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Yeger et al. J Cancer Metastasis Treat 2020;6:26 I http://dx.doi.org/10.20517/2394-4722.2020.61 Page 3 of 16

care in the United States in 2017 were $147.3 billion. In future years, costs are likely to increase as the
population ages and cancer prevalence increases. Costs are also likely to increase as new, and often more
expensive, treatments are adopted as standards of care.

[12]
From our perspective, if we then compare with the Canadian cancer statistics we note comparable
figures. It is estimated that 1 in 2 Canadians will be diagnosed with cancer in their lifetime, and that 220,400
[13]
new cases would be diagnosed in 2019 (113,000 in males and 107, 400 in females). In 2020 , it is projected
that 225,800 Canadians will receive a diagnosis of cancer and 83,300 will die of cancer. These estimates are
higher than previously reported for 2019, which are expected given the growing and aging population. In
contrast, the decline in age-standardized incidence rates (ASIR) overall shows progress is being made for
several leading cancers. For example, the ASIRs for some of the commonly diagnosed cancers are declining,
reflecting success in cancer-control activities around primary prevention (e.g., tobacco for lung cancer),
as well as changes in detection practices (prostate cancer) and possibly screening (colorectal). In addition,
there have been dramatic declines in mortality for these cancers, reflecting not only changes in incidence
but also improvements in early detection and treatments. In contrast, the lack of progress with pancreatic
cancer and the continued increase in the number of cases and deaths expected each year for this and other
cancer type shows further efforts in cancer control are urgently required.

Globally speaking, the World Health Organization (IARC, WHO Cancer Facts Sheet, Global Cancer
[14]
Observatory, March 2019 ) reported data from 2018 as excerpted for this review: Cancer is the second
leading cause of death globally, and is responsible for an estimated 9.6 million deaths in 2018. Globally,
about 1 in 6 deaths are due to cancer and approximately 70% of these occur in low- and middle-income
countries. Around one third of deaths from cancer are due to the 5 leading behavioural and dietary risks:
high body mass index, low fruit and vegetable intake, lack of physical activity, tobacco use, and alcohol use.
Note that the first two indicator risks relate directly to the values inherent in the Mediterranean diet.

As indicated previously the incidence of cancer in a number of favourable areas in the world tends to
decrease with better phytochemical enriched diets suggesting that a lot more has to be done in determining
how dietary factors can help to bring the incidence sharply down over time and aided by critical changes
in lifestyle habits and physiological burdens. Therefore it is vital to try to understand not only how to
treat cancer, but importantly how to prevent cancer (ideally early in life) even in light of the driving
forces of genetic susceptibility and epigenetics that can play important roles in subverting normal gene
[15]
expression . Finally, it also apparently clear that low- and middle-income populations may not have access
to sufficient vegetables and fruits in their diets to meet the threshold amount needed for chemoprevention
and chemoprotection. In fact, low-income populations because of limited resources do not purchase
the healthier fruits and vegetables they would need, thereby significantly limiting the intake of specific
nutrients that could effectively prevent cancer, or as we see, also capable of limiting infections, additional
contributing vectors. The MedDiet, very much aligned with other diets that favor greater ingestion of
vegetables and fruits, may be circumvented by the trend in the lower economic strata towards poorer
typical western diets that favor starches and meats.

On this point the MedDiet has been described with four sustainable benefits [16,17] in terms of nutrition
[18]
and health, environment, economy, and society and culture. Fresán et al. present a detailed analysis
comparing the western diet, MedDiet and provegetarian diet in terms of sustainability, health benefits
and cost. The MedDiet had the greatest health benefits but was considered more costly than the others.
[19]
In a recent review Truzzi et al. examined the broader benefits of sustainability, resilience and health
of the MedDiet and indicate that this diet promotes social interaction, protects biodiversity, and ensures
conservation and development of traditional activities with a definite emphasis on disease prevention.
Given these advantages, for the MedDiet to be transferable to other countries will require a multitude of