Hlw it helps you all to get knowledge regarding cancer.

2.  At the end of the Teaching students should be able to :
 - Define Cancer.
 identify the prevalence of cancer.
 list risk factors and etiology.
 Enumerate the warning sign of cancer.
 Describe types of cancer.
Lerarning Objectives

3.  Cancer may regarded as a group of diseases characterized by an
 Abnormal growth of cells
 Ability to invade tissue and even distant organs
 The eventually death of the affected patient if the tumor has progressed
beyond the stage when it can be successfully removed
Introduction

4.  Cancer is among the leading causes of death worldwide. In 2012, there were 14
million new cases and 8.2 million cancer-related deaths worldwide.
 The number of new cancer cases will rise to 22 million within the next two
decades.
 More than 60 percent of the world’s new cancer cases occur in Africa, Asia, and
Central and South America; 70 percent of the world’s cancer deaths also occur in
these regions.
 In 2016, an estimated 1,685,210 new cases of cancer will be diagnosed in the
United States and 595,690 people will die from the disease.
 The number of new cases of cancer (cancer incidence) is 454.8 per 100,000 men
and women per year (based on 2008-2012 cases). The number of cancer deaths
(cancer mortality) is 171.2 per 100,000 men and women per year (based on 2008-
2012 deaths).
Prevalence

5. Cancer Services in Nepal
SN Male Female
1 Lung Cervix
2 Oral Breast
3 Stomach lung
Pradhanga et al, 2005
Oncology in Nepal was heralded in 1991 when
country’s 1st radiation therapy center started
with instillation of telecobalt at Bir Hospital,
Kathmandu along with the 1st and single
oncologist in the country, Prof. Tara
Manandhar.

6.  The establishment of Bhaktapur Cancer Care Center in 1992, which was later
converted to Bhaktapur Cancer Hospital (BCH) by Nepal Cancer Relief Society
(NCRS) with the support from Rotary Clubs, local people of Bhaktapur and the
Government of Nepal.
 NCRS has now established its branches in 43 districts of Nepal and has been
mobilizing over 10,000 volunteers nationwide.
 Considering treatment of cancer in Nepal, at present, there are only 4 centers in
the country treating cancer patients with the radiation therapy facilities, thus
providing a huge load of radiation services every day.
-BPKMCH, Manipal Teaching Hospital, Bir Hospital & Bhaktapur Cancer Hospital
National Cancer Hospital, Jawlakhel(2009PrivateComprehensivecare)
Cancer Services in Nepal

7.  In United States:(American Cancer Society,2016)
- Bladder Cancer
- Breast Cancer
- Colon & Rectal Cancer
- Endometrial Cancer
- Kidney Cancer
- Leukemia
- Lung Cancer
- Non Hodgkin’s Lymphoma
Common Cancer

8.  In Nepal:(NCRS)
- Cervical Cancer 13.03% death rate
- Lung Cancer 11.92%
- Breast Cancer 8.13%
- Oral Cancer 6.225
- Stomach Cancer 5.60%
- Ovary Cancer 5.13%
- Lymphomas 3.97%
Common Cancer

9. Risk Factors & Etiology
 Non Modifiable
- Age
- Sex
- Genetic factor
 Modifiable
- Tobacco
- Chronic infection
- Alcohol drinking
- Occupational exposure
- Dietary factors
- Obesity and physical exercise
- Radiation
- Medical drugs and procdures
- Lifestyle

10. Tobacco Consumption
- Main single cause of human cancer worldwide
- Accounts for 30% approx of all human cancer in developed
countries.
- Responsible for 13 types of cancer: lung, oral cavity, nasal cavity
and nasal sinuses, pharynx, larynx, oesophagus, stomach,
pancreas, liver, urinary bladder, kidney, uterine cervix and myeloid
leukaemia.
- Any form of tobacco are risk( smoking, SHS, chewing)
- Benefit of quitting tobacco in adulthood for all kind of major
cancer.
worldl cancer report, 2008 IARC

11. Chronic infection
- Approx 15- 20% of cancer worldwide: 26% in developing
countries, 8% in developed countries.
- Common cancer associated with chronic infection: HCC- HBV
HCV,Cervical cancer and other malignancy- HPV, Lymphoma-
EBV, Leukemia- HTLV, Kaposi sarcoma- HHV8, Gastric cancer- H.
Pylori, Bladder cancer- schistosomiasis
oxford text book of public health, 5th edition

12. Alcohol Drinking
- Global burden of cancer attributed to alcohol -3.6%
- A causal association has been established between alcohol
drinking and cancers of the oral cavity, pharynx, larynx,
esophagus, liver, colon, rectum and, in women, breast
- For all cancer sites, risk if the function of amount of alcohol
consumption
oxford text book of public health, 5th edition

13. Dietary Factors, Obesity and Physical
activities
- Responsible for 25% of human cancers in high income countries but
exact role of dietary factors for causing cancer remains largely
obscure.
- Increased weight gain is associated with cancer of colon, gall
bladder, postmenopausal breast, endometrium, kidney and
esophagus.
- Increasing physical activities decrease the risk of the breast and
colon cancer
oxford text book of public health, 5th edition

14.  Smoked fish is related to stomach cancer
 Dietary fiber to intestinal cancer
 Beef consumption to bowel cancer
 High fat diet to breast cancer
 Food additives and contaminants have fallen under
suspicion as causative agents
Dietary factor

15.  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
Occupational exposures

16.  Hepatitis B & C - hepatocarcinoma
 HIV infection – kaposi’s carcinoma
 AIDS – non Hodgkin’s lymphoma
 Epstein – bar virus – Burkitts lymphoma and naso –
pharyngial carcinoma
 Cytomegalovirus – Kaposi’s Sa
 Pappiloma virus – cervix cancer
 Human T cell leukemia virus – T cell leukemia
Virus

17.  Parasite
 May be a cause of cancer
 Schistosomiasis can produce Ca of bladder
 Customs, habits and life style
 May be associated with an increased risk of cancer
 Smoking and lung cancer
 Tobacco and beetle chewing and oral cancer
Contd…

18.  Others
 Sunlight, radiation, water and air pollution, medication
and pesticides
 These are related to cancer as environmental factors
Contd….

19. Reproductive factor and exogenous
hormone
- Reproductive factors(Age at menarch, age at first child, number of
pregancy, age at last child, and age at menopause) strongly
associated with cancer of breast, ovaries and endometrium.
- Exogenous estrogens and progestin's in combination as HRT in
menopause and in steroid contraceptives increase the risk of breast
and ovarian cancers.
- OCP exert long term protection for ovarian and endometrial cancer
but increase risk for cervical and liver cancer.
oxford text book of public health, 5th edition

20. Genetic Factor
 Cancer susceptical genes may be oncogenes, tumor suppressor
gene, risk modifier genes.
 oncogenes are genes where either over-expression or gain of
function mutations contribute to tumorigenesis.
 Tumour suppressor gene: genes where either under-expression or
loss of function mutations contribute to tumorigenesis. melanoma
predisposition gene CDKN2A (p16), BRCA1, TP53
World cancer Report 2008 IARC

21. Others
 Ionizing and non ionizing radiation
 Medical procedures and drugs
 Sunlight

22. Warning Signs
- WeightChanges(Loss): Oesophagus ,Lung ,Pancrease Stomach
- Fever or Blood Loss : Leukemia Lymphoma or stomach
- Pain & Tiredness: Colon Prostate, Ovaries Rectum
- Persistent Cough; Lung Cancer & Thyroid
- Skin Changes;
Remember CAUTION for Warning signs
C= Change in Bowel or bladder habits
A=A sore that does not healing in given normal time
U= Unusual bleeding or discharge
T=Thickening of mass or lump
I= Indigestion, difficulty in swallowing
O= Obvious change to moles or wart
N=Nagging cough

23.  Major categories of cancer are
 Carcinoma
 Arises from the epithelial cells lining the internal surface of various organs
(e.g. mouth, oesophagus, uterus)
 Sarcoma
 Arises from the mesodermal cells constituting the various connective
tissues (e.g. fibrous tissue, bone)
 Lymphoma, myeloma and leukemia
 Arising from the cells of the bone marrow and immune system
Categories of Cancer

24. TYPES: BENIGN /MALIGNANT

26. Characteristics of Benign Tumour
• Cells tend not to spread
• Most grow slowly
• Do not invade nearby tissue
• Do not metastasize (spread) to other parts of
the body
• Tend to have clear boundaries

27. • Under a pathologist's microscope,shape,chromosomes, and
DNA of cells appear normal.
• Do not secrete hormones or other substances
(an exception: pheochromocytomas of the adrenal
gland)
• May not require treatment if not health threatening
• Unlikely to recure if removed or require further treatment
such as radiation or chemotherapy

28. Characteristics of Malignant Tumor
• Cells can spread
• Usually grow fairly rapidly
• Often invade basal membrane that surrounds
healthy tissue.
• Can spread via bloodstream or lymphatic system.

29. • May recur after removal, sometimes in areas other the original
site.
• Cells have abnormal chromosomes and DNA
characterized by large, dark nuclei; may have abnormal shape.
• Can secrete substances that cause fatigue and weight
loss (paraneoplastic syndrome).
• May require aggressive treatment, including surgery, radiation,
chemotherapy, and immunotherapy medications.

31. T U M O R S A N D T I S S U E T Y P E S

35.  Staging is the process of finding out how much cancer is in a
person’s body and where it’s located. It’s how the doctor
determines the stage of a person’s cancer.
 to know the amount of cancer and where it is in the body to be
able to choose the best treatment options.
 Staging is done on the basis of location, physical exam & etc
Overall stages grouping (Roman Staging):
 -Stage I: cancers are small localized cancers that are usually curable.
 Stage II & III: usually locally advanced and/or with involvement of
local lymph nodes.
 Stage IV: represents inoperable or metastatic cancer.
Stages of Cancer

36. TNM Staging System
T= T Classifies the extent of the primary tumor, and is normally given
as T0 through T4.
- T0 represents a tumor that has not even started to invade the local
tissues. This is called "In Situ".
- T4 on the other hand represents a large primary tumor that has
probably invaded other organs by direct extension, and which is
usually inoperable.
Stages of Cancer

37. TNM Staging System
- TX means the tumor can’t be measured.
- T0 means there is no evidence of a primary tumor (it cannot be
found).
- Tis means that the cancer cells are only growing in the most
superficial layer of tissue, without growing into deeper tissues. This
may also be called in situ cancer or pre-cancer.
- Numbers after the T (such as T1, T2, T3, and T4) might describe the
tumor size and/or amount of spread into nearby structures.
-
- The higher the T number, the larger the tumor and/or the more it
has grown into nearby tissues.
Stages of Cancer

38. TNM Staging System
N= N classifies the amount of regional lymph node involvement.
- Involvement of distant lymph nodes is considered to be metastatic
disease.
- N0 means no lymph node involvement while N4 means extensive
involvement.
Stages of Cancer

39. TNM Staging System:
 NX means the nearby lymph nodes cannot be evaluated.
 N0 means nearby lymph nodes do not contain cancer.
 Numbers after the N (such as N1, N2, and N3) might describe the
size, location, and/or the number of nearby lymph nodes affected
by cancer.
 The higher the N number, the greater the cancer spread to nearby
lymph nodes.
Stages of Cancer

40. TNM Staging System
M= M is either M0 if there are no metastases or M1 if there are
metastases.
- M0 means that no distant cancer spread was found.
- M1 means that the cancer has spread to distant organs or tissues
(distant metastases were found).
Stages of Cancer

41. Tumor Grading:
- Tumor grade refers to a measure of how abnormal cells from your
tumor appear under the microscope.
- This can refer to the appearance of the cells or to the percentage
that appear to be dividing.
- The higher the grade, the more aggressive and fast growing the
cancer.
- Tumors are typically classified from least to most aggressive as
grade I through IV.
Tumor Grading

42. Staging:
 Stage 0: carcinoma in situ, derived from the Latin
phrase meaning “in its place”
 Stage I: Tumor limited to the tissue of origin, localized
tumor growth
 Stage II: Limited tissue spread
 Stage III: extensive local and regional spread
 Stage IV: Metastasis

43. Grading:
Grade I: cells differ slightly from normal cells and are
well differentiated (mild dysplasia)
Grade II: cells are more abnormal and are moderately
differentiated (moderate dysplasia)
Grade III: cells are very abnormal and are poorly
differentiated (severe dysplasia)
Grade IV: cells are immature (anaplasia) and
undifferentiated; cells of origin is difficult to determine

44. TNM classification:
 T describes the size of the tumor and whether
it has invaded nearby tissue
 N describes regional lymph nodes that are
involved
 M describes distant metastasis

45. Mandatory parameters
 T (a, CIS,(0),1–4): size or direct extent of the primary tumor
 N (0–3): degree of spread to regional lymph nodes
 N0: tumor cells absent from regional lymph nodes
 N1: regional lymph node metastasis present; (at some sites: tumor
spread to closest or small number of regional lymph nodes)
 N2: tumor spread to an extent between N1 and N3
 N3: tumor spread to more distant or numerous regional lymph
nodes
 M (0/1): presence of metastasis
 M0: no distant metastasis
 M1: metastasis to distant organs (beyond regional lymph nodes)

46. A lowercase ‘c’ or ‘p’ is used in the TNM system to denote
whether a cancer is in the clinical or pathologic stage.
 Clinical Stage: Clinical stage cancers are identified using all of
the information that isprocured before the surgical removal of the
tumor. This information may include the results of a physical
examination and certain imaging tests.
 Pathologic Stage: The identity of pathologic stage cancers has
been embellished by the addition of information gained through
histological (microscopic) evaluation of tissue samples.
 Using the TNM system, a patient with a ‘cT1N0M0’ cancer would
have a clinical stage T1 tumor with no lymph node involvement
and no metastasis.

47. IMAGING TESTS USED TO
DETECT CANCER
• TEST : Tumor marker identification
• DESCRIPTION : Analysis of substances found in the blood
or other body fluids that are made by the tumor or by the
body in response to the tumor
• DIAGNOSTIC USES : Breast, colon, lungs, ovaries, testes,
protest

48. • TEST : Magnetic resonance imaging (MRI)
• DESCRIPTION : Use of magnetic fields and radiofrequency
signals to create sectioned images of various body structures
• DIAGNOSTIC USES : Neurologic, pelvic, abdominal,
thoracic cancers

50. • TEST : Computed tomography (CT scan)
• DESCRIPTION : Use of narrow beam x-ray to
scan successive layers of tissue for a cross-
sectional view
• DIAGNOSTIC USES : Neurologic, pelvic, skeletal,
abdominal, thoracic cancers

52. • TEST : Fluoroscopy
• DESCRIPTION : Use of x-rays that identify contrasts in body
tissue densities; may involve the use of contrast agents.
• DIAGNOSTIC USES : Skeletal, lung, gastrointestinal cancers

54. • TEST : Ultrasonography (ultrasound)
• DESCRIPTION : High-frequency sound waves echoing off
body tissues are converted electronically into images; used to
assess tissues deep within the body.
• DIAGNOSTIC USES : Abdominal and pelvic cancers

55. • TEST : Endoscopy
• DESCRIPTION : Direct visualization of a body cavity or
passageway by insertion of an endoscope into a body cavity or
opening; allows tissue biopsy, fluid aspiration and excision of
small tumors; both diagnostic and therapeutic.
• DIAGNOSTIC USES : Bronchial, gastrointestinal cancers

57. • TEST : Nuclear medicine imaging
• DESCRIPTION : Uses intravenous injection or ingestion of
radioisotope substances followed by imaging of tissues that
have concentrated the radioisotopes.
• DIAGNOSTIC USES : Bone, liver, kidney, spleen, brain,
thyroid cancers.

59. • TEST : Positron emission tomography (PET scan)
• DESCRIPTION : Computed cross-sectional images of
increased concentration of radioisotopes in malignant cells
provide information about biologic activity of malignant
cells; help distinguish between benign and malignant
processes and responses to treatment.
• DIAGNOSTIC USES : Lung, colon, liver, pancreatic, breast,
esophagus cancers; Hodgkin’s and non-Hodgkin’s lymphoma
and melanoma.

61. • TEST : Radioimmunoconjugates (Radio-immuno-conjugates)
• DESCRIPTION : Monoclonal antibodies are labeled with a
radioisotope and injected intravenously into the patient; the
antibodies that aggregate at the tumor site are visualized with
scanners
• DIAGNOSTIC USES : Colorectal, breast, ovarian, head and
neck cancers; lymphoma and melanoma

62. Cancer Prevention and control
 Four Strategies: WHO
- Primary Prevention
- Early Detection and Secondary Prevention
- Diagnosis and Treatment
- Palliative Care
Gobal cancer facts and figures 2007 ACS

63. Primary Prevention
 Goal: to reduce or eliminate exposure to cancer-causing factors
 Approaches :
- Immunization against, or treatment of, infectious agents that
cause certain cancers- HBV and HPV vaccine, eradication
treatment of H. pylori
- application of effective tobacco control measures
- reduction of excessive alcohol consumption
- maintenance of healthy body weight and physically active
lifestyles
- reduction in occupational exposure to carcinogens
- pharmacological intervention
Gobal cancer facts and figures 2007 ACS

64. Secondary Prevention
 Cancer Registration
- Provide base for assessing the magnitude of the
problem and for planning necessary services
- Two types: Hospital based Registries and Population
based Registries
Cancer Epidemiology: Principle and Methods IARC

65. Early Detection of Cases
 Objective: to detect pre-cancerous changes or early stage cancer
when they can be treated most effectively
 Two strategies of cancer screening
- Opportunistic Screening: Physician or individual
- Organized screening: Mass screening or selective screening
Cancers that have proven early detection methods include cervix,
colon and rectum, and breast
Global cancer facts and figures 2007 ACS

66. Diagnosis and Treatment
 Cancer diagnosis first step in cancer management
 Cancer staging
 Treatment- surgery, Radiotherapy, Chemotherapy ,
Hormonal therapy
Gobal cancer facts and figures 2007 ACS

67. Palliative care
 70% of cases presented in hospital at advance stage-
Goal: To improve quality of life of the patients & relief
of sufferings
To decrease the problems faced by the
families psychologically
To prolong the life
Gobal cancer facts and figures 2007 ACS

68.  It consists of prevention, detection, diagnosis,
treatment, after care and rehabilitation, reducing
incidence and prevalence
 Primary control
 Reducing the exposure to the risk factors
 Control of Tabaco and alcohol consumption
 Control of these two will reduce the total burden of cancer
by 1 million cases per year
Cancer control

69.  Personal hygiene
 Improvement in hygiene may decline the incidence of certain
types of cancers
 Radiation
 Effort should be made to reduce the amount of radiation
received by each individuals to a minimum without reducing
the benefits
 Occupational Exposure
 Should protect workers from exposure to industrial
carcinogens
Contd…..

70.  Food, drugs, and cosmetics
 Should be tested for carcinogens
 Air pollutions
 Control of air pollution is a preventive measure
 Treatment of pre cancerous lesions
 Early detection and prompt treatment of precanerous
lesions
Contd……

71.  Cancer Education
 Should be directed in high risk groups
 To motivate people for early diagnosis and treatment
 Remind early warning symptoms
 A lump or hard area in the breast
 A change in a wart or mole
 A persistent change in digestive and bowel habits
 A persistent cough or hoarseness
 Excessive loss of blood at the monthly period or loss of blood
outside the usual dates
 Blood loss from any natural orifice
 A swelling or sore that does not get better
 Unexplained loss of weight
Contd…..

72. Thank you
Who is the one smoking