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This overview describes the principles of the 4th edition of the European Code against Cancer and provides an introduction to the 12 recommendations to reduce cancer risk. Among the 504.6 million inhabitants of the member states of the European Union (EU28), there are annually 2.64 million new cancer cases and 1.28 million deaths from cancer. It is estimated that this cancer burden could be reduced by up to one half if scientific knowledge on causes of cancer could be translated into successful prevention. The Code is a preventive tool aimed to reduce the cancer burden by informing people how to avoid or reduce carcinogenic exposures, adopt behaviours to reduce the cancer risk, or to participate in organised intervention programmes. The Code should also form a base to guide national health policies in cancer prevention. The 12 recommendations are: not smoking or using other tobacco products; avoiding second-hand smoke; being a healthy body weight; encouraging physical activity; having a healthy diet; limiting alcohol consumption, with not drinking alcohol being better for cancer prevention; avoiding too much exposure to ultraviolet radiation; avoiding cancer-causing agents at the workplace; reducing exposure to high levels of radon; encouraging breastfeeding; limiting the use of hormone replacement therapy; participating in organised vaccination programmes against hepatitis B for newborns and human papillomavirus for girls; and participating in organised screening programmes for bowel cancer, breast cancer, and cervical cancer.

Lifestyle factors, including diet, have long been recognised as potentially important determinants of cancer risk. In addition to the significant role diet plays in affecting body fatness, a risk factor for several cancers, experimental studies have indicated that diet may influence the cancer process in several ways. Prospective studies have shown that dietary patterns characterised by higher intakes of fruits, vegetables, and whole-grain foods, and lower intakes of red and processed meats and salt, are related to reduced risks of death and cancer, and that a healthy diet can improve overall survival after diagnosis of breast and colorectal cancers. There is evidence that high intakes of fruit and vegetables may reduce the risk of cancers of the aerodigestive tract, and the evidence that dietary fibre protects against colorectal cancer is convincing. Red and processed meats increase the risk of colorectal cancer. Diets rich in high-calorie foods, such as fatty and sugary foods, may lead to increased calorie intake, thereby promoting obesity and leading to an increased risk of cancer. There is some evidence that sugary drinks are related to an increased risk of pancreatic cancer. Taking this evidence into account, the 4th edition of the European Code against Cancer recommends that people have a healthy diet to reduce their risk of cancer: they should eat plenty of whole grains, pulses, vegetables and fruits; limit high-calorie foods (foods high in sugar or fat); avoid sugary drinks and processed meat; and limit red meat and foods high in salt.

Better standardization among experimental and epidemiologic designs in assessing alcohol intake and timing of exposure may improve our understanding of the heterogeneity observed across studies, possibly allowing the quantification of the effects of occasional heavy drinking and the identification of a window of higher susceptibility to breast cancer development.

Physical activity is a complex, multidimensional behavior, the precise measurement of which is challenging in free-living individuals. Nonetheless, representative survey data show that 35% of the European adult population is physically inactive. Inadequate levels of physical activity are disconcerting given substantial epidemiologic evidence showing that physical activity is associated with decreased risks of colon, endometrial, and breast cancers. For example, insufficient physical activity levels are thought to cause 9% of breast cancer cases and 10% of colon cancer cases in Europe. By comparison, the evidence for a beneficial effect of physical activity is less consistent for cancers of the lung, pancreas, ovary, prostate, kidney, and stomach. The biologic pathways underlying the association between physical activity and cancer risk are incompletely defined, but potential etiologic pathways include insulin resistance, growth factors, adipocytokines, steroid hormones, and immune function. In recent years, sedentary behavior has emerged as a potential independent determinant of cancer risk. In cancer survivors, physical activity has shown positive effects on body composition, physical fitness, quality of life, anxiety, and self-esteem. Physical activity may also carry benefits regarding cancer survival, but more evidence linking increased physical activity to prolonged cancer survival is needed. Future studies using new technologies - such as accelerometers and e-tools - will contribute to improved assessments of physical activity. Such advancements in physical activity measurement will help clarify the relationship between physical activity and cancer risk and survival. Taking the overall existing evidence into account, the fourth edition of the European Code against Cancer recommends that people be physically active in everyday life and limit the time spent sitting.