Slide 1

CANCERBY BRIG DR HEMANT KUMAR

CATEGORIES OF CANCERCarcinoma Arises from the epithelial cells lining the internal surface of various organs (e.g. mouth, esophagus, uterus)SarcomaArises from the mesodermal cells constituting the various connective tissues (e.g. fibrous tissue, bone)Lymphoma, myeloma and leukemiaArising from the cells of the bone marrow and immune system

Signs/symptomsA lump or hard area in the breastA change in a wart or moleA persistent change in digestive and bowel habitsA persistent cough or hoarsenessExcessive loss of blood at the monthly period or loss of blood outside the usual datesBlood loss from any natural orificeA swelling or sore that does not get betterUnexplained loss of weight

PROBLEM STATEMENTCancers figure among the leading causes of morbidity and mortality worldwide, with approximately, 32.5 million cases, 14 million new cases and 8.2 million cancer related deaths in 2012 .

The number of new cancer cases will rise from 14 to 22 (by 70%) million within the next two decades.

ContdMore than 60 percent of the worlds new cancer cases occur in Africa, Asia, and Central and South America.

70 percent of the worlds cancer deaths also occur in these regions.

CANCER FREQUENCY Combined 182 per 100,000 in 2012. The rate was higher for men (205 per 100,000)than women (165 per 100,000).REGION : BOTH SEXESThe highest cancer rate for men and women together was found in Denmark with 338 people per 100,000 being diagnosed in 2012.The countries in the top ten come from Europe, Oceania, Northern America and Asia.

Age-Standardised Rate per 100,000 (World)(Both Genders)Denmark -338.12France (metropolitan)-324.63Australia-323.04Belgium-321.15Norway-318.36United States of America-318.0

MENThe highest cancer rate was found in France with 385 men per 100,000 being diagnosed in 2012.The age-standardised rate was at least 350 per 100,000 in eight countries (France, Australia, Norway, Belgium, Martinque, Slovenia, Hungary and Denmark).

MENFrance (metropolitan)385.32Australia373.93Norway368.74Belgium364.85Slovenia358.27Hungary356.18Denmark354.39United States of America347.0

WOMENThe age-standardised rate was at least 280 per 100,000 for Denmark, United States of America, Republic of Korea, The Netherlands and Belgium.Denmark328.82United States of America297.43Korea, Republic of293.64The Netherlands289.65Belgium288.9

COMMON CANCERSLung cancer is the most common cancer, with 1.8 million new cases diagnosed in 2012.

Hungary had the highest rate of lung cancer, followed by Serbia and Democratic People's Republic of Korea.

BREAST CANCERBreast cancer is the second most common cancer, with 1.7 million new cases diagnosed in 2012. Belgium had the highest rate of breast cancer, followed by Denmark and France.

COLORECTAL CANCERColorectal cancer is the third most common cancer, with 1.4 million new cases diagnosed in 2012. Republic of Korea had the highest rate of colorectal cancer, followed by Slovakia and Hungary.

PROSTATE CANCERProstate cancer is the fourth most common cancer, with 1.1 million new cases diagnosed in 2012. France had the highest rate of prostate cancer, followed by Norway and France.

STOMACH CANCERStomach cancer is the fifth most common cancer, with 952,000 new cases diagnosed in 2012. The Republic of Korea had the highest rate of stomach cancer, followed by Mongolia and Japan.

LIVER CANCERLiver cancer is the sixth most common cancer, with 782,000 new cases diagnosed in 2012. Mongolia has the highest rate of liver cancer, followed by Lao PDR and The Gambia.

CERVICAL CANCERCervical cancer is the seventh most common cancer, with 5,28,000 new cases diagnosed in 2012. Malawi had the highest rate of cervical cancer, followed by Mozambique and Comoros.About 84 per cent of cervical cancer cases occurred in less developed countries.

The overall incidence rate is almost 25% higher in men than in women, with rates of 205 and 165 per 100,000, respectively.

Male incidence rates vary almost five-fold across the different regions of the world, with rates ranging from 79 per 100,000 in Western Africa to 365 per 100,000 in Australia/New Zealand .

There is less variation in female incidence (three-fold) with rates ranging from 103 per 100,000 in South-Central Asia to 295 per 100,000 in USA.

INDIAN SCENARIOAccording to ICMR in 2016 the total number of new cancer cases are expected to be around 14.5 lakh and the figure is likely to reach nearly 17.3 lakh new cases in 2020. Over 7.36 lakh people are expected to succumb to the disease in 2016 while the figure is estimated to shoot up to 8.8 lakh by 2020. Data also revealed that only 12.5 per cent of patients come for treatment in early stages of the disease.

CONTD Cancer of breast with estimated 1.5 lakh (over 10 per cent of all cancers) new cases during 2016, is the number one cancer overall. Cancer of the lung is the next with estimated 1.14 lakh (83,000 in males and 31,000 in females) new cases during 2016 and 1.4 lakh cases in 2020.

"Cancer of the cervix is the third most common cancer with estimated 1 lakh new cases in 2016 .Cancers associated with the use of tobacco account for about 30 per cent of all cancers in males and females," the ICMR said.

The northeast reported the highest number of cancer cases in both males and females. Aizawl district in Mizoram reported the highest number of cases among males while Papumpare district in Arunachal Pradesh recorded the highest number among females.

It also stated there was a "significant" increase in cancers of rectum and colon in males in the PBCRs at Bangalore, Chennai, and Delhi and in females in Barshi and Bhopal.

ETIOLOGY OF CANCER

ENVIRONMENTAL FACTORSTOBACCO

Tobacco in various forms of usage can cause cancer of lungs, larynx, mouth, pharynx, esophagus, bladder, pancreas and probably kidney.Cigarette smoking is now responsible for more than one million death each yearALCOHOL: Excess intake of alcohol can cause esophageal and liver cancer.Beer consumption may be associated with rectal cancer.Alcohol contributes about 3 % of all cancer deaths

Dietary factor

Smoked fish is related to stomach cancerDietary fiber to intestinal cancerBeef consumption to bowel cancerHigh fat diet to breast cancerFood additives and contaminants have fallen under suspicion as causative agents

OCCUPATIONAL EXPOSURES

These includes exposure to benzene, cadmium, arsenic, chromium, vinyl chloride, asbestos, polycyclic hydrocarbons, etc.The risk of occupational exposure is said to be increased if the individual also smokes cigarette.Occupational exposure is usually reported 1-5% of human cancer

Virus

Hepatitis B & C - hepato-carcinomaHIV infection kaposis carcinomaAIDS Non Hodgkins lymphomaEpstein bar virus Burkitts lymphoma and naso pharyngial carcinomaCytomegalovirus Kaposis SaPappiloma virus cervix cancerHuman T cell leukemia virus T cell leukemia

ParasiteMay be a cause of cancerSchistosomiasis can produce Ca of bladderCustoms, habits and life styleMay be associated with an increased risk of cancer.Smoking and lung cancerTobacco and beetle chewing and oral cancer

GENETIC FACTORSGenetic influences have long been suspectedRetinoblastoma occurs in children of the same parentMongols are more likely to develop leukemiaThere is probably a complex relationship between hereditary susceptibility and environmental carcinogenic stimuli in the causation of cancer

Others

Sunlight, radiation, water and air pollution, medication and pesticides

Cancer control

THE AIM OF CANCER CONTROLReduction of Cancer Incidence, Morbidity & Mortality

38 The WHO model for cancer control is based on a public health approach to non-communicable disease control. It seeks to reduce the incidence of cancer, as well as its mortality and morbidity. To design an effective cancer control program at country level one needs to have a thorough understanding of the disease process and its epidemiology, as well as of the social and economic factors that influence how that understanding can be effectively used. That information was covered in the first lecture of this series, which should be consulted for details. The current lecture will address putting the science into practice - the interventions that are currently available for cancer control. To use the metaphor of the individual patient: one first makes a diagnosis, then selects an appropriate treatment strategy, and finally formulates a treatment plan to guide its implementation. By analogy, at country level, the first lecture deals with the diagnosis of the cancer problem. This lecture describes the treatment strategy that can be used. A final third lecture is planned to deal with how one formulates the treatment plan to implement the strategy at the country level. There are four principal approaches to cancer control, as listed on the slide. They must be combined into integrated programming to be effective. This lecture will examine each in detail so that the reader may gain a practical knowledge of the available interventions.

THE W.H.O. PUBLIC HEALTH MODEL FOR CANCER CONTROLAssess the magnitude of the cancer problemEvaluate possible strategies for cancer controlChoose priorities for initial cancer control activities of prevention, screening, therapy and palliative careSet measurable cancer control objectives

39 A cancer control program is like a chair with four legs, a seat and a back. The four legs represent the interventions or programs of prevention, screening, treatment and palliation. The seat joins the four legs into a functional chair. It represents the organizational structure, management and governance of a national cancer control program that integrates its four programs into a functional unity. The back of the chair provides support. Here it represents the infrastructure that needs to be in place for the four programs to function.

Primary preventionSecondary preventionTertiary prevention

1. PRIMARY PREVENTION OF CANCERTobacco ControlControl of Alcohol ConsumptionOccupation and EnvironmentDietInfections (viruses and parasites)Reducing Sunlight ExposureSexual and Reproductive Factors

41 Prevention is a key component of all national cancer control programs. It is estimated that up to 30% of cancer is preventable by effective cancer prevention programs. Tobacco control has the largest effect and so is always the anchor of an integrated prevention program. The slide lists the areas where prevention activities can have an effect. The particular combination used in any country depends on the relative incidence and mortality at particular cancer sites characteristic of the countrys population.

Personal hygieneImprovement in hygiene may decline the incidence of certain types of cancersRadiationEffort should be made to reduce the amount of radiation received by each individuals to a minimum without reducing the benefitsOccupational ExposureShould protect workers from exposure to industrial carcinogens

Food, drugs, and cosmeticsShould be tested for carcinogensAir pollutionsControl of air pollution is a preventive measureTreatment of pre cancerous lesionsEarly detection and prompt treatment of precanerous lesionsLegislation

CANCER EDUCATION

To motivate people for early diagnosis and treatment & Remind early warning symptoms

A lump or hard area in the breastA change in a wart or moleA persistent change in digestive and bowel habitsA persistent cough or hoarsenessExcessive loss of blood at the monthly period or loss of blood outside the usual datesBlood loss from any natural orificeA swelling or sore that does not get betterUnexplained loss of weight

SECONDARY PREVENTIONA. Cancer registrationHospital-based registriesPopulation based registriesB. Early detection of cases/Screening

National Cancer Registry Programme was launched in 1981 by INDIAN COUNCIL OF MEDICAL RESEARCH With an aim to provide authentic information on cancer prevelance and incidence.

OBJECTIVES:-

1. To generate reliable data on the magnitude and patterns of cancer

2. Undertake epidemiological studies based on results of registry data

3. Help in designing, planning, monitoring and evaluation of cancer control activities under the National Cancer Control Programme (NCCP)

4. Develop training programmes in cancer registration and epidemiology

POPULATION BASED REGISTRIESWith these objectives three Population Based Cancer Registries (PBCRs) at Bangalore, Chennai and Mumbai and three Hospital Based Cancer Registries (HBCRs) at Chandigarh, Dibrugarh and Thiruvananthapuram were commenced from 1 January 1982.

The PBCRs have gradually expanded over the years and as of now there are 23 PBCRs under the NCRP network.

THESE REGISTRIES PROVIDE INFORMATION ON

1.COMMON CANCERS IN INDIA,

2.GEOGRAPHICAL VARIATION OF OCCURENCE OF CANCER

3.NATURE OF CANCERS FOR EFFECTIVE CONTROL MEASURES

HOSPITAL BASED REGISTRIESThese are located in within identified hospitals. Cancer extent,stages,therapy and survival rate information are more reliable on such dataThe existing programme through Mobile Cancer Detection Unit and Hospital Based Cancer Detection unit is based on opportunistic screening

Mode of data collection for cancer registriesActive Methods: developing countries including India, the provision of information is on voluntary basis. Exact methodology of data collection would necessarily depend upon the local circumstances.

Passive method: The hospitals in areas with compulsory notification and the hospital cancer registries, abstract the information from the patient records on a specified proforma and send it to the registry.

CANCER SCREENING

Cancer screeningaims to detectcancerbefore symptoms appear.This may involveblood tests,urine tests, other tests, ormedical imaging.

The benefits of screening in terms ofcancer prevention, early detection and subsequent treatment must be weighed against any harms.

ContdUniversal screening,mass screeningorpopulation screeninginvolves screening everyone, usually within a specific age group.Selective screening involves people who are known to be at higher risk of developing cancer.

Screening tests must be effective, safe, well-tolerated with acceptably low rates offalse positiveandfalse negative results.

Screening for cancer can lead to cancer prevention and earlier diagnosis. Early diagnosis may lead to higher rates of successful treatment and extended life.

Screening testsScreening for Breast, Cervical, Colorectal and Lung CancersBreast CancerMammograms are the best way to find breast cancer early, when it is easier to treat. Cervical CancerThe Pap test can find abnormal cells in the cervix which may turn into cancer. Pap tests also can find cervical cancer early, when the chance of being cured is very high

Contd..Colorectal (Colon) CancerColorectal cancer almost always develops from precancerous polyps (abnormal growths) in the colon or rectum. Screening tests can find precancerous polyps, so they can be removed before they turn into cancer. Lung Cancer Yearly screening with low-dose computed tomography (LDCT) for people who are smokers , have a history of heavy smoking, and are between 55 and 80 years old.

Ovarian CancerThere is no evidence that any screening test reduces deaths from ovarian cancer. Prostate CancerThe U.S. Preventive Services Task Force recommends against prostate specific antigen (PSA)-based screening for men who have no symptoms.

National Cancer Control Programme 1975-76 National Cancer Control Programme was launched with priorities given for equipping the premier cancer hospital/institutions.

In 1984-85 The strategy was revised and stress was laid on primary prevention and early detection of cancer cases.

1990-91 District Cancer Control Programme was started in selected districts (near the medical college hospitals).

GOALS & OBJECTIVES OF NCCP1. Primary prevention of cancers by health education specially regarding hazards of tobacco consumption and necessity of genital hygiene for prevention of cervical cancer. 2. Secondary prevention i.e. early detection and diagnosis of cancers, for example, cancer of cervix, breast and of the oro-pharyngeal cancer by screening methods and patients education on self examination methods. 3. Strengthening of existing cancer treatment facilities, which are woefully inadequate. 4. Palliative care in terminal stage of the cancer.