Cancer nazar 2016

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Cancer
By
Nazar A. Mahmood
PhD Student
Community medicine department
College of Medicine
Hawler Medical University
2016

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The word cancer is derived from the Latin word for crab because cancers are often
very irregularly shaped, and because, like a crab, they "grab on and don't let go."
Cancer:
“Group of heterogeneous disorders characterized by Clonality, Autonomy, Anaplasia
and Metastasis”.
The reason is that cancers, as they are defined, are
− Clonality: arise from a single stem cell that clones into carcinomatous cells.
− Autonomy: the cell division and growth is uncontrolled.
− Anaplasia : lack of cell differentiation.
− Metastasis: (distant spread)”.
Definition

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Neoplasm:
A neoplasm is an abnormal new growth of cells. The cells in a neoplasm usually grow more rapidly
than normal cells and will continue to grow if not treated. As they grow, neoplasms can impinge
upon and damage adjacent structures. The term neoplasm can refer to benign (usually curable) or
malignant (cancerous) growths.
Tumor:
is a commonly used, but non-specific, term for a neoplasm. The word tumor simply refers to a
mass. This is a general term that can refer to benign (generally harmless) or malignant (cancerous)
growths.
Mutation
is a permanent alteration of the nucleotide sequence of the genome of an organism, virus, or
extrachromosomal DNA or other genetic elements.
Definition

Pathophysiology
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 Cancer can start almost anywhere in the human body, which is made up
of trillions of cells. Normally, human cells grow and divide to form new
cells as the body needs them. When cells grow old or become
damaged, they die, and new cells take their place.
 When cancer develops, however, this orderly process breaks down. As
cells become more and more abnormal, old or damaged cells survive
when they should die, and new cells form when they are not needed.
These extra cells can divide without stopping and may form growths
called tumors.

Pathophysiology
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 Cancer is a genetic disease—that is, it is caused by changes to genes that
control the way of cells function, especially how they grow and divide.
 Genetic changes that cause cancer can be inherited from parents. They can also
arise during a person’s lifetime as a result of errors that occur as cells divide or
because of damage to DNA caused by certain environmental exposures. Cancer-
causing environmental exposures include substances, such as the chemicals in
tobacco smoke, and radiation, such as ultraviolet rays from the sun.
 Each person’s cancer has a unique combination of genetic changes. As the
cancer continues to grow, additional changes will occur. Even within the same
tumor, different cells may have different genetic changes.
 In general, cancer cells have more genetic changes, such as mutations in DNA,
than normal cells. Some of these changes may have nothing to do with the
cancer; they may be the result of the cancer, rather than its cause.

Classification
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1. Carcinoma: Cancers derived from epithelial cells. This group includes many of the most
common cancers, particularly in the aged, and include nearly all those developing in
the breast, prostate, lung, pancreas, and colon.
2. Sarcoma: Cancers arising from connective tissue (i.e. bone, cartilage, fat, nerve),
each of which develops from cells originating in mesenchymal cells outside the bone
marrow.
3. Lymphoma and leukaemia: These two classes of cancer arise from hematopoietic
(blood-forming) cells that leave the marrow and tend to mature in the lymph nodes and
blood, respectively. Leukaemia is the most common type of cancer in
children accounting for about 30%.
4. Germ cell tumor: Cancers derived from pluripotent cells, most often presenting in
the testicle or the ovary (seminoma and dysgerminoma, respectively).
5. Blastoma: Cancers derived from immature "precursor" cells or embryonic tissue.
Blastomas are more common in children than in older adults.

Danger signs
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 Lump/hard area in breast.
 Sudden change in a previous wart/mole.
 Persistent change in bowel habit (constipation/ diarrhoea /bleeding).
 Persistent cough/hoarseness.
 ↑ menstrual blood loss/ metrorrhagia.
 Blood loss from any natural orifice.
 Swelling/ sore throat that does not heal.
 Unexplained weight loss.

Stages of Cancer
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Stage 0. This stage describes cancer in situ, which means “in place.” Stage 0
cancers are still located in the place they started and have not spread to nearby
tissues. This stage of cancer is often highly curable, usually by removing the entire
tumor with surgery.
Stage I. This stage is usually a small cancer or tumor that has not grown deeply into
nearby tissues. It also has not spread to the lymph nodes or other parts of the body.
It is often called early-stage cancer.
Stage II and III. These stages indicate larger cancers or tumors that have grown
more deeply into nearby tissue. They may have also spread to lymph nodes but not
to other parts of the body.
Stage IV. This stage means that the cancer has spread to other organs or parts of
the body. It may also be called advanced or metastatic cancer.

Agent
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A carcinogen is any substance, radionuclide or radiation that is an agent
directly involved in the exacerbation of cancer or in the increase of its
propagation.
 Physical carcinogens, such as ultraviolet and ionizing radiation.
 Chemical carcinogens, such as asbestos, components of tobacco
smoke, aflatoxin (a food contaminant) and arsenic (a drinking water
contaminant).
 Biological carcinogens, such as infections from certain viruses, bacteria
or parasites; such agents are responsible for almost 22% of cancer deaths
in the developing world and 6% in industrialized countries.

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Chemical
Benzene Leukemia
Polycyclic hydrocarbons (encountered in industrial
and car exhaust)
All cancers
Aromatic amines (those in a cigarette) Bladder
Occupational exposure to asbestos, chromium,
arsenic, nickel, uranium
Many cancers (esp Lung)
Coaltar, X-ray, dyes, heat Skin
Food
Ascorbate deficiency Leukoplakia
↑ saturated fat Breast, colon
Vitamin A deficiency
Betel, areca
Oral, esophageal, colorectal
Carcinogens

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Carcinogens
Beef
Iron deficiency
Tobacco (either in cigarettes or in its various
chewable forms) Lung, oral
Alcohol Liver
Smoked fish (a popular dish in Japan), nitrosamines
(food additive)
Stomach
Dietary fiber deficiency Colorectal
Virus
Hepatitis B and C Liver
HIV, cytomegalovirus Kaposi sarcoma, non-
Hodgkin's lymphoma
Epstein Barr virus Burkitt lymphoma,
nasopharyngeal carcinoma
Human T lymphotropic virus T cell leukemia
Human papilloma virus Cervix
Parasites
Schistosoma Bladder
Fungal toxin (aflatoxins), which is produced by the
fungus Aspergillus flavus growing on stored grains,
nuts and peanut butter
Liver

Host
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Age
Ageing is another fundamental factor for the development of cancer. The incidence of cancer
rises dramatically with age, most likely due to a build-up of risks for specific cancers that
increase with age. The rising incidence of cancer is partly due to the rise of life expectancy.
Sex
It is readily observable that some cancers are 'male' (oral, lung, oesophagus, stomach,
bladder) and some 'female' (breast, cervix). The difference is attributed to exposure (more
men smoke than women) rather than susceptibility. On the other hand, breast cancer is an
oestrogen dependent neoplasm, which the male body can not sustain, and cervical cancer is
frequently caused by human papillomavirus, which causes similar tumor (papilloma) over
male genitalia and perianal region.
Obesity was found to be a risk factor for cancer in a study by International Cancer
Collaborators, as well as ↓ consumption of fruits and vegetables, physical inactivity and
indoor smoke from household fuels.

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'A'bloodgroup stomachcarcinoma
Down'ssyndrome Leukemia
Othergeneticcancers Polyposiscoli,retinoblastoma
Genetic factors

Magnitude of the Problem Worldwide :
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 The number of new cases of cancer which occurred worldwide in 2012 has been
estimated at about 14,090,000
 of which it was projected that 4,653,000 deaths occurred in men and 3,547,000 in
women in the same year.
 Among men, the 5 most common sites of cancer diagnosed in 2012 were lung,
prostate, colorectum, stomach, and liver cancer.
 While Among women the 5 most common sites diagnosed were breast, colorectum,
lung, cervix, and stomach cancer.
 In more developed and less-developed regions of the world, approximately 2,878,000
and 5,323,000 cancer deaths have resulted, respectively.
 Around one third of cancer deaths are due to the 5 leading behavioural and dietary
risks: high body mass index, low fruit and vegetable intake, lack of physical activity,
tobacco use, alcohol use.

Top leading causes of death (CDC, April 27, 2016)
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Different types of cancer show different distribution in different countries

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World Health Organization - Cancer Country Profiles, 2014.

Prevention
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A. Primordial prevention: is prevention of development of cancer’s risk factors
B. Primary prevention
1. Control of tobacco and alcohol consumption
2. Maintenance of personal hygiene and being in a monogamous relationship
prevents HPV infection and carcinoma cervix.
3. Lessen radiation exposure, esp. reduce unnecessary X-rays done (which
exposes both the patient and the technician to radiation); provide personal
protective equipment to workers in radiation plants/ radioactive mines.
4. Lessen occupational exposure to carcinogens through both engineering
measures and personal protection.
5. Immunization—Hepatitis B vaccine is now being incorporated in National
Immunization Schedule; the human papilloma virus vaccine is now being
used against HPV infection.
6. Legislation and surveillance of food additives, drugs and cosmetics.
7. Control of air pollution.
8. Treatment of precancerous lesions like cervical tears, polyposis, genital
warts, chronic gastritis, chronic cervicitis.

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C. Secondary prevention
A- Cancer registration
1. Hospital based.
2. Population based
B- Early detection by screening
1. Mass screening—Multisite (comprehensive cancer detection by
clinicians by a thorough check-up of whole body).
2. Selective screening of risk groups.
C- Treatment
Chemotherapy, Radiation, Surgery, Immunotherapy.
Prevention

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D. Tertiary prevention
1. Rehabilitation (after amputation/ laryngectomy / colostomy/facial
surgery).
2. Palliative care. Palliative care is treatment to relieve, rather than cure,
symptoms caused by cancer. Palliative care can help people live more
comfortably; it is an urgent humanitarian need for people worldwide
with cancer and other chronic fatal diseases.
Prevention

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− Breast cancer is a kind of cancer that develops from breast cells.
− Breast cancer usually starts off in the inner lining of milk ducts or the lobules
that supply them with milk. A malignant tumor can spread to other parts of the
body. A breast cancer that started off in the lobules is known as lobular
carcinoma, while one that developed from the ducts is called ductal
carcinoma.
− Breast cancer is the most important cause of cancer death among women, and
accounted for an estimated 521,000 deaths worldwide in 2012
− It accounts for 16% of all female cancers and 22.9% of invasive cancers in
women. 18.2% of all cancer deaths worldwide, including both males and
females, are from breast cancer.
Definition

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− Breast cancer rates are much higher in developed nations compared to
developing ones. There are several reasons for this, with possibly life-
expectancy being one of the key factors - breast cancer is more common in
elderly women; women in the richest countries live much longer than those in
the poorest nations. The different lifestyles and eating habits of females in rich
and poor countries are also contributory factors.
− According to the National Cancer Institute, 232,340 female breast cancers and
2,240 male breast cancers are reported in the USA each year, as well as about
39,620 deaths caused by the disease.
Definition

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− A breast lump or thickening that feels different from the surrounding
tissue
− Bloody discharge from the nipple
− Change in the size, shape or appearance of a breast
− Changes to the skin over the breast, such as dimpling
− A newly inverted nipple
− Peeling, scaling or flaking of the pigmented area of skin surrounding
the nipple (areola) or breast skin
− Redness or pitting of the skin over your breast, like the skin of an
orange
Signs and symptoms

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Breast cancer staging
The main stages are:
• Stage 0 is a pre-cancerous or marker condition, either ductal
carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS).
• Stages 1–3 are within the breast or regional lymph nodes.
• Stage 4 is 'metastatic' cancer that has a less favourable
prognosis since it has escaped into the blood stream.

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Pathophysiology
• Breast cancer, like other cancers, occurs because of an interaction between an
environmental (external) factor and a genetically susceptible host. Normal cells
divide as many times as needed and stop. They attach to other cells and stay in
place in tissues. Cells become cancerous when they lose their ability to stop
dividing, to attach to other cells, to stay where they belong, and to die at the
proper time.
• Normal cells will commit cell suicide (apoptosis) when they are no longer needed.
Until then, they are protected from cell suicide by several protein clusters and
pathways. Sometimes the genes along these protective pathways are mutated in
a way that turns them permanently "on", rendering the cell incapable of
committing suicide when it is no longer needed. This is one of the steps that
causes cancer in combination with other mutations.

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Risk factors
Risk factors can be divided into two categories:
1. Modifiable risk factors (things that people can change themselves, such
as consumption of alcoholic beverages), and
2. Fixed risk factors (things that cannot be changed, such as age and
biological sex).

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Modifiable risk factors
− weight gain after the age of 18 and/or being overweight or obese (for
postmenopausal breast cancer).
− use of menopausal hormone therapy (combined oestrogen and
progestin).
− physical inactivity, and alcohol consumption.
− In addition, recent research indicates that long-term, heavy smoking
may also increase breast cancer risk, particularly among women who
start smoking before their first pregnancy.

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Fixed (Non-modifiable) risk factors
older age (+50); a personal or family history of breast or ovarian cancer; inherited
mutations (genetic alterations) in BRCA1, BRCA2, or other breast cancer
susceptibility genes; certain benign breast conditions (such as atypical hyperplasia);
a history of ductal or lobular carcinoma in situ; high-dose radiation to the chest at a
young age (e.g., for cancer treatment); high breast tissue density (the amount of
glandular tissue relative to fatty tissue measured on a mammogram); high bone
mineral density (evaluated during screening for osteoporosis); and type 2 diabetes
(independent of obesity). Reproductive factors that increase risk include a long
menstrual history (menstrual periods that start early and/or end later in life), recent
use of oral contraceptives, never having children, having one’s first child after age 30,
and high natural levels of sex hormones.

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Prevention of breast cancer
Primary prevention of breast cancer has been attempted via
nutritional intervention, involving:
 Reduction of energy intake, reduction of the proportion of
calories from fat
 Increase in fruit and vegetable consumption.
 Control of weight gain, particularly of post-menopausal women,
would have favourable implications in breast cancer risk.
 Breastfeeding women who breastfeed run a lower risk of
developing breast cancer compared to other women

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Secondary prevention
Screening:
• Mammography: The effectiveness of screening by mammography in
women older than 50 years has been demonstrated, and
programmes have been established in various countries.
• The effectiveness in women younger than 50 is not yet
demonstrated.
• Other screening techniques, including breast self -examination, have
not been proven to reduce breast cancer mortality

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The main breast cancer treatment options may include:
1. Radiation therapy (Radiotherapy)
2. Surgery: Lumpectomy, Mastectomy, Sentinel node biopsy, Axillary
lymph node dissection, Breast reconstruction surgery
3. Biological therapy (targeted drug therapy): Trastuzumab
(Herceptin), Lapatinib (Tykerb), Bevacizumab (Avastin), Low dose
aspirin
4. Hormone therapy: Tamoxifen, Aromatase inhibitors, Ovarian
ablation or suppression.
5. Chemotherapy: cytotoxic drugs

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Lung cancer
− Lung cancer, also known as lung carcinoma, is a malignant lung
tumor characterized by uncontrolled cell growth in tissues of the lung.
− In 2012 lung cancer was the most frequent cancer in the world as there were
1,824,701 new lung cancer cases, accounting for approximately 13.0 per
cent of the global cancer burden.
− Lung cancer was also the most common cause of cancer death, causing
1,589,800 deaths in 2012.
− Incidence and mortality rates for lung cancer are approximately twice as
high among men as among women.

Signs and symptoms
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Symptoms do not usually occur until the cancer is advanced, and
may include:
 Respiratory symptoms: coughing, coughing up blood,
wheezing, or shortness of breath
 Systemic symptoms: weight loss, weakness, fever, or
clubbing of the fingernails
 Symptoms due to the cancer mass pressing on adjacent
structures: chest pain, bone pain, superior vena cava
obstruction, or difficulty swallowing

Types and Staging of Lung Cancer
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There are two major types of lung cancer:
1. Non-small cell lung cancer (NSCLC)
2. Small cell lung cancer (SCLC)

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Non-small cell lung cancer accounts for about 85 % of lung cancers and
includes:
1. Adenocarcinoma, the most common form of lung cancer in the United
States among both men and women;
2. Squamous cell carcinoma, which accounts for 25 % of all lung
cancers;
3. Large cell carcinoma, which accounts for about 10 % of NSCLC
tumors.

STAGES OF NON-SMALL CELL LUNG CANCER
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Stage I: The cancer is located only in the lungs and has not spread to any lymph
nodes.
Stage II: The cancer is in the lung and nearby lymph nodes.
Stage III: Cancer is found in the lung and in the lymph nodes in the middle of the
chest, also described as locally advanced disease. Stage III has two subtypes:
• If the cancer has spread only to lymph nodes on the same side of the chest where
the cancer started, it is called stage IIIA.
• If the cancer has spread to the lymph nodes on the opposite side of the chest, or
above the collar bone, it is called stage IIIB.
Stage IV: This is the most advanced stage of lung cancer, and is also described as
advanced disease. This is when the cancer has spread to both lungs, to fluid in the
area around the lungs, or to another part of the body, such as the liver or other
organs.

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2. Small Cell Lung Cancer
Small cell lung cancer accounts for the remaining 15 % of
lung cancers in the United States. They tend to grow more
quickly than NSCLC tumors. Usually, SCLC is more
responsive to chemotherapy than NSCLC.

STAGES OF SMALL CELL LUNG CANCER
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Limited stage: In this stage, cancer is found on one side of the chest, involving just
one part of the lung and nearby lymph nodes.
Extensive stage: In this stage, cancer has spread to other regions of the chest or
other parts of the body.

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Primary Versus Secondary Lung Cancer
Primary lung cancer starts in the lungs. The cancer cells are abnormal lung
cells. Sometimes, people will have cancer travel from another part of their body
or metastasize to their lungs. This is called secondary lung cancer because the
lungs are a secondary site compared to the original primary location of the
cancer.
Example
breast cancer cells which have travelled to the lung are not lung cancer but rather
metastatic breast cancer, and will require treatment prescribed for breast cancer
rather than lung cancer.

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All cells in the body contain the genetic material called deoxyribonucleic acid
(DNA). Every time a mature cell divides into two new cells, its DNA is exactly
duplicated. The cells are copies of the original cell, identical in every way. In this
way our bodies continually replenish themselves. Old cells die off and the next
generation replaces them.
A cancer begins with an error, or mutation, in a cell’s DNA. DNA mutations can be
caused by the normal aging process or through environmental factors, such as
cigarette smoke, breathing in asbestos fibres, and to exposure to radon gas.
Researchers have found that it takes a series of mutations to create a lung cancer
cell. Before becoming fully cancerous, cells can be precancerous, in that they have
some mutations but still function normally as lung cells. When a cell with a genetic
mutation divides, it passes along its abnormal genes to the two new cells, which
then divide into four cells with errors in their DNA and so on. With each new
mutation, the lung tissue cell becomes more mutated and may not be as effective in
carrying out its function as a lung cell. At a later stage of disease, some cells may
travel away from the original tumor and start growing in other parts of the body. This
process is call metastasis and the new distant sites are referred to as metastases.
The Genetic Basis of Lung Cancer

Risk factors
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− Cigarette smoking is by far the most important risk factor for lung
cancer; 80% of lung cancer deaths are caused by smoking. Risk
increases with both quantity and duration of smoking. Cigar and pipe
smoking also increase risk.
− Exposure to radon gas released from soil and building materials is
estimated to be the second-leading cause of lung cancer.
− occupational or environmental exposure to second-hand smoke,
asbestos (particularly among smokers), certain metals (chromium,
cadmium, arsenic), some organic chemicals, radiation, air pollution,
and diesel exhaust. rubber manufacturing

Risk factors
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− Risk is also probably increased among people with a history of
tuberculosis.
− Genetic susceptibility plays a role in the development of lung cancer,
especially in those who develop the disease at a young age.

Prevention of lung cancer
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Primary prevention
 Control of tobacco smoking (including involuntary smoking) remains the
key strategy for the prevention of lung cancer.
 Reduction in exposure to occupational and environmental carcinogens
(in particular indoor pollution and radon).
 Increase in consumption of fruits and vegetables.

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 Early detection: Screening with low-dose spiral computed tomography
(LDCT) has been shown to reduce lung cancer mortality by 20% compared
to standard chest x-ray among adults with at least a 30 pack-year smoking
history who were current smokers or had quit within 15 years.
 Treatment: surgery, radiation therapy, chemotherapy, and/or targeted
therapies.

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Tertiary prevention
1. Rehabilitation (after thoracotomy, segmentectomy,
lobectomy, or pneumonectomy).
2. Palliative care. led to significant improvements in both quality
of life and mood.

Introduction
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Cervical cancer is a malignant tumour deriving from cells of the "cervix uteri",
which is the lower part, the "neck" of the womb, the female reproductive organ.
− The estimated worldwide burden of cervical cancer in 2012 was approximately
528,000 new cases and 266,000 deaths.
− Cervical cancer is a major public health problem in less developed regions,
where about 84 % of cases (445,000) and 86 % of deaths (230,000) occurred in
2012.
− The number of estimated cervical cancer deaths in these regions is third to
breast cancer (324,000) and lung cancer (281,000) among women.
− Incidence rates are high (over 30/100,000) in Eastern, Southern, and Middle
Africa and Melanesia. Rates are lowest in Australia/New Zealand (5.5), Western
Asia (4.4), Middle-East (6.4), Northern American (6.6), and Northern Africa
(6.6).

Introduction
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− Incidence and mortality rates have decreased steadily in high-income countries,
but an upturn in incidence had been observed among young women in a few of
these.
− The cervical cancer incidence rate declined by half between 1975 (14.8 per
100,000) and 2012 (6.7 per 100,000) due to the widespread uptake of
screening with the Pap test and removal of precancerous lesions.
− the cervical cancer death rate in 2012 (2.3 per 100,000) was less than half that
in 1975 (5.6 per 100,000) due to declines in incidence and the early detection of
cancer with the Pap test.

Signs and symptoms:
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Preinvasive cervical lesions often have no symptoms. Once abnormal cervical cells
become cancerous and invade nearby tissue, the most common symptoms are:
− Abnormal vaginal bleeding, which may start and stop between regular menstrual
periods or occur after sexual intercourse, douching, or a pelvic exam.
− Menstrual bleeding may last longer and be heavier than usual.
− Bleeding after menopause and increased vaginal discharge may also be
symptoms.
− Symptoms of advanced cervical cancer may include: loss of appetite, weight loss,
fatigue, pelvic pain, back pain, leg pain, swollen legs, heavy vaginal bleeding,
bone fractures, and/or (rarely) leakage of urine or feces from the vagina.

Cervical cancer staging
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Stage I. Cancer is confined to the cervix.
Stage II. Cancer at this stage includes the cervix and uterus, but
hasn't spread to the pelvic wall or the lower portion of the vagina.
Stage III. Cancer at this stage has moved beyond the cervix and
uterus to the pelvic wall or the lower portion of the vagina.
Stage IV. At this stage, cancer has spread to nearby organs, such as
the bladder or rectum, or it has spread to other areas of the body,
such as the lungs, liver or bones.

Risk factors
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− Persistent infection with certain types of human papillomavirus (HPV)
(16,18,31,33).
− While women who begin having sex at an early age or who have had many
sexual partners are at increased risk for HPV infection and cervical cancer, a
woman may be infected with HPV even if she has had only one sexual partner. In
fact, HPV infections are common in healthy women and only rarely cause cervical
cancer.
− Both persistence of HPV infection and progression to cancer may be influenced
by many factors, including a suppressed immune system, a high number of
childbirths, and cigarette smoking.
− Long-term use of oral contraceptives (birth control pills) is also associated with
increased risk of cervical cancer.
− Multiple pregnancies (seven or more full-term pregnancies).

Prevention of cervical cancer
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Primary prevention
• Health promotion. Safe sexual practices, improvement of hygiene.
• Specific protection. The HPV vaccine is a bivalent vaccine (against two
strains that cause 70% of cervical cancer) which is injected IM in three
doses over a period of six months.
• Vaccination is recommended for use in girls 11 to 12 years of age, but may
be given as young as age 9 and up to age 26.

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• Screening can prevent cervical cancer by detecting precancerous lesions
that can be treated so they do not progress to cancer.
• The Pap test is a simple procedure in which a small sample of cells is
collected from the cervix and examined under a microscope.
• HPV tests, which detect HPV infections associated with cervical cancer.

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• Treatment: Precancerous cervical lesions may be treated with a loop
electrosurgical excision procedure (LEEP), which removes abnormal tissue
with a wire loop heated by electric current; cryotherapy (the destruction of
cells by extreme cold); laser ablation (removal of tissue); or conization (the
removal of a cone-shaped piece of tissue containing the abnormal tissue).

Definition
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• Colorectal cancer is cancer that starts in the colon or rectum.
• Colon cancer is cancer of the large intestine (colon), the lower part of
digestive system. Rectal cancer is cancer of the last several inches of the
colon. Together, they're often referred to as colorectal cancers.
• Cancers of the colon and rectum are rare in developing countries, but are the
second most frequent malignancy in affluent societies; over 940,000 cases
occur annually worldwide. With increasing industrialization and improving
economy with consequent changes in lifestyle in many of the developing
countries, the incidence may rise.
• The majority (55 per cent) of cases of colorectal cancer occur in high-income
regions of the world, and geographical patterns are very similar in men and
women. Generally, rates are slightly higher among men than women.
(GLOBOCAN 2012).

Definition
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• Cancers of the colon and rectum accounted in 2012 for an estimated
1,361,000 new cases and 694,000 deaths worldwide.
• As of 2012, it is the second most common cause of cancer in women (9.2%
of diagnoses) and the third most common in men (10.0%) with it being the
fourth most common cause of cancer death after lung, stomach, and liver
cancer.
• Incidence rates have generally been decreasing since the mid-1980s due to
both changes in risk factors (e.g., decreased smoking, increased use of non-
steroidal anti-inflammatory drugs) and the uptake of screening among adults
50 years of age and older.
• From 2008 to 2012, incidence rates declined by 4.5% per year among adults
50 years of age and older, but increased by 1.8% per year among those
younger than age 50.

Signs and symptoms
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• A change in the bowel habits, including diarrhoea or constipation
or a change in the consistency of the stool, that lasts longer than
four weeks
• Rectal bleeding or blood in the stool
• Persistent abdominal discomfort, such as cramps, gas or pain
• A feeling that bowel doesn't empty completely
• Weakness or fatigue
• Unexplained weight loss

Stages of colon cancer
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Stage I. Your cancer has grown through the superficial lining (mucosa) of the
colon or rectum but hasn't spread beyond the colon wall or rectum.
Stage II. Your cancer has grown into or through the wall of the colon or rectum
but hasn't spread to nearby lymph nodes.
Stage III. Your cancer has invaded nearby lymph nodes but isn't affecting
other parts of your body yet.
Stage IV. Your cancer has spread to distant sites, such as other organs — for
instance, to your liver or lung.

Risk factors
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Older age. The great majority of people diagnosed with colon cancer are older than 50. Colon
cancer can occur in younger people, but it occurs much less frequently.
African-American race. African-Americans have a greater risk of colon cancer than do
people of other races.
A personal history of colorectal cancer or polyps. If you've already had colon cancer or
adenomatous polyps, you have a greater risk of colon cancer in the future.
Inflammatory intestinal conditions. Chronic inflammatory diseases of the colon, such as
ulcerative colitis and Crohn's disease, can increase your risk of colon cancer.
Inherited syndromes that increase colon cancer risk. Genetic syndromes passed through
generations of your family can increase your risk of colon cancer. These syndromes include
familial adenomatous polyposis and hereditary non-polyposis colorectal cancer, which is also
known as Lynch syndrome.

Risk factors
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Family history of colon cancer. You're more likely to develop colon cancer if you have a
parent, sibling or child with the disease. If more than one family member has colon cancer or
rectal cancer, your risk is even greater.
Low-fiber, high-fat diet. Colon cancer and rectal cancer may be associated with a diet low in
fiber and high in fat and calories. Research in this area has had mixed results. Some studies
have found an increased risk of colon cancer in people who eat diets high in red meat and
processed meat.
A sedentary lifestyle. If you're inactive, you're more likely to develop colon cancer. Getting
regular physical activity may reduce your risk of colon cancer.
Diabetes. People with diabetes and insulin resistance may have an increased risk of colon
cancer.
Obesity. People who are obese have an increased risk of colon cancer and an increased risk
of dying of colon cancer when compared with people considered normal weight.

Risk factors
73
Smoking. People who smoke may have an increased risk of colon cancer.
Alcohol. Heavy use of alcohol may increase your risk of colon cancer.
Radiation therapy for cancer. Radiation therapy directed at the abdomen to treat previous
cancers may increase the risk of colon cancer.

Prevention
74
Primary prevention:
• Increased physical activity.
• Avoidance of overweight and obesity,
• Reduced alcohol drinking.
• Quitting smoking.
• While aspirin use could prevent colorectal cancer as well, its use is
not routinely recommended because of its spectrum of side effects.

Prevention
75
Secondary prevention:
• Early detection: Beginning at the age of 50, men and women who are at
average risk for developing colorectal cancer should begin screening.
• either annual faecal occult blood testing or one colonoscopic examination which
does not need to be repeated in 10 years if results are normal.
• Randomized trials have also demonstrated the efficacy of sigmoidoscopy in
reducing colorectal cancer mortality, primarily for the distal colon.

Prevention
76
• Treatment: Surgery is the most common treatment for colorectal cancers that
have not spread. A permanent colostomy (creation of an abdominal opening for
elimination of body waste) is not usually required for rectal cancer and is rarely
necessary for colon cancer.
• Chemotherapy alone, or in combination with radiation, is given before
(neoadjuvant) or after (adjuvant).
• Supportive (palliative) care: Palliative care is provided by a team of doctors,
nurses and other specially trained professionals.

Introduction
78
− The prostate is a gland found only in men. It’s part of the reproductive
system and helps to make semen. It’s located in front of the rectum and
under the bladder. A healthy prostate gland is about the size of a walnut.
− Prostate cancer starts in the cells of the prostate.
− Prostate cancer is one of the most common types of cancer in men.
− Prostate cancer is the second most common cancer and the fifth leading
cause of death from cancer in men worldwide with an estimated 1,111,000
newly diagnosed cases and 307,000 deaths in 2012.
− Black men in the US and Caribbean men of African descent have the
highest documented prostate cancer incidence rates in the world.

Introduction
79
− An estimated 180,890 new cases of prostate cancer will occur in the US
during 2016. Prostate cancer is the most frequently diagnosed cancer in
men aside from skin cancer. For reasons that remain unclear, the risk of
prostate cancer is 70% higher in blacks than in non-Hispanic whites.
− Almost 70 per cent of the cases (759,000) occurred in more developed
regions. It is the most common malignant neoplasm in men from Australia/
New Zealand (111.6/100,000), North America (97.2/100,000), and Western
Europe (94.9/100,000).
− The incidence is 69.5/100,000 in high-income regions and 14.5/100,000 in
low- and middle-income regions..

Signs and symptoms
80
 Prostate cancer may cause no signs or symptoms in its early
stages.
 Prostate cancer that is more advanced may cause signs and
symptoms such as:
 Trouble urinating
 Decreased force in the stream of urine
 Blood in the semen
 Discomfort in the pelvic area
 Bone pain
 Erectile dysfunction

Prostate cancer staging Whitmore-Jewett staging system:
81
In this system, the tumor is classified by letters (A to D).
• Stage A: Indicates that the cancer cannot be felt or seen by the naked
eye
• Stage B: Indicates that the cancer is not detectable by the presence of
a tumour
• Stage C: Indicates that the cancer has spread to surrounding tissues
and vesicles of the prostate
• Stage D: Indicates that the cancer has spread to bones and organs
throughout the body

Risk factors:
82
 The only well-established risk factors for prostate cancer are increasing age
(+50).
 In the United States it is more common in the African American population
than the White American population.
 Having a first degree relative with the disease increases the risk 2 to 3 fold.
Genetic studies suggest that strong familial predisposition may be responsible
for 5%-10% of prostate cancers. Inherited conditions associated with
increased risk include Lynch syndrome and BRCA1 and BRCA2 mutations.
 Studies suggest that obesity and smoking do not increase the overall risk of
developing prostate cancer, but may increase risk of developing aggressive/
fatal disease.

Prevention
83
Primary prevention
 Lowering prostate cancer risk
o Choose a healthy diet full of fruits and vegetables.
o Choose healthy foods over supplements.
o Exercise most days of the week.
o Maintain a healthy weight.
 The chemoprevention of prostate cancer is an active area of research. Two
drugs of interest, finasteride and dutasteride, reduce the amount of certain
male hormones in the body and are approved to treat the symptoms of benign
prostatic hyperplasia.

Prevention
84
 Early detection:
Screening for prostate cancer can be done with:
o Prostate-Specific Antigen (PSA) blood test.
o Digital Rectal Exam (DRE)Choose healthy foods over supplements.
 Management:
surgery (open, laparoscopic, or robotic-assisted), external beam
radiation, or radioactive seed implants (brachytherapy). Hormonal
therapy may be used along with surgery or radiation therapy in more
advanced cases.
 Palliative care.

Introduction
86
 The stomach is an organ between the oesophagus and the small intestine. It
mixes food with stomach acid and helps digest protein.
 Stomach cancer, also known as gastric cancer, is cancer developing from the
lining of the stomach.
 Stomach cancer mostly affects older people - two-thirds of people who have
it are over age 65.
 About one million new cases of stomach cancer were estimated to have
occurred in 2012 (6.8% of the total), making it currently the fifth most
common malignancy in the world, behind cancers of the lung, breast,
colorectum and prostate. More than 70% (677,000) of cases occur in
developing countries (456,000 in men, 221,000 in women), and half the world
total occurs in Eastern Asia.

Introduction
87
 Highest rates (over 40 per 100,000 in males) are reported from Japan,
China, the former USSR, and certain countries in Latin America. And The
lowest rates (< 15 per 100,000) are seen in North America (specifically, its
white population), India, the Philippines, most African countries, some
countries in Western Europe, and Australia.
 stomach cancer is the third most common cause of cancer death worldwide
(723,000 deaths in 2012, 8.9 per cent) in 2012. This marks a substantive
decrease in incidence since 1975 when stomach cancer was the most
common neoplasm worldwide.

Signs and symptoms of stomach cancer
88
 Fatigue
 Feeling bloated after eating
 Feeling full after eating small amounts of food
 Heartburn that is severe and persistent
 Indigestion that is severe and unrelenting
 Nausea that is persistent and unexplained
 Stomach pain
 Vomiting that is persistent
 Weight loss that is unintentional

Risk factors
89
 A diet high in salty and smoked foods
 A diet low in fruits and vegetables
 Eating foods contaminated with aflatoxin fungus
 Family history of stomach cancer
 Infection with Helicobacter pylori
 Long-term stomach inflammation
 Pernicious anaemia
 Smoking
 Stomach polyps
 The latest research indicated that Alcohol and Processed Meats
May Raise Stomach Cancer Risk (04/21/2016, Health Day)

Prevention
90
Primary prevention:
A. Dietary means is feasible by encouraging high-risk populations to:
• Eat more fruits and vegetables.
• Decrease consumption of processed meats, smoked and salt
preserved foods.
• Stop smoking and alcohol.
B. Eradication of H. pylori infection, particularly in childhood and
adolescence, and by avoiding mother to child transmission, at least in
those who are Asian.

Prevention
91
 Screening and early detection of stomach cancer have been developed in
Japan with the use of X-ray photofluorography to identify early lesions,
followed by gastroscopy.
 Treatment for stomach cancer may include surgery, chemotherapy, and/or
radiation therapy. New treatment approaches such as biological therapy and
improved ways of using current methods are being studied in clinical trials.

References
92
Parikshit, S. Community Medicine: A Students Manual, First Edition: 2015,
Jaypee Brothers Medical Publishers, Bhotahity, Kathmandu, Nepal, pp: 337-
341.
Roger, D et al. Oxford Textbook of Global Public Health, Sixth Edition, 2015,
Oxford University Press, USA, pp: 923-991
Park, K. Textbook of Preventive & Social Medicine. 23th edition. India: M/s
Banarsidas Bhanot; 2015, pp: 381-390.
RajVir, B. Textbook of Public Health & Community Medicine, 2009,1st edition.
India, Department of Community Medicine in Collaboration with WHO. pp:
1221-1231.
Cancer Facts & Figures 2016. the Legal department of the American Cancer
Society, 250 Williams Street, NW, Atlanta, GA 30303-1002.

References
93
Websites:
www.who.int/mediacentre/factsheets/fs297/en/
www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
https://en.wikipedia.org/wiki/Cancer
www.webmd.com/cancer/
www.cancer.org/
www.mayoclinic.org/diseases.../cancer/.../con-2003237
www.nhs.uk/conditions/cancer/Pages/Introduction.aspx
http://globocan.iarc.fr/Default.aspx

Cancer nazar 2016

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