exposure (67.1%), fatigue (54%), nuclear accident (96%) had moderate consensus. Air pollution (86.8%) and washing agents (77.7%) had fair consensus. Age (34.2%) was not a risk factor for cancer. All risk factors were reliable between the two assessments except age (p

Updated fraction of cancer attributable to lifestyle and environmental factors in Denmark in 2018

Environmental exposures and avoidable risk factors account for a large proportion of cancer burden. Exposures and lifestyle vary over time and between populations, which calls for updated and population-specific quantification of how various avoidable risk factors influence cancer risk to plan and design rational and targeted prevention initiatives. The study considered 12 risk-factor groups categorized as class I carcinogens by IARC/WCRF. Exposure data was derived from national studies and surveys and were linked to cancer incidence in 2018 based on the nationwide Danish Cancer Registry. In 2018, 23,078 men and 21,196 women were diagnosed with cancer excluding non-melanoma skin cancer, in Denmark. Of these, 14,235 (32.2%) were estimated to be attributable to avoidable class I carcinogens. Tobacco smoking accounted for 14.6% of total cancers, followed by UV-radiation that accounted for 5.8%. Based on exposure data from 2008, one-third of the cancers in Denmark in 2018 are estimated to be caused by class I carcinogens with tobacco use being the main contributor followed by UV-radiation. Our results should be integrated with public health policies to effectively increase awareness and promote strategies to decrease risk factor exposures at population level.

The future excess fraction of cancer due to lifestyle factors in Australia

BACKGROUND

Many cancers are caused by exposure to lifestyle, environmental, and occupational factors. Earlier studies have estimated the number of cancers occurring in a single year which are attributable to past exposures to these factors. However, there is now increasing appreciation that estimates of the future burden of cancer may be more useful for policy and prevention. We aimed to calculate the future number of cancers expected to arise as a result of exposure to 23 modifiable risk factors.

METHODS

We used the future excess fraction (FEF) method to estimate the lifetime burden of cancer (2016-2098) among Australian adults who were exposed to modifiable lifestyle, environmental, and occupational risk factors in 2016. Calculations were conducted for 26 cancer sites and 78 cancer-risk factor pairings.

RESULTS

The cohort of 18.8 million adult Australians in 2016 will develop an estimated 7.6 million cancers during their lifetime, of which 1.8 million (24%) will be attributable to exposure to modifiable risk factors. Cancer sites with the highest number of future attributable cancers were colon and rectum (n = 717,700), lung (n = 380,400), and liver (n = 103,200). The highest number of future cancers will be attributable to exposure to tobacco smoke (n = 583,500), followed by overweight/obesity (n = 333,100) and alcohol consumption (n = 249,700).

CONCLUSION

A significant proportion of future cancers will result from recent levels of exposure to modifiable risk factors. Our results provide direct, pertinent information to help determine where preventive measures could best be targeted.

An approach to estimating the environmental burden of cancer from known and probable carcinogens: application to Ontario, Canada

BACKGROUND

Quantifying the potential cancer cases associated with environmental carcinogen exposure can help inform efforts to improve population health. This study developed an approach to estimate the environmental burden of cancer and applied it to Ontario, Canada. The purpose was to identify environmental carcinogens with the greatest impact on cancer burden to support evidence-based decision making.

METHODS

We conducted a probabilistic assessment of the environmental burden of cancer in Ontario. We selected 23 carcinogens that we defined as "environmental" (e.g., pollutants) and were relevant to the province, based on select classifications provided by the International Agency for Research on Cancer. We evaluated population exposure to the carcinogens through inhalation of indoor/outdoor air; ingestion of food, water, and dust; and exposure to radiation. We obtained or calculated concentration-response functions relating carcinogen exposure and the risk of developing cancer. Using both human health risk assessment and population attributable fraction models in a Monte Carlo simulation, we estimated the annual cancer cases associated with each environmental carcinogen, reporting the simulation summary (e.g., mean and percentiles).

RESULTS

We estimated between 3540 and 6510 annual cancer cases attributable to exposure to 23 environmental carcinogens in Ontario. Three carcinogens were responsible for over 90% of the environmental burden of cancer: solar ultraviolet (UV) radiation, radon in homes, and fine particulate matter (PM_2.5) in outdoor air. Eight other carcinogens had an estimated mean burden of at least 10 annual cancer cases: acrylamide, arsenic, asbestos, chromium, diesel engine exhaust particulate matter, dioxins, formaldehyde, and second-hand smoke. The remaining 12 carcinogens had an estimated mean burden of less than 10 annual cancer cases in Ontario.

CONCLUSIONS

We found the environmental burden of cancer in Ontario to fall between previously estimated burdens of alcohol and tobacco use. These results allow for a comparative assessment across carcinogens and offer insights into strategies to reduce the environmental burden of cancer. Our analysis could be adopted by other jurisdictions and repeated in the future for Ontario to track progress in reducing cancer burden, assess newly classified environmental carcinogens, and identify top burden contributors.

Diet, Physical Activity, Obesity, and Breastfeeding: How French People Perceive Factors Associated with Cancer Risk

The French Cancer Barometer, a population-based-survey, is carried out every five years and is, to date, one of the few national studies conducted to investigate individual perception linked to cancer risk factors. The aims of the present study were to describe the perceptions of the French population in 2015 and to assess their evolution over a 5-year period (2010–2015). The French Cancer Barometer surveyed a randomly selected sample of participants aged 15–75 years (n = 3345 in 2010) and 15–85 years (n = 3764 in 2015), representative of the French population. Questions were on perception of diet, physical activity, obesity, and breastfeeding as cancer risk factors. In 2015, nutritional/activity factors were perceived as having an important role in cancer development for the majority of those surveyed (diet (90.8%), obesity (76%), and physical activity (70%)) with the exception being breastfeeding (34%). However, there was a moderate perception of the risks of red meat (43%) and salt or salty food (55%) consumption. Perceptions of nutritional risk factors were mostly associated with age and education level. Interestingly, there was a greater perception of nutritional risk factors in 2015 compared to 2010, and the participants’ opinions were also stronger. Efforts should be made on individuals with lower educational level and to promote the beneficial effects of breastfeeding. However, to impact food behavior, measures are needed at the environmental level and not only at the individual one.

Nutrition and Cancer Prevention: Why is the Evidence Lost in Translation?

With the high burden of cancer worldwide, primary prevention has been identified as a key cancer control strategy to reduce this burden. Diet and nutrition are important modifiable factors that may alter the risk of developing cancer, because several dietary components including alcohol consumption, fruit and vegetable intake, and dietary fiber have been shown to significantly impact cancer risk. Consequently, a number of organizations have developed cancer prevention guidelines that highlight the importance of nutrition (and related factors including body size and physical activity) to reduce the risk of cancer. However, there are barriers to the uptake of these guidelines, particularly with respect to diet and nutrition including awareness, communication, and other factors that influence eating behavior. Improved knowledge translation (KT) of recommendations may help facilitate uptake. The purposes of this narrative review are: 1) to examine issues and challenges related to KT of diet and nutrition evidence in the context of cancer prevention, including public awareness and attitudes towards cancer prevention, engagement in cancer prevention strategies, and effects of KT on diet-cancer preventive behaviors; 2) to discuss examples of effective and ineffective KT of diet and nutrition evidence; and 3) to provide recommendations for improving KT to help move the field of diet, nutrition, and cancer prevention forward. Evidence shows that adherence to nutrition recommendations for cancer prevention significantly reduces the risk of cancer; however, engagement in nutrition-based preventative behaviors is low. Skepticism and confusion around evidence linking diet and nutrition with cancer may arise, in part, through ineffective media KT; the primary source of health information for many people. Simple, tailored, targeted KT communication strategies aimed at increasing the general public's awareness, attitudes, and engagement in cancer preventive behavior should be emphasized to encourage cancer control.

The current and future burden of cancer attributable to modifiable risk factors in Canada: Summary of results

Nearly one in two Canadians are expected to be diagnosed with cancer in their lifetime. However, there are opportunities to reduce the impact of modifiable cancer risk factors through well-informed interventions and policies. Since no comprehensive Canadian estimates have been available previously, we estimated the proportion of cancer diagnosed in 2015 and the future burden in 2042 attributable to lifestyle and environmental factors, and infections. Population-based historical estimates of exposure prevalence and their associated risks for each exposure-cancer site pair were obtained to estimate population attributable risks, assuming the exposures were distributed independently and that the risk estimates were multiplicative. We estimated that between 33 and 37% (up to 70,000 cases) of incident cancer cases among adults aged 30 years and over in 2015 were attributable to preventable risk factors. Similar proportions of cancer cases in males (34%) and females (33%) were attributable to these risk factors. Tobacco smoking and a lack of physical activity were associated with the highest proportions of cancer cases. Cancers with the highest number of preventable cases were lung (20,100), colorectal (9800) and female breast (5300) cancer. If current trends in the prevalence of preventable risk factors continue into the future, we project that by 2042 approximately 102,000 incident cancer cases are expected to be attributable to these risk factors per year, which would account for roughly one-third of all incident cancers. Through various risk reduction interventions, policies and public health campaigns, an estimated 10,600 to 39,700 cancer cases per year could be prevented by 2042.

The burden of cancer attributable to modifiable risk factors in Canada: Methods overview

Up-to-date estimates of current and projected future cancer burden attributable to various exposures are essential for planning and implementing cancer prevention initiatives. The Canadian Population Attributable Risk of Cancer (ComPARe) study was conducted to: i) estimate the number and proportion of cancers diagnosed among adults in Canada in 2015 that are attributable to modifiable risk factors and ii) project the future avoidable cancers by 2042 under various intervention targets. We estimated the population attributable risk (with 95% confidence intervals) and the potential impact fraction of cancers associated with selected lifestyle, environmental, and infectious factors. Exposure-specific sensitivity analyses were also completed where appropriate. Several exposures of interest included active and passive smoking, obesity and abdominal adiposity, leisure-time physical inactivity, sedentary behaviour, alcohol consumption, insufficient fruit and vegetable intake, red and processed meat consumption, air pollution (PM2.5, NO₂), indoor radon gas, ultraviolet radiation (UVR), hepatitis B and C virus, Helicobacter pylori, Epstein-Barr virus, human papillomavirus, human herpesvirus type 8 and human T-cell lymphotropic virus type 1. We used the 2015 cancer incidence data for 35 cancer sites from the Canadian Cancer Registry and projected cancer incidence to 2042 using historical data from 1983 to 2012. Here, we provide an overview of the data sources and methods used in estimating the current and future cancer burden in Canada. Specific methodologic details for each exposure are included in the individual articles included as part of this special issue.

Epidemiology and burden of pancreatic cancer

Pancreatic cancer, although infrequent, has a very poor prognosis, making it currently the fourth common causes of cancer mortality in most developed countries including the European Union (EU). Its incidence varies across regions, which suggests that lifestyle factors play an important role in its etiology, although part of the variation could be ascribed to difference in diagnostic and coding practices. Because pancreatic cancer is strongly age-dependent, increasing population longevity and ageing will lead to an increase of the global burden of pancreatic cancer. It was estimated that, by 2040, the total number of cases in the EU will increase by more than 30%. Pancreatic cancer is a multifactorial disease and many risk factors have been identified. Hereditary factors are responsible for less than 10% of the cases while tobacco smoking and excess body weight, the two most important potentially modifiable risk factors, are responsible for 10 to 30% of the cases, affording a unique opportunity for preventing one of our deadliest cancers.

The future burden of cancer in Canada: Long-term cancer incidence projections 2013-2042

BACKGROUND

Cancer is the leading cause of death in Canada and the estimated annual spending associated with cancer is approximately $7.5 billion. Projecting the future burden of cancer in Canada is essential for health planning and evaluation. We aimed to estimate the future incidence of cancer in Canada to 2042.

METHODS

Age-sex-region-specific cancer incidence data were obtained for the years 1983-2012 and cancer incidence was projected from 2013 to 2042 for the top five cancer sites. The modelling algorithm combined a mixture of cancer projection methods to select the best-fitted model. When the chosen model produced by the modelling algorithm resulted in estimates that were not consistent with expert opinion, an alternate model was selected that took into consideration historical changes in policy, screening and lifestyle behaviours. Incidence projections were made for Canada and its provinces.

RESULTS

Lung cancer incidence is estimated to rise to 14,866 cases in men and 19,162 in women in 2042. Colorectal cancer incidence is estimated to rise to 28,146 in men and 21,102 in women. Cases of bladder cancer are projected to rise to 10,708 and 3,364 in men and women, respectively. Breast cancer incidence is predicted to rise to 40,712 and prostate cancer incidence is projected to rise to 92,949.

CONCLUSION

These cancer incidence projections up to 2042 can be used for planning cancer control strategies and prevention programs. Given the ongoing changes in the prevalence of risk factors and in cancer prevention policies, these estimates should be interpreted with caution.

Health Care Provider's Role in Obesity Prevention and Healthy Development of Young American Indian Children

INTRODUCTION

Health care providers (HCPs) serving American Indian (AI) populations are critical stakeholders in promoting healthy weight-related behaviors of young AI children. The purpose of this study is to develop an understanding of how HCP perceive their role in the healthy development of young AI children, and how they envision working with early care and education teachers and parents to enhance children's health.

METHOD

Twenty HCP that serve young AI children in Oklahoma participated in individual interviews. Thematic analysis was conducted on coded transcripts and three main themes, each with two to four subthemes were identified.

RESULTS

HCP had limited contact with teachers, felt family health was equal or more important than child health, and parental empowerment and gradual change was essential for success.

CONCLUSION

Creating ways to involve HCP, early care and education teachers, and parents together in multilevel and multisector interventions has the potential to improve the health of young AI children.

Early Care and Education Teacher’s Role in Obesity Prevention and Healthy Development of Young American Indian Children

Introduction: The purpose of this study was to develop an understanding of how stakeholders, specifically early care and education (ECE) teachers, perceive their role in the development of young American Indian children, and envision working with health care providers and parents in order to enhance children’s health. Methodology: Twenty tribally affiliated ECE teachers from Oklahoma participated in interviews. Thematic analysis was conducted, and three main themes, each with two to three subthemes, emerged. Results: Teachers felt that nutrition and physical activity were important to children’s health. Teachers had little professional interaction with health care providers but desired more. Parental empowerment was conveyed as essential to actualize positive changes in their child’s behavior. Discussion: Teachers of tribally affiliated ECE centers are important stakeholders in promoting the health and well-being of young American Indian children. Additional efforts are needed to more effectively integrate teachers and nurses in order to create effective interventions. We propose a stakeholder partnership to guide the development of future interventions.

A healthy lifestyle index and its association with risk of breast, endometrial, and ovarian cancer among Canadian women

PURPOSE

Several modifiable risk factors have been associated with risk of female cancers, but there is limited data regarding their combined effect on risk among Canadian women. Therefore, we assessed the joint association of modifiable risk factors, using a healthy lifestyle index (HLI) score, with risk of specific reproductive cancers.

METHOD

This study included a subcohort of 3,185 of the 39,618 women, who participated in the Canadian Study of Diet, Lifestyle, and Health, and in whom 410, 177, and 100 postmenopausal breast, endometrial, and ovarian cancers, respectively, were ascertained. We estimated hazard ratios (HR) and 95% confidence intervals (CI) using Cox proportional hazards regression models modified for the case-cohort design.

RESULTS

Each unit increase in the HLI score was associated with 3% and 5% reductions in risk of postmenopausal breast cancer and endometrial cancer, respectively (HR 0.97; 95% CI 0.94-0.99 and HR 0.95; 95% CI 0.90-0.99, respectively). Compared to those with HLI score in the lowest category, those in the highest category had 30% and 46% reductions in risk of these cancers, respectively. The HLI score was not associated with altered risk of ovarian cancer.

CONCLUSION

Our findings suggest that promoting a healthy lifestyle may aid in the primary prevention of postmenopausal breast and endometrial cancers.

The fraction of cancer attributable to modifiable risk factors in England, Wales, Scotland, Northern Ireland, and the United Kingdom in 2015

BACKGROUND

Changing population-level exposure to modifiable risk factors is a key driver of changing cancer incidence. Understanding these changes is therefore vital when prioritising risk-reduction policies, in order to have the biggest impact on reducing cancer incidence. UK figures on the number of risk factor-attributable cancers are updated here to reflect changing behaviour as assessed in representative national surveys, and new epidemiological evidence. Figures are also presented by UK constituent country because prevalence of risk factor exposure varies between them.

METHODS

Population attributable fractions (PAFs) were calculated for combinations of risk factor and cancer type with sufficient/convincing evidence of a causal association. Relative risks (RRs) were drawn from meta-analyses of cohort studies where possible. Prevalence of exposure to risk factors was obtained from nationally representative population surveys. Cancer incidence data for 2015 were sourced from national data releases and, where needed, personal communications. PAF calculations were stratified by age, sex and risk factor exposure level and then combined to create summary PAFs by cancer type, sex and country.

RESULTS

Nearly four in ten (37.7%) cancer cases in 2015 in the UK were attributable to known risk factors. The proportion was around two percentage points higher in UK males (38.6%) than in UK females (36.8%). Comparing UK countries, the attributable proportion was highest in Scotland (41.5% for persons) and lowest in England (37.3% for persons). Tobacco smoking contributed by far the largest proportion of attributable cancer cases, followed by overweight/obesity, accounting for 15.1% and 6.3%, respectively, of all cases in the UK in 2015. For 10 cancer types, including two of the five most common cancer types in the UK (lung cancer and melanoma skin cancer), more than 70% of UK cancer cases were attributable to known risk factors.

CONCLUSION

Tobacco and overweight/obesity remain the top contributors of attributable cancer cases. Tobacco smoking has the highest PAF because it greatly increases cancer risk and has a large number of cancer types associated with it. Overweight/obesity has the second-highest PAF because it affects a high proportion of the UK population and is also linked with many cancer types. Public health policy may seek to mitigate the level of harm associated with exposure or reduce exposure levels-both approaches may effectively impact cancer incidence. Differences in PAFs between countries and sexes are primarily due to varying prevalence of exposure to risk factors and varying proportions of specific cancer types. This variation in turn is affected by socio-demographic differences which drive differences in exposure to theoretically avoidable 'lifestyle' factors. PAFs at UK country level have not been available previously and they should be used by policymakers in devolved nations. PAFs are estimates based on the best available data, limitations in those data would generally bias toward underestimation of PAFs. Regular collection of risk factor exposure prevalence data which corresponds with epidemiological evidence is vital for analyses like this and should remain a priority for the UK Government and devolved Administrations.