life resumed after possibly a month of some discomfort. In the worst case, if the cervical cancer progressed anyway and eventually led to death, her final days could have been relatively free of pain and her other basic physical, psychological, and emotional needs met by village palliative care workers and family—services already available in some parts of Africa. If the 38-year-old has a daughter entering adolescence, that daughter soon might be able to get a vaccine that will protect her against cervical cancer by preventing its cause, infection with human papillomavirus (HPV). Even in LMCs, these alternate endings are possible, with increased global awareness of the magnitude of the cancer problem, the opportunities that exist already, and those just around the corner.

The long view back over the 20th century in the United States and other wealthy countries, where the picture of cancer incidence and mortality is reasonably clear, gives perspective and reason for optimism that the cancer burden can be lessened in LMCs today.

REASONS FOR OPTIMISM

Over the course of the 20th century, the cancer burden changed dramatically—positively and negatively—in the United States and other wealthy countries. Changing lifestyles, environmental influences, and improved health care all have contributed. In 1900, cancer was eighth in the list of causes of death.1 By 1950, it was second only to heart disease. Cancer death rates continued to rise through the early 1990s, when overall rates were nearly three times the 1900 rate (National Cancer Institute, 1997). The single greatest cause of the cancer increase was the rise in lung cancer from tobacco use. While lung cancer (and other smoking-related cancers) increased, rates for other cancers were falling. Death rates for stomach cancer—the most frequent cause of cancer deaths early in the 20th century—fell by nearly 90 percent over that period, with the greatest declines occurring in the 1950s. The reasons are thought to be improved living conditions, which reduced chronic infection with the cancer-inducing bacterium Helicobacter pylori, and better diet, including more fresh and less preserved food. Treatment of stomach cancer is still relatively ineffective, so medical care contributed little. The story is different for cervical cancer, which claimed more women’s lives than any other cancer in the United States in the early 1900s. Declines in death rates began early, again probably due to better living conditions. Death rates decreased quickly and were driven to their current low levels by early detection and curative medical care.

After the earlier continuous increases, by the early 1990s, lung cancer

1

This statistic is adjusted for the age structure of the population, so it is not simply a reflection of a larger older population.



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