Cancer Prevention and Early Detection - ICEDOCicedoc.org/March_2008/Rabab Gaafar_Cancer Prevention...

Cancer Prevention and Early Cancer Prevention and Early Detection:

Rabab Gaafar,MD

Prof. Medical OncologyNCI,Cairo, Cairo University

Director Early Detection UnitDirector Early Detection Unit

Prevention and Early DetectionPrevention and Early Detection

Definition

Goals of Cancer Prevention and Control

Magnitude of the Problem

Local Strategies to fight Cancer

Breast Cancer early detection

Breast cancer Prevention Elderly

Prevention and Early DetectionPrevention and Early DetectionDefinition






DefinitionDefinition"primary" prevention (intervention for relatively healthy individuals with no invasive cancer and an average risk for developing cancer).

" d " ti (i t ti f ti t d t i d b "secondary" prevention (intervention for patients determined by early detection to have asymptomatic, subclinical cancer).

"tertiary" prevention (symptom control rehabilitation or other tertiary prevention (symptom control, rehabilitation, or other issues in patients with clinical cancer .

Cancer prevention science and practice are just beginning to gain public, academic, t d i d t iti j t f l government and industry recognition as a major aspect of oncology .

Cancer prevention spans a wide range of disciplines, including population, behavioral, and social sciences; diagnostics; and clinical therapeutics (chemoprevention, risk

d ti ) reduction).

Diverse training and skills are required to fully address the spectrum of carcinogenesis and its control.

Risk-based management is the process of determining the best cancer prevention approaches for specific cancer risks

PreventionPrevention

-Cancer can be caused by a number of factors-May develop over a number of years.-Some risk factors can be controlledSome risk factors can be controlled.-Choosing the right health behaviors-preventing exposure to certain environmental risk factorscan help prevent the development of cancercan help prevent the development of cancer.-For this reason, it is important to follow national trends

data to monitor the reduction of these risk factors.

Early Detection

The use of screening tests to detect cancers early may allow patients to obtain more effective treatment with fewer side effects. Patients whose cancers are found early and treated in a timely manner are more likely to survive these cancers than are those whose cancers are not found until symptoms appear until symptoms appear.



Magnitude of the Problemg




ASCO Strategic Plan 2004–2007: Goal C P ti d C t l Cancer Prevention and Control

Advocate for rapid worldwide reduction and ultimate elimination of tobacco products Advocate for rapid, worldwide reduction and ultimate elimination of tobacco products and exposure to environmental tobacco smoke, in collaboration with other organizations and professional societies

Increase core knowledge about cancer risk and risk reduction through new education Increase core knowledge about cancer risk and risk reduction through new education initiatives

Promote clinical, behavioral, and translational research, and education and training in cancer prevention and controlcancer prevention and control

Work to eliminate healthcare disparities in cancer risk assessment and early detection

Provide prevention-oriented messages for individuals with a prior history of cancer and for the general public

Economic Benefit of Cancer Prevention / Early Detection

Improves beneficiary health

Averts direct medical costs

Reduces lost productivity

Reduces disability

Reduces employee turnover

Reduces excess medical costs from related conditions, complications, or sequelae

Leading causes of death

23.2

31.0Heart Diseases

Cancer

4 2

4.8

6.8Cerebrovascular Diseases

Chronic Obstructive Lung Diseases

A id t

2.8

3.9

4.2Accidents

Pneumonia & Influenza

Diabetes Mellitus

1 1

1.1

1.3Suicide

Nephritis

Cirrhosis of the Liver 1.1

Percentage of Total Deaths, USPercentage of Total Deaths, US

Cirrhosis of the Liver

Developed CountriesDeveloped Countries

2006 Estimated US Cancer Cases*

Men720,280

Women679,510

31% Breast31% Breast

12% Lung & bronchus

11%Colon & rectum

Prostate 33%

Lung & bronchus 13%

Colon & rectum 10%6% Uterine corpus

4% Non-Hodgkinlymphoma

4% M l f ki

Urinary bladder 6%

Melanoma of skin 5%

Non-Hodgkin 4% l h 4% Melanoma of skin

3% Thyroid

3% Ovary

lymphoma

Kidney 3%

Oral cavity 3%2% Urinary bladder

2% Pancreas

22% All Other Sites

Leukemia 3%

Pancreas 2%

All Other Sites 18%

*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2006.

Lifetime Probability of Developing Cancer, by Site, Men, 2000-2002*

Site RiskAll sites† 1 in 2Prostate 1 in 6Lung and bronchus 1 in 13Colon and rectum 1 in 17Urinary bladder‡ 1 in 28Non-Hodgkin lymphoma 1 in 46Melanoma 1 in 52Melanoma 1 in 52Kidney 1 in 64Leukemia 1 in 67Oral Cavity 1 in 73Stomach 1 in 82

* For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002.

Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

‡ Includes invasive and in situ cancer cases† All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder.

Lifetime Probability of Developing Cancer, by Site, Women, US, 2000-2002*

Site RiskAll sites† 1 in 3Breast 1 in 8Lung & bronchus 1 in 17Colon & rectum 1 in 18Uterine corpus 1 in 38Non-Hodgkin lymphoma 1 in 55Ovary 1 in 68Ovary 1 in 68Melanoma 1 in 77Pancreas 1 in 79Urinary bladder‡ 1 in 88Uterine cervix 1 in 135

Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

* For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002.† All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder.‡ Includes invasive and in situ cancer cases

U S Cancer MortalityU.S. Cancer Mortality

Lung & bronchus 32% 25% Lung & bronchusLung & bronchus 32%Prostate 10%Colon & rectum 10%P 5%

25% Lung & bronchus15% Breast10% Colon & rectum6% OvaryPancreas 5%

Leukemia 5%NH lymphoma 4%E h 4%

6% Ovary6% Pancreas4% Leukemia3% NH l hEsophagus 4%

Liver & bile duct 3%Urinary bladder 3%

3% NH lymphoma3% Uterine corpus2% Multiple myeloma2% B i /ONSKidney 3%

All other sites 21%2% Brain/ONS24% All other sites

American Cancer Society, 2004

Cancer Death Rates*, for Men, US,1930-2002

100 Rate Per 100,000

80 Lung

40

60

StomachProstate

20

40Colon & rectum

Pancreas

0

930

935

940

945

950

955

960

965

970

975

980

985

990

995

000

Pancreas

LiverLeukemia

*Age-adjusted to the 2000 US standard population.Source: US Mortality Public Use Data Tapes 1960-2002, US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2005.

19 19 19 19 19 19 19 19 19 19 19 19 19 19 20

Cancer Death Rates*, for Women, US,1930-2002

100Rate Per 100,000

80

40

60

LungUt

20

40

Colon & rectum

Uterus

Stomach

Breast

0

930

935

940

945

950

955

960

965

970

975

980

985

990

995

000

Ovary

Pancreas

*Age-adjusted to the 2000 US standard population.Source: US Mortality Public Use Data Tapes 1960-2002, US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2005.

19 19 19 19 19 19 19 19 19 19 19 19 19 19 20

Tobacco Use in the US, 1900-2002

5000 100Male lung cancer

3000

3500

4000

4500

5000

onsu

mpt

ion

60

70

80

90

100

ance

r Dea

th

Per capita cigarette consumption

death rate

1500

2000

2500

3000

apita

Cig

aret

te C

o

30

40

50

60

Adj

uste

d Lu

ng C

aRa

tes*

Female lung cancer death rate

0

500

1000

1900

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

Per

C

0

10

20

Age

-A

2

Year

*Age-adjusted to 2000 US standard population. Source: Death rates: US Mortality Public Use Tapes, 1960-2002, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2005. Cigarette consumption: US Department of Agriculture, 1900-2002.

Five-year Relative Survival (%)* during Three Time Periods By Cancer Site

All sites 50 53 65

Site 1974-1976 1983-1985 1995-2001

Breast (female) 75 78 88

Colon 50 58 64

Leukemia 34 41 48

Lung and bronchus 12 14 15

Melanoma 80 85 92

Non Hodgkin lymphoma 47 54 60Non-Hodgkin lymphoma 47 54 60

Ovary 37 41 45

Pancreas 3 3 5

†

Prostate 67 75 100

Rectum 49 55 65

Urinary bladder 73 78 82y

*5-year relative survival rates based on follow up of patients through 2002. †Recent changes in classification of ovarian cancer have affected 1995-2001 survival rates.Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control andPopulation Sciences, National Cancer Institute, 2005.

Why?

• Better screening for prevention and early detection

• Better diagnostics/imaging technology

• Better treatments

• Better drugs and understanding how to use them—and how not to use them

• Better availability of care

Scientists estimate that as many as 50 to 75 percent of cancer deaths in USA are caused by human behaviorssuch as smoking, physical inactivity, and poor dietary choices.

Not using cigarettes or other tobacco products: Not drinking too much alcoholNot drinking too much alcoholEating five or more daily servings of fruits and vegetablesEating a moderate-fat dietConsuming a diet in which total calories eaten are balanced with calories expended by physical activityMaintaining or reaching a healthy weightg g y gBeing physically activeProtecting skin from sunlight

Future

19 % decline in the rate at which new cancer cases occur 19 % decline in the rate at which new cancer cases occur

29 % decline in the rate of cancer deaths could potentially be achieved by 2015 if efforts to help people change their behaviors that y p p p gput them at risk were stepped up and if behavioral change were sustained.

Thi ld t t th ti f i t l 100 000 This would equate to the prevention of approximately 100,000 cancer cases and 60,000 cancer deaths each year by the year 2015.

Developing CountriesDeveloping Countries

Estimated cancer incidences in the EM region

Most common sites in Males Females

10

10

17

8

11

11

16

9

10

12

17

Leukemia

Lymphoma

Liver

Bladder

6

5

35

7

6

38

6

6

38

Lymphoma

Leukemia

Breast

7

5

6

8

3

4

6

8

4

4

5

6

Soft tissue

Colorectal

Lung

Leukemia

20032002

2001

4

4

5

6

4

4

4

4

4

4

5

Colorectal

Ovary

Bladder

20032002

2001

3

3

3

3

3

3

2

3

4

0 5 10 15 20

Bones

Larynx

Skin

3

6

4

2

3

2

4

2

3

3

4

Thyroid

Cervix

Soft tissue

Liver

Percent of cases 22

0 10 20 30 40 50

Thyroid

Percent of cases

NCI, Cairo

Causes of the Growing Cancer BurdenCauses of the Growing Cancer Burden

Aging populations

Impact of infectious diseases

Increased tobacco use and pollutionp

Nutrition and lack of physical activity

Aging Populations

2050

2000

1950

5% 10% 15% 20%

Percentage of global population 60 and olderPercentage of global population 60 and older

Cancer and the Environment

Tobacco10

4

6

8

10

DevelopingNationsDe eloped

0

2

4

2000 2030

DevelopedNations

1500

2000

2500

3000

Developed

Annual deaths from tobacco

0

500

1000

1500

1970-72 1980-82 1990-92

Developing

Annual number of cigarettes consumed per adult

ChichaChichain the 90’s :

new flavored tobacco + satellites/electronic media = new fashion

1h chicha session = 70 to 200 cigarettes

Water does not filtrate carcinogens g(carbon monoxide, heavy metals, other carcinogens)

h l d h charcoals produce their own toxicants

Second hand smoke = tobacco smoke + charcoals smoke

Pollution

Etiologic Factors of HCCEtiologic Factors of HCC

Prevalence of schistosomiasisin Egypt: 1935-2003

40%

25

30

35

15

20

25

0

5

10

01980 1985 1990 1995 2000 2005

Action needed

Study of the viral etiology of HCCand the role played by HBV and HCV (possibly a

lti ti l ti t d )multinational comparative study).

• HBV vaccination specially children and high risk groups.

• Proper follow up of hepatitis patients, specially cirrhotic for early detection of p y yHCC.

The National Cancer InstituteCairo UniversityCairo University

www.nci.cd.edu.eg

Cairo University National Cancer Institute

Main StrategiesNCI Cairo UniversityNCI , Cairo University

Management: Diagnosis and TreatmentCancer RegistryEducation: Training and degree-granting g g g gprogramsResearch: Basic science, Population, and Clinical studies of National InterestPrevention and early detection

Key PointKey Point

Detecting cancer in its initial stages presents the opportunity to treat diseasebefore it spreadsbefore it spreads.the ability to reduce a person’s risk of developing cancer opens the way foroptimum prevention strategies.

The NCI – Cairo University is committed to progress in cancer detection andrisk assessment that allows interventions to focus on the earliest stages ofdisease.

Secondary Preventiony

Referred cases for managementBreast

Soft tissuef f g Soft tissue

Colon

Ovary

ThyroidBreast

Liver

Prostate

thymoma

scapula mass

With limited advertising, matching with our resourcesour resources

1500 New Cases visit our clinic with dramatically rising curvedramatically rising curve

400 2006

300

400

20032004

2005300

No.

2003200

100

01Total cases

Secondary Prevention

Triage for every patient

Accurate history taking .y g

Pedigree designPedigree design .Meticulous clinical examination

We provide Lectures & Outdoor Campaignp p g

Primary Preventiony

We provide support services to ti t d th i f ilicancer patients and their families.

Primary Preventiony

We support and encourage research and studies l t d t ti d l d t ti frelated to prevention and early detection of

cancer.

1. Early Detection & classification of Lymphoma

2. Pilot Study of Inflammatory Breast Cancer in2. Pilot Study of Inflammatory Breast Cancer in Egypt and Tunisia in collaboration withNational Cancer Institute – U.S.A.

3. IBIS II Prevention protocol an international multi-center study of anastrazole vs placebo in postmenopausal women at increased risk of breast cancer

We are trying to prevent malpractice i i i i iwhich is vital issue in management

of cancer patient by establishing training programs to the GPs and junior staff to know welljunior staff to know well.

How to suspect cancer ?How to deal with cancer patients and when they should refer to cancer centre ?

Screening Guidelines for the Early Detection of g yBreast Cancer, American Cancer Society

Yearly mammograms are recommended starting at age 40.

A clinical breast exam should be part of a periodic health exam, about every three years for women in their 20s and 30s, and every year for women 40 y , y yand older.

Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self-exam is an option for women starting in their 20s.

Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of t ti h i li h i dditi l t t (i b t starting mammography screening earlier, having additional tests (i.e., breast

ultrasound and MRI), or having more frequent exams.

High risk groups

factors RRfactors RR

Nb of 1st degree relatives with BC1 vs none 21 vs none2 vs none

23-5

First child age >30 vs <20 2-3

Breast feeding none vs 4 children 2.5

M h <11 >15 1 5Menarche <11 vs >15 1.5

Number of child none vs 3 1.5

Breast cancer screening testsBreast cancer screening tests

• Breast self examination (BSE)

• Clinical breast examination (CBE)

• Mammography

• Ultrasonography• Ultrasonography

• Electrical impedance imaging

• Magnetic resonance imaging

• Positron emission tomography (PET)

• Scinti-mammography

i i l h• Digital mammography

*IARC handbook of cancer prevention

Clinical Breast ExaminationClinical Breast ExaminationSensitivity (western countries)

• From 40% to 70%* # in western countries

Specificity• From 85% to 95%* in western countriesFrom 85% to 95% in western countries

AdvantagesAdvantages

Low cost technique

Performable by non medical staff

Efficiency for screening is under evaluation (No RT results to date)

Duffy et Al. BHGI 2006: Modelisations suggest that the benefit of CBE is a little

*IARC handbook of cancer prevention, #BHGI guidelines

more than half of the benefit of Mammography

MammographyMammographySensitivity

• From 53% to 92% in western countries*

• Low in pre-menopausal women (from 44% to 76 % in women <50*)to 76 % in women <50 )

Specificity• From 82% to 98% in western countries*

Mammography requires quality control

C ti T i i d M it iContinuous Training and Monitoring,

Double reading

*IARC handbook of cancer prevention



Magnitude of the Problemg




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