cancer

1. Definition • “Cancer is an abnormal growth of cells which has ability to involve adjacent tissues and even distant organs and eventual death of the affected patient if the tumor has progressed to the stage where it cannot be treated.’’

2. Cont… • “Cancer may be regarded as a group of diseases characterized by an abnormal growth of cells, ability to invade adjacent tissues and even distant organs and the eventual death of the affected patient if the tumor has progressed beyond that stage where it can be successfully removed.’’

3. Incidence (new cases) • Prevalence (old +new cases) depends • A. availability of treatment of cancer is possible • B. stage of ca • C. age • D. type of ca (aggressiveness, histology) • So if we compare at international level we considers how many new ca cases came and cause of death

4. Incidence

5. Incidence cont… india • India:

8. Epidemiology • Agent factor: • Nutritional: High fat diet is related to breast and colon cancer, high fiber diet to intestinal cancer, smoked fish to stomach cancer and beef consumption is related to bowel cancer. Alcohol can cause esophageal and liver cancer. • Chemical: Exposure to chemical substances such as arsenic, cadmium, chromium, asbestos, aniline, benzol and coal tar are related to cancers involving various sites/organs. • Tobacco: Tobacco use in various forms of its usage, e.g. Smoking and betel chewing causes cancers of the lung, pharynx, mouth, esophagus, bladder, pancreas and probably kidney.

9. Cont… • Biological: • Virus: Hepatitis B and C are usually related to hepato-cellular carcinoma. HIV infection is a risk factor for Kaposi’s sarcoma. Human papilloma virus is a risk factor for cancer of cervix. • Parasites:Schistosomiasis in Middle East is associated with risk of bladder cancer. • Physical: Factors such as sunlight heat and ionizing radiation are related to cancer such as basal cell cancer, oral cancer and leukemia.

10. Cont… • Host factor: • Sex: Males are more often affected than females except for cancers of the reproductive organs. • Age: Elderly people are often affected than younger age groups. Some cancers have bimodal occurrence like Hodgkin’s disease, kidney cancer and leukemia which are common in young adults and elderly persons. • Habits: Habits of chewing pan, zarda and tobacco are associated with orophayngeal cancer. Excessive sex with multiple partners is associated with cancer of cervix. Smoking and alcoholism are associated with lung cancer. Poor personal hygiene increases the chance of occurrence of cancer of the cervix.

11. Cont… • Genetics : • Genetic factors such as translocation of chromosomes are found in certain forms of cancers such as in myeloid leukemia. Mongols are more likely to develop cancer than normal children. • Defective gene present on the long arm of chromosome13 predisposes to familial retinoblastoma. • There is a familial tendency in the occurrence of breast cancer.

12. Cont… • Environmental Factors : • Air pollution: due to hydrocarbons emitted by automobiles predisposes to lung cancer. Over use of estrogen can lead to cancer of the body of the uterus.

13. Prevention and control of cancer • Pre-mordial Prevention: • Measures in this concentrate on modification or elimination of risk factors among population group in which they have not yet developed eg. people can be made aware about protecting from carcinogenic exposures and danger signs of cancer by health education. • Women can be educated about warnings signs of cancer of cervix such as bleeding after menopause or bleeding in between menstrual period. Young girls in particular and women in general should be taught menstrual and genital hygiene for prevention of cancer cervix.

14. Cont… • Educating children and adolescents to develop healthy habit and lifestyle, educating about hazards of smoking and alcohol, benefits of exercise, healthy diet and personal hygiene. • Parents and teachers should be role model for children in the family school and colleges. Tobacco free society should be aimed at school and colleges.

15. Cont… • Primary Prevention: • High Risk strategy: • This is aimed at bringing preventive care to those people who are at special risk of getting cancer. • High risk individuals should be educated regarding the association or risk factor with cancer smoking, use of tobacco, alcohol, eating beef, smoked fish, exposure to carcinogens history of breast cancer in immediate family members poor perineal hygienic practices etc. are related different types of cancers.

16. Cont… • Nurses can teach the following to high risk groups : • To quit smoking and stop chewing tobacco. • Alcohol intake should be restricted • To have only one faithful married partner. • Family history breast cancer. • Change dietary habits. • Women should have marriage at appropriate age. • Practice good personal hygiene and perinel hygiene • Women should have pap smear test for screening cervical cancer • Individuals who have the above risk factors should be referred for screening for cancer.

17. Cont… • Population Strategy: • Cancer education to general public regarding the warning signals of cancer which are the following: • A lump in the breast • A non healing ulcer of more than two weeks duration • A change in mole or wart • A persistent cough • A lump in the testicle • Unexplained loss of weight • Difficulty in chewing and swallowing

18. Cont… • Health education to people regarding the following: • Maintaining personal and genital hygiene. • Exercise regularly to reduce the risk of obesity and early menarche • BSE- encourages women to perform BSE every month, a week after menstruation. Women after menopause also should perform BSE every month • Testicular Self Examination should be performed by men regularly to detect any lump in the testis.

19. Cont… • Avoid exposure to radiation: Special efforts should be made to reduce the radiation amount received by each individual to a minimum without reducing the benefits. • Health education: Educate to use fruit, vegetables at least 500 g/day, legumes and whole grain cereals and avoid foods, junk foods and avoid coloring agents. Fatty foods should be avoided and obesity should be prevented to prevent breast cancer. 

20. Cont… • Treatment of precancerous lesions: Early detection and prompt treatment of precancerous lesions, e.g. Cervical tears, intestinal polyposis, warts, chronic gastritis, chronic cervicitis and adenomata should be sought for preventive cancer. • Specific Protection • Avoiding X-ray and radiation exposures by wearing protecting devices and rotation of workers if harmful effects are found after every two monthly examination • Industrial workers should wear protective devices apron lead gloves and respirators • To prevent certain specific cancer vaccines are available. Cancer vaccines are either intended to treat existing cancer or to prevent the development of cancer

21. Cont… • Legislative and restrictive measures: • Government of India has enacted an act, the cigarettes(regulation of production, supply and distribution) act of 1975 states all the persons trading in cigarettes have to display a statuary warning prominently that is “cigarette smoking is injurious to health”. • Legislative measures to control air pollution also exists, aimed at prevention of lung cancer • Legislative measures to protect occupational workers from cancer hazards also are enacted in the Indian factories act 1948 and ESI 1948.

22. Cont… • Secondary Prevention: • Cancer Registration: • It provides a baseline data regarding magnitude of the cancer problem and for planning and implementing the required services they are of two types • Hospital Based Registries: It includes all out patient as well as in patients on treatment in the hospital. It should be done as per “WHO handbook for standardized cancer registers” • Population Based Registries: It should include situation in a given geographical area. The optimum size of base population recommended for cancer registry is from 2-7million such data can provide significant information about incident of cancer and causes of cancer time trends common cancer for planning and evaluation of operational activities related to all cancer control activities.

23. Cont… • Early Detection of cases: • This is done by cancer screening at a stage where the lesion is localized. • Treatment: • Treatment of cancer include the following methods: • Surgery • Chemotherapy • Radiotherapy • Immunotherapy

24. Cont… • Tertiary Prevention: Tertiary prevention aims at disability limitation and rehabilitation • Disability limitation: • This is done by intensive treatment to prevent development of disability patient may develop disability due to pain, decreased vitality, loss of weight, fatigue, and discomfort in advance stage of cancer. • Rehabilitation: • Patients who have undergone surgery are rehabilitated. After amputation of leg they are given prostheses and physiotherapy in order to train them to walk with prostheses. • Rehabilitation also includes management of psychological problem of the patient and management of the social spiritual and family problem.

25. Oral cancer • Epidemiology • Problem in world • Oral cancer has a high frequency in central and south east Asian countries. • During 2008, an estimated 2.6 lakh new cases and 1.27 lakh deaths occurred worldwide.

26. Cont… • Problem in India • An estimated incidence of 9.8 cases per 1000 population for males and 5.2 cases per lac population for females. • Epidemiological features • The factors associated with oral cancer are: • Tobacco chewing or smoking are linked to oral cancer in about 90% of cases. • Alcohol has a synergistic effect in tobacco for oral cancer. • Some individual’s indigenous methods of smoking e.g. Bidi, chillum, hookah and powder form as a snuff to inhale. • Prevention: Early detection of cases and treatment.

27. Cervix cancer • Epidemiology • Problem in world • Cancer of the cervix is one of the most common cancer among women globally. • GLOBCON (2008) reported an estimated 530000 deaths with overall incidence: mortality ratio of 52% in developed countries. • The number of cases and deaths has declined due to reduction of risk factors and early detection through screening programmes.

28. Cont… • Problem in India • Cancer of the cervix is the leading killer cancer among women. • The incidence rate of 27/lakh population and mortality rate of 15.2/lakh population has been reported in 2008.

29. Cont… • Natural history • The Disease: It is observed that cancer of cervix begins with Epithelial dysplasia and progresses to carcinoma in situ to invasive carcinoma in 15-20years or more • Causative Agent: HPV sexually transmitted is evidence to be the cause of cervical cancer. The virus is found in more than 95% of the cancers. • Risk factors • Age: Women between the age group of 25-45years are more affected. • Genital Warts: Present and past occurrence of genital warts is a risk factor for cervix cancer.

30. Cont… • Marital Status: • Early Marriage: Early Child bearing and repeated child births have been associated with increasing risk of cervix cancer. • Oral Contraceptives: A WHO study has found that users of oral Contraceptives with estrogen have increased risk of cervix cancer • Socio Economic Status: More common among women with lower Socio Economic Status, probably due to poor personal and genital hygiene. • Prevention and control: Early detection of cases and treatment.

31. Breast cancer • Epidemiology • Problem in the world • Most frequent cancer among women, with 1.38million new cases diagnosed in 2008. • Problem in India • During year2008 new cases of Breast cancer in India, accounting for 12.14% of all malignant cases.

32. Cont… • Risk factors • Breast cancer incidence between the ages of 35-50years the mean age of its occurrence is 42. Besides age, risk factors for breast cancer include: • Unmarried Women • Delayed marriages • Obesity • High Fat Diet • Lack of Exercise • High level of Estrogen • Family History of Breast cancer of mainly first degree relatives.

33. Cont… • Prevention • Primary Prevention: Health Education to eliminate risk factors can help in preventive cancer of Breast. • Promotion of Physical activity, decreased fat intake to prevent childhood Obesity can help to prevent Breast cancer by increasing the average age of menarche. • Secondary Prevention: Secondary prevention includes all the measures taken as for the treatment of general cancers.

34. Lung cancer • Epidemiology • Problem in the world • Death rate due to lung cancer is increased by 76% in men and by 13.5% in women in 1980 it is the most common cancer in men world-wide and 4th most common in females.

35. Cont… • Problem in India • There were an estimated 58000 new lung cancer cases in 2008 in India. • About 51000 persons died due to lung cancer. • Epidemiological features • Age and Sex: About 1/3rd of all lung cancer deaths occur below the age of 65 years. • Risk factors :Risk factor for lung cancer include tobacco smoking, bidi smoking, air pollution, exposure to radiation and occupational exposure such as asbestos, polycyclic, aromatic hydrocarbons.

36. Cont… • Prevention • Primary prevention: It includes measures to control smoking. WHO expert committee 1982 has described various methods to control smoking epidemic. • Information, education and communication: To make the whole public aware of the hazards of smoking information and educations should be provided through mass media with greatest emphasis to be laid on young people.

37. Cont… • Legislative and restrictive measures: Legislative measures to protect occupational workers from cancer hazard also are enacted in the Indian Factories Act: 1948 and ESI act 1948. • Government of India passed a “cigarettes and other tobacco products act in 2003. According to this act there is a complete ban on advertisement of tobacco products in all media, ban on smoking in public places and ban on sale of tobacco products to person below the age of 18.

38. Cont… • Smoking cessation activities: These includes such method as smoking cessation clinics, nicotine substitutes hypnotics etc. • These are aimed at relieving the smokers of “abstinence symptoms”. • People should be helped to prevent quite smoking and prevent chewing tobacco. • National and international coordination : • In 2003, 171 member states of the WHO formulated a treaty to control tobacco supply and consumption. • According to this treaty agreement was reached on final text for WHO framework convention of tobacco control(FCTC), governing tobacco, taxation, smoking prevention and treatment, illicit trade, advertising, sponsorship and promotion and production regulation. • Secondary prevention: It includes measures for early detection and treatment of lung cancer.

39. Stomach cancer • Epidemiology • Problem in world • In 2008 about 1 million new cases of stomach cancer were estimated to have occurred. • 4th most common malignancy in the world. • Stomach cancer is the 2nd leading cause of cancer in both sexes. • Developing countries account for more than 70% of cases.

40. Cont… • Problem in India • 5th most common cancer in males in India. • During 2008 about 35059 new cases of stomach cancer were estimated to have occurred. • About 33564 persons died with stomach cancer • Factors associated with stomach cancer are smoked foods and diet lacking in fruits and vegetables. Other factors include chronic inflammation of stomach, pernicious anemia, smoking, gastric ulcers, etc.

41. Cont… • Prevention • Primary prevention • Avoid taking preserved and cured foods. Include fruits and vegetables. Smoked fish should not be eaten as it causes stomach cancer. • Prevention of smoking as it is a risk factor for cancer of the stomach.

42. Cont… • Secondary prevention • Early detection of stomach cancer: Diagnosis is performed by barium X- rays and with biopsy. • Treatment of stomach cancer: Treated by surgical removal of tumor, with or without adjuvant chemotherapy. • Stomach cancer cases have a generally poor survival prognosis, averaging no more than 20% survival after five years.

43. References • Park K., Text Book of Preventive and Social Medicine.18th Edition, BanarsidasBhanot: 378-381. • Singh SimratKaur N.J., Community Health Nursing. 1st Edition, Lotus Publishers. Page No. 522-525.