WORLD

Cancer -12% of deaths throughout the world. In the

developed countries cancer is the second leading

cause

21% of deaths in the developing countries

Cancer ranks third as the cause of death an accounts

for 9.5% of all deaths

MAGNITUDE OF PROBLEM

Otis W. Brawley, MD, chief medical officer, of the

American Cancer Society,

2.6 million of the 7.6 million cancer deaths that

occurred in 2008

About 7,300 cancer deaths per day

International Agency for Research on Cancer (IARC) in

2008

12.7 million new cancer cases

5.6 million-economically developed countries

7.1 million in economically developing countries

7.6 million cancer deaths

2.8 million in developed countries

4.8 million in developing countries

INDIA

Metric Count

Incidence Male 477,482

Incidence Female 537,452

Mortality Male 356,730

Mortality Female 326,100

Prevalence Male 664,538

Prevalence Female 1,125,960

By 2030, the global cancer burden is expected to nearly

double, growing to 21.4 million cases and 13.2 million

deaths.

CANCER EPIDEMIOLOGY

70- 90% - Environmental.

Tobacco & smoking- 50%

Dietary practices, reproductive and sexual practices -20-30%

Tobacco

40 to 50% men

20% to women

Oral cancers and oral precancerous conditions..

DIET

10-70% of cancers

Cancers of the upper aero digestive tract (mouth,

throat, oesophagus and lungs), stomach, large

intestine, and breast cancer in women.

Diet rich in animal proteins

Smoking and alcohol

CANCER OF THE HEAD AND NECK

Tobacco and alcohol

Green and yellow vegetables will protect against

oral cancer

CANCER OF THE STOMACH

Japanese had the highest rate

Dietary pattern is a risk factor

Consumption of large amounts of

red chillies

food at very high temperatures

alcohol consumption

Tobacco extract 'Tuibur' cause high rates of Stomach cancer in Mizoram.

Primary prevention

India

CANCER OF THE LARGE INTESTINE

Heavy consumption of red meat can lead to

risk of colon cancer

CANCER OF THE BREAST IN WOMEN

leading cancer in women

Risk factors

Late age at first pregnancy (greater than 30 years)

single child

late age at menopause

High fat diets during the pubertal age and obesity in the

post-menopausal age are risk factors for breast cancer.

CANCER OF THE UTERINE CERVIX

most common cancer among women in India.

Risk factors

Early age at first intercourse

Multiple sexual partners

Poor sexual hygiene

Repeated child birth

Prevention

Regular cervical cytology examination (papsmear) by all

women who have initiated sexual activity

RISK FACTORS

A) Environmental and Life style Factors:

Tobacco-Lung Ca, Oral Ca

Alcohol

•Breast cancer in women

• Primary liver cancer

• Ovarian cancer

• Prostate cancer

• Thyroid cancer

Dietary factors

Smoked fish - stomach cancer

lack of dietary fibre- intestinal cancer

beef consumption- bowel cancer

high fat diet to breast cancer

Food additives and contaminants may also be the

causative agents

Occupational exposures

Accounts for 1-5 % of cancers.

Exposure to benzene, arsenic, cadmium, chromium,

asbestos, polycyclic hydro carbons.

Viruses

HepB & C -hepatic cancer.

HIV- Kaposi Sarcoma.

Ebstein Barr -Burkitt's lymphoma and nasopharyngeal carcinoma

Hodgkin disease is also believed to be caused by virus.

Parasites- Schistosomiasis in Middle East producing

carcinoma of the bladder.

Customs, habits & life styles

Others-sunlight, radiation air pollution and water

pollution, medication; pesticides etc are related to

cancer.

B) GENETIC FACTORS

Retinoblastoma occurs in children of the same

parent

Mongols are more likely to develop cancer

(leukemia) than normal children.

However genetic factors are less conspicuous and

more difficult to identify.

PATHOPHYSIOLOGY OF THE

MALIGNANT PROCESS

Disease process that begins when an abnormal cell

is transformed by the genetic mutation of the

cellular DNA

This abnormal cell forms a clone and begins to

proliferate abnormally,

The cells acquire invasive characteristics, and

changes occur in surrounding tissues. The cells

infiltrate these tissues and gain access to lymph

and blood vessels, which carry the cells to other

areas of the body.

SIGNS AND SYMPTOMS

LOCAL SYMPTOMS

Lump or swelling

Haemorrhage

Pain or ulceration

SYMPTOMS OF METASTASIS

Enlarged lymph nodes

Cough

Haemoptysis

Hepatomegaly

Bone pain

Fracture

Neurological symptoms

SYSTEMIC SYMPTOMS

Weight loss

Poor appetite

Fatigue

Cachexia

Diaphoresis

Anaemia

CAUTION

C: Change in bowel or bladder habits

A: A sore that does not heal

U: Unusual bleeding or discharge

T: Thickening or lump in the breast or

elsewhere

I: Indigestion or difficulty in swallowing

O: Obvious change in a wart or mole

N: Nagging cough or hoarseness

CLASSIFICATION

BSED ON THE TISSUE PRESUMED TO BE

THE ORIGIN OF THE TUMOR…..

Carcinoma: Malignant tumors derived from epithelial

cells. This group represents the most common cancers,

including the common forms of breast, prostate, lung

and colon cancer

Sarcoma: Malignant tumors derived from connective

tissue, or mesenchymal cells.

Lymphoma and leukemia: Malignancies derived from

hematopoietic (blood-forming) cells

Germ cell tumor: Tumors derived from totipotent cells.

In adults most often found in the testicle and ovary; in

foetuses, babies, and young children most often found

on the body midline, particularly at the tip of the

tailbone

Blastic tumor or blastoma: A tumor (usually malignant)

which resembles an immature or embryonic tissue.

Many of these tumors are most common in children.

BASED ON INVASIVE NATURE:

Benign

Malignant

BENIGN MALIGNANT

Grows slowly

Enlarging and expanding

growth

Capsule present

Well differentiated cell

Recurrence not common

Metastasis never occur

Neoplasm is not harmful to

host

Prognosis is very good

Grows rapidly

Infiltrating surrounding

tissues

Capsule absent

Poorly differentiated cell

Recurrence is common

Metastasis is very common

Neoplasm is harmful to the

host

Poor prognosis

BASED ON THE TISSUE OF

ORIGIN..

Benign neoplasms

Fibromas ( uterus)

Lipomas ( adipose tissue)

Leiomyomas ( smooth muscle)

Malignant neoplasms

Carcinoma ( epithelial tissue)

Sarcoma ( mesenchyma)

Lymphoma ( hematopoetic)

DIAGNOSIS

Determine the presence of tumor and its extent

Identify possible spread (metastasis) of disease or

invasion of other body tissues

Evaluate the function of involved and uninvolved

body systems and organs

Obtain tissue and cells for analysis, including

evaluation of tumor stage and grade

TNM CLASSIFICATION

•Cytology studies ( pap smear)

•Chest x-ray

•Complete blood count

•Proctoscopy examination

•Liver function studies

•Radiographic studies

•Computed tomography

•Presence of onco-fetal antigens( CEA, AFP)

•Bone marrow aspiration

•Lymphangiography

•Biopsy

MANAGEMENT OF CANCER

surgery

chemotherapy

radiation therapy

immunotherapy

monoclonal antibody therapy

hormonal therapy

biologic response modifier (BRM) therapy

complimentary & alternative therapies

CHEMOTHERAPY

Drugs that can destroy cancer cells. It

also referred as ‘ cytotoxic drugs’ which

affect rapidly dividing cells by interfering

with the DNA duplication or the separation

of newly formed chromosomes.

MONOCLONAL ANTIBODY THERAPY

In this, therapeutic agent is an

antibody which specifically builds to a

protein on the surface of the cancer cells.

IMMUNOTHERAPY

It refers to a diverse set of therapeutic

strategies designed to induce the patient’s own

immune system to fight tumor.

Example, intravesical BCG therapy for cancer

bladder

STEM CELL TRANSPLANTATION

A stem cell transplant also called a blood or

marrow transplant is the injection or infusion of

healthy stem cells into your body to replace

damaged or diseased stem cells.

A stem cell transplant may be necessary if your

bone marrow stops working and doesn't produce

enough healthy stem cells.

leukemia, lymphoma, multiple myeloma or sickle

cell anemia.

PREVENTION OF CANCER

A) Primordial prevention

B) Primary prevention of cancer

C) Secondary prevention of cancer

D) Tertiary prevention

PRIMORDIAL PREVENTION

Minimize future hazards to health

Inhibit the establishment factors known to

increase the risk of disease (environmental,

economic, social, behavioural, cultural)

-Combating tobacco smoking

-Healthy diets

-Preventing obesity, supporting sports and

exercise

-Reducing alcohol consumption

-Providing vaccination against the Hepatitis B

virus

-Avoiding the effects of excessive sunbathing

Information on prevention through the schools,

and to promote media coverage, through articles

and programmes, of knowledge on risk factors

and on ways of controlling them.

Anti- tobacco groups and other NGOs and social

organizations in their educational and

information dissemination efforts.

B) PRIMARY PREVENTION OF CANCER

Control of Alcohol & Tobacco consumption

Personal Hygiene

Radiation

Occupational exposures

Immunization

Foods, Drugs & Cosmetics

Air Pollution

Treatment of Precancerous lesions

Legislation

Health Education

Cancer vaccine

C) SECONDARY PREVENTION OF

CANCER

Cancer Registration

Early Detection of cases

Treatment

D) TERTIARY PREVENTION

Aimed at detecting complications and

second cancers in long-term survivors.

To improve their quality of life.

CANCER PREVENTION AND

TREATMENT STRATEGIES FOR INDIA

Formulated a National Cancer Control

Programme

control of tobacco related cancers

early diagnosis and treatment of uterine

cervical cancer

distribution of therapy services, pain

relief and palliative care

PRIMARY PREVENTION AND SCREENING

PROGRAMS

Most cost effective prevention

Aims to reduce the incidence of cancer by

risk factor modification

ORAL CANCER

Fifty percent of all cancers in males are tobacco

related and can be prevented by anti-tobacco

programs

Teen age students need to be targeted

Legislation has to be enforced for prohibiting

tobacco advertisement and sale of tobacco to

youngsters

Importance of a healthy diet rich in green and

yellow vegetables and fruits has to be

highlighted.

CANCER OF THE UTERINE CERVIX

Proper genital hygiene and safe sexual practices.

Cervical cytology (pap smear) screening

35 to 64 years should undergo regular pap smear

screening.

BREAST CANCER

Mammographic screening

Regular breast self-examination needs to be

promoted for early detection of breast

cancer.

Breast self-examination can be propagated

through print and electronic media as well

as through health care personnel in various

settings

STRATEGIES FOR EARLY DETECTION

OF COMMON CANCERS IN INDIA

Pap smear

Mammography

Periodic examination

APPROACHES TO CANCER CONTROL

There are four principal approaches to

cancer control:

1. Prevention

2. Early Detection

3. Diagnosis and Treatment

4. Palliative Care

increasing with age

National Cancer Control

Programme

EVOLUTION OF NCCP

1975-76 National Cancer Control Programme was

launched with priorities given for equipping the

premier cancer hospital/institutions. Central

assistance at the rate of Rs.2.50 lakhs was given to

each institution for purchase of cobalt machines.

1984-85 The strategy was revised and stress was

laid on primary prevention and early detection of

cancer cases.

1990-91 District Cancer Control Programme was

started in selected districts (near the medical

college hospitals).

2000-01 Modified District Cancer Control

programme initiated.

2004 Evaluation of NCCP was done by

National Institute of Health & Family

Welfare, New Delhi

2005 The programme was further revised

after evaluation

GOALS & OBJECTIVES OF NCCP

1. Primary prevention of cancers by health

education specially regarding hazards of

tobacco consumption and necessity of genital

hygiene for prevention of cervical cancer.

2. Secondary prevention i.e. early detection and

diagnosis of cancers, for example, cancer of cervix,

breast and of the oro-pharyngeal cancer by

screening methods and patients’ education on self

examination methods.

3. Strengthening of existing cancer treatment

facilities, which are woefully inadequate.

4. Palliative care in terminal stage of the cancer.

STRATEGIES

1. Prevention and early detection of cancer through

district cancer activities and strengthened IEC

campaign.

2. Development of early diagnostic capacities in

district hospitals.

3. Encouraging public private partnership.

4. Increase capacity for palliative are in cancer

5. Promote research in cancer that would be

relevant to cancer control in India

6. Promote innovation in cancers care and

indigenization of cancer treatment equipment.

7. To promote ‘centers of excellence’ in the field of

cancer management with support to existing RCC

of 20 years of proven track record by providing

financial assistance.

8. To augment comprehensive cancer care facilities

across the country through institutional capacity

building in new and existing regional cancer

centers and through new and existing oncology

wings.

9. Capacity building and training of all personnel in

cancer prevention and early detection to be done for

all categories in phased manner.

10. Health education of the general public

through use of audio, video and print media

regarding prevention and early detection of

cancers.

EXISTING SCHEMES UNDER NATIONAL

CANCER CONTROL PROGRAMME (NCCP)

1. RECOGNITION OF NEW REGIONAL

CANCER CENTRES (RCCS)

To enhance the cancer treatment facilities across

the country and reduce the geographical gap in

the country in the availability of cancer care

facilities, A one-time grant of Rs. 5.00 crores is

being provided for New RCC’s.

2. STRENGTHENING OF EXISTING

REGIONAL CANCER CENTRES

A one-time grant of Rs.3.00 crores is provided to

the existing Regional Cancer Centres to further

strengthen the cancer care services.

ROLE OF THE RCC

a. The RCCs should provide Comprehensive

cancer treatment services.

b. There should be a mechanism in place or

proposed, to spread awareness in the community

and among health personnel regarding common

cancers and their early detection/ prevention.

c. The institution should undertake training of

medical officers and health workers, in early

detection and prevention of cancers and

supportive care.

d. Training of medical officers and health

workers, in early detection and prevention of

cancers and supportive care should be

undertaken by the institution.

e. A referral linkage should be developed between

the RCC and the hospitals under the DCCP so as to

ensure continuity in the treatment chain.

f. Outreach and research activities in prevention

and treatment of cancers should also be carried

out.

g. The RCC will have to undergo periodic

monitoring and evaluation to ensure satisfactory

functioning.

3. DEVELOPMENT OF ONCOLOGY WING

Objective- reducing the geographical gaps in

cancer treatment facilities in the country by

establishing cancer treatment centres in areas

where these are deficient. Government Hospitals

& Government Medical Colleges are provided with

a grant of Rs.3.00 crores for the development of

Oncology Wing.

Provisions under the scheme

1. Priority for sanction of grant-in-aid would be

given to institutions located in areas where there

are no treatment facilities. First-time grantees will

be given priority over institutions that have

already received grants earlier.

2. Institutions, which had earlier availed of the

grant at the rates prevailing then, would be

eligible to get the differential amount between the

grant received earlier and the grant admissible

under the revised scheme.

3. Financial Provisions:

a. The selected government institute will be

provided one-time financial assistance of Rs.3 crore

for procurement of any equipment from the list

appended with the document.

b. A part of the grant, not exceeding 30% of the total

grant may be used if required, for construction of

building to house the radiotherapy equipment’s,

patient care units, etc.

4. DISTRICT CANCER CONTROL PROGRAMME

Launched in 1990-91

The district programme has five elements:

1. Health education.

2. Early detection.

3. Training of medical & paramedical personnel’s.

4. Palliative treatment and pain relief.

5. Coordination and monitoring.

The District programmes are linked with

Regional Cancer Centres

Government Hospitals

Medical Colleges

For effective functioning started have one

District Cancer Society..

that is chaired by local Collector/Chief Medical

Officer.

Other members are Dean of medical college, Zila

parishad representative, NGO representative

etc.

5. DECENTRALIZED NGO SCHEME

This scheme has been devised to promote (IEC)

prevention and early detection of cancers.

NGO will implement these activities under the

coordination of the Nodal Agency, which will be

an RCC or an Oncology wing

A grant of Rs.8000/- per camp will be provided to

the NGOs for IEC activities.

ACHIEVEMENTS

Regional Cancer Centres:

As of now, there are 27 Regional Cancer

Centres, including 6 NGOs, providing

comprehensive cancer care services. Outreach and

research activities in prevention and treatment of

cancers are carried out by these centres.

Oncology wing:

Support has been given to 82 institutes in

both Government Medical Colleges and

Government Hospitals for development of Oncology

wing. At present there are 246 institutions with

radiotherapy facilities across the country,

including the 27 Regional Cancer Centres.

District Cancer Control Programme:

The District Cancer Control Programme,

which has been developed to initiate awareness

and early detection activities at the district level;

are in place in 28 districts at present.

IEC Activities:

The programme supports activities of health

magazine ‘Kalyani’ and telecast by Prasar Bharti

targeting especially those living in the most

populous States.

It is an interactive programme which provides

an interface to the people with experts on

various health and social issues.

NEW INITIATIVES:

India has become the member of international

agency for research on cancer(IARC)

The pap smear kits and can-scan software

supplied to 12 RCC.

Onconet India: telemedicine project to connect 27

RCCs and 4 to 5 peripheral centers is being

operationalized.

Training of cytopathologists and cytotechicians in

the quality assurance in pap smear.

Participation in health mela and distribution of

health education material.

Postage stamp depicting ‘breast self-examination’

was brought out by department of post on national

cancer awareness day.

National cancer awareness day is celebrated on the

birth anniversary of Nobel laureate madam curie,

7th November

Telecast of health magazine ‘kalyani’ in the current

year with cancer and anti tobacco items under the

agreement with prasar bharti & MOHFW.

Broadcast of health education audio material

developed by CNCI, kolkatta, through FM radio.

Community based Cancer Control Program

carried out with help of WHO:

Training of health care personnel at district level in

early detection and awareness of cancer.

Telemedicine in cancer

IEC activities including National Cancer Awareness

Day celebrated on 7th November.

NATIONAL CANCER REGISTRY PROGRAMME

National Cancer Registry Programme was

launched in 1982 by Indian Council of Medical

Research (ICMR) to provide true information on

cancer prevalence and incidence. Cancer

registration is the process of systematically and

continuously collecting information on

malignant neoplasm.

Objectives

1. To generate authentic data on the magnitude of

cancer problem in India;

2. To undertake epidemiological investigations and

advice control measures; and

3. Promote human resource development in cancer

epidemiology.

2 TYPES OF REGISTRIES

1. Population Based Cancer Registry and

2. Hospital Based Cancer Registries

Population based registries:

There are six in number ; 5 in urban areas

( delhi , Bhopal, Mumbai, Bangalore,Chennai) and

one in rural areas ( barshi in Maharashtra).

Hospital based registries:

At Chandigarh, dibrugarh, thiruvanathapuram,

Bangalore, Mumbai, and Chennai , six hospital based

registries are maintained.

CANCER ATLAS

To bridge the gap, a project of atlas of the cancer

in India was started under WHO-ICMR since 2003

mainly to have an idea of patterns of cancer in

several parts of the country.

Under this programme ICMR has developed an

Atlas of cancer in India based on the information

collected for the year 2001-02 from 105

collaborating centres to have an idea of the

pattern of cancer across the country.

Main objectives:

(i) To obtain an overview of patterns of

cancer in different parts of the country;

(ii) To calculate estimates of cancer

incidence wherever feasible.

JOURNAL PRESENTATION Indian Journal of cancer

Title:- Risk factors of female breast carcinoma: A case

control study at Puducherry

Investigators:-SM Balasubramaniam, SB Rotti, S

Vivekanandam

Objective: To identify and quantify various demographic,

reproductive, socio-economic and dietary risk factors

among women with breast cancer.

Study Design: Case control study.

Study Period : February 2004 to May 2005.

Study Setting: Departments of Surgery, Medicine and

Radiotherapy of JIPMER

Materials and Methods: Cases were women with

pathologically confirmed breast cancer. Controls

were age-matched women from medicine and

surgery wards without any current breast

problem or previous breast cancer. A total of 152

cases and 152 controls were enrolled. They were

interviewed for parity, breast feeding, past history

of benign breast lesion, family history and dietary

history with a pre-tested interview schedule after

obtaining informed written consent.

Results:The significant risk factors were previous

history of biopsy for benign breast lesion 10.4,

nulliparity 2.4 (1.14-5.08), consumption of fats more

than 30 g/day 2.4 (1.14-5.45) and consumption of oils

containing more of saturated fat 2.0 (1.03-4.52).

Conclusions: Nulliparity, past history of benign

breast lesion, high fat diet and consumption of oils

with more saturated fats were the risk factors.

Journal name:- Journal of Physiology and Pharmacology

Advances

Title:- A Case Control Study to Assess Impact of Risk

Factors on Trends of Lung Cancer

Investigators:- Arunima Gupta, Siddhartha Das,

Shatarupa Dutta, Santu Mondal, Krishnangshu Bhanja

Choudhuri, Sumana Maiti.

Objective:- Identify impact of risk factors on changing

trends of lung cancer in a case control study

Duration:- 2006 to 2010 included newly diagnosed

patients of histological proven lung carcinoma

attending the radiotherapy department

Methodology:- For each case, one control was

identified and matched with same sex, age ± 5

years, and unmatched for residence, smoking

status and socioeconomic condition. For

categorical variables, Chi Square and Fisher’ test

and for numerical variables t test and Mann

Whitney tests were used. All univariate analyses

used ANOVA test.

RESULT:-

During the study period 1524 cases and their controls

were accounted. Change in trend was observed in

patients diagnosed at younger age of 57.48 ± 0.56 years

in 2010 with adenocarcinoma unlike 62.89 ± 1.21 years

in 2006. Females show increase in incidence of lung

cancer in 2010, p value < 0.001 . The “active” smokers

and years of smoking were significantly high among

cases. The incidence of squamous cell carcinoma declined

from 47.4% in 2006 to 15% in 2010 whereas

adenocarcinoma increased, p value 0.001. Significant

change in trend involving younger age at presentation

specially for female who also show increased incidence of

lung cancer has been observed. This hypothesis needs

confirmation through further studies.

HEALTH PROMOTION MODEL