How cancer changes

At the end of the Angelus on Sunday 11 October, Pope Leo XIV was not merely restrained; he was, quite literally, minimalist. “Recently, during some check-ups, the doctors found a localised lump in my lung,” says the Pope. He then specifies that the lump “was detected at a very early stage and is well localised”, which is why “the doctors consider it advisable to intervene and so, following their advice, I have decided to undergo surgery to have it removed”. End.

There have been numerous announcements like this from famous figures in the worlds of cinema and television, music and entertainment, sport, art and politics. It has, one might well say, been a crescendo, almost as if no one who knows they have cancer could help but share this bitter discovery, this painful realisation, in order to gather support and human warmth around them. But Leone did so in a particularly understated manner, taking care to specify that the lump was ‘localised’, ‘at an early stage’ and ‘well-defined’. Everyone knows how things unfolded from there. The operation, the recovery, the Pope’s return to the Angelus on Sunday 18 October, when he, once again with the utmost restraint and simplicity, thanked all those who had prayed for him.

This was not the usual announcement for a number of good reasons, not only because this time it came from the Pope – perhaps the figure in the world most surrounded by affection and hope. But also because, whilst it is true that Leo XIV did not shy away from announcing his cancer, it is even more true that he did so in the name, one might say, of a sort of Gorbachevian glasnost – that is, in the name of transparency rather than publicity – without imbuing the announcement with dramatic tones, sparing himself any rhetoric about the battle that awaited him (and still awaits him) to defeat the cancer. With this approach, it is fair to say that Pope Leo XIV has reduced cancer to an adverse possibility like so many others, starting precisely with illnesses, which cannot be eradicated from human experience, which may always arise one day or another, in one way or another, and for which it is wise to be prepared. One might even go so far as to say that, with Leo XIV, the narrative of cancer definitively moved away from rhetoric and into dialectic.

Pope Leo XIV has thus brought to completion the journey we have undertaken so that cancer might appear to us – to each and every one of us – as just one illness amongst many. An illness that we can discuss with a new sense of awareness, because it too, like all others, is open to the possibility of a cure.

Now, let’s be clear, this is because much has happened – for those who believe, like Pope Leo, with the support of the Holy Spirit – in the fight against cancer, which the Indian doctor Siddhartha Mukherjee, in his extraordinary 2011 Pulitzer Prize-winning essay "The Emperor of Evil. A Biography of Cancer’ traces back to the discovery of leukaemia, the blood cancer, so named in 1847 by the then young doctor Rudolf Virchow, the greatest pathologist of the nineteenth century, from the Greek ‘leukos’, meaning white: white blood, blood overwhelmingly invaded by white blood cells.

Much has happened since then. There have been many victories against what, in the twentieth century, was dubbed the ‘scourge of the century’ – a scourge that was never referred to directly, except by calling it a ‘nasty illness’ or, more subtly but also more dramatically, an ‘incurable disease’. As such, being incurable, it was also a source of shame. Anyone with cancer was careful not to reveal it, and when it became evident from outward physical signs, they did not hesitate to shut themselves away at home, going out only when absolutely necessary, limiting their social and interpersonal interactions as much as possible – in some cases (by no means extreme) to the point of cutting them off entirely. In other words, people died of cancer even before the disease had run its course.

Paradoxically, the resounding successes in the fight that medicine (and not just medicine – think of genetics over the last few decades) has waged against cancer since that distant year of 1847, when ‘leukaemia’ was given the name of the first recognised form of cancer, can be heard precisely in the flourishing – at first uncertain but proud, now commonplace and almost assertive – of announcements by those who discover they are suffering from some form of cancer. These announcements promise commitment, a battle, and the mobilisation of every resource – physical and psychological – against an enemy, cancer, which is no longer regarded as invincible but increasingly vulnerable, with good hopes of victory. On what do these hopes rest, at the present time?

In a study published in 1988, one of Italy’s leading demographers and a scientist of world renown, Antonio Golini, went so far as to hypothesise that, given the expectation that average life expectancy would reach over 80 years for men and 90 for women within the coming decades, there would be a reduction in deaths from cardiovascular diseases and, conversely, an unstoppable rise in deaths from some form of cancer, which would come to account for 67 per cent of all deaths among men and 44 per cent of all deaths among women, such that cancer deaths would represent well over 50 per cent – more than half – of total deaths.

Antonio Golini got the first part of his prediction spot on, but he got the second part – the one about cancer – spectacularly wrong. At the time, it was a widely held view that the coming years would see a dramatic rise in cancer deaths among the Italian population (and, more generally, among Western populations), essentially as a result of an ageing population—a process believed to be closely linked to the proliferation of cancer, and to some extent certainly is. Today in Italy, life expectancy at birth for men is approaching 82 years, while for women it is almost 86 years, placing the country in a scenario that is broadly similar to the one used by Antonio Golini for his forecasts, although women remain four years short of an average life expectancy of 90 years.

However, deaths from malignant tumours, which accounted for 30 per cent of all deaths in the early 2000s, now account for just under 25 per cent of total deaths: instead of more than one in two deaths, as predicted, the figure is now less than one in four, as is the reality today. We must not be misled by the absolute figures for deaths, which show that whilst there were 158,468 cancer deaths in 2004, practically twenty years later, in 2023 (the latest available data), this figure had risen to 164,841: 6,373 more cancer deaths.

There are two reasons for this. Firstly, in 2023 the population was 2.3 million higher than in 2004; secondly, in 2023 the population was considerably older than in 2004, and in fact there were 193 people aged over 65 for every 100 children and young people up to the age of 14, compared with just 135 in 2004. The correct comparison is made by examining standardised mortality rates – that is, rates calculated on the basis of an equal number of inhabitants and an equal age distribution of the population: In this way we can see that the figure has fallen from 29.2 cancer deaths per 100,000 inhabitants in 2004 to 24.9 cancer deaths per 100,000 inhabitants in 2023. Therefore, not only do deaths from malignant tumours account for a smaller proportion of total deaths – falling from 30 per cent to 25 per cent – but cancer mortality has also fallen significantly over the last twenty years.

Men have contributed far more than women to the improvement in cancer mortality rates, but in the early 2000s, men’s cancer mortality rates were almost double those of women; Today that gap has narrowed to 60 per cent: cancer mortality among men is still 60 per cent higher than that among women: 27.7 deaths per 100,000 men compared with 17.3 deaths per 100,000 women. Cancer risk factors among men and women have indeed become more similar, but they continue to be much more pronounced among men than among women. Nevertheless, it cannot be ruled out that the annual number of new cancer cases – which currently stands at around 390,000 per year, of which 215,000 are among men and 175,000 among women – may begin to fall precisely as a result of a marked reduction in the number of cancer cases among men.

The strategy for tackling cancer is increasingly focused on prevention. Even more so than on drug-based treatments, and even more so than on surgical techniques – although both treatments and techniques are constantly evolving.

The latest report on the current situation, “I numeri del cancro in Italia – 2025”, illustrates this trend. Right from the very beginning, it states that “we have an ever-greater need for prevention, both to reduce the number of people falling ill and to ensure that diagnoses are made, where possible, as early as possible, when the probability of recovery is very high and the therapeutic burden (for the patient and the National Health Service) is lower”. Many organizations have contributed to the publication: from the Italian Association of Medical Oncology to the Italian Society of Pathological Anatomy and Diagnostic Cytology, including various associations and foundations, reflecting the growing commitment (a) to the fight against cancer in all its forms and manifestations in different parts of the human body and (b) to an approach to this fight that is increasingly focused on prevention. This approach would appear to be paying off, given that, as the report specifies, “the data show some significant progress: the cancer mortality rate in Italy is lower than the European Union average, and the five-year survival rate for breast, colorectal and lung cancers is higher than the European average and continues to improve”.

In turn, particular emphasis is placed on primary prevention, that is, the form of prevention aimed at limiting the risk factors for the onset of cancer, even more so than on secondary prevention, which consists of the early diagnosis of an existing tumour. This is currently supported by screening programmes for breast, colorectal and cervical cancer, which are becoming increasingly widespread throughout the country, albeit with disparities both geographically (more prevalent in the Centre-North than in the South) and socially.

Since the risk factors for the development of cancer fall into two broad categories – non-modifiable factors, such as gender, DNA and age, and modifiable factors, which are linked to individual behaviours that can always be addressed – primary prevention involves promoting the management of modifiable risk factors, thereby reducing the likelihood of cancer developing.

The prevention advice aimed at the entire population, regardless of age group, is in fact very well known: such as avoiding or giving up smoking, taking regular exercise, following a varied and balanced diet, reducing or eliminating alcohol consumption, and avoiding risky behaviour, such as having unprotected sex.

These are, one might say, common-sense guidelines, but they are not always easy to follow; indeed, they are often difficult to follow precisely by those who would benefit most from doing so. However, it must be said that certain guidelines issued by services and practitioners often suffer from two limitations, two flaws that do little to encourage people to follow that advice. The first is a certain dogmatism, according to which even the slightest deviation from impeccable behaviour regarding the indicated risk factors is a harbinger of harm and must therefore be condemned and ruthlessly eradicated from individual lifestyles. The second, on the other hand, is the sin of determinism: the idea – which inevitably arises precisely when one views prevention through the lens of dogmatism – that if you follow the instructions to the letter, as if you were assembling one of those infernal electronic contraptions of today, you will avoid the cancer that will otherwise strike you if you refuse to do so.

There has always been, in the concept of prevention – particularly primary prevention, as advocated by the National Health Service and, more generally, within the medical world – a Savonarolan streak which, rather than encouraging people to follow its advice, actually makes them want to steer well clear of it. That world – the world of prevention – struggles to understand that there is also an ‘epidemiology of pleasure’ which is good for you and helps prevent the development of diseases, starting with cancer. A prevention strategy with a tight, if not extremely tight and restrictive, framework works less well than one where the framework allows for some leeway – a little flexibility, a few exceptions, some room for manoeuvre, and a little pleasure. It would be wise to recognise this and restore a better balance between the narrative of risks and that of benefits.