As everybody knows, cancer is a major killer among all developed nations, and that includes Malta.

While we have a fairly good idea of what causes some types of cancer, including, for instance, the undoubted correlation between smoking and cancer of the lung and other sites in the body, the causation of other types of cancer is less well-established.

In Malta, in particular, there are about 1,000 new cases of cancer every year, giving a rate of just under five per thousand of the population.

The devil, they say, is in the detail, and these gross figures (referred to as crude rates) hide the actual details.

From global studies it is evident that out of 192 countries, Malta is placed 19th with the highest mortality rate from urinary bladder, 21st from cancer of the pancreas, and 24th from both cancer of the breast as well as cancer of the bowel.

The obvious question is why are these types of cancer so common in the Maltese community? There must be factors at work which lead to such a relatively high rate of cancer here. We know that obesity, smoking and alcohol are all associated with increased cancer incidence involving various sites in the body.

In Malta, there are about 1,000 new cases of cancer every year

There is, moreover, no doubt also that certain basic genetic propensities might have to be taken into consideration, but the exact nature of these is not well established.

A second important point comes out from an analysis of the trends in cancer incidence and mortality from data released by the Health Department. Data comparing the cancer-associated incidence and mortality over a 10-year period between 2003 and 2012 show that in the vast majority of categories of cancer, there was no improvement in the incidence rate or mortality rate in most cancers. With the only exception of cancer of the prostate, there was an unmistakable trend in the wrong direction, namely upward.

With an increasing population, one might well expect that the actual number of cases of cancer would increase year by year, but this is no explanation for an increase in the rate.

Overall, the cancer incidence rate in this 10-year period has increased from 335 to 421 per 100,000 in men, with an even more marked increase in women (from 308 to 453).

The rate of breast cancer incidence has increased from 108 to 149 per 100,000. The mortality rate for most cancers likewise shows an upward trend.

One could argue that perhaps with improving diagnostic tools, one would expect an increase in detection of cancers within the community. No doubt, this might explain some of the demonstrated increase in incidence rates.

However, there is no explanation for increased mortality rates, which likewise show a tendency to increase over the years. For instance, the mortality rate from all cancers has increased from 183 to 233 (per 100,000) in men and 167 to 205 in women.

The only exception to this seems to be prostate cancer, whereby the mortality rate has actually fallen slightly (from 17.2 to 15.8 per 100,000).

Finally, one could add that even in those conditions where men used to be more affected than women, there has now been a considerable catch-up.

For instance, in 2003, the incidence rate, as well as the mortality rate, from lung cancer were five times as many in men as in women. Ten years later, the incidence rate of lung cancer in women had trebled (to 31/100,000) and the mortality rate has doubled (to 18.5/100,000).

No doubt this is the result of the marked increase in the number of women smokers in the community, a change which has occurred within the last generation.

We seem to be faced with a major public health issue here. Why is it that in spite of all the educational effort by those responsible for the health of the nation, in spite of all the advances in diagnosis and treatment and in spite of the fact that Malta spends more on health than most other countries (around nine per cent of GDP), there seems to be little impact on the actual situation as measured by the total number of cases, and, more significantly, by rates of disease incidence and mortality over the past decade?