Role of primary physicians in early detection of cancer

1. 1

2. BURDEN OF CANCER IN INDIA
• India has nearly three times the incidence of US and China for head
and neck and cervical cancers.
• Real cancer incidence in India is conservatively estimated to be 1.5 to
2.0 times higher than the reported incidence by Indian cancer
registries i.e. 1.1 million in 2015.
• India’s age-standardized cancer incidence estimated at 150-200 per
100,000 population is higher than Africa and on par with China.
• Breast and cervical cancers among women, and head and neck, lung
and gastrointestinal cancers among men, represent >60% of the
incidence burden.
Ref: Call for Action: Expanding cancer care in India. 2015. Executive Summary.
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5. INDIA FACES A SERIOUS CHALLENGE OF
HIGH INCIDENCE RATES COUPLED WITH
LOW DETECTION
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9. 9

10. INDIA IS EXHIBITING A DETERIORATION
OF THE KEY RISK FACTORS THAT
CONTRIBUTE TO CANCER INCIDENCE
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12. REPORTED CANCER INCIDENCE IN INDIA
IS ESTIMATED TO INCREASE FROM;
90 PER 100,000 POPULATION TO 130-
170 PER 100,000 POPULATION BY 2020,
WHICH WILL MIRROR INCIDENCE RATES
OF CHINA AND OTHER DEVELOPING
COUNTRIES. 12

13. MORTALITY RATES OBSERVED IN INDIA
CAN BE ATTRIBUTED TO POOR DIAGNOSIS
AND INADEQUATE TREATMENT
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15. KEY FACTORS IMPACTING MORTALITY RATES
• Poor awareness levels resulting in ulcers being ignored by
many patients, consequently delaying diagnosis.
• Lack of overt presentation of symptoms and standard
screening tests results in poor detection rates.
• In addition, physicians, who are the first point of contact for
such patients, may not be adequately aware or trained to
detect and refer, or treat these patients.
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16. PRIMARY CARE PHYSICIAN ROLE AS
“SECURITY OFFICER-
(FIRST CONTACT PERSON)”
in ONCOLOGY SERVICES
THE ROLE IN EARLY DIAGNOSIS
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17. • Cancer screening and early detection.
• A major challenge for physicians:
– Symptoms of many cancers are common in the
community and overlap with prevalent benign
conditions.
• Physicians need to;
– Assess the risk, or diagnostic probability, of an
underlying cancer and determine whether further
investigation is justified. 17

18. 18
Ref: Jon D. Emery, et al. The role of primary care in early detection
and follow-up of cancer. 2014. Nat. Rev. Clin. Oncol. (11)38–48.

19. • Understanding of the epidemiology of cancer symptoms
in primary care:
– Analysis by UK general practice databases:
• QCancer Research:
–Freely available on websites www.qcancer.org
–Risk models for men and women that estimate
risks of multiple cancers according to baseline
risk factors, patterns of symptoms and specific
clinical conditions.
–It can be incorporated into English in physicians
computer systems of their potential clinical
utility.
19
Ref: Emery JD, et al. The role of primary care in early detection and follow-
up of cancer. 2014. Nat. Rev. Clin. Oncol. (11)38–48

20. • Primary care has a pivotal role in facilitating uptake
(by improve screening), which can be enhanced
using:
– Audit and feedback systems
– Office prompt systems
– General practitioner endorsement.
• Education and Training:
– Understanding of epidemiology of cancer symptoms.
– Risk models can be applied to identify patients requiring
investigation for cancer. 20

21. • Fast-track referral routes might be a useful approach
to reducing diagnostic delay in cancer.
• Primary care-led follow-up of breast and colorectal
cancer is as effective as hospital-led care, but
requires clear guidance for general practitioners, as
well as good communication and access to
specialists.
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22. BREAST CANCER
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23. • Women having more clinician office visits were:
– 50% less likely to have late-stage cancer diagnosed.
– 41% lower breast cancer mortality.
– 27% lower overall mortality.
• Breast cancer Patients had better outcomes if they made
greater use of a primary care physician’s ambulatory
services, i.e.
– Including greater use of mammography
– Reduced odds of late stage diagnosis
– Lower breast cancer and overall mortality.
23
Ref: Roetzheim RG, et al. Influence of Primary Care on Breast Cancer Outcomes
Among Medicare Beneficiaries. 2012. Ann Fam Med;10:401-411.

24. Ref: Gale J. Inside India’s cancer epidemic. CancerWorld; (63) Nov-Dec 2014.
24

25. Forms in the
tissues of the
breast
BREAST CANCER
Spreads mainly
through the
Lymphatic system
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26. • Malignant
• Cancerous
BREAST TUMORS
 Benign
 Not - Cancerous
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27. • Not cancerous.
• Benign breast tumors are abnormal growths, but
they do not spread outside of the breast and they
are not life threatening.
BENIGN TUMORS
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28. • Most lumps are caused by the combination of cysts and
fibrosis
• Cysts are fluid-filled sacs.
• Fibrosis is the formation of scar - like tissue.
• These changes can cause breast swelling and pain.
BENIGN TUMORS
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30. • Breast cancer is a malignant (cancerous) tumor that
starts in the cells of the breast. It is found mostly in
women, but men can get breast cancer, too.
BREAST TUMORS
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31. BREAST CANCER
Invasive
• Cancerous
• Malignant
• Spreads to other
organs (metastasis)
Non - Invasive
• Pre – Cancerous
• Still in its original
position
• Eventually develops into
invasive breast cancer.
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32. GENDER - All
women are
at risk
Age
Family/Personal
History
Reproductive
History
Menstrual
HistoryRace
Genetic
Factors
Breast Cancer Risk Factors
unalterable factors
Radiation
Treatment with
DES
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33. All
women are
at risk
Obesity
Breastfeeding
Not having
children
Birth Control
Pills
Alcohol
Hormone
Replacement
Therapy
Exercise
Obesity
Breastfeeding
Not having
children
Birth Control
Pills
Alcohol
Hormone
Replacement
Therapy
Breast Cancer Risk Factors
that can be controlled
Exercise
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34. • Screening by mammography and physical examination
• Early Diagnosis: 25 to 30 % decrease in mortality over
age of 50 years & probably in btw age of 40-50 years.
• American Cancer Society, the National Cancer Institute
recommend;
– Annual Mammography For > 40 yrs
– High-risk families, with BRCA1 or BRCA2 mutant at;
• 25 years of age or 5 years earlier
• Standard method for confirming diagnosis:
• fine-needle aspiration or core needle biopsy
DIAGNOSTIC APPROACHES
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35. Diagnostic tests and procedures for
breast cancer include:
• Breast exam
• Mammograms
• Breast ultrasound
• Breast MRI scan
• Biopsy
METHODS OF DIAGNOSIS
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36. Clinical Breast
Examination(CBE)
Breast Self
Examination (BSE)
BREAST EXAMINATIONS
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37. • Women in their 20s and 30s should have a clinical
breast exam every 3 years.
• After age 40, women should have a breast exam
every year
CLINICAL BREAST EXAMINATIONS
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39. • BSE is an option for women starting in their 20s.
• Any changes detected should be reported to a
medical expert.
• BSE: Conducted standing or reclining
BREAST - SELF EXAMINATION
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42. BREAST IMAGING
TECHNIQUES
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43. • An x-ray of the breast.
• It uses a very small amount of radiation.
Mammograms
screening diagnosis
MAMMOGRAMS
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44. • A technologist will position your breast for the test.
• The breast is pressed between 2 plates to flatten and
spread the tissue.
• The pressure lasts only a few seconds while the picture
is taken.
• The breast and plates are repositioned and then another
picture is taken.
• The whole process takes about 20 minutes.
MAMMOGRAMS
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47. • Uses sound waves to outline a part of the body.
• The sound wave echoes are picked up by a computer to
create a picture on a computer screen.
• Used to investigate areas of concerns found by a
mammogram.
BREAST ULTRASOUND
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49. BREAST ULTRASOUND
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50. • Alcohol consumption
• Physical exercise
• Diet
• Postmenopausal hormone therapy
• Bodyweight
• Breast cancer screening
• Breastfeeding
PREVENTION
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51. CONCLUSION
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52. • It is estimated that 70% or 80% of cancer could be
controlled if preventive measures which primarily
involve lifestyle modification and early diagnostic
procedures could be instituted in all our population.
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53. • PCPs must adopt an:
– Evidence based protocol
– Engage the patient
– Most importantly commit resources to
institutionalize clinical cancer prevention and early
detection policy.
• If the patient at risk can be convinced that:
– their lives will be longer, better, and more
productive because of prospective health care, they
will be more likely to seek this kind of care and
advice from their PCP on a continuing basis. 53

54. REFERENCES
1. Emery JD, et al. The role of primary care in early detection and follow-up of cancer. 2014. Nat. Rev.
Clin. Oncol. (11)38–48. Available online at: http : / / www.nature.com /nrclinonc /journal /v11
/n1/full/nrclinonc.2013.212.html
2. Klabunde CN, et al. The Role of Primary Care Physicians in Cancer Care. 2009. J Gen Intern Med
24(9):1029–36. Available online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2726889/
3. Gale J. Inside India’s cancer epidemic. CancerWorld; (63) Nov-Dec 2014. Available online at:
http://www.cancerworld.org / Articles /Issues /63/ November-December-2014/Best-Cancer-
Reporter-Award/688/Inside-Indias-cancer-epidemic.html
4. Roetzheim RG, et al. Influence of Primary Care on Breast Cancer Outcomes Among Medicare
Beneficiaries. 2012. Ann Fam Med;10:401-411. Available online at:
http://www.ncbi.nlm.nih.gov/pubmed/22966103
5. American Cancer Society Breast Cancer Screening Guideline (2015). Available online at:
http://www.cancer.org/ healthy/ information for health care professionals /acsguidelines
/breastcancerscreeningguidelines/index
6. Call for Action: Expanding cancer care in India. 2015. Executive Summary. Available online at:
http://www.ey.com/Publication/vwLUAssets/EY-Call-for-action-expanding-cancer-care-in-
india/$FILE/EY-Call-for-action-expanding-cancer-care-in-india.pdf
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55. THANKS
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