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The Public Health Aspects

Objectives
 Give an estimate of the magnitude of the
cancer problem in the Philippines
 Discuss the levels of prevention of cancer
 Give details regarding each level of cancer
prevention
Magnitude of Cancer Problem
in the Philippines
INCIDENCE
 3rd in incidence after communicable &
cardiovascular diseases
 1 out of 1,000 Filipinos has cancer
 114:103 Females to Males, Filipino
Estimated 10 Leading Cancer Sites 2005

Rate: /100,000 population Source:C-network.org.ph


Estimated 10 Leading cause of cancer
death 2005

Rate: /100,000 population Source:C-network.org.ph


CANCER PREVENTION
Levels of Prevention
 Primary – prevention in an individual who
does not have the disease
 Secondary – early detection of cancer who
has the disease but is asymptomatic
 Tertiary – prevention of disease
progression, recurrence, relapse or
complications in patients who is has and is
symptomatic for the disease
1 0
2 0
3 0

Biologic
Effect
Normal
Cell Invasive metastasis
proliferation atypia In situ
cancer
Genetic
Alterations

exposure
Which Level???
 1. Adjuvant chemotherapy after
mastectomy
 2. Hepatitis B vaccination
 3. Pap smear in the general population
 4. Stop smoking campaign
Primary Prevention
Cervical Cancer Protected sex
HPV vaccination
Lung, Oral cavity, esophagus, Quitting smoking
stomach, pancreas, bladder,
kidney
Stomach cancer No nitrates/nitrites/salt
preservatives
H. Pylori eradication
Liver Cancer Hepatitis B vaccine
Hepatitis C screening of blood
products
No moldy foods
Colorectal cancers Diet rich in fruits and vegetables
Primary Prevention
 Chemoprevention:
 BreastCancer: Tamoxifen or Raloxifene for
patients at high risk of developing invasive
cancers
Calculate your breast cancer risk:
http://www.cancer.gov/bcrisktool/
 Gastric cancer: H. pylori eradication
(antibiotics)
 Colorectal Cancers: Aspirin/NSAIDS for those
at high risk or with previous adenomas
Primary Prevention
 Vaccination:
 Hepatocellular cancer: Hepatitis B Vaccination

 Cervical cancer: HPV vaccination


HPV 16 & 18, the cause for over 70% of cervical
cancers
Quadrivalent vaccine against HPV 6, 11, 16 & 18
9-26 years old
Does not protect against all HPV infections and
continued screening is recommended
Primary Prevention
 Surgical Prevention
 Colectomy for patients with FAP syndrome or
Ulcerative colitis

 Prophylactic
mastectomy for patients with
BRCA1 or BRCA2 mutations
1 0
2 0
3 0

Biologic
Effect
Normal
Cell Invasive metastasis
proliferation atypia In situ
cancer
Genetic
Alterations

exposure
SCREENING
Do Screening if…
 The disease is an important health problem.
 The disease has a recognizable early stage.
 Treatment at an early stage is more
beneficial than treatment at a later stage.
 Screening test is convenient and tolerable to
patients.
 Adequate facilities exist for diagnosis and
treatment.
 The screening cost is acceptable to society.
BREAST CANCER
 30% reduction in deaths due to early
screening
 Mammography at 40 yrs and above
 Annual clinical breast exam (by physician)
every 1-3 years
 Monthly breast self-breast exam starting
20 years.

NCCN Guidelines 2008


BIRADS for Mammogram
 Breast Imaging Reporting and Data System
 0 - Incomplete - Additional tests are necessary to further evaluate
the findings, or follow up may be needed
1 - Negative - No imaging findings; recommends routine screening
2 - Benign - There are mammogram findings, but benign in nature;
still recommends routine screening
3 - Probably Benign - Breast mammogram findings are most likely
benign (>90%), short term follow up test is necessary
4 - Suspicious - Breast findings have probability of a malignant
nature, biopsy is recommended.
5 - Highly Suspicious of Cancer - The breast findings have a very
high chance of being malignant (>90%). Biopsy or more definitive
treatment is recommended.
COLON CANCER
 Screening recommended for persons 50
years old and above
 Fecal occult blood test every year
 Sigmoidoscopy every 5 years
 Colonoscopy every 10 years
 Double contrast barium enema every 5
years

NCCN Guidelines 2008


LUNG CANCER
 CIGARETTE SMOKING causes 83% of
cancer cases and 30% of all cancer
deaths.
 Those who smoke 2 or more packs of
cigarettes a day have deaths due to lung
cancer 15-25 times more than
nonsmokers.
LUNG CANCER
 Investigated screening tools:
 ChestX-ray
 Sputum studies
 Low-dose CT scan (showing promise)

 STILLNO EFFECTIVE SCREENING


TOOL FOR LUNG CANCER
 SO… STOP SMOKING!!!
Cervical Cancer
 Screening begins 3
years after onset of
sexual intercourse, or
21 years old, which
ever comes first
 Yearly pap-smear until
age 30, then 2-3 years
thereafter (if with 3
normal smears)
 HPV-DNA testing for
those >30y/o
Prostate Cancer
 For people >50 years old
 Annual PSA determination (still controversial)
 Annual Digital Rectal Exam
No standard recommendations
 Ovarian Cancer
 Adnexal palpation +/- ultrasound in high risk
paients
 Skin cancer
 Full skin examination by physician
 Endometrial cancer
 Transvaginal ultrasound
9 Danger Signs of Cancer
 From Pre-clinical Asymptomatic State to Clinical
Disease
 Change in bowel or bladder habits
 A sore that does not heal
 Unusual bleeding and/or discharge
 Thickening or lump in breast or elsewhere
 Indigestion or difficulty in swallowing
 Obvious change in wart or mole
 Nagging cough or hoarseness
 Unexplained anemia
 Sudden weight loss
9 Danger Signs of Cancer
 From Pre-clinical Asymptomatic State to Clinical
Disease
 Change in bowel or bladder habits
 A sore that does not heal
 Unusual bleeding and/or discharge
 Thickening or lump in breast or elsewhere
 Indigestion or difficulty in swallowing
 Obvious change in wart or mole
 Nagging cough or hoarseness
 Unexplained anemia
 Sudden weight loss
CARE FOR THE
TERMINALLY-ILL
CARE FOR THE TERMINALLY-ILL

 Philosophy of care in terminal illness

A time comes in the advanced stage of


progressive incurable disease, death being
certain and approaching, when further attempts
to cure become irrelevant, unkind and bad
medicine, a change in the role and attitude is
then required by all those caring for the patient.
CARE FOR THE TERMINALLY-ILL

 The doctor and the dying patient

To cure sometimes, to relieve often, to comfort


always.
CARE FOR THE TERMINALLY-ILL

 The doctor and the dying patient

 Control of any symptoms/ condition


 Level of patient’s participation in the total process
 Past memories / experiences of the dying patient
 Present concerns of the patient
 Future concerns of the patient
 Secret life of the patient
 Spirituality before death
CARE FOR THE TERMINALLY-ILL

 Communicating with the patient

 Listenwith care
 Always be truthful
 Patient has the absolute right to information
 Patient has the right not to know his prognosis/diagnosis
CARE FOR THE TERMINALLY-ILL

 Communicating with the patient

 Listen attentively
 Listen with your eyes
 Listen with a third ear
 Do not abhor silence
CARE FOR THE TERMINALLY-ILL

 Communicating with the patient

 Explain reasons for the symptoms


 Open the way for the patient to inquire
 Visit the patient alone or another occasion
 “Is there anything you would like to ask me?”
CARE FOR THE TERMINALLY-ILL

 Communicating with the patient

 Generally patients who do not want to know will not ask


 Do not make unwise promises to the patient and relatives
about non-disclosure
 Patients always prefer the gentle truth
 NOT: You have got cancer
 BUT: Tests indicate that it is a form of cancer

 NOT: You have only 3 months to live


 BUT: Time is probably limited
CARE FOR THE TERMINALLY-ILL

 Various needs to be addressed:

 Physiological comfort
 Physical comfort
 Social comfort Hospice team/palliative care
team
 Spiritual comfort
 Bereavement support
CARE FOR THE TERMINALLY-ILL

 Chemotherapy for the terminally-ill

 Is
chemotherapy indicated?
 What kind and how aggressive should it be?
 When should the treatment be discontinued?
 What the risks?
 What is the balance between side effects and benefit?
CARE FOR THE TERMINALLY-ILL

 Chemotherapy for the terminally-ill


 Management factors to be considered:

Symptom relief
Natural history of tumor and responsiveness to chemo
Age of patient
PS (performance status)
CARE FOR THE TERMINALLY-ILL

 Chemotherapy for the terminally-ill


 Management factors to be considered:

Nutritional status
Concurrent medical problems
Psychological status
Quality of life
CARE FOR THE TERMINALLY-ILL
 WHO3-STEP LADDER FOR CANCER PAIN
CONTROL
Pain relief is the hallmark in palliative care
What the subject says hurts
By the mouth, by the clock, by the ladder
Low pain - non-opioid +/- adjuvant
Moderate pain - weak opioid +/- non-opiod +/- adjuvant
Severe pain - strong opioid +/- non-opiod +/- adjuvant
Pain persists Pain persists
PAIN or increases or increases

Strong opiod +/-


non-opiod +/-
Weak opiod +/- adjuvant
non-opiod +/-
Non-opiod +/- adjuvant
adjuvant
Anticancer Tx possible and appropriate - RT, systemic
therapy, surgery
Local therapy for regional pain (e.g. nerve blocks)
Treat other aspects of suffering which may cause or
aggravate pain - psychological, social, cultural,
spiritual
CARE FOR THE TERMINALLY-ILL

 ETHICS AT THE END OF LIFE

Beneficence: Acting in the best interest of the patient


Non-maleficence: First do no harm
Autonomy: Patient’s right to choose or refuse treatment
Justice: Decision of who gets what treatment
10 COMMANDMENTS FOR CANCER
SURVIVAL

1. Thou shalt regard the word cancer as


exactly that: a word.Nothing more,
nothing less (another version: cancer is
just a word… not a sentence)
2. Thou shalt love thy chemotherapy, thy
radiotherapy, and other treatments even
as thyself, for they are thy friends and
companions.
3. Thou shalt participate fully in thy
recovery
4. Thou shalt regard thy ailment as
temporary detour in thy life and shalt
plan thy future as if this detour had not
occurred.
5. Thou shalt express thy feeling candidly
and openly to thy loved ones for they,
too, are stricken.
6. Thou shalt be a comfort to the fellow
cancerites providing knowledge,
encouragement, understanding and love.
7. Thou shalt never reliquish hope, no
matter how thou may feelest at the
moment, for thou knowest, in the deep
recess of thy heart, that thy
discouragement is but fleeting and that a
better day awaits thee.
8. Thou shalt not regard thy ailment as the
sum total of thy life but merely a part of
it.
9. Thou shalt maintain, at all times and in all
circumstances, thy sense of humor, for
laughter lightens thy heart and hastens
thy recovery.
10. Thou shalt have enduring and
unassailable faith, whether thy faith be in
a Supreme Being, in medical science, in
thy future, in thyself , or in whatever.