This presentation highlight the commonest risk factors for cancer and present the ways of early screening as well as the ways of how to prevent cancer

1. Cancer Early Screening and
Prevention
Zagazig University
Member of AGA, EASL and ISC-Hepatitis WG
April 4, 2019

3. Gut Brain Axis, Integrative Psychiatry. Accessed May 1st 2017
Diseases of Civilization
Multiple lines of study have shown that the primary cause of this
environmental associated inflammation may be dysfunction of the
"gut-brain axis.“ secondary to alteration of gut microbiota.

4. Did you know?
35 000 000
people died from
chronic diseases
in 2005
Preventing
CHRONIC DISEASES
a vital investment
58 000 000
Global mortality
worldwide
in 2005

5. o Cardiovascular disease,
mainly heart disease, stroke
o Cancer
o Chronic respiratory diseases
o Diabetes
Chronic diseases
Preventing
CHRONIC DISEASES
a vital investment

6. Definitions
• Cancer: Cancer is a group of diseases characterized by the
uncontrolled growth and spread of abnormal cells. If the
spread is not controlled, it can result in death.
• Screening: Checking for cancer (or for conditions that may
become cancer) in people who have no symptoms
• Surveillance: Screening of high risk patients
• Biomarkers: Serum (or tissue) molecules that
– Reveal the presence of a specific subclinical (asymptomatic)
disease
– Confirm its diagnosis when it is clinically suspected
– Predict the risk of disease development

8. Incidence and Prevalence of
Cancer

9. New Global Cancer Data: GLOBOCAN 2018
• New global cancer data suggests that the
global cancer burden has risen to 18.1 million
cases and 9.6 million cancer deaths.
• The International Agency for Research on
Cancer (IARC) estimates that one-in-five men
and one-in-six women worldwide will develop
cancer over the course of their lifetime.
• One-in-eight men and one-in-eleven women
will die from their disease.

10. • A number of factors appear to be driving this
increase, particularly a growing and ageing
global population and an increase in exposure
to cancer risk factors linked to social and
economic development.
• For rapidly-growing economies, the data
suggests a shift from poverty- or infection-
related cancers to those associated with
lifestyles more typical in industrialized
countries. ( Westernization )

11. Global Cancer Data 2018 (IARC)

12. Global Cancer Data 2018 (IARC)

18. Risk Factors

20. Age
• The most significant risk factor is age.
• According to cancer researcher Robert A.
Weinberg:
"If we lived long enough, sooner or
later we all would get cancer."
•

21. Carcinogens Associated With Cancer Development
• Cigarette/Tobacco Use
– Acute myelogenous leukemia
– Bladder
– Cervix
– Esophagus
– Kidney
– Lung
– Oral cavity
– Pancreas
– Stomach
• Infections
– Epstein-Barr virus
• Burkitt lymphoma
– Helicobacter pylori
• Gastric
– Human papillomavirus
• Anal
• Cervical
• Oropharyngeal
• Penile
• Vaginal
• Vulvar
– Hepatitis B and C
• Liver
• Immunosuppression
– Non-Hodgkin lymphoma
– Kidney
– Liver
– Lung
• Radiation
– Ionizing radiation
• Breast
• Hematologic malignancies (i.e.,
leukemia, lymphoma)
• Lung
• Thyroid
– UV radiation
• Melanoma
• Nonmelanoma skin cancers

22. Risk Factors Worldwide
• Smoking is the single most preventable cause of
death in the world, and around a third of
tobacco-caused deaths are due to cancer (2015
projected).
– Worldwide, 1 billion adults currently smoke
cigarettes.
• Alcohol drinking causes an estimated 6% of
deaths worldwide, around 1 in 8 of which are
due to cancer (2012). Alcohol drinking
prevalence is highest in Europe and America.

23. • Overweight and obesity prevalence is
increasing particularly in low- and middle-
income countries. Overweight and obesity are
leading causes of death worldwide.
• Unhealthy diets, e.g. low in fruit and
vegetables and high in salt, are becoming
more common in lower-resource countries.
• Infections cause 18% of the global cancer
burden, with a much higher proportion in low-
income countries.
• Ultraviolet and Ionizing Radiation

28. Cancer Prevention

29. KEY FACTS IN CANCER PREVENTION
• Most cancers develop as a result of exposure
to modifiable risk factors!
• Most cancers have a long detectable
preclinical phase which allows for early
detection and effective treatment!
• WHO estimates that 40% of all cancer deaths
are preventable.

30. Prevention
• Primary = directed to susceptibility stage
– Example: Needle exchange to prevent AIDS, HPV
vaccine
• Secondary = directed to subclinical stage
– Example: Screen for cervical cancer with Pap
Smear
• Tertiary = directed to clinical stage
– Example: Treat diabetic retinopathy to prevent
blindness

31. PRIMARY PREVENTION
• Vaccination
• Avoiding tobacco
• Skin protection
• Avoiding alcohol intake
• Keeping a healthy weight
• Healthy diet
• Decreasing exposure to environmental
carcinogens (radon, asbestos)

32. HPV vaccination
• The FDA approved a human papillomavirus
(HPV) vaccine for females aged 9–26 and
males aged 9–21. It protects against the HPV
types that most often cause cervical, vaginal,
vulvar, and anal cancers.

34. HBV Vaccination
• Hepatitis B is a liver disease caused by the
Hepatitis B virus (HBV). It ranges in severity
from a mild illness, lasting a few weeks
(acute), to a serious long-term (chronic) illness
that can lead to liver disease or liver cancer.
• The hepatitis B vaccine is available for all age
groups to prevent HBV infection.

35. AVOIDING TOBACCO
• Compared to nonsmokers, men who smoke are
about 23 times more likely to develop lung cancer
and women who smoke are about 13 times more
likely.
• Smoking causes about 90% of lung cancer deaths
in men and almost 80% in women.
• Smoking also causes cancer of the larynx, oral,
esophagus, bladder, kidney, pancreas, cervix, and
stomach, and causes acute myeloid leukemia.

36. SKIN PROTECTION
• Exposure to ultraviolet (UV) rays from the sun
and tanning beds appears to be the most
important environmental factor involved with
developing skin cancer.
• There is reasonably consistent evidence for a
positive association between intermittent sun
exposure and melanoma (RR=1.61).

37. AVOIDING ALCOHOL INTAKE
• Studies around the world have shown that drinking
alcohol regularly increases the risk of getting mouth,
voice box, and throat cancers. Daily consumption of
around 50g of alcohol doubles or triples the risk for
these cancers, compared with the risk in nondrinkers.
• A large number of studies provide strong evidence that
drinking alcohol is a risk factor for primary liver cancer,
and more than 100 studies have found an increased
risk of breast cancer with increasing alcohol intake. The
link between alcohol consumption and colorectal
(colon) cancer has been reported in more than 50
studies.

38. KEEPING A HEALTHY WEIGHT
• Research has shown that being overweight or
obese substantially raises a person's risk of
getting endometrial (uterine), breast,
prostate, and colorectal cancers.

39. HEALTHY DIET
• The EPIC (European Prospective study Into
Cancer) study is the largest study into diet and
cancer to date, and it involves over 500,000
people from 10 European countries who are
being followed for many years.
• Estimates show that one in every ten cancers is
caused by an unhealthy diet.
• Cancer preventive diet consist of:
– High intake of vegetables, fruits and fibers
– Low intake of red meat, salt

41. Secondary Protection

42. Early Diagnosis
• Early diagnosis of cancer generally increases
the chances for successful treatment by
focusing on detecting symptomatic patients as
early as possible.
• Delays in accessing cancer care are common
with late-stage presentation, particularly in
lower resource settings and vulnerable
populations.

43. Early diagnosis
Early diagnosis aims at reducing the proportion of
patients who are diagnosed at late stage. There are
three steps to cancer early diagnosis. Barriers exist
during each of these three steps, and interventions are
needed to address delays in care.

44. Screening
• Screening is defined as the identification
of unrecognized disease in an apparently
healthy, asymptomatic population by
means of tests, examinations or other
procedures that can be applied rapidly
and easily to the target population.
.

45. • For cancer screening to be effective,
screening tests must meet two
criteria.
1. First, the screening test must be able
to detect cancer at an earlier stage
than if it was detected as a result of
symptom development.
2. Second, evidence must support that
treatment given at an earlier stage
results in improved outcomes

46. • Potential harms from screening tests also
must be weighed against potential benefits.
– Some screening tests are invasive, such as
colonoscopy for colon cancer, and carry risks
associated with any invasive procedure, including
some serious if not life-threatening complications
(such as bowel perforation with colonoscopy).
– Other potential harms include the emotional
anxiety associated with false-positive results and
the dangers of missing an early malignancy with
false-negative test results.
• The financial cost of different screening tests
varies widely.

47. • Multiple organizations have published
screening guidelines for a variety of
malignancies, both for average-risk and
high-risk populations.
• In general, consensus exists among
screening recommendations for the most
common malignancies, including breast,
cervical, colorectal, lung, and prostate
cancer.

48. Selected Cancer Screening Recommendations for Average-Risk
Population (American Cancer Society )

49. Selected Cancer Screening Recommendations for Average-Risk
Population (American Cancer Society )

51. Screening for HCC

52. Epidemiology of Liver Cancer
• Liver cancer is the sixth most common cancer
worldwide
• An estimated 841,100 new liver cancer cases
diagnosed during 2018.
• Liver cancer rates are the highest in Eastern and
South-Eastern Asia, Micronesia, West and Central
Africa, and Egypt .
• Worldwide, liver cancer is the second-leading
cause of cancer death in men and the sixth-
leading cause among women, with about 781,600
deaths in 2018.

53. Risk Factors
• HCC is strongly associated with:
– Chronic infection with HBV or HCV.
– Heavy alcohol drinking,
– Excess body weight,
– Type 2 diabetes,
– NAFLD(associated with obesity),
– Smoking
– Consumption of food contaminated with aflatoxin
– Infection with parasitic liver flukes, which causes
cancer of the bile ducts (cholangiocarcinoma).

54. Prevention and early detection
• vaccine that protects against HBV has been available
since 1982. The WHO recommends that all countries
include the HBV vaccine in routine infant immunization
programs. By the end of 2016, 186 countries had
introduced the HBV vaccine into their national infant
immunization schedules,101 with most countries
achieving more than 80% coverage for the full
recommended dose .
• There is no vaccine available to prevent HCV infection.
• Antiviral therapies for HBV or HCV infection can
substantially reduce cancer risk among those already
infected.

55. • HCV prevention strategies include
– screening of blood, organ, and tissue donors for
antibodies to HCV;
– adherence to infection control practices during all
medical, surgical, and dental procedures; and
– needle exchange programs for injection drug
users.
• Globally, an estimated 95% of people living with
chronic viral hepatitis are unaware of their status; in
its Global Health Sector Strategy on Viral Hepatitis
2016-2021, the WHO recommends that all countries
integrate hepatitis testing into their national policies
and guidelines.

56. • Additional preventive strategies include
avoiding smoking and alcohol
consumption.
• In lower-HDI countries, liver cancer can
be prevented by reducing aflatoxin
contamination of foods and preventing
and treating parasitic infections with liver
flukes.

57. Whom to Screen for HCC?
• Groups suitable for screening
– Hepatitis B carriers
• Asian males
̃ 40 years ( incidence 0.4 – 0.6 %
/year)
• Asian females
̃ 50 years ( incidence 0.2 % /year)
• Africans over age 20 ( incidence unknown but likely >
0.2 %/year)
• Cirrhosis (HCC incidence 3-5 %/year)
• Family history of HCC – mainly Asian and African

58. • Groups suitable for screening
– Non-hepatitis B cirrhosis
• Hepatitis C
– Incidence of HCC 3-5% / yeay
• PBC
• Alcoholic cirrhosis
• Genetic hemochromatosis
• Alpha1 antitrypsin deficiency
• Autoimmune hepatitis
Whom to Screen for HCC?

59. • Imaging modalities (US)
• Serum biomarkers
How to Screen for HCC?

73. What should we do now?
EASL 2018
AASLD/IDSA 2018
Surveillance for hepatocellular carcinoma with twice-yearly
ultrasound examination is recommended for patients with
advanced fibrosis (ie, Metavir stage F3 or F4) who achieve
SVR. (I, C)
Patients with advanced fibrosis (F3) or cirrhosis (F4) with
SVR should undergo surveillance for HCC every 6 months
by means of ultrasound (A1).

74. Conclusion
• Cancer prevention and screening can prevent
many cancers and detect precancerous or early-
stage cancers, significantly reducing morbidity
and mortality. Developing an appropriate cancer
screening and, if appropriate, prevention plan,
should be part of routine preventive care
medicine.
• Cancer prevention strategies are available for
women who have the BRCA1 and/or BRCA2
mutation or other high-risk features.

75. • Low-dose aspirin (75–100 mg by mouth
daily or 100–325 mg by mouth every
other day) is recommended for adults
age 50–59 with a life expectancy of at
least 10 years and not at risk of bleeding
to prevent CRC; adults age 60–69 may
also benefit.
• Polyps should be removed, when
detected, to prevent CRC development.

76. • The HPV vaccine should be administered to adults
age 22–26 who are immunocompromised, to
prevent HPV related cancers.
• Routine cancer-screening recommendations are
available for breast, cervical, CRC, lung, and
prostate cancer in both patients at average risk
and those at high risk.
• For HCC Screening should be with US only and
screening interval should be 6 months.

78. ۷۸
Monkez M Yousif