Cancer

ERA’S LUCKNOW MEDICAL COLLEGE &
HOSPITAL
DEPARTMENT OF COMMUNITY MEDICINE
LECTURE TOPIC: CANCER
By:
Dr. Avi Singh
Assistant Professor

WHAT IS CANCER?
 Cancer is a group of diseases involving abnormal cell growth with the potential to invade or
spread to other parts of the body.
 These contrast with benign tumors, which do not spread.
 In 2015, about 90.5 million people had cancer.
 As of 2019, about 18 million new cases occur annually.
 Annually, it caused about 8.8 million deaths (15.7% of deaths).

HISTORY OF CANCER
• The earliest known descriptions of cancer appear in several papyri from Ancient Egypt. The Edwin
Smith Papyrus was written around 1600 BC (possibly a fragmentary copy of a text from 2500 BC)
and contains a description of cancer, as well as a procedure to remove breast tumors by cauterization,
wryly stating that the disease has no treatment.
• Hippocrates (ca. 460 BC – ca. 370 BC) described several kinds of cancer, referring to them by the
term karkinos (carcinos), the Greek word for crab or crayfish, as well as carcinoma. This comes from
the appearance of the cut surface of a solid malignant tumor, with "the veins stretched on all sides as
the animal the crab has its feet, whence it derives its name“
• Through the centuries it was discovered that cancer could occur anywhere in the body, but
Hippocrates' humor-theory based treatment remained popular until the 19th century with the discovery
of cells.

• The first cause of cancer was identified by British surgeon Percivall Pott, who discovered in 1775
that cancer of the scrotum was a common disease among chimney sweeps. The work of other
individual physicians led to various insights, but when physicians started working together they could
draw firmer conclusions.
• With the widespread use of the microscope in the 18th century, it was discovered that the 'cancer
poison' eventually spreads from the primary tumor through the lymph nodes to other sites
("metastasis"). This view of the disease was first formulated by the English surgeon Campbell De
Morgan between 1871 and 1874.
• Cancer patient treatment and studies were restricted to individual physicians' practices until World
War II when medical research centers discovered that there were large international differences in
disease incidence. This insight drove national public health bodies to enable the compilation of health
data across practices and hospitals, a process found in many countries today.

CAUSES OF CANCER
• The majority of cancers, some 90–95% of cases, are due to genetic mutations from environmental
and lifestyle factors. The remaining 5–10% are due to inherited genetics.
• Some major causes of cancer are:
I. Genetics
II. Physical and Chemical Agents
III. Lifestyle
IV. Hormones
V. Infection and Inflammation
VI. Radiation
VII. Other rare causes.

GENETIC CAUSES OF CANCER
• Although there are over 50 identifiable hereditary forms of cancer, less than 0.3% of the population are
carriers of a cancer-related genetic mutation and these make up less than 3–10% of all cancer cases.
• Hereditary cancers are primarily caused by an inherited genetic defect. A cancer syndrome or family
cancer syndrome is a genetic disorder in which inherited genetic mutations in one or more genes
predisposes the affected individuals to the development of cancers and may also cause the early onset
of these cancers.
• Many of the cancer syndrome cases are caused by mutations in tumor suppressor genes that regulate
cell growth. Gene mutations are classified as germline or somatic depending on the cell type where
they appear. The germline mutations are carried through generations and increase the risk of
cancer.

• Some important cancer syndromes are:
i. Ataxia telangiectasia
ii. Bloom syndrome
iii. BRCA1 & BRCA2
iv. Fanconi anaemia
v. Familial adenomatous polyposis
vi. Hereditary breast and ovarian cancer
vii. Hereditary non-polyposis colon cancer
viii. Li-Fraumeni syndrome
ix. Naevoid basal cell carcinoma syndrome
x. Von Hippel-Lindau disease
xi. Werner syndrome
xii. Xeroderma pigmentosum

PHYSICAL AND CHEMICAL AGENTS CAUSING CANCER
• Exposure to particular substances have been linked to specific types of cancer. These substances are called
carcinogens.
• Tobacco smoke, for example, causes 90% of lung cancer. It also causes cancer in the larynx, head, neck, stomach,
bladder, kidney, oesophagus and pancreas. Tobacco smoke contains over fifty known carcinogens, including
nitrosamines and polycyclic aromatic hydrocarbons.
• Tobacco is responsible for about one in five cancer deaths worldwide and about one in three in the developed world.
• However, the numbers of smokers worldwide is still rising, leading to what some organizations have described as the
tobacco epidemic.
• Electronic cigarettes or e-cigarettes are handheld electronic devices that simulate the feeling of tobacco smoking. Daily
long-term use of high voltage (5.0 V) electronic cigarettes may generate formaldehyde-forming chemicals at a greater
level than smoking, which was determined to be a lifetime cancer risk of approximately 5 to 15 times greater than
smoking.

• Some substances cause cancer primarily through their physical, rather than chemical, effects on cells.
• Usually, physical carcinogens must get inside the body (such as through inhaling tiny pieces) and require years of
exposure to develop cancer. Common occupational carcinogens include:
i. Arsenic  Bladder cancer, skin cancer, Lung cancer.
ii. Asbestos  Mesothelioma.
iii. Benzene  Leukemia.
iv. Beryllium  Lung Cancer.
v. Cadmium  Lung cancer, Prostate cancer, Kidney Cancer.
vi. Chromium  Lung Cancer.
vii. Ethylene Oxide  Cancers of WBC, NHL, Myeloma, Lymphocytic Leukemia.
viii. Nickel  Lung cancer and nasopharyngeal cancers.
ix. Plutonium  Lung cancer.

LIFESTYLE CAUSES OF CANCER
• Many different lifestyle factors contribute to increasing cancer risk. Together, diet and obesity are
related to approximately 30–35% of cancer deaths.
I. Alcohol: Alcohol is an example of a chemical carcinogen. The World Health Organization has
classified alcohol as a Group 1 carcinogen. Worldwide, 3.6% of all cancer cases and 3.5% of cancer
deaths are attributable to alcohol. In particular, alcohol use has been shown to increase the risk of
developing cancers of the mouth, esophagus, pharynx, larynx, stomach, liver, ovaries, and colon.
II. Diet: Some specific foods have been linked to specific cancers. Studies have shown that
individuals that eat red or processed meat have a higher risk of developing breast cancer, prostate
cancer, and pancreatic cancer. A high-salt diet is linked to gastric cancer. Aflatoxin B1, a frequent
food contaminate, is associated with liver cancer. Betel nut chewing has been shown to cause oral
cancers.

III. Obesity: There is an association between obesity and colon cancer, post-menopausal breast cancer,
endometrial cancer, kidney cancer, and esophageal cancer. The current understanding regarding the
mechanism of cancer development in obesity relates to abnormal levels of metabolic proteins
(including insulin-like growth factors) and sex hormones (estrogens, androgens and progestogens).
Adipose tissue also creates an inflammatory environment which may contribute to the development
of cancers.

HORMONAL CAUSES OF CANCER
• Some hormones play a role in the development of cancer by promoting cell proliferation.
Insulin-like growth factors and their binding proteins play a key role in cancer cell growth,
differentiation and apoptosis, suggesting possible involvement in carcinogenesis.
• Other factors are also relevant: obese people have higher levels of some hormones associated
with cancer and a higher rate of those cancers.
• Women who take hormone replacement therapy have a higher risk of developing cancers
associated with those hormones. On the other hand, people who exercise far more than
average have lower levels of these hormones, and lower risk of cancer. Osteosarcoma may be
promoted by growth hormones.

INFECTION & INFLAMMATION CAUSES OF CANCER
• Worldwide, approximately 18% of cancer cases are related to infectious diseases. This proportion varies in
different regions of the world from a high of 25% in Africa to less than 10% in the developed world.
I. Virus: Viral infection is a major risk factor for cervical and liver cancer. A virus that can cause cancer is called
an oncovirus. These include human papillomavirus (cervical carcinoma), Epstein–Barr virus (B-cell
lymphoproliferative disease and nasopharyngeal carcinoma), Kaposi's sarcoma herpesvirus (Kaposi's sarcoma
and primary effusion lymphomas), hepatitis B and hepatitis C viruses (hepatocellular carcinoma), and Human
T-cell leukemia virus-1 (T-cell leukemias).
II. Bacteria and Parasites: Certain bacterial infections also increase the risk of cancer, as seen in Helicobacter
pylori-induced gastric carcinoma. The mechanism by which H. pylori causes cancer may involve chronic
inflammation or the direct action of some of the bacteria's virulence factors. Parasitic infections strongly
associated with cancer include Schistosoma haematobium (squamous cell carcinoma of the bladder) and the
liver flukes, Opisthorchis viverrini and Clonorchis sinensis (cholangiocarcinoma).

III. There is evidence that inflammation itself plays an important role in the development and progression of cancer.
Chronic inflammation can lead to DNA damage over time and the accumulation of random genetic alterations in
cancer cells. Inflammation can contribute to proliferation, survival, angiogenesis and migration of cancer
cells by influencing tumor microenvironment. Individuals with inflammatory bowel disease are at increased
risk of developing colorectal cancers.

RADIATION INDUCED CANCER
• Exposure to ionizing radiation is known to increase the future incidence of cancer, particularly
leukemia.
• According to the prevalent model, any radiation exposure can increase the risk of cancer. Typical
contributors to such risk include natural background radiation, medical procedures, occupational
exposures, nuclear accidents, and many others.
• Some major contributors of radiation are:
I. Radon: responsible for the worldwide majority of the mean public exposure to ionizing radiation.
It is often the single largest contributor to an individual's background radiation dose, and is the most
variable from location to location. Radon gas from natural sources can accumulate in buildings,
especially in confined areas such as attics, and basements. It can also be found in some spring waters
and hot springs.

• Residential exposure to radon gas has similar cancer risks as passive smoking. Radiation is a more
potent source of cancer when it is combined with other cancer-causing agents, such as radon gas
exposure plus smoking tobacco.
II. Medical: In industrialized countries, Medical imaging contributes almost as much radiation dose to
the public as natural background radiation. CT scans alone, which account for half the medical
imaging dose to the public, are estimated to be responsible for 0.4% of current cancers in the
United States, and this may increase to as high as 1.5-2% with 2007 rates of CT usage.
III.Occupational: In accordance with ICRP recommendations, most regulators permit nuclear energy
workers to receive up to 20 times more radiation dose than is permitted for the general public. Some
occupations are exposed to radiation without being classed as nuclear energy workers. Airline crews
receive occupational exposures from cosmic radiation because of reduced atmospheric shielding at
altitude. Mine workers receive occupational exposures to radon, especially in uranium mines.

IV.Accidental: Nuclear accidents can have dramatic consequences to their surroundings, but their global
impact on cancer is less than that of natural and medical exposures.
The most severe nuclear accident is probably the Chernobyl disaster. In addition to conventional fatalities
and acute radiation syndrome fatalities, nine children died of thyroid cancer, and it is estimated that there
may be up to 4,000 excess cancer deaths among the approximately 600,000 most highly exposed people.
Of the 100 million curies (4 exabecquerels) of radioactive material, the short lived radioactive
isotopes such as 131I Chernobyl released were initially the most dangerous. Due to their short half-lives of
5 and 8 days they have now decayed, leaving the more long-lived 137Cs (with a half-life of 30.07 years)
and 90Sr (with a half-life of 28.78 years) as main dangers.

Chernobyl Nuclear disaster: Reactor # 4

RARE CAUSES OF CANCER
• Organ Transplantation: The development of donor-derived tumors from organ transplants is exceedingly rare.
The main cause of organ transplant associated tumors seems to be malignant melanoma, that was undetected at
the time of organ harvest.
• Trauma: Physical trauma resulting in cancer is relatively rare. One accepted source is frequent, long-term
application of hot objects to the body. It is possible that repeated burns on the same part of the body, such as those
produced by kanger and kairo heaters (charcoal hand warmers), may produce skin cancer, especially if
carcinogenic chemicals are also present. Frequently drinking scalding hot tea may produce esophageal cancer.
• Maternal-fetal transmission: In the United States, approximately 3,500 pregnant women have a malignancy
annually, and transplacental transmission of acute leukemia, lymphoma, melanoma and carcinoma from mother to
fetus has been observed. Excepting the rare transmissions that occur with pregnancies and only a marginal few
organ donors, cancer is generally not a transmissible disease. The main reason for this is tissue graft rejection
caused by MHC incompatibility.

THE HALLMARKS OF CANCER
• The hallmarks of cancer comprise six biological capabilities acquired during the multistep development of human
tumors. The idea was coined by Douglas Hanahan and Robert Weinberg in their paper The Hallmarks of
Cancer published January 2000 in Cell.

SIGNS AND SYMPTOMS OF CANCER
• As cancer affect various parts of body, signs and symptoms differ.
• However there are some cardinal signs and symptoms that are present in majority of patients suffering from
cancer. These are:
The presence of unusual lump in the body.
Changes in a mole on the skin, such as size, color or shape thickness.
A persistent cough or hoarseness.
A change in bowel habits, such as unusual diarrhea or constipation.
Difficulty in swallowing or continuing indigestion.
Any abnormal bleeding, including bleeding from the vagina, or blood in urine or faeces.

A persistent sore or ulcer.
Difficulty passing urine.
Unexplained weight loss.
Unexplained pain.
Unexplained tiredness or fatigue.
Skin changes such as an unexplained rash or unusual texture.
Unexplained night sweats.
Abdominal pain
Unexplainable pains (headaches)

Image by: Häggström, Mikael (2014). Medical gallery of Mikael Häggström 2014: WikiJournal of Medicine 1

DIAGNOSIS OF CANCER
• Most cancers are initially recognized either because of the appearance of signs or symptoms or through screening. Neither of
these leads to a definitive diagnosis, which requires the examination of a tissue sample by a pathologist. People with
suspected cancer are investigated with medical tests. These commonly include blood tests, X-rays, (contrast) CT scans and
endoscopy.
• The tissue diagnosis from the biopsy indicates the type of cell that is proliferating, its histological grade, genetic abnormalities
and other features. Together, this information is useful to evaluate the prognosis and to choose the best treatment.
• Cytogenetics and immunohistochemistry are other types of tissue tests. These tests provide information about molecular
changes (such as mutations, fusion genes and numerical chromosome changes) and may thus also indicate the prognosis and
best treatment.
• Cancer diagnosis can cause psychological distress and psychosocial interventions, such as talking therapy, may help people
with this.

CLASSIFICATION OF CANCERS
• Cancers are classified by the type of cell that the tumor cells resemble and is therefore presumed to be the origin of the tumor.
These types include:
• Carcinoma: Cancers derived from epithelial cells. This group includes many of the most common cancers and include nearly all
those in the breast, prostate, lung, pancreas and colon.
• Sarcoma: Cancers arising from connective tissue (i.e. bone, cartilage, fat, nerve), each of which develops from cells originating in
mesenchymal cells outside the bone marrow.
• Lymphoma and leukemia: These two classes arise from hematopoietic (blood-forming) cells that leave the marrow and tend to
mature in the lymph nodes and blood, respectively.
• Germ cell tumor: Cancers derived from pluripotent cells, most often presenting in the testicle or the ovary (seminoma and
dysgerminoma, respectively).
• Blastoma: Cancers derived from immature "precursor" cells or embryonic tissue.
• Benign tumors (which are not cancers) are named using -oma as a suffix with the organ name as the root. For example, a benign
tumor of smooth muscle cells is called a leiomyoma Some types of cancer are named for the size and shape of the cells under a
microscope, such as giant cell carcinoma, spindle cell carcinoma and small-cell carcinoma.

TREATMENT OF CANCER
• The treatment of cancer has undergone evolutionary changes as understanding of the underlying
biological processes has increased. Some major treatment modalities are:
i. Surgery
ii. Radiation therapy
iii. Chemotherapy
iv. Targeted therapies: Monoclonal antibody therapy, Photodynamic therapy
v. Immunotherapy
vi. Hormonal therapy
vii. Angiogenesis Inhibitors
viii. Synthetic Lethality

CANCER PREVENTION
• Cancer prevention is the practice of taking active measures to decrease the incidence of cancer and
mortality.
• Globalized cancer prevention is regarded as a critical objective due to its applicability to large
populations, reducing long term effects of cancer by promoting proactive health practices and
behaviors, and its perceived cost-effectiveness and viability for all socioeconomic classes.
• The majority of cancer cases are due to the accumulation of environmental pollution being inherited
as epigenetic damage and many, but not all, of these environmental factors are controllable lifestyle
choices. Greater than a reported 75% of cancer deaths could be prevented by avoiding risk factors
including: tobacco, overweight / obesity, an insufficient diet, physical inactivity, alcohol, sexually
transmitted infections, and air pollution.
• Steps can be taken to prevent cancer. These are:

1) Dietary: While many dietary recommendations have been proposed to reduce the risk of cancer, the evidence to
support them is not definitive. For example, Consumption of coffee is associated with a reduced risk of liver cancer.
Dietary recommendations for cancer prevention typically include an emphasis on vegetables, fruit, whole grains, and
fish, and an avoidance of processed and red meat (beef, pork, lamb), animal fats, and refined carbohydrates.
2) Physical Activity: Research shows that regular physical activity helps to reduce up to 30% the risk of a variety of
cancer types, such as colon cancer, breast cancer, lung cancer and endometrium cancer. Physical activity reduces
cancer risk by helping weight control, reducing hormones such as estrogen and insulin, reducing inflammation and
strengthening the immune system.
3) Medication: The concept that medications can be used to prevent cancer is attractive, and evidence supports their
use in a few defined circumstances. In the general population, NSAIDs reduce the risk of colorectal cancer however
due to the cardiovascular and gastrointestinal side effects they cause overall harm when used for prevention. Aspirin
has been found to reduce the risk of death from cancer by about 7%. Daily use of tamoxifen or raloxifene has been
demonstrated to reduce the risk of developing breast cancer in high-risk women.

4) Vaccination:Anti-cancer vaccines can be preventive / prophylactic or be used as therapeutic treatment. All such
vaccines incite adaptive immunity by enhancing cytotoxic T lymphocyte (CTL) recognition and activity against
tumor-associated or tumor-specific antigens (TAA and TSAs). Human papillomavirus vaccine (Gardasil and
Cervarix) decreases the risk of developing cervical cancer. The hepatitis B vaccine prevents infection with
hepatitis B virus and thus decreases the risk of liver cancer.
5) Screening: Screening procedures, commonly sought for more prevalent cancers, such as colon, breast, and
cervical, have greatly improved in the past few decades from advances in biomarker identification and detection.
Cervical Cancer: through in vitro examination of the cells of the cervix (e.g. Pap smear), colposcopy, or direct
inspection of the cervix (after application of dilute acetic acid), or testing for HPV, the oncogenic virus that is the
necessary cause of cervical cancer. Screening is recommended for women over 21 years, initially women between
21–29 years old are encouraged to receive Pap smear screens every three years, and those over 29 every five years.
For women older than the age of 65 and with no history of cervical cancer or abnormality, and with an appropriate
precedence of negative Pap test results may cease regular screening.

Colorectal cancer: Colorectal cancer is most often screened with the fecal occult blood test (FOBT). Variants of
this test include guaiac-based FOBT (gFOBT), the fecal immunochemical test (FIT), and stool DNA (sDNA)
testing. Further testing includes flexible sigmoidoscopy (FS), total colonoscopy (TC), or computed tomography
(CT) scans if a TC is non-ideal. A recommended age at which to begin screening is 50 years. However, this is
highly dependent on medical history and exposure to CRC risk factors. Effective screening has been shown to
reduce CRC incidence by 33% and CRC morality by 43%.
Breast Cancer: Mammograms are widely used to screen for breast cancer, and are recommended for women 50–74
years of age by the US Preventive Services Task Force (USPSTF). However, the USPSTF recommended against
mammography for women 40–49 years old due to possibility of overdiagnosis. Also women can do self
examination for breast lump/cancer.
Prostate Cancer: Digital rectal examination (DRE) is a test in which the doctor inserts a gloved, lubricated finger
into the rectum and feels the surface of the prostate through the bowel wall for any irregularities.
Prostate Specific Antigen blood test is useful for detecting early-stage prostate cancer, especially in those with
many risk factors, which helps some get the treatment they need before the cancer grows and spreads.

EPIDEMIOLOGY OF CANCER
 According to estimates from the World Health Organization (WHO) in 2019, cancer is the
first or second leading cause of death before the age of 70 years in 112 of 183 countries and
ranks third or fourth in a further 23 countries.
 Cancer's rising prominence as a leading cause of death partly reflects marked declines in
mortality rates of stroke and coronary heart disease, relative to cancer, in many countries.
 Overall, the burden of cancer incidence and mortality is rapidly growing worldwide; this
reflects both aging and growth of the population as well as changes in the prevalence and
distribution of the main risk factors for cancer, several of which are associated with
socioeconomic development.

• As a consequence of growing and ageing populations, developing countries are
disproportionately affected by the increasing number of cancers.
• The “ westernization” trend: Low HDI countries become more developed through rapid
societal and economic changes that are likely to become westernized. This leads to increase in
incidence of cancer which is generally seen in high HDI settings.
• For epidemiological purpose, cancer registry formed for systematic collection of data about
cancer and tumor diseases. The data are collected by Cancer Registrars. Cancer Registrars
capture a complete summary of patient history, diagnosis, treatment, and status for every
cancer. They can be national and international registry.

• In the United States of America, The Surveillance, Epidemiology and End Results (SEER)
program of the National Cancer Institute (NCI) was established in 1973 and The National
Program of Cancer Registries (NPCR) was established in 1992, and administered by the
Centers for Disease Control and Prevention (CDC).
• NPCR and SEER together collect cancer data for the entire U.S. population. CDC and NCI, in
collaboration with the North American Association of Central Cancer Registries, have been
publishing annual federal cancer statistics in the United States Cancer Statistics: Incidence and
Mortality report.
• In India, ICMR runs the National Cancer Registry Program (NCRP) with aim to obtain an
overview of patterns of cancer in different parts of the country and to calculate estimates of
cancer incidence wherever feasible.

• Certain subsidiary objectives that emerge out NCRP are:
• a) Strengthening of departments of pathology in medical colleges and other hospitals with personal
computers and internet connection;
• b) Providing orientation/ training in cancer registration and epidemiology to pathologists.
• The cancer registries under the National Cancer Registry Program (NCRP) have provided since 1982
an idea of the magnitude and pattern of cancer in selected urban centers and in a couple of rural
pockets.
• However, large areas of the population, particularly the rural areas remain largely uncovered and
therefore the patterns of cancer in several urban centers and rural areas remain largely unknown. India
is a vast country with populations having varied cultures, customs and habits. The environment differs
and so does dietary praises, and socioeconomic status.
• Important differences exist in the ways of living of the urban and rural populations. Geographic
differences in patterns of cancer have already been observed among the different registries.

CANCER STATISTICS, 2020: REPORT FROM NATIONAL CANCER
REGISTRY PROGRAM, INDIA

NATIONAL PROGRAM FOR PREVENTION AND CONTROL OF CANCER,
DIABETES, CARDIOVASCULAR DISEASES AND STROKE (NPCDCS)
• It is estimated that any given point of time, there are 2.8 million cancer cases in India.
• With the objective of prevention, early diagnosis and treatment, National Cancer Control Program was
launched in 1975-1976.
• In 2010, the program was integrated in National Program For Prevention And Control Of Cancer, Diabetes,
Cardiovascular Diseases And Stroke.
• The objectives of the program are:
• a. Primary prevention of cancers by health education
• b. Secondary prevention: early diagnosis and treatment by screening/self examination.
• c. Tertiary Prevention: Strengthening of the existing institutions of comprehensive therapy including palliative
care.

• Schemes under revised program are:
A. Regional Cancer Centre Scheme.
B. Oncology Wing Development Scheme.
C. Decentralised NGO Scheme.
D. IEC activities at central level.
E. Research and Training.

CANCER SERVICES UNDER NPCDCS
1. Common diagnostic services, basic surgery, chemotherapy and palliative care for cancer cases in 100 district
hospitals.
2. Chemotherapy drugs for 100 patients at each district hospital.
3. Day- care chemotherapy being established at 100 district hospitals.
4. Facility for lab investigations including mammography is being provided at 100 district hospitals with option to
outsource at govt. rates if service not available at district hospital.
5. Home based palliative care for chronic , debilitating and progressive cancer patients at 100 districts.
6. Support through outsourcing for 1 medical oncologist, 1 cytopathologist, 1 cytopathology assistant, 2 nurses for
day care
7. State Cancer Institutes to provide comprehensive cancer diagnosis, treatment and care services. SCI to be the apex
institution.
8. 45 centres to be strengthened as Tertiary Cancer Centres for comprehensive Cancer Care.

CIGARETTES AND OTHER TOBACCO PRODUCTS (PROHIBITION OF
ADVERTISEMENT AND REGULATION OF TRADE AND COMMERCE,
PRODUCTION, SUPPLY AND DISTRIBUTION)ACT 2003
• Salient features of COTP Act are:
I. Prohibition of smoking in public spaces.
II. Prohibition of advertisement, sponsorship and promotion of tobacco products.
III. Prohibition of sale of tobacco to minors.
IV. Prohibition of sale of tobacco products near educational institutions.
V. Display of pictorial health warning on tobacco product. (covering 85% of packaging.)
VI. Regulation of tar and nicotine content in a tobacco product.

NATIONAL TOBACCO CONTROL PROGRAM
• National Tobacco Control Program (NTCP) in 2007- 08 in 42 districts of 21 States/Union Territories of the
country.
• Currently, the Program is being implemented in all States/Union Territories covering over 600 districts across the
country.
• NTCP is implemented through a three-tier structure, i.e.
 National Tobacco Control Cell (NTCC) at Central level
 State Tobacco Control Cell (STCC) at State level &
 District Tobacco Control Cell (DTCC) at District level. There is also a provision of setting up Tobacco Cessation
Services at District level

• The prevalence of tobacco use has reduced by six percentage points from 34.6% to 28.6% during the period from
2009-10 to 2016-17. The number of tobacco users has reduced by about 81 lakh (8.1 million).
• The Government launched the National Tobacco Cessation Quitline Services (1800-112-356) which aims to guide
tobacco addicts to quit tobacco.
• Large specified health warnings on tobacco products covering 85% on both side of the principal display area of
tobacco product packs and inclusion of Quitline Number.
• 'mCessation' initiative is being supported by Ministry to support tobacco users towards successful quitting
through text-messaging via mobile phones (011 22901701).
• Regulation of the use of Cigarettes and other tobacco products in films and TV programmes.
• Acceded to the Protocol to Eliminate Illicit Trade in Tobacco Products under the Article 15 of WHO FCTC.
• Issued an Advisory to ban Electronic Nicotine Delivery System (ENDS) including e-Cigarettes, Heat-Not-Burn
devices, Vape, e-Sheesha, e-Nicotine Flavoured Hookah, and the like devices that enable nicotine delivery except
for the purpose & in the manner and to the extent, as may be approved under the Drugs and Cosmetics Act, 1940
and Rules made thereunder.
• Established three National Tobacco Testing Laboratories
• Enacted The Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale,
Distribution, Storage and Advertisement) Act, 2019.

SUGGESTED READING
2011: Pulitzer Prize for General Nonfiction, winner.
2011: PEN/E. O. Wilson Literary Science Writing Award, winner (inaugural).
2011: Guardian First Book Award, winner.
2011: Wellcome Trust Book Prize, shortlist.
2010: New York Times Best Books of the Year.

LUNG CANCER
• Lung cancer, also known as lung carcinoma, is a malignant lung tumor characterized by uncontrolled
cell growth in tissues of the lung. This growth can spread beyond the lung by the process of
metastasis into nearby tissue or other parts of the body.
• The two main types are small-cell lung carcinoma (SCLC) and non-small-cell lung carcinoma
(NSCLC).
• Worldwide in 2012, lung cancer occurred in 1.8 million people and resulted in 1.6 million deaths.
This makes it the most common cause of cancer-related death in men and second most common in
women after breast cancer.

CLASSIFICATION OF LUNG CANCER
• Lung cancers are classified according to histological type.
• For therapeutic purposes, two broad classes are distinguished: non-small-cell lung carcinoma and
small-cell lung carcinoma.
Non Small Cell Carcinoma Small Cell Lung Carcinoma
Adenocarcinoma
In SCLC, the cells contain dense neurosecretory
granules (vesicles containing neuroendocrine
hormones), which give this tumor an endocrine or
paraneoplastic syndrome association. Most cases arise
in the larger airways (primary and secondary bronchi)
Squamous cell carcinoma
Large cell carcinoma
Pulmonary enteric carcinoma (RARE)

LUNG CANCER STAGING
Stage I A and I B Stage II A Stage II B
One option for stage IIB lung cancer, with
T2b; but if tumor is within 2 cm of
the carina, this is stage 3
Stage III A Stage IIIA lung cancer, if there is
one feature from the list on each
side

Stage III A
Stage III B
Stage III B Stage IV

SIGN AND SYMPTOMS
• Signs and symptoms which may suggest lung cancer include:
• Respiratory symptoms: coughing, coughing up blood, wheezing, or shortness of breath.
• Systemic symptoms: weight loss, weakness, fever, or clubbing of the fingernails.
• Symptoms due to the cancer mass pressing on adjacent structures: chest pain, bone pain, superior vena cava obstruction, or
difficulty swallowing.
• Depending on the type of tumor, paraneoplastic phenomena — symptoms not due to the local presence of cancer — may initially
attract attention to the disease.
• In lung cancer, these phenomena may include hypercalcemia, syndrome of inappropriate antidiuretic hormone (SIADH, abnormally
concentrated urine and diluted blood), ectopic ACTH production, or Lambert–Eaton myasthenic syndrome (muscle weakness due
to autoantibodies).
• Tumors in the top of the lung, known as Pancoast tumors, may invade the local part of the sympathetic nervous system, resulting
in Horner's syndrome (dropping of the eyelid and a small pupil on that side), as well as damage to the brachial plexus.

CAUSATIVE AGENTS OF LUNG CANCER
I. Smoking: Tobacco smoking is by far the main contributor to lung cancer. Cigarette smoke contains at least 73
known carcinogens eg: benzopyrene, NNK, 1,3-butadiene, polonium-210. Smoking accounts for about 85% of
lung cancer cases.
II. Radon gas: Radon is a colorless and odorless gas generated by the breakdown of radioactive radium, which in
turn is the decay product of uranium, found in the Earth's crust. The radiation decay products ionize genetic
material, causing mutations that sometimes become cancerous. Radon is the second most-common cause of lung
cancer in the US.
III. Asbestos: Asbestos can cause a variety of lung diseases such as lung cancer. Tobacco smoking and asbestos
both have synergistic effects on the development of lung cancer. In smokers who work with asbestos, the risk of
lung cancer is increased 45-fold compared to the general population. Asbestos can also cause cancer of the
pleura, called mesothelioma – which actually is different from lung cancer.

IV.Air Pollution: Outdoor air pollutants, especially chemicals released from the burning of fossil fuels,
increase the risk of lung cancer. Fine particulates (PM2.5) and sulfate aerosols, which may be
released in traffic exhaust fumes, are associated with a slightly-increased risk For nitrogen dioxide,
an incremental increase of 10 parts per billion increases the risk of lung cancer by 14%. Outdoor air
pollution is estimated to cause 1–2% of lung cancers.
V. Genetics: About 8% of lung cancer is caused by inherited factors. In relatives of people that are
diagnosed with lung cancer, the risk is doubled, likely due to a combination of genes.
Polymorphisms on chromosomes 5, 6, and 15 are known to affect the risk of lung cancer.
VI.Other causes: Certain metals (Aluminum, cadmium, beryllium). Certain gases ((methyl ether
(technical grade), and bis-(chloromethyl) ether, sulfur mustard, MOPP (vincristine-prednisone-
nitrogen mustard-procarbazine mixture), ubber production and crystalline silica dust.

DIAGNOSIS
1. Chest X-Ray: This may reveal an obvious mass, the widening of the mediastinum (suggestive of
spread to lymph nodes there), atelectasis (lung collapse), consolidation (pneumonia), or pleural
effusion.
2. CT imaging: may reveal a spiculated mass which is highly suggestive of lung cancer, and is also
used to provide more information about the type and extent of disease.
3. Bronchoscopic or CT-guided biopsy: often used to sample the tumor for histopathology.
The definitive diagnosis of lung cancer is based on the histological examination of the suspicious tissue
in the context of the clinical and radiological features.

PREVENTION
a. Smoking ban.
b. Screening.
c. For individuals with high risk of developing lung cancer, computed tomography (CT) screening can
detect cancer and give a person options to respond to it in a way that prolongs life.
d. Other prevention strategies: The long-term use of supplemental vitamin A, vitamin C, vitamin D or
vitamin E does not reduce the risk of lung cancer. Some studies have found vitamin A, B, and E may
increase the risk of lung cancer in those who have a history of smoking.

ORAL CANCER
• Epidemiology
• Oral cancer has a high frequency in central and south east Asian countries.
• Oral cancer is the third-most-common form of cancer in India with over 77 000 new cases
diagnosed in 2012.
• Studies estimate over five deaths per hour. One of the reasons behind such high incidence might be
popularity of betel and areca nuts, which are considered to be risk factors for development of oral
cavity cancers.
• Globally, it newly occurred in about 355,000 people and resulted in 177,000 deaths in 2018.Of these
355,000, about 246,000 are males and 108,000 are females.
• In 2013, oral cancer resulted in 135,000 deaths, up from 84,000 deaths in 1990.Oral cancer occurs
more often in people from lower and middle income countries

• The factors associated with oral cancer are:
Tobacco chewing or smoking are linked to oral cancer in about 90% of cases.
Alcohol has a synergistic effect in tobacco for oral cancer.
Some individual’s indigenous methods of smoking e.g.
Bidi, chillum, hookah and powder form as a snuff to inhale.
• Prevention: Early detection of cases and treatment.

CERVICAL CANCER
• Cancer of the cervix is the most common cancer among women globally.
• Worldwide, cervical cancer is both the fourth-most common cause of cancer and deaths from cancer
in women.
• In 2018, 570,000 cases of cervical cancer were estimated to have occurred, with over 300,000 deaths.
• It is the second-most common cause of female-specific cancer after breast cancer, accounting for
around 8% of both total cancer cases and total cancer deaths in women.
• About 80% of cervical cancers occur in developing countries. It is the most frequently detected cancer
during pregnancy, with an occurrence of 1.5 to 12 for every 100,000 pregnancies.

• The Disease:
• It is observed that cancer of cervix begins with Epithelial dysplasia and progresses to carcinoma in situ to
invasive carcinoma in 15-20years or more
• Causative Agent:
• HPV sexually transmitted is evidence to be the cause of cervical cancer. The virus is found in more than 95%
of the cancers.
• Risk factors
• Age: Women between the age group of 25- 45years are more affected.
• Genital Warts: Present and past occurrence of genital warts is a risk factor for cervix cancer.
• Early Marriage: Early Child bearing and repeated child births have been associated with increasing risk of
cervix cancer.
• Oral Contraceptives: A WHO study has found that users of oral Contraceptives with estrogen have increased
risk of cervix cancer
• Socio Economic Status: More common among women with lower Socio Economic Status, probably due to
poor personal and genital hygiene.

CANCER SUBTYPES
• Squamous cell carcinoma (about 80–85).
• adenocarcinoma (about 15% of cervical cancers in the UK).
• Adenosquamous carcinoma.
• Small cell carcinoma.
• Neuroendocrine tumour.
• Glassy cell carcinoma.
• Villoglandular adenocarcinoma.

PREVENTION
• Screening: Checking cervical cells with the Papanicolaou test (Pap test) for cervical pre-cancer has
dramatically reduced the number of cases of, and mortality from, cervical cancer.
• In the United States, screening is recommended to begin at age 21, regardless of age at which a
woman began having sex or other risk factors.
• Pap tests should be done every three years between the ages of 21 and 65.
• In women over the age of 65, screening may be discontinued if no abnormal screening results were
seen within the previous 10 years and no history of CIN2 or higher exists.
• HPV vaccination status does not change screening rates.

• Barrier protection
• Barrier protection or spermicidal gel use during sexual intercourse decreases, but does not eliminate
risk of transmitting the infection, though condoms may protect against genital warts. They also provide
protection against other sexually transmitted infections, such as HIV and Chlamydia, which are
associated with greater risks of developing cervical cancer.
• Vaccination
• Three HPV vaccines (Gardasil, Gardasil 9, and Cervarix) reduce the risk of cancerous or precancerous
changes of the cervix and perineum by about 93% and 62%, respectively. The vaccines are between
92% and 100% effective against HPV 16 and 18 up to at least 8 years.
• Nutrition
• Vitamin A is associated with a lower risk as are vitamin B12, vitamin C, vitamin E, and beta-Carotene.

BREAST CANCER
• Breast cancer most commonly presents as a lump that feels different from the rest of the breast tissue.
More than 80% of cases are discovered when a person detects such a lump with the fingertips. The
earliest breast cancers, however, are detected by a mammogram. Lumps found in lymph nodes located
in the armpits may also indicate breast cancer.
• Indications of breast cancer other than a lump may include thickening different from the other breast
tissue, one breast becoming larger or lower, a nipple changing position or shape or becoming inverted,
skin puckering or dimpling, a rash on or around a nipple, discharge from nipple/s, constant pain in part
of the breast or armpit and swelling beneath the armpit or around the collarbone.
• Pain ("mastodynia") is an unreliable tool in determining the presence or absence of breast cancer, but
may be indicative of other breast health issues.

Hyperdense tissue suggestive of Ca Breast ( In white)

• Another symptom complex of breast cancer is Paget's disease of the breast. This syndrome presents
as skin changes resembling eczema; such as redness, discoloration or mild flaking of the nipple skin.
As Paget's disease of the breast advances, symptoms may include tingling, itching, increased
sensitivity, burning, and pain. There may also be discharge from the nipple. Approximately half the
women diagnosed with Paget's disease of the breast also have a lump in the breast.
• Inflammatory Breast Cancer presents with similar effects. Inflammatory Breast Cancer is a rare (only
seen in less than 5% of breast cancer diagnosis) yet aggressive form of breast cancer characterized by
the swollen, red areas formed on the top of the Breast. The visual effects of Inflammatory Breast
Cancer is a result of a blockage of lymph vessels by cancer cells. This type of breast cancer is seen in
more commonly diagnosed in younger ages, obese women and African American women. As
inflammatory breast cancer does not present as a lump there can sometimes be a delay in diagnosis.

EPIDEMIOLOGY
• Worldwide, breast cancer is the most-common invasive cancer in women. Along with lung cancer,
breast cancer is the most commonly diagnosed cancer, with 2.09 million cases each in 2018.
• Breast cancer affects 1 in 7 (14%) of women worldwide.
• Breast cancer comprises 22.9% of invasive cancers in women and 16% of all female cancers.
• In 2012, it comprised 25.2% of cancers diagnosed in women, making it the most-common female
cancer.
• Breast Cancer is the most common cancer in women in India. 27.7% of all new cancers detected in
women in India in the year 2018, were breast cancers.

• One woman is diagnosed with breast cancer, in India, every 4 minutes.
• One woman dies of Breast cancer, in India, every 8 minutes.
• An estimated 1,62,468 women were newly detected with breast cancer, in India, for the year 2018.
87,090 women died of breast cancer in India, for the year 2018, the second highest in the world for that
year.
• India has a predominant young population and hence the numbers of women being diagnosed with
breast cancer, in that age group is only going to increase.

RISK FACTORS
• Risk factors are divided into 2 types. These are:
Modifiable Non Modifiable
Dietary: High fat, High salt diet Age
Alcohol and tobacco Sex
High multivitamin intake Genetic
High brassica vegetables
Radiation
miscelleneous

PREVENTION
• Change in lifestyle
• Women can reduce their risk of breast cancer by maintaining a healthy weight, reducing alcohol use,
increasing physical activity, and breast-feeding.
• These modifications might prevent 38% of breast cancers in the US, 42% in the UK, 28% in Brazil,
and 20% in China.
• The benefits with moderate exercise such as brisk walking are seen at all age groups including
postmenopausal women.
• High levels of physical activity reduce the risk of breast cancer by about 14%.

• Pre-emptive surgery
• Removal of both breasts before any cancer has been diagnosed or any suspicious lump or other lesion
has appeared (a procedure known as "prophylactic bilateral mastectomy" or "risk reducing
mastectomy") may be considered in women with BRCA1 and BRCA2 mutations, which are associated
with a substantially heightened risk for an eventual diagnosis of breast cancer.
• Removing the second breast in a person who has breast cancer (contralateral risk‐reducing
mastectomy or CRRM) may reduce the risk of cancer in the second breast, however, it is unclear if
removing the second breast in those who have breast cancer improves survival.
• Famous personality who underwent Pre-emptive surgery for Breast Cancer? Angelina Jolie.

• Medications
• The selective estrogen receptor modulators (such as tamoxifen) reduce the risk of breast cancer but
increase the risk of thromboembolism and endometrial cancer. There is no overall change in the risk of
death.
• They are thus not recommended for the prevention of breast cancer in women at average risk but it is
recommended they be offered for those at high risk and over the age of 35.
• The benefit of breast cancer reduction continues for at least five years after stopping a course of
treatment with these medications

MANAGEMENT OF BREAST CANCER
1. Surgery: Mastectomy, Quadrantectomy, Lumpectomy
2. Medication: Chemotherapy, Monoclonal antibodies therapy, Hormonal Therapy
3. Radiotherapy.

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