MALIGNANCY

INTRODUCTION
Cancer may be regarded as a group of diseases characterised
by an
(i) abnormal growth of cells
(ii) ability to invade adjacent tissues and even distant
organs, and
(iii) the eventual death of the affected patient if the tumour
has progressed beyond that stage when it can be
successfully removed.
Cancer can occur at any site or tissue of the body and may
involve any type of cells.
 Contd...

The major categories of cancer are :

(a) Carcinomas, which arise from epithelial cells lining the
internal surfaces of the various organs (eg mouth,
oesophagus, intestines, uterus) from the skin epithelium;
(b) Sarcomas, which arise from mesodermal cells
constituting the various connective tissues e.g. fibrous
tissue, fat and bone); and
(c,) Lymphomas-myeloma and leukaemias arising from the
cells of bone marrow and immune system.
 Contd...

The term "primary tumour" is used to denote cancer in the

organ of origin,
while "secondary tumour" denotes cancer that has spread to
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 metastases becomes clinically evident
 PROBLEM STATEMENT WORLD
Cancer afflicts all communities worldwide, approximately10 million
people are diagnosed with cancer and more than 5 million die of the
disease every year.
About 14 million persons were living with cancer in the year 2012
Expects to increase to 20 million in next 2 decades
In terms of incidence, the most common cancers worldwide are lung
cancer (12.3%), breast cancer (10.4%) and colorectal cancer (9.4 %)
Lung cancer accounts for most deaths from cancer in the world (1.1
million) annually, since it is most invariably associated with poor
prognosis
the top three causes of death from cancer, which are respectively
cancers of the lung, stomach, and liver
Appropriate intervention is often effective in avoiding fatal outcome
following diagnosis of breast cancer.
 PROBLEM STATEMENT WORLD contd..
The most conspicuous feature of the distribution of cancers between
the sexes is the male predominance of lung cancer.
Stomach, oesophageal, liver and bladder cancer are also much more
common in males
Differences in distribution between the sexes are attributable to
differences in exposure to causative agents rather than to variation in
the susceptibility.
For other tumour types, including cancers of pancreas and colorectum,
there is little difference in the sex distribution
The burden of cancer is distributed unequally between developed and
developing countries, with particular cancer types exhibiting different
patterns of distribution.
Total cancer burden highest in effluent societies due to high incidence
of tumour associated with smoking and western life style- ca lung,
prostate, colorectum, breast
 PROBLEM STATEMENT WORLD contd..
In developing countries 25% tumour associated with chronic infection
ie hepatitis B - Liver ca
HPV- cervical ca
helicobacter pylori- stomach ca
Some western countries cancer mortality in decline due to decrease
in smoking, improved early detection and advances in cancer therapy
The westernization trend:
as low HDI countries become more developedthrough rapid societal
and economic changes, they become more westernized.. Pattern of
cancer incidence is likely to follow that seesn in high HDI settings-
increase in ca cervix, uteri, stomach
this results in decrease in infection related ca and increase in ca
associated with reproductive, dietary and hormonal factors
 PROBLEM STATEMENT INDIA
IN India national cancer registry program of ICMR provides data on
morbidity, mortality & distribution of ca from 25 population based
registries & 5 hospital based registries
2012- 10.15 lac new cases; 4.77 lac males; 5.37 lac females, 6.83 ac
died of cancer
Mortality rate 69.7 per lac population
Five most frequent cancers in men ca lung, lip & oral cavity, stomach,
colorectum, pharynx
In women ca breast, cervix uteri, colorectum, ovary, lip & oral cavity
Ca men- tobacco relate
 PROBLEM STATEMENT INDIA

Ca cervix associated with poor genital hygiene, early consummation

of marriage, multiple pregnancies, and contact with multiple sexual
partners

Also reported that breast cancer is proportionately in increase in a few

metropolitan areas of India.

related to late marriage, birth of the first child at late age, fewer
children, and shorter period of breast feeding which are increasingly
common practice among urban women
 TIME TRENDS
Previously ca 6th cause of death in industrialised countries now 2nd
cause of death
This is due to longer life expectancy, more accurate diagnosis and the
rise in cigarette smoking, especially among males since World War I.
The overall rates do not reflect the different trends according to the
type of cancer.
For example, there has been a large increase in lung cancer incidence
since the 1930s; the stomach cancer has shown a declining trend in
most developed countries for reasons not understood.
 Cancer patterns
There are wide variations in the distribution of cancer throughout the
world.

The cancer of the stomach is very common in Japan, and has a low
incidence in United States.

The cervical cancer is high in Columbia and has a low incidence in

Japan. In the South East Asia Region of WHO, the great majority are
cancers of the oral cavity and uterine cervix.

These and other international variations in the pattern of cancer are

attributed to multiple factors such as environmental factors, food
habits, life style, genetic factors or even inadequacy in detection and
reporting of cases.
 Cancer patterns
Hospital data clearly indicates that the two organ sites most commonly
involved are: (i) the uterine cervix in women, and (ii) the oropharynx
in both sexes.
These two sites represent approximately 50 per cent of all cancer
cases.
Both these cancers are predominantly environment related and have a
strong socio-cultural relationship.
It is also important to note that these two kinds of cancer are easily
accessible for physical examination and amenable to early diagnosis
by knowledge already available. i.e., good clinical examination and
exfoliative cytology.
The cure rate for these neoplasma is also very high if they are treated
surgically at stages I and IL But unfortunately, in most cases, the
patients present themselves to a medical facility when the disease is
far advanced and is not amenable to treatment. This is the crux of the
problem.
 Environmental factors
80-90%
Tobacco :
major environmental cause of cancers of the lung, larynx, mouth,
pharynx, oesophagus, bladder, pancreas and probably kidney.
estimated that, in the world as a whole, cigarette smoking is
nownresponsible for more than one million premature deaths each
year
Alcohol :
associated with oesophageal and liver cancer.
Some recent studies have suggested that beer consumption may be
associated with rectal cancer
It is estimated that alcohol contributed to about 3 per cent of all cancer
deaths
 Environmental factors
Dietary factors :
Smoked fish is related to stomach cancer, dietary fibre to intestinal
cancer, beef consumption to bowel cancer and a high fat diet to breast
cancer.
A variety of other dietary factors such as food additives and
contaminants have fallen under suspicion as causative agents.
Occupational exposures :
lnclude exposure to benzene, arsenic, cadmium, chromium,
vinyl chloride, asbestos, polycyclic hydrocarbons, etc.
The risk of occupational exposure is considerably increased if the
individuals also smoke
Account for 4-5% of all human cancers
 Environmental factors
Viruses:
hepatitis B and C virus is related to hepatocellular carcinoma.
The relative risk of Kaposi's sarcoma occurring in patients with HIV
infection is so high that it was the first manifestation of the AIDS epidemic
to be recognized.
Non-Hodgkin's lymphoma, a cancer of the lymph nodes and spleen is a late
complication of AIDS.
Epstein-Barr virus (EBV) is associated with 2 human malignancies, viz.
Burkitt's lymphoma and nasopharyngeal carcinoma.
Cytomegalovirus (CMV) is a suspected oncogenic agent and classical
Kaposi's sarcoma is associated with a higher prevalence of antibodies to
CMV.
Human papilloma virus (HPV) is a chief suspect in cancer cervix.
Hodgkin's disease is also believed to be of viral origin.
The human T-cell leukaemia virus is associated with adult T-cell leukaemia/
lymphoma in the United States and southern parts of Japan
 Environmental factors
Parasites
increase the risk of cancer, as for example, schistosomiasis in Middle
East producing carcinoma of the bladder.

Customs, habits and life-styles :

The familiar examples are the demonstrated
association between smoking and lung cancer,
tobacco and betel chewing and oral cancer, etc

Others:
There are numerous other environmental factors such as sunlight,
radiation, air and water pollution, medications (e.g., oestrogen) and
pesticides which are related to cancer.
 GENETIC FACTORS

Genetic influences have long been suspected.

retinoblastoma occurs in children of the same parent.
Mongols are more likely to develop cancer (leukaemia) than normal
children.
However, genetic factors are less conspicuous and more difficult to
identify.
There is probably a complex interrelationship between hereditary
susceptibility and environmental carcinogenic stimuli in the causation
of a number of cancers
 CANCER CONTROL
Primary prevention:
Advancing knowledge has increased our understanding of causative
factors of some cancers and it is now possible to control these factors
in the general population as well as in particular occupational groups.
They include the following :

Control of tobacco and alcohol consumption:

Primary prevention offers the greatest hope for reducing the number
of tobacco-induced and alcohol related cancer deaths. It has been
estimated that control of
tobacco smoking alone would reduce the total burden of cancer by
over a million cancers each year
 PRIMARY PREVENTION contd..
B. Personal hygiene
Improvement in personal hygiene improves incidence of certain type
of ca eg. Ca cervix
c.Radiation
Efforts made to reduce exposure to radiation including medical
radiation received by each individual to a minimum without reducing
the benefits
D.Occupational exposure
Measures to protect workers from exposure to industrial carcinogens
should be enforced in industries
E.Immunization
Primary liver ca- immunization against hep B
F. Foods, drugs and cosmetics:
should be tested for carcinogens
 PRIMARY PREVENTION contd..
G.Air pollution
Control of air pollution
H.Treatment of precancerous lesion
Early detection and prompt treatment of pre cancerous lesion
cervical tears,intestinal polyposis, warts, chronic gastritis , chronic
cervicitis, adenomata
Legislation:
Also a role in primary prevention
Legislation to control known environmental carcinogen
Cancer EDUCATION:
It should be aimed at "high-risk" groups.
The aim of cancer education is to educate people to seek early
diagnosis and early treatment.
Cancer organizations in many countries remind the public of the
warning signs ("danger signals") of cancer.
 Primary prevention contd..
These are :
lump or hard area in the breast
A change in a wart or mole
a persistent change in digestive and bowel habits
a persistent cough or hoarseness
excessive loss of blood at the monthly period or loss of blood outside
the usual dates
blood loss from any natural orifice
A swelling or sore that does not get better
unexplained loss of weight.
 CANCER CONTROL

Since primary prevention is directed at large population groups (e.g.,

high risk groups, school children, occupational groups, youth clubs),
the cost can be high and programmes difficult to conduct

Primary prevention although a hopeful approach, is still in its early

stages

Major risk factors have been identified for a small number of cancers
only and far more research is needed.
 SECONDARY PREVENTION
1.CANCER REGISTRATION
Cancer registration is a sine qua non for any cancer control me. It
provides a base for assessing the magnitude of the problem and for
planning the necessary services. 2 types:
A.HOSPITAL BASED REGISTRIES
includes all patients treated by a particular institution, whether in-
patients or out-patients.
should collect the uniform minimum set of data recommended in the
"WHO Handbook for Standardized cancer Registers"
lf there is a long-term follow-up of patients hospital based registries
can be of considerable value in the evaluation of diagnostic and
treatment programmes.
Since hospital population will always be for selected population, the
use of these registries for epidemiological purposes is thus limited
 SECONDARY PREVENTION
b.Population BASED REGISTRIES
Right step is to start hospital based entry and extend it into population
based entry
Aims to cover the complete cancer situation ina given geographic area
The optimum of base population for a population based cancer
registry is in the range of 2-7 million
Data from such registries alone provide incidence rate & serve as
useful tool for initiating epidemiological inquiries into causes of
cancer, surveillance of time trends, planning & evaluation of
operational activities in all areas of cancer control
Established at mumbai, bhopal, delhi, barshi chennai under national
cancer registry project of ICMR
 SECONDARY PREVENTION
2.EARLY DETCTION OF CASES
Cancer screening is the main weapon for early detection of cancer at a
pre-invasive (in situ) or pre malignancy stage
Effective screening programmes have been developed for cervical
cancer, breast cancer and oral cancer
early diagnosis has to be conducted on a larger scale;
however, it may be possible to increase the efficiency of screening
programmes by focusing on high risk groups
Clearly, there is no point in detecting cancer at an early stage unless
facilities for treatment and aftercare are available
detection programmes will require mobilization of all available
resources and development of a cancer infrastructure starting at the
level of primary health care, ending with complex cancer centres or
institutions at the state or national levels
 SECONDARY PREVENTION
2.TREATMENT
Treatment facilities should be available to all cancer patients.
Certain forms of cancer are amenable to surgical removal, while some
others respond favourably to radiation or chemotherapy or both
multi modality approach to cancer control has become a standard
practice in cancer centres all over the world.
For those beyond the curable stage, the goal must be to produce pain
relief .
A largely neglected problem in cancer care is management of pain.
The WHO has developed guidelines for relief of cancer pain
"Freedom from cancer pain" is considered a right for cancer patients
 CANCER SCREENING
early detection & prompt treatment of early cancer and precancerous
condition provide the best possible protection against cancer for
individual and the community.
cancer screening may be defined as "search for unrecognized
malignancy by means of Laboratory & applied tests
Cancer screening is possible because :
(a) in many instances, malignant disease is preceded for a period of
months or years by a premalignant lesion, removal of it prevents
subsequent development of cancer:
(b) mosr cancer begin as localised lesions and if found at this stage a
high rate of cure is obtainable: and
(c) as much as 75 % of cancers occur in body sites that are accessible.
 CANCER SCREENING
METHODS OF CANCER SCREENING
(a) Mass screening by comprehensive cancer 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 : This comprises examination of

single sites such as uterine cervix, breast or lung.

(c) Selective screening : This refers to examination of those people

thought to be at special risk. 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, etc.
 SCREENING FOR CANCER CERVIX
The prolonged early phase of cancer in situ can be detected by the Pap
smear.
Current policy suggests that all women should have a Pap test
(cervical smear) at the beginning of sexual activity, and then every 3
years thereafter
A periodic pelvic examination is also recommended.
the Pap test should be directed at women in poor socio economic
circumstances who are at the greatest risk of developing the disease
There are a few problems posed by screening for cancer cervix. These
are related to the disease and the test.
A.The disease:
One of the criteria that must be fulfilled before a screening
programme is initiated is that natural history of the disease and its
development from latent to declared disease should be adequately
understood.
 SCREENING FOR CANCER CERVIX
The crux of the matter is uncertainty about the natural history of
cancer cervix, which has still many gaps.
There is no firm evidence on two crucial points
- the frequency with which carcinoma in situ progresses to
invasive carcinoma,
and the frequency with which invasive carcinoma is preceded by
abnormal smears
(b) The test:
Regarding the screening test, two particular aspects deserve
consideration, that is, the response rate and the sensitivity of the test.
the response rate being the least in women thought to be most at risk,
as for example the poorest and the least educated women
 SCREENING FOR CANCER CERVIX

The second factor influencing the benefit of screening is the

sensitivity of the test in detecting neoplastic changes.
It has been estimated that the false-negative rate is of the order of 20
per cent (sensitivity 80 per cent).
The sensitivity will also depend upon whether the cervical smear is
prepared from vaginal aspiration or direct cervical scraping - the latter
is more reliable than the former.
The question that arises is whether improved quality of smear taking,
proper laboratory handling and the pathologist's diagnostic
competence can reduce the number of false-negatives .
Screening intervals and selection of age groups are matters which are
under discussion continuously.
 SCREENING FOR CANCER CERVIX

Unfortunately, there were no randomised controlled studies of the

benefits of the Pap test when it was introduced.

However, there is indirect evidence from certain countries (e.9.,

Norway, Sweden, Finland, Iceland) that early detection can reduce
both incidence and mortality
 SCREENING FOR CANCER BREAST

Basic techniques for early detection of breast cancer are :

(a) breast self examination (BSE) by the patient

(b) palpation by a physician
(c) thermography, and
(d) mammography.
 BREAST SELF EXAMINATION

All women should be encouraged to perform breast self examination.

Breast cancers are more frequently found by women themselves than

by a physician during a routine examination.

Although the effectiveness of BSE has not been adequately quantified

,it is a useful adjuvant to early case detection

ln many countries, BSE will probably be the only feasible approach to

wide population coverage for a long time to come
 Contd...
Palpation
unreliable for large fatty breasts.
Thermography
has the advantage that the patient is not exposed to radiation.
Unfortunately, it is not a sensitive tool.
Mammography
most sensitive and specific in detecting small tumours that are
sometimes missed on palpation.
The use of mammography has three potential drawbacks:
(i) exposure to radiation. This may amount to a dose of 500
milliroentgen compared to a 30-40 milliroentgen dose received in
chest X-ray. Therefore, there has been concern about exposure to
radiation from repeated mammographies and the risk of breast
cancer developing as a result
 Contd...
(ii) mammography requires technical equipment of a high standard
and radiologists with very considerable experience - these two factors
limit its more widespread use for mass screening purposes, and

(iii) biopsy from a suspicious lesion may end up in a false-positive in

as many as 5-10 cases for each case of cancer detected

Although recent evidence points to the superiority of mammography

over clinical examination in terms of sensitivity and specificity,
medical opinion is against routine mammography on the very young.

Women under 35 years of age should not have X-rays unless they are
symptomatic or a family history of early onset of breast cancer
 SCREENING FOR LUNG CANCER
At present there are only two techniques for screening for lung cancer,
viz.
chest radiograph and
sputum cytology.
Mass radiography has been suggested for early diagnosis at six
monthly intervals, but the evidence in support of this is not
convincing. So it is not recommended
It is doubtful whether the disease satisfies the criteria of suitability for
screening
 ORAL CANCER
EPIDEMIOLOGICAL FEATURES
Tobacco
Alcohol
Precancerous lesion- erythroplakia, leukoplakia
High risk groups- smokers, tobacco quid in mouth
Cultural patterns- indigenous form of tobacco use

PREVENTION
PRIMARY PREVENTION
Public education and motivation for changing life styles
Legislation- banning / restricting tobacco
 ORAL CANCER
SECONDARY PREVENTION
Easily available for inspection allowing early detection
Precancerous lesion can be detected upto 15 years prior to their
change to invasive ca
Main treatment- surgery, radiotherapy
Primary health care workers detect cancer at early stage during hme
visits
 CANCER CERVIX
NATURAL COURSE
A.Disease
Cancer cervix seems to follow a progressive course from epithelial
dysplasia to carcinoma in situ into invasive carcinoma
There is good evidence that carcinoma in situ persists for a long time,
more than 8 years
The proportion of cases progressing to invasive ca from preinvasive
stage is not known - it may average 15 years or longer
There is evidence that some in situ case spontaneously regress
without treatment.
Once the invasive stage is reached, the disease spreads by direct
extension into Iymph nodes and pelvic organs
 CANCER CERVIX
NATURAL COURSE
b.CAUSATIVE AGENT
HPV sexually transmitted

RISK FACTORS
AGE- 25 TO 45 years
Genital status
Marital status- mutiple sexual partners
Early marriage
OCP
Low socio economic status
 CANCER CERVIX
PREVENTION AND CONTROL
PRIMARY PREVENTION Education, birth control
SECONDARY PREVENTION- Early diagnosis, screening, treatment
 BREAST CANCER
RISK FACORS
Age- >35 yrs
Parity-nulliparous
Family history
Age at menarche early
Age at menopause-late
Hormonal factors-hiogh estrogen and progesterone
Diet
Prior biopsy
Socioeconomic status-high
Radiation
OCP
 BREAST CANCER
PREVENTION AND CONTROL
PRIMARY PREVENTION Education elimination of risk factors
SECONDARY PREVENTION- Early diagnosis, screening, treatment
 LUNG CANCER
RISK FACTORS
Age-<65 YRS
SEX-male
Smoking
Radiation
Asbestos exposure
Air pollution
 LUNG CANCER
PREVENTION AND CONTROL
PRIMARY PREVENTION Education elimination of risk factors
Public information and education
Legislative and restrictive measures
Smoking cessation activities
National and international coordination
SECONDARY PREVENTION- early diagnosis and treatment
THANK YOU