Cancer

• Cancer may be regarded as a group of diseases
having following characteristics
1) Abnormal growth of cells.
2) Ability to invade the adjacent tissues
and even distant organs (metastasis).
3)Eventual death of the patient when the
tumor has gone to the stage which is
inoperable.
4) Cancer can occur at any site of the tissue of the body
and may involve any type of cells or tissues.

• The major categories of cancers are
1)Carcinomas(epithelial linings of the
internal surfaces of the various organs.
2) Sarcomas:- Arise from mesodermal
cells constituting the various connective
tissues i.e. Fibrous tissue, fat and bone).
3) Lymphomas ,Myelomas, Leukemias
arising from the cells of bone marrow.

• Primary tumor:- The tumor arising from the organ of
origin.
• Secondary Tumor:- The cancer that has spread from
the regional lymph nodes and distant organs.
• When cancer cells multiply and reach a critical size,
the cancer is clinically evident as a lump or ulcer
localized to the organ of origin in early stages.
• As the disease advances, symptoms and signs of
invasion and distant metastasis becomes clinically
evident.

• Cancer affects all communities worldwide, approximately 10
million people are diagnosed with cancer and more than 6
million die of the disease every year.
• The most cancer in the world is Lung cancer ( 12.3% of all
cancers), Breast cancer ( 10.4%) and Colo-rectal cancer is
9.4%.
• Lung cancer accounts for the highest mortality in the world
with poor prognosis.
• Breast cancer which is second among the cancer, is not among
the top 3 cancer deaths in the world.
• Among the Cancer deaths, the highest is the cancer of lung,
then comes the Stomach and next is liver.

• Male predominance cancer are the
1) Lung cancer
2) Stomach
3) Esophageal
4) Bladder cancer

• There is little sex difference in the cancer
between Pancreas and Colorectal cancer.
• The total burden of cancer is in effluent
countries( Developed) and is due to Smoking
and western life styles i.e. Cancer of the
Lung, Colo-rectum, Breast and Prostate.
• In developing countries, the burden of
disease is due to chronic infections like
Hepatitis B infections (Liver cancer), Human
Papilloma virus (Cervical cancer) and
Helicobacter Pylori infections ( Stomach
Cancer)

• INDIAN SCENARIO
The National Cancer Registry Programme of the
ICMR provides data on incidence from five
populations based registries and One rural based
registry at Barshi Maharashtra.
It is estimated that at any point of time,2-2.5 million
cases of cancer in India at given point of time, with
around 7-9 lakh new cases detected each year.
Nearly half of cases die each year.
These, population based studies shows that
Tobacco related deaths were prevalent among
males.
The number of cancer cases among males is estimated
to be 3.9 lakh and among females 4.3 lakh.

• Mortality data from Cancers from these
population based studies:-
The deaths were
25.19/ 100,000population for males
and
23.52/ 100,000 population for females .

• The four most frequent cancers in males in India are
1) Mouth/ Oropharynx
2) Esophagus
3) Stomach
4) Lower Respiratory tract(Trachea/ Bronchus/ Lungs)
The four most frequent cancers in females in India are
1) Cancers of the cervix (poor genital hygiene, early
marriage, multiple pregnancies and contact with
multiple sexual partner)
2) Breast (New metropolitan areas and is related to late
marriage, Late birth of first child , fewer children and shorter
period of breast feeding which are the common practice among the
educated Urban women.)
3) Mouth/ Oropharynx
4) Oesophagus

• Time Trend:-
At the beginning of the century, cancer
was the Sixth cause of death in
Industrialized countries now it is
Second most leading cause of death.
The Three main causes are
1) Longer life expectancy
2) more accurate diagnosis
3) Rise in cigarettes smoking

• The multiple factors attributed to this are
1) Environmental factors
2) Food habits
3) Life–style
4) Genetic factors
5) Inadequacy of detection and reporting
of cases.
The cancer patterns worldwide shows that
1) Cancer in the stomach is highest in Japan and lowest
in USA.
2) Cervical cancer is high in Columbia and has a low
incidence in Japan.
3) In SEAR countries, the commonest cancer is Oral Cavity and
Uterine cervix.

• Causes of Cancer:-
Multifactorial causes
Environmental factors
a) Tobacco( Smoking and Chewing), The organs involved are lung,
Larynx, Mouth, pharynx, Oesophagus, Bladder, Pancreas and
probably kidney. Whole Cigarette smoking is responsible for 1 million
Premature deaths each year.
b) Alcohol (esophageal and Liver cancer), Beer consumption may be
associated with rectal cancer.
c) Dietary factors like smoked fish is related to Cancer
stomach. Dietary fibre is associated with intestinal cancer and
beef consumption to bowel cancer .A high fat diet is associated
with Breast cancer. Food additives and contaminants are under
suspicion of causing some types of cancer.

• Occupational Exposures:- These include exposure to
Benzene, arsenic, cadmium, chromium, Vinyl chloride, asbestos,
Polycyclic hydrocarbons etc. It gives rise to 1 to 5% of all human
cancers.
• Viruses:-Hepatitis B or C (HCC) and kaposi sarcoma
in HIV/AIDS.Non- Hodgkin’s Lymphoma of the lymph
nodes and Spleen is a late complications of HIV/AIDS.
• Epstein – Barr virus is associated with two important
cancers i.e. Burkitt’s Lymphoma and Naso-pharyngeal
carcinoma.
• Cyto-megalo virus(CMV) is associated with classical
Kaposi’s sarcoma.
• Human papilloma virus is chief suspect in cancer cervix.
The Human T – cell Leukemia/Lymphoma virus is
associated with adult T-cell leukemia / lymphoma in the
USA and Southern stares of Japan.

• Parasitic infections:-Schistomiasis infection
of the bladder in middle east is causing Bladder
tumor or carcinoma of bladder.
• Other examples are customs, habits and life styles
which may cause increased risks of cancer like
Smoking. Tobacco chewing.
• Numerous other environmental factors are Sunlight,
radiation, Air and water pollution.
• Medications like estrogen and Pesticides are also
incriminated to be related cancer.

Genetic factors:-
Retinoblastoma occurs in children of the same
parent.
Mongols are more likely to develop ( leukemia) tgan
other children.
CANCER CONTROL:-1)Prevention 2) Detection 3)
diagnosis 4) treatment 5) After care 6) Rehabilitation
Primary prevention is more concerned with the Early
diagnosis and Treatment and probably at the pre-
cancerous stage.

• A) Control of tobacco and Alcohol
consumption .
B) Personal Hygiene
C) Radiation
D) Occupational exposure
E) immunization
F) Avoidance of carcinogens in food stuff
G) Treatment of pre-cancerous lesions like Cervical
tears, Intestinal polyposis, warts, Chronic gastritis
,Chronic cerviciitis, Adenomata are the cornerstones of
cancer prevention.
H) Cancer education for high risk groups , the aim of
cancer education is to motivate the people regarding
seeking early diagnosis and treatment

• Early warning signs( Danger Signals) of
Cancer
a) A lump or hard area in the breast
b) A change in a wart or mole
c) A persistent change in digestive and
bowel habits
d) A persistent cough or hoarseness of voice.
e) Excessive loss of blood at the monthly period or loss of blood
outside the usual dates.
f) Blood loss from any natural orifices.
g) A swelling or sore throat does not get better.
i) Unexplained weight loss.

CANCER REGISTRATION
• Cancer registration is the Sine qua non for any cancer
control program. It provides a base for assessing the
magnitude of the problem and for planning the
necessary services.
• Cancer registries are of Two types
1) Hospital -based registries (all patients treated both In
patients and Out- patients)
2) Population- based registries (Population of 2 to 7
-million)

• Early Detection of Cases
Cancer detection by screening is the main
tool for early diagnosis at a pre-invasive
stage( in situ) or pre- malignant stage.
Effective screening program is there for
Cervical , Breast and Oral cancer.
Treatment of cancers is Multi- modalities
like Surgery, Chemotherapy or
Radiation.

• Methods of Cancer screening
a) Mass screening by comprehensive screening
detection examination : a rapid clinical examination
and examination of one or more body sites by the
physician is one of the important approaches for
screening for cancer.
b) Mass screening at single sites such as Uterine cervix,
Breast and or Lung.
c) Selective screening for High risk people, for example,
parous women of lower Socio-economic strata upwards
of 35 years of age for detection of cancer
cervix, Chronic smokers for lung cancer.

•SCREENING FOR
CANCER CERVIX

• The prolonged early phase of cancer inprolonged early phase of cancer in
–situ can–situ can be detected by Pap smear.
• All women must undergo pap test at
the beginning of Sexual activity, and
then every 3 years thereafter.
• A periodic pelvic examination is also
advised.

• The problems posed by screening for
cancer cervix. These are related to
disease and test .
• There are Two related problems to this
disease frequency with which
“Carcinoma in situ” progresses to
Cervical cancer and that frequency with
which how many “Cervical cancer are
also preceded by abnormal smears”.

• There are two problems to this test, One is “Response
rate” and the “Sensitivity test”.
• The “Response rate” for the test is more in case of
educated women(50 to 60%) and least among the poor
uneducated women from poor-socio–economic status
who are more vulnerable for the disease.
• The Sensitivity (True Positives )of the test is around
80% and False negative test is 20%.

• SCREENING FOR BREAST CANCER
1) Self Breast examination by the patient.
2) Palpation by the physician
3) Thermography
4) Mammography

• “Thermography” is good because as the
patient is not exposed to radiation.
• “Mammography” is good in the sense
that very small tumors which are missed
on deep palpation are diagnosed by this.

Breast Cancer Symptoms
• There are often no symptoms of breast cancer,
but sometimes women may discover a breast
problem on their own. Signs and symptoms to
be aware of may include:
• A painless lump in the breast.
• Changes in breast size or shape.
• Swelling in the armpit.
• Nipple changes or discharge.
• Breast pain can also be a symptom of
cancer, but this is not common.

• Signs of Inflammatory Breast
Cancer
• Inflammatory breast cancer is a rare,
fast-growing type of cancer that often
causes no distinct lump. Instead,
breast skin may become thick, red, and
may look pitted -- like an orange peel.
The area may also feel warm or tender
and have small bumps that look like a
rash.

Breast Cancer & Mammograms
• The earlier breast cancer is found, the easier it is to
treat. And mammograms, X-rays of the breast, can
detect tumors before they are large enough to feel. The
American Cancer Society recommends yearly
mammograms beginning at age 40 for women at
average risk. While the U.S. Preventive Services Task
Force recommends a screening mammogram every two
years from age 50 to 74. It also notes that before age 50,
each woman should check with a doctor to find out what
screening schedule is right for her, considering the
potential benefits and harms from screening.

• Breast Ultrasound and MRI
• Besides a mammogram, your doctor may
order additional imaging with breast
ultrasound. An ultrasound can help
determine the presence of cysts, fluid-
filled sacs that are not cancer. An MRI
may be recommended along with a
mammogram for routine screening in
certain women who have a higher risk of
breast cancer.

• Breast Self-Exams
• It was once widely recommended that
women check their own breasts once a
month. But studies suggest these breast
self-exams play a very small role in finding
cancer. The current thinking is that it's
more important to know your breasts and
be aware of any changes, rather than
checking them on a regular schedule. If
you want to do breast self-exams, be sure
to go over the technique with your doctor.

• What If You Find a Lump?
• First, don't panic. Eighty percent of breast
lumps are not cancerous. Lumps often
turn out to be harmless cysts or tissue
changes related to your menstrual cycle.
But you should let your doctor know right
away if you find anything unusual in your
breast. If it is cancer, the earlier it's found
the better. And if it's not, testing can give
you peace of mind.

• Breast Biopsy
• The only sure way to determine whether a
lump is cancer is to do a biopsy. This
involves taking a tissue sample for further
examination in the lab, sometimes through
a small needle. Sometimes surgery is
done to take part of or the entire lump for
testing. The results will show whether the
lump is cancer, and if so, what type. There
are several forms of breast cancer, and
treatments are carefully matched to the
type of cancer.

Hormone-
Sensitive Breast
Cancer

• Some types of breast cancer are fueled
by the hormones estrogen or
progesterone.
• A biopsy can reveal whether a tumor has
receptors for estrogen (ER-positive)
and/or progesterone (PR-positive).
• About two out of three breast cancers
are hormone sensitive.
• There are several medications that keep
the hormones from promoting further
cancer growth.

•The image below shows a molecular model of an estrogen receptor.

• HER2-Positive Breast Cancer
• In about 20% of patients, breast cancer
cells have too many receptors for a protein
called HER2. This type of cancer is known
as HER2-positive, and it tends to spread
faster than other forms of breast cancer.
It's important to determine whether a
tumor is HER2-positive, because there are
special treatments for this form of cancer.
• A HER2-positive breast cancer cell is
illustrated here, with abnormal growth
signals shown in green.

• Breast Cancer Stages
• Once breast cancer has been diagnosed, the
next step is to
a) Determine how big the tumor is ?
b) How far the cancer has spread. This process
is called “Staging”.
c) Doctors use Stages 0-4 to describe whether
cancer is localized to the breast, has
invaded nearby lymph nodes, or has
spread to other organs, such as the lungs.
d) Knowing the stage and type of breast cancer
will help your health care team formulate a
treatment strategy.

• Breast Cancer Survival Rates
• The odds of surviving breast cancer are strongly
tied to how early it is found.
• According to the American Cancer Society,
100% of women with Stage 1 breast cancer
live at least five years, compared to women
without cancer – and many women in this
group remain cancer-free for good.
• The more advanced the cancer, the lower this
figure becomes.
• By Stage 4, the five-year relative survival rate
declines to 20%.
• But these rates can improve as more effective
treatments are found.

• Breast Cancer Surgery
• There are many types of breast cancer surgery,
from taking out the area around the lump
(lumpectomy)
or
• Breast-conservation surgery)
to
• removing the entire breast (mastectomy).
• It's best to discuss the pros and cons of each of
these procedures with your doctor before
deciding what's right for you.

• Radiation Therapy for Breast Cancer
• It uses high-energy rays to kill cancer
cells. It may be used after breast cancer
surgery to wipe out any cancer cells that
remain. It can also be used along with
chemotherapy for treatment of cancer
that has spread to other parts of the body.
• Side effects - fatigue and swelling or a
sunburn-like feeling in the treated area.

Chemotherapy for Breast Cancer
• Chemotherapy uses drugs to kill cancer cells
anywhere in the body. The drugs are often
given by IV, but are sometimes taken by
mouth or shot.
• Chemotherapy may be done after surgery to
lower the odds of the cancer coming back.
• In women with advanced breast cancer,
chemotherapy can help control the cancer's
growth.
• Side effects :- hair loss, nausea, fatigue, and
a higher risk of infection.

• Targeted Drugs for Breast Cancer
• Targeted therapies are newer drugs that
target specific properties within cancer
cells. For example, women with HER2-
positive breast cancer have too much of a
protein called HER2. Targeted therapies
can stop this protein from promoting the
growth of cancer cells. These drugs are
often used in combination with
chemotherapy. They tend to have milder
side effects compared to chemotherapy.

• Life After Diagnosis
• There's no doubt that cancer is a life-
changing experience. The treatments can
wear you out. You may have trouble
managing daily chores, work, or social
outings. This can lead to feelings of
isolation. It's crucial to reach out to friends
and family for support. They may be able
to go with you to treatments, help out with
chores, or just remind you that you are not
alone. Many people choose to join a
support group -- either locally or online

• Breast Reconstruction
• Many women who have a breast removed
choose to undergo reconstructive surgery.
This replaces the skin, nipple, and breast
tissue that are lost during a mastectomy.
Reconstruction can be done with a breast
implant or with tissue from somewhere
else in your body, such as the tummy.
Some women opt to begin reconstruction
at the same time as their mastectomy. But
it's also possible to have reconstructive
surgery months or years later.

• Medical Author: Melissa Conrad Stöppler
, MD
Medical Editor:
Charles P. Davis, MD, PhD
• A research study presented at the Fourth
AACR Conference on the Science of
Cancer Health Disparities in September
2011 revealed an association between
psychological stress and one of the most
aggressive types of breast cancer.

• The study was performed on 989 women with
breast cancer. Two to three months after
diagnosis, the women were asked to rate their
degree of anxiety, fear, and isolation. These self-
reported stress scores were higher for black and
Hispanic women than in white women. Further,
those women who reported having higher levels
of stress tended to have more aggressive
tumors (defined as being negative for the
presence of estrogen receptors, meaning that
therapies designed to block the effects of
estrogen will not be effective) than those with
lower stress levels. The association between
stress level and aggressive tumors was strong

• Oral cancer is one of the most common cancer in the
world. It has hig frequency in the central and South- East
Asia, e.g. Central and South East Asian countries like
Bangladesh, Srilanka, Thailand, Indonesia and Pakistan.
• Each year, 5,75,000 new cases and 3,35,000 deaths
occur worldwide.
Problem in India
12.48 cases per 1,00,000 population for males
and 5,52 per 100,000 population in females.
Mortality due to Oral Cancer in India
3.48 per 100,000 males and 1.34 per 1,00,000
in females.

• Epidemiological features
1) Tobacco, it causes some types of pre-cancerous
lesions and the site of occurrence is the mouth where
tobacco quid was kept.
the risk was 36 times higher than non- chewers , as the
quid was kept during sleep.
2) Alcohol (Synergistic effect with tobacco)
3) Pre-cancerous stage( Leukoplakia and
Erythroleukoplakia)
4) High- risk groups
5) Cultural patterns (Bidi, Chilum, Hookah. The most
common form of Tobacco taken is“Quid”. The next
common variety is called as Khaini.

• The picture on the slide below shows a
Cancer of the uvula in a patient that had
a 75 pack year history of smoking and
consumed alcohol. Both smoking and
alcohol are risk factors for oral cancer.
• This patient also had a Second cancer in
his lungs and eventually developed
spread of the cancer to his brain.

• The picture on the below is from a 22 year old male
who has used over 1 can per day of snuff for the past
15 years.
• He has high blood pressure from the
vasoconstrictive (contraction of blood vessels) effect
of nicotine and gastro- esphageal reflux disease
(stomach acid coming up from the stomach towards
the mouth) which is also made worse from using
tobacco products. The picture below shows extensive
Leukoplakia forming between his gums and lips.
• This is a Pre-cancerous condition and if it does not
resolve with his cessation of using tobacco products, it
will need to be surgically removed.

The picture on the below shows a patient undergoing a jaw, tongue,
neck operation. The lip is split and the neck skin and cheeks are
reflected. The jaw, tongue, neck and part of the soft palate and uvula
can then be removed.

• Causes and risk factors for cervical cancer have been identified and
include human Papillomavirus (HPV) infection, having many sexual
partners, smoking, taking birth control pills, and engaging in early
sexual contact.
• HPV infection may cause cervical dysplasia, or abnormal
growth of cervical cells.
• Regular pelvic exams and Pap testing can detect precancerous
changes in the cervix.
• Precancerous changes in the cervix may be treated with
Cryosurgery, Cauterization, or Laser surgery.
• The most common symptoms and signs of cervical cancer are
abnormal bleeding and pelvic pain.
• Cervical cancer can be diagnosed using a Pap smear or other
procedures that sample the cervix tissue.

the most common noxious components in
Cigarettes are
a) Carbon Monoxide
b) Nicotine
c) radio isotope substanxces

• Screening for Lung Cancer
There two techniques for screening Lung cancer viz,
Chest radiograph and sputum cytology.
Mass radiography has been suggested for early
diagnosis at Six monthly intervals but evidence in this
regard is not convincing.
Risk factors:-
Cigarette smoking :- It is 8.6 times higher in Smokers than Non-
Smokers.
The factors responsible are
1) Age of starting of smoking
2) No of cigarettes smoked
3) Nicotine amount
4) Tar content
5) Length of cigarettes

Cancer

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