Focus area 1: Norway will be a leading country in cancer prevention and early detection

A considerable proportion of cancer cases can be prevented by targeting known risk factors. The report Kreft i Norge – hvor mange tilfeller kan forebygges (‘Cancer in Norway – how many cases can be prevented?’ – in Norwegian only) (2023) estimated that 13,000 cases a year, or more than one in three cancer cases, are preventable. This can be achieved if the population refrains from using tobacco and alcohol, avoids sunburn and sunbeds, eats a healthy diet, engages in sufficient physical activity, maintains a normal body weight and follows national vaccination programmes. Many environmental factors can cause cancer to develop, including exposure to ultraviolet radiation, radon, asbestos and outdoor air pollution.

Exposure to carcinogens in the workplace is an important cause of work-related cancer. Good and systematic HSE work and preventive measures are important in order to prevent work-related cancer.

Prevention and health promotion work will be crucial in determining how many people develop cancer in the years to come, and measures must target the general population as well as high-risk groups. Information and communication measures can help to raise the population’s knowledge and awareness of risk factors for cancer as well as the health benefits associated with healthy lifestyle choices. There are significant social inequalities in the populiation’s lifestyle habits and cancer prevention will therefore also help to reduce social inequalities in health. Social inequalities in cancer diagnosis and treatment will be reduced. The health service must make active efforts to prevent cancer by supporting people in making lifestyle changes and coping with health issues.

Norway has committed to meet the World Health Organization’s target of reducing premature deaths from the non-communicable diseases cancer, cardiovascular disease, diabetes and chronic respiratory diseases by one third by 2030 compared to 2015. Over the coming years, Norway will also be leading a major EU project on prevention of cancer and other non-communicable diseases, the Joint Action Prevent Non-Communicable Diseases (JA PreventNCD), which will provide new knowledge about effective measures.

Efforts to reduce risk factors

Tobacco smoking is the single most important risk factor for cancer and will be discussed in more detail under the ten-year goals.

Overweight and obesity bring an increased risk of 13 different forms of cancer. Cancer prevention measures targeting overweight and obesity will therefore become important over the coming decade, for example in the form of measures to promote a healthier diet and an increase in physical activity in line with the national recommendations. The 2024 Children and Media survey (Norwegian Media Authority) shows that 30 percent of children and young people spend more time on screen than they would like. This could displace physical activity.

Much is known about the link between dietary factors and the risk of developing different forms of cancer. Some foods and nutrients increase the risk of developing cancer, while others reduce it. A diet in line with the national dietary recommendations will help to reduce the risk of many cancers.

Regular physical activity will reduce the risk of many forms of cancer, help to increase survival and prevent cancer from recurring. A national target has been set of reducing physical inactivity by 15 percent by 2030, but Norway has a long way to go to achieve this as far as children and young people are concerned. Recent knowledge shows that an activity level consistent with national recommendations will promote physical and mental health and, not least, increase the number of disability-adjusted life years (DALYs) in a lifetime perspective while providing protection against several forms of cancer. Cancer patients should be offered appropriate physical activity/exercise as part of their treatment.

Exposure to ultraviolet radiation (UV exposure) from the sun and sunbeds is the most important external cause of skin cancer. Short-term intense exposure causing sunburn and significant exposure over time will both increase the risk. Following the sun protection recommendations will reduce the risk. The Norwegian Radiation and Nuclear Safety Authority (DSA) has revised its national UV and skin cancer strategy with effect from 2024. The purpose of the strategy is to reduce the increase in all types of skin cancer caused by exposure to UV radiation from the sun or sunbeds by 25 percent by 2040 compared to 2018.

Alcohol consumption is one of the most important risk factors for death and loss of disability-adjusted life years. It is a well documented fact that even a low level of alcohol consumption will increase the risk of several types of cancer, and spreading this knowledge in the population will be a key measure in the time ahead. The continuation of a comprehensive and solidarity-based alcohol policy with effective measures will contribute to reduce the population’s total alcohol consumption, but it will prove challenging to achieve the target of reducing harmful alcohol consumption by 20 percent by 2030.

It is well known that various environmental factors can cause cancer to develop, including ultraviolet radiation, radon, asbestos and outdoor air pollution. Environmental toxins such as persistent organic compounds (chemicals whose breakdown in the environment is very slow) and heavy metals such as mercury, cadmium and lead are subject to strict regulation and monitoring for the purpose of protection against negative impact on nature, health and the environment. The new 2024 national radon strategy aims to reduce the population’s exposure. It is hoped that information and new incentives will encourage more people to measure and reduce high radon levels.

For people who have already been diagnosed with cancer, their lifestyle can have an effect on their treatment, quality of life and the risk of recurrence or new cancer occurring. It is important to integrate measures to promote systematic lifestyle improvement during treatment and rehabilitation. Healthcare professionals should discuss the importance of lifestyle with their patients at an early stage as well as in the course of their treatment.

Ten-year goal 1

Facilitate that people born after 2010 are growing up to be tobacco-free and nicotine-free and offer help to give up smoking

Preventing new generations from becoming addicted to nicotine is crucial in order to reduce the number of cancer cases in future. A variety of different measures could help to achieve this goal, cf. the Government’s 2023 tobacco control strategy. There is also a need to do more to help people to give up smoking.

Tobacco smoking is a primary or contributory cause of at least 15 different forms of cancer. Smoking causes about 5,000 deaths a year in Norway alone, and it remains the single most important cause of illness and premature death. Tobacco smoke contains at least 70 carcinogenic substances, and more than 80 percent of all lung cancer cases are linked to smoking. It has been calculated that if the current smoking habits persist, 95,000 persons in Norway could develop cancer by 2045. In recent years, we have seen a worrying increase in smoking among young men, and 24 percent of people aged 16–24 years are now occasional smokers.

The use of snus , e-cigarettes and other tobacco and nicotine products brings serious health risks. Surveys indicate that the use of snus continues to increase among young people. Thirty percent of people aged between 16 and 24 years use snus, while the corresponding proportion in the age group 25–34 years is 37 percent. We see an increase in the use of e-cigarettes and other new tobacco and nicotine products among young people. Social media contribute to exposure and accessibility, also for under-18s. We do not yet have sufficient knowledge about the long-term effects and possible cancer risks associated with these new products.

The Norwegian Act relating to Prevention of the Harmful Effects of Tobacco sets out an overall long-term vision for a tobacco-free society. In 2023, the Government presented an ambitious national tobacco strategy as part of the white paper on public health. One of the main goals of this strategy is to lower the proportion of daily tobacco users to less than five percent in all age and educational groups. This target is to be achieved by introducing a new national smoking cessation programme, limiting the availability of tobacco products and extending protection against passive smoking, among other measures. Another main goal is to ensure that children born in 2010 and later does not use tobacco and nicotine products.

The vast majority of people who try to give up smoking, fail, but their chance of success increases many times with an evidence-based smoking cessation method (medication and counselling). During the period 2020–2023, the Norwegian Directorate of Health conducted a pilot smoking cessation project in Vestre Viken health trust in which participants received free smoking cessation medication and counselling at healthy life centres. The evaluation showed excellent results and thus forms a potential basis for developing a national programme.

Ten-year goal 2

Eliminate cervical cancer and other cancers caused by HPV

Cervical cancer and other cancers caused by human papillomavirus (HPV) infection can be eliminated by consistently high uptake of vaccination among both boys and girls. High uptake in the national cervical cancer screening programme will help to identify cervical precancer and prevent it from developing into cancer. This will require us to work to promote high vaccination programme uptake and implement low-threshold testing and follow-up in the screening programme.

It has been estimated that 15 percent of cancer cases worldwide are virus-related. The most widely known viruses that can contribute to cancer developing are the hepatitis B virus, which can cause liver cancer, and the human papillomavirus (HPV), which can cause cancer of the cervix, vaginal mucous membranes, vulva, penis, anus and anal canal, as well as different types of cancer in the head and neck.

More than 600 new cases of HPV-related cancer are diagnosed in Norway each year, of which about 300 cases are cervical cancer. The number of head and neck cancer cases in particular has increased in recent years. The greatest increase is seen in mouth and neck cancers in men.

HPV vaccination prevents infection and disease. All boys and girls are currently offered HPV vaccination at the age of 12 as part of the Norwegian child vaccination programme. As it takes between 10 and 30 years to develop cancer after being infected with HPV, it could take many years to see a reduction in the number of cancer cases due to the preventive effect of vaccination.

HPV infection and cervical precancer can be identified through the Norwegian Cervical Cancer Screening Programme and prevented from developing into cancer. There is no screening programme for other HPV-related cancers.

The EU aims to eliminate all cancer caused by HPV. Norway will also work towards this ambitious goal by ensuring consistently high HPV vaccination uptake among boys and girls alike.

The hepatitis B and C viruses can also cause cancer. Vaccines and treatments are available for both these viruses. Vaccination of persons in the group at elevated risk of infection should be continued, as should the national programme for antiviral treatment against hepatitis C.

There is also a known link between certain bacteria and cancer, for example stomach cancer (the bacterium Helicobacter pylori). Diagnosing and treating infection with such bacteria could help to minimise the risk of cancer. We can also expect to gain more knowledge in future about other cancers caused by microbes.

The Norwegian Cervical Cancer Screening Programme has introduced self-sampling. More than half of all cases of cervical cancer diagnosed in Norway are found in women who have not followed the recommended cervical screening programme. Moreover, cancer in women who rarely or never attend cervical screening is more often diagnosed at a more advanced stage than in women who follow the recommended screening programme. Self-sampling is introduced in an attempt to increase participation in the Norwegian Cervical Cancer Screening Programme and thus lower the number of women who develop cervical cancer in the long term.

Ten-year goal 3

Offer more precise screening programmes with high uptake with the aim of introducing screening programmes for lung cancer and prostate cancer, among others

During the strategy period, more personalised screening programmes will be offered in line with EU initiatives. It is a goal to be able to use artificial intelligence (AI) and identification of targeted biomarkers and genetic risk factors both to diagnose cancer at an early stage and in the assessment of cancer patients. AI technology has the potential to increase the benefits and reduce the disadvantages of screening. Lung and prostate cancer are the cancers currently looked into, but AI and health technology developments could also make it relevant to other cancers.

Three national screening programmes have so far been established in Norway: CervicalScreen Norway (the Norwegian Cervical Cancer Screening Programme), BreastScreen Norway and the ColorectalScreen Norway. The purpose of the screening programmes is to identify precancer or early-stage cancer so that it can be treated to prevent cancer from developing. The cancer screening programmes plan to increase the benefits and reduce the disadvantages of participation, among other things by employing personalised strategies and artificial intelligence. This will help to ensure that people participate in modern, safe and cost-effective programmes. The national cancer screening programmes are subject to constant follow-up, and quality-raising measures are implemented as required.

It is a goal to increase participation in the national screening programmes. Spreading general knowledge about cancer screening, as well as about its effects and the benefits and disadvantages of participation, is an important public health mission. Good knowledge and information are important in order to allow those invited to make an informed decision and to help to increase participation. The information provided must be adapted to different levels of health literacy, cultural understanding and individual preferences. Information should be published in different languages and accommodate the need for cultural adaptation. Healthcare professionals play a key role in this information work.

In order to increase participation in cancer screening programmes, equitable access to national screening programmes regardless of sociodemographic differences must be facilitated. It is important to lower financial and cultural barriers that could contribute to social inequality in screening programme uptake.

It is a goal for the screening programmes to offer a higher degree of personalisation during the strategy period in line with EU initiatives. It is a goal to be able to use artificial intelligence (AI) and identification of targeted biomarkers and genetic risk factors both to diagnose cancer at an early stage and in the assessment of cancer patients.

The screening programmes are developed taking into account new knowledge, and necessary adaptations are made to make screening easily accessible and ensure good uptake. When the introduction of new national cancer screening programmes is proposed, a knowledge base must be prepared in which research is summarised, costs and effects are analysed and the ethical, legal, organisational, health-related and personnel-related consequences are assessed. The Norwegian Directorate of Health assesses and makes recommendations regarding changes to the screening programmes and the establishment of new programmes in cooperation with the relevant parties. The Ministry of Health and Care Services is responsible for considering cases in connection with its annual budget processes.

The EU will take major cancer-related initiatives in the years ahead, including in screening. Norway will contribute actively to the European cancer prevention and screening work and participates in this work through EU4Health, JA PreventNCD, JA screening (EUCanScreen) and JA SAMIRA.

Lung cancer screening

Norway has no screening programme for lung cancer. Key challenges include selection criteria and investigation capacity. The Norwegian Directorate of Health will look into the possibility of introducing lung cancer screening during the strategy period. Scientific studies, experience from the Norwegian trial at Akershus University Hospital in which 1,000 people were screened for lung cancer, the introduction of such screening in the UK and revised EU recommendations will all form important parts of the basis for its report.

Prostate cancer screening

Most countries, including Norway, has not introduced population-based screening for prostate cancer. Several studies have shown that PSA-based screening programmes could reduce mortality from prostate cancer in the population. No studies have so far been able to demonstrate increased overall survival with PSA screening, however, but then the studies were not designed to examine this issue.

In September 2022, the European Commission issued a recommendation to consider introducing screening for more forms of cancer, including prostate cancers, and several European pilot projects are under way.

Ten-year goal 4

Cancer is to be diagnosed at an earlier stage than today for cancers where this has a bearing on the prognosis

Cancer should be diagnosed at an earlier stage if this has a bearing on the treatment options and prognosis, without using limited investigation capacity on examinations that are not expected to be particularly useful. We regularly have to update recommendations on early diagnosis methods in the cancer patient pathways to keep up with medical and technological developments. Measures to ensure appropriate referrals, including from GPs, are important to ensure that patients are referred to hospital when there is reason to suspect cancer.

Early symptoms and signs of cancer are often vague and similar to short-term complaints that will clear up without treatment, or they resemble the early stages of other diseases or complaints. Many common symptoms and complaints that people see their GP for could be caused by cancer, but in most cases, there are other, far more likely, causes. Immediate hospital investigation of any situation where cancer is a possibility would overstretch the hospitals’ investigation capacity and delay the investigation of other, more likely, causes. Such a practice would also delay the investigation of other patients with suspected cancer who have a much higher probability of actually suffering from cancer.

The potential importance of early detection varies between cancers and should be made clear in the patient pathways. Screening is introduced or considered in cases where a significantly better treatment outcome is expected if cancer is detected at an early stage, preferably before signs and symptoms arise. Early diagnosis has a bearing on the prognosis for a number of cancers. Examples include colorectal and lung cancer.

The most important measures for ensuring early diagnosis will be:

• high screening programme uptake
• investigation and treatment in accordance with defined patient pathways when patients are referred to the specialist health service with suspected cancer, with patient pathways being regularly updated to take account of developments relating to the type of cancer in question
• continuous follow-up of the stage at which patients are diagnosed with cancer, with interventions if the distribution is unfavourable or develops in an unfavourable direction in all or parts of Norway

Ten-year goal 5

Reduction of work-related cancer through strengthening of systematic HSE work

Exposure to carcinogenic factors in the workplace is an important cause of work-related cancer. Such factors include chemicals, radiation and other factors such as night shift work. Historically speaking, many employees have been exposed to carcinogens, and although a lot of progress has been made, we still need to strengthen efforts to prevent work-related cancer.

It is a goal to reduce work-related cancer by strengthening systematic HSE work. A report entitled Work today and in the Future was recently issued by a Nordic expert group of which the Norwegian Labour Inspection Authority is a member, and the report states that 46 percent of all work-related deaths in the Nordic countries are caused by cancer following exposure to carcinogenic factors in the workplace. Work-related cancer accounts for more than 120,000 new cases and 100,000 deaths per year in the EU (European Agency for Safety and Health at Work). The most common forms of cancer are mesothelioma, lung cancer and cancer of the nose and sinuses.

Around 325,000 Norwegian employees work in jobs where they could be exposed to carcinogens. About two thirds of them state that they can see or smell dust, fumes, smoke, gas or chemicals at work, according to the National Occupational Health Surveillance (NOA). This applies to employees working in male-dominated industries and jobs such as construction and manufacturing, plumbers, electricians, mechanics and carpenters/joiners. In addition, the International Agency for Research on Cancer (IARC) has classified night shift work as probably carcinogenic in relation to breast cancer in women.

Effective prevention of work-related cancer requires systematic HSE work that includes mapping, risk assessment and measures to minimise exposure. This could entail eliminating chemicals, substituting dangerous chemicals, establishing closed systems, ventilation and personal protective equipment.

The Norwegian Labour Inspection Authority will intensify its efforts to prevent work-related cancer in the time ahead. Since work-related cancer can be caused by exposure to a great number of different factors, the Norwegian Labour Inspection Authority has chosen to focus on five factors that are common in Norwegian workplaces. The factors selected are quartz dust (respirable crystalline silica), asbestos, diesel exhaust, welding fumes and radon. Other policy instruments, such as providing guidance, cooperation with industries at the national level, cooperation at the European level and regulatory development, will also be used to strengthen work to prevent exposure to carcinogenic chemicals.

Knowledge about and understanding of causal relationships enables targeted HSE work in enterprises and regulatory risk-reducing measures imposed by the authorities. The National Institute of Occupational Health in Norway, occupational medicine departments and occupational health services are all important partners in the Norwegian Labour Inspection Authority’s work to monitor and prevent cancer. The institute’s priority areas include research and dissemination of knowledge about chemical and biological factors.