A Conversation with Dr. Annie Sasco
Dr. Annie J. Sasco is Team Leader of Epidemiology for Cancer Prevention in an INSERM (Institut national de la santé et de la recherche médicale) Research Unit at the Medical School of the Université Victor-Segalen, Bordeaux 2, in France. After training at Bordeaux Medical School, she earned two master’s degrees and a doctoral degree at Harvard University where she was also a Teaching Fellow.
She worked for 22 years at the International Agency for Research on Cancer (IARC) in Lyon, France, including 9 years as Group Leader, then was Unit Chief of Epidemiology for Cancer Prevention. (IARC is the World Health Organization agency specializing in cancer research.)
An expert on the human health effects of growth promoters used in animal husbandry, Dr. Sasco also holds a Visiting Professorship appointment at the University of Sao Paulo, Brazil. Having been described as an “over graduated” woman, she considers herself a positive mix of European and American medico-scientific training, thus providing the background and expertise to carry out the sound, methodologically valid, yet innovative epidemiological research required by policy-making individuals and institutions.
Her goal is to contribute to inspiring and training future generations of scientists, including her own children. Author of more than 400 articles, she occupies numerous editorial roles with peer-reviewed journals and serves as a member of many expert committees, scientific and other boards, as well as civil society groups. She is co-founder and Vice President of the European Society of Environmental Health and was one of the 1000 women nominated for the 2005 Nobel Peace Prize.
A true citizen of the world, Dr. Sasco speaks and works in French, English and Italian, and can manage in German and Spanish.
Dr. Sasco was recently in Montreal to speak about 'Cancer and Globalization', with a focus on environmental concerns. She graciously agreed to speak with BCAM about cancer prevention.
ML: Does the goal of cancer prevention get enough attention either in terms of research funding, or in the media and to public awareness?
AS: As a prevention person, and taking into account the significant impact of prevention on health (as in diseases or deaths avoided), there is probably greater attention placed on it now, but it is still far from enough; there is a need for much more.
Obviously, funding for treatment is necessary to deal with what is already there; funding also often comes from the pharmaceutical industry because there is a return, and this also helps in the immediate treatment of disease. Within medicine, prevention appears as a less important activity because the number of cases (of illness and death) that are avoided because of preventive measures cannot be easily “seen”.
Furthermore, the politicians who design programs to fund research have a short-term bias – their terms of office – whereas environmental exposures, particularly in the case of cancer, happen over a much longer period of time. More research and action on prevention are needed.
Much of the time now, when we have toxicological data, we can act on it using the precautionary principle; we don’t necessarily need to wait when there are available substitutes. It makes sense to eliminate a substance when it is not absolutely essential or when there are substitutes that are safer.
With regard to the media, it is true that more headlines are devoted to advances in research and treatment, both of which have a definitive solution. The gains made in terms of lives extended or deaths avoided [because of preventative efforts], however, are less obvious and very difficult to measure.
I think the situation is changing for the better and we are hearing more and more discussion about some of the preventive aspects of cancer, smoking and diet, for instance. Clearly, behaviours are changing, and the general level of environmental awareness is going in the right direction.
ML: Is enough research focused on environmental elements, such as endocrine disruptors? Is enough research tailored to the geographical realities of cancer prevention? Can the public influence this?
AS: Endocrine disruption is a very important factor because it can happen over a lifetime, and because humans are sensitive to it. Some experimental data show that the developing foetus is extremely sensitive to this type of exposure. Likewise, during peri-puberty – the period between early puberty and sexual puberty – particularly in girls, while their breast tissue is developing, systems are exceedingly sensitive to hormonal pattens and to endocrine disruptors, and these might play a direct role in the way breast cancer develops. This also applies to all hormones, like thyroid and others; teens may be especially vulnerable to any such changes.
Geographical analysis is important, and computer software now allows us to produce world maps to see patterns of cancer. Even with a more limited focus this can be informative; it can give researchers leads about where to look to assess local risk factors.
Another useful aspect of this mapping are the issues of social and economic environments. When we use mapping and look at the higher mortality rates of cancer, it is possible to link them to social patterns and socioeconomic factors. Associations can be made between certain cancers and high income groups, and other cancers and low income groups.
The public is the engine that will move [the government] toward this type of prevention, and epidemiological research provides the added weight needed to influence policy.
ML: To many North Americans involved in environment issues, Europe seems years ahead of us [in awareness and action]. Do you think this is also true of public awareness of environmental illnesses or health risks (and lifestyle -factors)?
AS: In terms of public awareness, I am not so sure. Europe is diverse and different groups react in different ways; there is an enormous difference between northern and southern Europe in terms of reaction. Social class is also a major influence. The better educated in both North America and Europe are very conscious of the influence of [lifestyle and environmental] risk factors. More recently, I see Canada doing quite well with regard to the environment -- laws banning pesticides, for example. Except, of course, for the important issue of [the export of] asbestos.
But the fact that activists have had an impact on public policy, like pesticides, is a good sign that things are headed in the right direction.
Even organizations like the Canadian Cancer Society, which used to limit itself to speaking about behavioural change [i. e., lifestyle risks], are now giving the environment more importance. And politicians also, which is good to hear, but we really want to see that awareness reflected in budgets.
ML: Canada moved last year to remove Bisphenol-A from many consumer products. Should we be optimistic that more of such substances will come under scrutiny and government action?
AS: I remember when that regulation was passed because I was interviewed in France about it; it was an excellent decision. Bisphenol-A has not disappeared from every [consumer] item, but at least it was removed from the products affecting the most sensitive – babies are no longer taking it in.
I think such action need not depend entirely on research when it comes to potential endocrine disruptors or long-term reproductive toxins. As mentioned, when some indication of toxicity is present, especially when the substance can be substituted or eliminated, the precautionary principle should prevail. I think public pressure will get these changes made and have a real impact. Ideally, substances should be evaluated before they appear on the market.
The International Agency for Research on Cancer has had a program in place for 30 years studying synthetic chemicals for safety. Over that period, it was able to evaluate only 900 compounds for carcinogenicity [among the many thousands currently in use]. The effect of multiple exposures (and their interaction) is difficult to take into account unless biological measurements are used; this is a much more difficult and expensive type of study.
ML: In a recent conversation with a Montreal researcher, he touched on the importance of epidemiology to cancer prevention, but also mentioned some obstacles to carrying out research. One notable obstacle was from Ethics Committees and access to patient data, thus limiting the large population surveys vital for this kind of study on prevention. Is this a general trend?
AS: I agree that such difficulties exist. To give an example from France, the national cancer registry forbids recording race or skin colour. It had been observed that the incidence of breast cancer was higher among black men and we wanted to do a study on the incidence comparing populations in France and on the island of Martinique, which is 95% black. But, without the data for France, a proper comparison was impossible.
The fear of stigmatization because of disease is very understandable and some of those worries are well founded. Some research has led to stigmatization (as with HIV or psychiatric illness, for instance) and, once labeled with a disease, it can be difficult to overcome. In France, insurance is a big problem; [a history of] cancer treatments, psychiatric disease or hospitalizations sometimes prevents an individual from getting health insurance or a mortgage.
Some rules of ethnic etiquette are undoubtedly motivated by very good intentions. What we need to do is to convince the public that it is not curiosity that impels us to compile statistics; it is to produce thorough research that will best serve public health. As researchers, we understand this and need to be cautious about how results are presented.
ML: Thank you very much for your time.