Wastewater Surveillance to Inform Cancer Epidemiology and Evidence-Based Interventions

Cancer is a leading cause of mortality worldwide. The incidence and outcomes of cancer remain unequally distributed on global and local scales, driven in part by unequal carcinogen exposures, healthcare access, socioeconomic factors, and screening compliance. Cancer surveillance systems are critical for informing resource allocation and policies for cancer prevention, screening, diagnosis, and treatment but are limited in many countries. Where they do exist, surveillance systems suffer from long latencies between disease progression, diagnosis, and data reporting as well as reporting bias due to screening disparities and evolving policies. Furthermore, integrated surveillance is lacking for cancer-related targets, including those associated with carcinogen exposure as well as those indicating cancer prevalence or risk factors. Improved geospatial surveillance of cancer-related targets could inform evidence-based screening and prevention efforts and predict future burden for an increasing global health threat. In this article, we─a team of environmental engineers and microbiologists, oncologists, cancer epidemiologists, and bioethicists─assert that wastewater surveillance of cancer-related targets holds promise for integration into existing cancer epidemiology infrastructure to enable earlier and more equitable public health decision-making. First, we highlight opportunities for wastewater surveillance to complement existing cancer surveillance. We next identify candidate targets that indicate cancer risk─including oncoviruses, bacterial carcinogens, oncogenes, and chemical carcinogens─and detail prior evidence of their detection in wastewater and potential use cases. Finally, we present research needs and ethical considerations for this technological expansion of the practice.