Cancer

• Cancer is the uncontrolled growth and spread

of cells.
• It can affect almost any part of the body.
• The growths often invade surrounding tissue
and can metastasize to distant sites.
• Other terms used are malignant tumours and
neoplasms
 Types according to cellular origin
• Carcinomas- epithelial cells- oral, esophageal,
uterine, intestinal, skin
• Sarcomas- mesodermal cells- bone, muscle,
cartilage
• Lymphoma, myeloma, leukemia- cells of bone
marrow, immune system
• Primary tumour
• Secondary tumour
• Cancer is a leading cause of death worldwide(2nd)
• 7.6 million deaths (around 13% of all deaths) occurred
due to cancer in 2008.
• The main types of cancer are:
lung (1.37 million deaths)
stomach (736 000 deaths)
liver (695 000 deaths)
colorectal (608 000 deaths)
breast (458 000 deaths)
cervical cancer (275 000 deaths)
Fig: Most frequent cancers: both sexes
• Approximately 70% of cancer deaths occur in
low- and middle-income countries
• 30% of cancers are preventable.
 Worldwide, the 5 most common types of cancer
that kill men in order of frequency are
• lung,
• liver,
• stomach,
• colorectal,
• oesophagus.
 Worldwide, the 5 most common types of cancer
that kill women are in the order of frequency are
• breast,
• lung,
• colorectal ,
• cervical and
• stomach
• In many developing
countries, cervical
cancer is the most
common cancer. 
 In Nepal
• Population based registries, which are vital,
are lacking
• Regional data are extrapolated to obtain
approximate estimates
Fig: Estimated age-standardised incidence and mortality rates: men
Estimated age-standardised incidence and mortality rates: women
Estimated age-standardised incidence and mortality rates: both sexes
 Fig: Major cancers in Nepal
DHUNGANA A. EPIDEMIOLOGY AND IMPACT OF CANCER ON PATIENTS AND CARETAKERS: A COMBINED HOSPITAL AND COMMUNITY BASED STUDY IN KATHMANDU VALLEY.
 Causes
Interaction between a person's genetic factors and
three categories of external agents, including:
• Physical carcinogens- ultraviolet and ionizing
radiation
• Chemical carcinogens- asbestos, components of
tobacco smoke, aflatoxin, arsenic
• Biological carcinogens- infections from certain
viruses, bacteria or parasites.
 Risk factors for cancers

• Ageing
• Unhealthy diet
• Physical inactivity
• Genetic susceptibility
• Pollution
Prevention and Control
 Primary prevention
• Increase avoidance of the risk factors.
• Vaccinate against human papilloma virus
(HPV) and hepatitis B virus (HBV).
• Control occupational hazards.
• Reduce exposure to sunlight.
 Tobacco

• Tobacco use is the single greatest avoidable risk factor for cancer
mortality worldwide
• 22% of cancer deaths each year attributed to it
• In 2004, 1.6 million of the 7.4 million cancer deaths were due to
tobacco use.
• Tobacco smoking causes cancers of the lung, esophagus, larynx,
mouth, throat, kidney, bladder, pancreas, stomach and cervix.
• About 70% of the lung cancer burden can be attributed to smoking
alone.
• Second-hand smoke (SHS), also known as environmental tobacco
smoke, has been proven to cause lung cancer in nonsmoking adults.
• Smokeless tobacco (oral tobacco, chewing tobacco or snuff) causes
oral, esophageal and pancreatic cancer.
•  
 Physical inactivity, dietary factors, obesity and being
overweight
• Cancers of esophagus, colorectum, breast, endometrium and
kidney are linked to these factors.
• Diets high in fruits and vegetables may have a protective effect
against many cancers.
• Conversely, excess consumption of red and preserved meat
may be associated with an increased risk of colorectal cancer.
• Regular physical activity and the maintenance of a healthy
body weight, along with a healthy diet, will considerably
reduce cancer risk.
• National policies and programmes should be implemented to
raise awareness and reduce exposure to cancer risk factors,
and to ensure that people are provided with the information
and support they need to adopt healthy lifestyles.
 Alcohol use
• Cancers of the oral cavity, pharynx, larynx,
oesophagus, liver, colorectum and breast.
• Risk of cancer increases with the amount of alcohol
consumed.
• The risk from heavy drinking for several cancer types
e.g. oral cavity, pharynx, larynx and oesophagus
substantially increases if the person is also a heavy
smoker.
• Attributable fractions vary between men and women
for certain types of alcohol-related cancer, mainly
because of differences in average levels of
consumption.
 Infections
• Infectious agents are responsible for almost 22% of
cancer deaths in the developing world and 6% in
industrialized countries.
• Viral hepatitis B and C cause cancer of the liver
• Human papilloma virus infection causes cervical cancer
• Helicobacter pylori increases the risk of stomach
cancer.
• Schistosomiasis increases the risk of bladder cancer
• Liver fluke increases the risk of cholangiocarcinoma
• Preventive measures include vaccination and
prevention of infection and infestation.
 Environmental pollution
• Environmental pollution of air, water and soil with
carcinogenic chemicals accounts for 1–4% of all cancers.
• Exposure to carcinogenic chemicals in the environment
can occur through drinking water or pollution of indoor
and ambient air, contamination of food by chemicals, such
as aflatoxins or dioxins.
• In Bangladesh, 5–10% of all cancer deaths in an arsenic-
contaminated region were attributable to arsenic
exposure.
• Indoor air pollution increaseses the risk of lung cancer
• Worldwide, indoor air pollution from domestic coal fires is
responsible for approximately 1.5% of all lung cancer
 Occupational carcinogens
• More than 40 agents, mixtures and exposure
circumstances in the working environment are
carcinogenic to humans
• They are related to cancer of the lung, bladder,
larynx and skin, leukaemia and nasopharyngeal
cancer, mesothelioma
 Radiation
• Ionizing radiation is carcinogenic to humans.
• Knowledge on radiation risk has been mainly acquired from
epidemiological studies of the Japanese A-bomb survivors
as well as from studies of medical and occupational
radiation exposure cohorts.
• Ionizing radiation can induce leukaemia and a number of
solid tumours, with higher risks at young age at exposure..
• Ultraviolet (UV) radiation, and in particular solar radiation, is
carcinogenic to humans, causing all major types of skin
cancer, such as basal cell carcinoma (BCC), squamous cell
carcinoma (SCC) and melanoma.
• Avoiding excessive exposure, use of sunscreen and
protective clothing are effective preventive measures.
 Secondary prevention
• Early diagnosis
• Treatment
 Early diagnosis

• Early detection of cancer greatly increases the chances for

successful treatment.
• There are two major components of early detection of cancer:
education to promote early diagnosis and screening.
• Recognizing possible warning signs of cancer and taking prompt
action leads to early diagnosis.
• Increased awareness of possible warning signs of cancer, among
physicians, nurses and other health care providers as well as among
the general public, can have a great impact on the disease.
• Some early signs of cancer include lumps, sores that fail to heal,
abnormal bleeding, persistent indigestion, and chronic hoarseness,
change in wart or mole, unexplained weight loss.
• Early diagnosis is particularly relevant for cancers of the breast,
cervix, mouth, larynx, colon and rectum, and skin.
 Screening
• Screening refers to the use of simple tests across a healthy
population in order to identify individuals who have disease, but
do not yet have symptoms.
• Mass screening and high risk screening
• Breast cancer screening using mammography, breast self
examination
• Cervical cancer screening using Pap smears, VIA, VILI .
• Mass population screening can be advocated only for breast and
cervical cancer
• Mammography screening and cytology screening (PAP smear) in
countries where resources are available for wide coverage of the
population.
• In low-resource settings, visual inspection with acetic acid, clinical
breast examination
 Screening programmes should be undertaken only
• when their effectiveness has been demonstrated
• when resources (personnel, equipment, etc.) are
sufficient to cover nearly all of the target group
• when facilities exist for confirming diagnoses and
for treatment and follow-up of those with abnormal
results, and
• when prevalence of the disease is high enough to
justify the effort and costs of screening.
Fig: Lead time bias
 Treatment
• Surgery
• Chemotherapy
• Radiotherapy
• Palliative care
NEPAL HEALTH SECTOR PROGRAMME- IMPLEMENTATION PLAN II (NHSP-IP 2) 2010 – 2015
 NHSP-II

• BCC via multiple channels, aimed at encouraging

better diet, more exercise, reduced smoking and
alcohol consumption.
• Ministry will also advocate the implementation and
enforcement of tobacco and alcohol controls.