Demographic changes mean that cancer incidence will dramatically increase over the next twenty years as developed countries feel the burden of an ageing population. In addition, and despite substantial reductions in many countries the scourge of tobacco will continue to be reaped in developed countries and increasingly in developing countries. Strategies for cancer control will need to be twin tracked - socio-political to deal with tobacco control and scientific to address the need for cost-effective anti-cancer treatments. The next twenty years will need to shift to a fundamentally anti-tobacco culture that moves beyond simple legislation. Society needs to address the pervasive addiction and image of tobacco as a social emollient. When members of the public see tobacco in the same light as asbestos then it will be under control.
Despite great advances in the control and cure of cancer so many areas remain out-of-reach. For example there has been glacial progress against almost all types of metastatic disease. In addition over-treatment and under-treatment remain commonplace as we have few practical ways of predicting who will respond to treatment and who will develop toxicities. The personalisation of treatment is not only the grail for cancer research, but remains the only hope of ensuring that increasingly expensive treatments are affordable to society. Even when we have mastered the complexities of death in old age whether through cancer, or other degenerative disease, all our advances over the next twenty years must not be at the expense of providing a pain-free and dignified death to all.