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Increasing the focus on system-level policies and programs for cancer prevention: Cancer Care Ontario’s 2016 Prevention System Quality Index


I  Introduction
II Development and structure of the report
III Reducing the prevalence of cancer risk factors and exposures at the system level
IV Key findings and opportunities
V How the report can be used
VI Resources
VII References

Submitted by Maria Chu, Senior Policy Specialist, and Caroline Silverman, Lead, Population Health and Prevention, Cancer Care Ontario

I Introduction

Cancer is the leading cause of death in Ontario and the number of new cases continues to rise. [1] As many as half of all cancers could be prevented by eliminating known modifiable risk factors and exposures, [2-4] making cancer prevention a key public health issue. Targeting cancer risk factors and exposures such as smoking, excess alcohol consumption, insufficient vegetable and fruit consumption, physical inactivity, and outdoor air pollution also addresses the burden of other major chronic diseases such as cardiovascular diseases, chronic respiratory diseases and diabetes.

2016 Prevention System Quality Index: Monitoring Ontario’s Efforts in Cancer Prevention ( is the second report by Cancer Care Ontario focused on indicators of effective system-level policies and programs that can reduce cancer risk factors and exposures in the population. The report identifies achievements and gaps in the prevention system and highlights opportunities to advance cancer prevention in Ontario.

II Development and structure of the report

The 2016 Prevention System Quality Index reports on 21 policy and program indicators related to tobacco, alcohol, healthy eating, physical activity, ultraviolet radiation, environmental carcinogens (radon and fine particulate matter), occupational carcinogens (formaldehyde and nickel) and infectious agents (human papillomavirus and hepatitis B). The report places the findings of these indicators within the context of research on effective system-level policies and programs and the evidence supporting the inclusion of the selected indicators. Brief summaries of the research and evidence are included in the report.

A variety of methods were used to identify the cancer risk factors and exposures, system-level policies and programs and indicators included in the 2016 Prevention System Quality Index. These methods included: reviews of evidence from the International Agency for Research on Cancer and the World Cancer Research Fund/American Institute for Cancer Research; reviews of the most recently published and widely cited systematic reviews, meta-analyses, and grey literature outlining recommendations from leading organizations such as the World Health Organization; and the use of indicator criteria.

The 2016 Prevention System Quality Index Advisory Committee provided strategic advice on the vision and objectives of the report. Expert panels provided advice on evidence, policies and programs and indicators and data sources. Advisory committee and expert panel members included representatives from public health units, government ministries and agencies, non-governmental organizations and academic institutions. Feedback from stakeholders following the release of the inaugural 2015 Prevention System Quality Index report was also gathered and reviewed.

The report makes use of the best data available, but there are many gaps, particularly in province-wide data. The evidence and current status of effective system-level policies and programs that are lacking adequate data to develop indicators are also described in the report.

III Reducing the prevalence of cancer risk factors and exposures at the system level

In Ontario, four cancer risk factors are regularly tracked: smoking, alcohol consumption, physical inactivity, and inadequate vegetable and fruit consumption. With the exception of smoking, which has been a major focus of government strategy and legislation, the proportion of the population with these risk factors has not changed substantially over the past decade, [5] highlighting the need for stronger prevention policies and programs.

The 2016 Prevention System Quality Index builds on this and other existing population health monitoring in Ontario that focuses mainly on the behaviours of individuals. It brings together data and describes policies and programs from a variety of sectors, including health, education, labour, municipal affairs, transportation, environment and finance, with a focus on the system-level policies and programs that can create healthier environments and supports. Research suggests that system-level policies and programs are more effective at reducing the prevalence of cancer risk factors and exposures than strategies focused on individuals. [6-8]

IV Key findings and opportunities

The 2016 Prevention System Quality Index report shows that while strides are being made in many areas, such as tobacco control, investments in high-quality physical education instruction in schools and commitments to reduce air pollution, there are opportunities to strengthen existing policies and programs to ensure that they are comprehensive and sustained. There is also a need for improved coordination of cancer and chronic disease prevention efforts across the province, including in areas considered beyond the scope of the public health or healthcare systems.
Key findings and opportunities reported in the 2016 Prevention System Quality Index include the following.

  • Tobacco: Approximately 30 percent of cancer deaths are caused by tobacco smoking. To reduce smoking, the World Health Organization recommends a 75 percent minimum tax on the total retail price of tobacco. As of April 2016, tobacco taxes in Ontario were just 65 percent of the average total tobacco retail price, which means that a substantial increase in tobacco taxes in the province is needed. Ontario has the second lowest tax rate on tobacco in Canada.
  • Alcohol: Each year, an estimated 1,000 to 3,000 new cancer cases in Ontario are caused by alcohol consumption. Privatizing alcohol outlets and increasing the physical availability of alcohol may increase alcohol consumption in the population. Ongoing monitoring will be required to determine whether alcohol consumption will increase as a result of the Ontario government’s recent decisions to offer the online sale of alcohol and allow up to 450 grocery stores to sell beer, wine and cider over the next few years.
  • Healthy Eating: There is evidence that increased consumption of foods containing dietary fibre reduces the risk of colorectal cancer, and that eating non-starchy vegetables and fruit probably reduces the risk of some cancers. Adults and some children experiencing household food insecurity tend to eat significantly fewer servings of vegetables and fruit. In 2014, 11.9 percent of households in Ontario were food insecure, and the severity of food insecurity for some households appears to have worsened from 2005 to 2014. Increases in the general minimum wage, social assistance and the employment insurance benefit, as well as implementing other poverty reduction policies, could help increase household food security.
  • Physical Activity: Physical activity reduces the risk of colon cancer, and probably reduces the risk of post-menopausal breast cancer and endometrial cancer. Active transportation (walking and bicycling) is used in about one fifth of trips taken to or from work by adults in Greater Golden Horseshoe regions in Ontario. Most of these trips are taken to or from public transit, suggesting that public transit is an important contributor to physical activity.
  • Ultraviolet Radiation: Ultraviolet radiation (UVR) from the sun and UVR-emitting tanning devices is the cause of most skin cancers. In 2014, there were an estimated 39,400 cases of skin cancer in Ontario, making it the most common type of cancer. Shade provided by built structures and tree canopies can protect people from UVR exposure more effectively than sunscreen. As of March 2016, three local municipalities with a population of 100,000 or more—Ajax, Kitchener and Waterloo—have strong shade policies. The guidelines that these municipalities follow when evaluating plans for developing or redeveloping sites state that shade should be provided for a broad range of municipally and privately owned sites.
  • Environmental Carcinogens: Outdoor air pollution and one of its major components, fine particulate matter (PM2.5), are established causes of lung cancer. In 2014, PM2.5 concentrations were higher than the World Health Organization and Canadian reference level of 10 μg/m³ at three monitoring stations in Ontario: Hamilton Downtown, Windsor West and Windsor Downtown.
  • Occupational Carcinogens: Occupational cancer is the leading cause of work-related deaths in Ontario. Asbestos causes mesothelioma, as well as cancers of the lung, larynx and ovary. Approximately 52,000 workers in Ontario are exposed to asbestos in the workplace. Currently, the most common occupational exposure to asbestos occurs through the construction industry. Ontario’s asbestos register should be expanded to collect data on all workers who may have been exposed to this carcinogen and it should identify asbestos-containing public buildings.
  • Infectious Agents: In Ontario, human papillomavirus (HPV) is estimated to cause 1,090 new cancers each year. Population-based vaccination programs can prevent HPV infections. In 2007, Ontario introduced a publicly funded school-based HPV vaccination program for girls in Grade 8. At the end of the 2012/13 school year, the vaccination coverage for the school-based HPV vaccination program in Grade 8 girls in Ontario was 80.2 percent. As of September 2016, boys also receive the HPV vaccine as part of the school-based vaccination program and the timing of the vaccine administration changes from Grade 8 to Grade 7, which may increase vaccination coverage.

V How the report can be used

The findings of the 2016 Prevention System Quality Index show that while there are already key policies and programs in place in Ontario, there are still many opportunities to work across sectors to create healthier environments and supports that could prevent cancer.

The report aims to provide evidence and data that can help policy-makers, policy-influencers and program planners in governments, non-governmental organizations, and public health units implement effective system-level policies and programs in Ontario to reduce cancer risk factors and exposures. Some non-governmental organizations used the evidence and findings from the inaugural 2015 Prevention System Quality Index report to promote policies to reduce alcohol consumption and enhance physical education. In addition, some public health unit staff brought the findings, particularly their local data, to the attention of their boards of health when discussing policy changes in their municipalities.

VI Resources

The 2016 Prevention System Quality Index report, highlights, supplementary tables, technical appendix, and slide deck are available on the Cancer Care Ontario website at

VII References

  1. Cancer Care Ontario. Ontario Cancer Statistics 2016. Toronto: Queen’s Printer for Ontario; 2016.
  2. Danaei G, Vander Hoorn S, Lopez AD, Murray CJ, Ezzati M, Comparative Risk Assessment Collaborating Group. Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. Lancet. 2005;366(9499):1784-93.
  3. Parkin DM, Boyd L, Walker LC. 16. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Br J Cancer. 2011;105 Suppl 2:S77-81.
  4. Colditz GA, Wolin KY, Gehlert S. Applying what we know to accelerate cancer prevention. Sci Transl Med. 2012;4(127):127rv4.
  5. Data from the Canadian Community Health Survey, 2003, 2005, 2007–2014 (Statistics Canada); prepared by Cancer Care Ontario, Prevention and Cancer Control (Population Health and Prevention).
  6. Brownson RC, Baker EA, LF N. Community-based prevention: programs that work. Gaithersburg, MD: Aspen Publishers; 1999.
  7. Green L, Kreuter MW. Health program planning: an educational and ecological approach. 4th ed. Boston: McGraw-Hill; 2005.
  8. Hann NE, Kean TJ, Matulionis RM, Russell CM, Sterling TD. Policy and environmental change: new directions for public health. Health Promot Pract. 2004;5(4):377-81.