Magnitude of Cancer Problem in the Philippines

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1 Cancer in Women

2 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 Incidence rates increase w/ Age: 0-14 yr.: 3.6% of cancers >35 yr.: 91% of cancers >=50 yr.: 76% of cancers

3 What are the Top Ten Cancers in the Philippines? Male Female Child Lung Breast Leukemia (ALL) Liver Cervix Lymphoma (NHL) Stomach Lung Brain/ Spinal (Medullablastoma; Astrocytoma) Colon Ovary Retinoblastoma Rectum Stomach Bone (Osteosarcoma) Nasopharynx Leukemia Oral cavity Pancreas NHL Liver Thyroid Oral cavity Colon Rectum STS (Rhabdo-myosarcoma) Kidney (Wilm s) Gonadal GCT Epithelioma

4 TEN LEADING CANCER SITES IN WOMEN BREAST(1) THYROID(4) LUNG(3) LIVER(8) OVARY(5) STOMACH(9) COLON(7) CERVIX(2) UTERUS(10) LEUKEMIAS(6) Philippine Cancer Facts and Estimates, 1998

5 FEMALE-RELATED LEADING CANCER SITES Breast Cervix Uterus Ovary

6 BREAST CANCER Breast cancer is a malignant (cancerous) tumor that starts from cells of the breast. The disease occurs mostly in women, but men can get breast cancer too A woman s breast is made up of glands that make breast milk (lobules), ducts (small tubes that carry milk from the lobules to the nipple), fatty and connective tissue, blood vessels, and lymph (pronounced limf) vessels. Most breast cancers begin in the cells that line the ducts (ductal cancer), some begin in the lobules (lobular cancer), and the rest in other tissues.

7 BREAST lumps Benign Breast Lumps Most breast lumps are benign; that is, they are not cancer. Benign breast tumors are abnormal growths, but they do not spread outside of the breast and they are not life threatening. But some benign breast lumps can increase a woman s risk of getting breast cancer. Most lumps turn out to be caused by fibrocystic changes. Cysts are fluid-filled sacs. Fibrosis is the formation of scar-like tissue. Such changes can cause breast swelling and pain. The breasts may feel lumpy, and sometimes there is a clear or slightly cloudy nipple discharge.

8 BREAST CANCER RISK FACTORS YOU CAN T CHANGE Gender Simply being a woman is the main risk for breast cancer. While men also get the disease, it is about 100 times more common in women than in men. Age The chance of getting breast cancer goes up as a woman gets older. About 2 out of 3 women with invasive breast cancer are age 55 or older when the cancer is found. Genetic Risk Factors About 5% to 10% of breast cancers are thought to be linked to changes (mutations) in certain genes. The most common gene changes are those of the BRCA1 and BRCA2 genes. Women with these gene changes have up to an 80% chance of getting breast cancer during their lifetimes. Other gene changes may raise breast cancer risk as well. Family History Breast cancer risk is higher among women whose close blood relatives have this disease. The relatives can be from either the mother s or father s side of the family. Having a mother, sister, or daughter with breast cancer about doubles a woman s risk. (It's important to note that 70% to 80% of women who get breast cancer do not have a family history of this disease.) Personal History of Breast Cancer A woman with cancer in one breast has a greater chance of getting a new cancer in the other breast or in another part of the same breast. Race White women are slightly more likely to get breast cancer than are African-American women. But African American women are more likely to die of this cancer. At least part of the reason seems to be because African-American women have faster growing tumors. Asian, Hispanic, and American Indian women have a lower risk of getting breast cancer.

9 BREAST CANCER RISK FACTORS YOU CAN T CHANGE Abnormal Breast Biopsy Certain types of abnormal biopsy results can be linked to a slightly higher risk of breast cancer AxLN++, >2 cm mass size, poorly differentiated, lymphovascular invasion, Her-2 neu++ Menstrual Periods Women who began having periods early (before age 12) or who went through the change of life (menopause) after the age of 55 have a slightly increased risk of breast cancer. Earlier Breast Radiation Women who have had radiation treatment to the chest area (as treatment for another cancer) earlier in life have a greatly increased risk of breast cancer. Treatment with DES In the past, some pregnant women were given the drug DES (diethylstilbestrol) because it was thought to lower their chances of losing the baby (miscarriage). Recent studies have shown that these women (and their daughters who were exposed to DES while in the womb), have a slightly increased risk of getting breast cancer.

10 BREAST CANCER RISK FACTORS YOU CAN CHANGE Breast Cancer Risk and Lifestyles Not Having Children or Having Them Later in Life Women who have had not had children, or who had their first child after age 30, have a slightly higher risk of breast cancer. Being pregnant more than once and at an early age reduces breast cancer risk. Birth control pills Studies have found that women who are using birth control pills have a slightly greater risk of breast cancer than women who have never used them. Women who stopped using the pill more than 10 years ago do not seem to have any increased risk. Postmenopausal Hormone Therapy (PHT) PHT or HRT has been used for many years to help relieve symptoms of menopause and to help prevent thinning of the bones (osteoporosis). There are 2 main types of PHT. For women who still have a womb (uterus), doctors generally prescribe estrogen and progesterone (known as combined PHT). Because estrogen alone can increase the risk of cancer of the uterus, progesterone is added to help prevent this. For women who no longer have a uterus (those who've had a hysterectomy), estrogen alone can be prescribed. This is commonly known as estrogen replacement therapy (ERT). long-term use (several years or more) of combined PHT increases the risk of breast cancer and may increase the chances of dying of breast cancer. The breast cancer may also be found at a more advanced stage, perhaps because PHT seems to reduce the effectiveness of mammograms. Five years after stopping PHT, the breast cancer risk seems to drop back to normal. when used long-term (for more than 10 years), some studies have found that ERT increases the risk of ovarian and breast cancer. Breast-feeding and Pregnancy Some studies have shown that breast-feeding slightly lowers breast cancer risk, especially if the breastfeeding lasts 1½ to 2 years. This could be because breast-feeding lowers a woman s total number of menstrual periods, as does pregnancy. One study found that having more children and breast-feeding longer could reduce the risk of breast cancer by half.

11 BREAST CANCER RISK FACTORS YOU CAN CHANGE Breast Cancer Risk and Lifestyles Alcohol Use of alcohol is clearly linked to an increased risk of getting breast cancer. Women who have 1 drink a day have a very small increased risk. Those who have 2 to 5 drinks daily have about 1½ times the risk of women who drink no alcohol. Limit the amount you drink. Being Overweight or Obese Being overweight or obese is linked to a higher risk of breast cancer, especially for women after change of life and if the weight gain took place during adulthood. Also, the risk seems to be higher if the extra fat is in the waist area. But the link between weight and breast cancer risk is complex, and studies of fat in the diet as it relates to breast cancer risk have often given conflicting results. Maintain a healthy weight throughout your life and avoid gaining too much weight. Exercise Studies show that exercise reduces breast cancer risk. The only question is how much exercise is needed. One study found that as little as 1 hour and 15 minutes to 2 and a half hours of brisk walking per week reduced the risk by 18%. Walking 10 hours a week reduced the risk a little more. Exercise for 45 to 60 minutes 5 or more days a week.

12 BREAST CANCER UNCERTAIN RISK FACTORS High Fat Diets Eat a healthy diet that includes 5 or more servings of vegetables and fruits each day, choosing whole grains over processed (refined) grains, and limiting the amount of processed and red meats. Pollution Tobacco Smoke Night Work

13 PREVENTING BREAST CANCER FOR WOMEN AT INCREASED RISK Genetic Testing There are tests that can tell if a woman has certain changed (mutated) genes linked to breast cancer. With this information, women can then take steps to reduce their risk. Genetic counseling is strongly recommended before a woman has these tests and before she makes any decisions about preventive measures. Only women with a strong family history be evaluated for genetic testing for BRCA mutations. Breast Cancer Chemoprevention Chemoprevention is the use of drugs to reduce the risk of cancer - tamoxifen; raloxifene Preventive Surgery Preventive (prophylactic) mastectomy: For the few women who are at very high risk for breast cancer, this surgery (a double mastectomy) may be an option. In this operation both breasts are removed before there is any known breast cancer. While this operation removes nearly all of the breast tissue, a small amount remains, wherein disease can still develop although to date rarely Preventive ovary removal (prophylactic oophorectomy): Women with a certain gene change (BRCA mutation) who have their ovaries removed may reduce their risk of breast cancer by half or more. This is because taking out the ovaries removes the main sources of estrogen in the body. Women with this gene change also have a high risk of getting ovarian cancer. Most doctors recommend that these women have their ovaries removed after they are done having children.

14 EARLY BREAST CANCER DETECTION Finding breast cancer early in women without symptoms: Mammogram: Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer. Clinical breast exam (CBE): Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health expert, preferably every 3 years. After age 40, women should have a breast exam by a health expert every year. Have the CBE shortly before the mammogram. Breast self-exam (BSE): BSE is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any changes in how their breasts look or feel to their health professional right away. If you do BSE on a regular basis, you get to know how your breasts normally look and feel. Then you can more easily notice changes. For premenopausal women, do BSE 7 days after menses monthly; for postmenopausal women do BSE every first day of the month. See your doctor right away if you notice any of these changes: a lump or swelling, skin irritation or dimpling, nipple pain or the nipple turning inward, redness or scaliness of the nipple or breast skin, or a discharge other than breast milk. But remember that most of the time these breast changes are not cancer. Women at high risk: Women with a higher risk of breast cancer should talk with their doctor about the best approach for them. This might mean starting mammograms when they are younger, having extra screening tests, or having more frequent exams.

15 HOW TO EXAMINE YOUR BREAST Lie down and place your right arm behind your head. The exam is done while lying down, and not standing up. This is because when lying down the breast tissue spreads evenly over the chest wall and it is as thin as possible, making it much easier to feel all the breast tissue. Use the finger pads of the three middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue. Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. A firm ridge in the lower curve of each breast is normal. If you re not sure how hard to press, talk with your doctor or nurse. Use each pressure level to feel the breast tissue before moving on to the next spot. Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone.(sternum or breastbone). Be sure to check the entire breast area going down until you feel only ribs and up to the neck or collar bone (clavicle). There is some evidence to suggest that the up and down pattern (sometimes called the vertical pattern) is the most effective pattern for covering the entire breast without missing any breast tissue. Repeat the exam on your left breast, using the finger pads of the right hand.

16 HOW TO EXAMINE YOUR BREAST While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, dimpling, or redness or scaliness of the nipple or breast skin. (The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes.) Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it difficult to examine.

17 BREAST CANCER - DIAGNOSIS Imaging Tests Mammograms: Diagnostic - might show that a biopsy should be done. Even if the mammogram doesn t show a tumor, if you or your doctor can feel a lump you may need a biopsy. The exception would be if ultrasound (see below) shows that the lump is a cyst. Mammograms are often less effective in younger women, mostly because their breasts are dense and this can hide a tumor. This is also true for pregnant women and women who are breast feeding. Since most breast cancers occur in older women, this is usually not a major problem. It is, however, a problem for young women who have a genetic risk factor for breast cancer because they often develop breast cancer at a younger age. For this reason, some doctors now suggest MRI as well as mammograms for screening these women. A mammogram cannot show for sure whether or not cancer is present. If your mammogram shows a possible problem, a sample of breast tissue is removed and looked at under a microscope. This is called a biopsy.

18 BREAST CANCER - DIAGNOSIS Imaging Tests Breast ultrasound: An ultrasound uses sound waves to outline a part of the body. The sound wave echoes are picked up by a computer to create a picture that is displayed on a computer screen. Ultrasound is a good test to use along with mammograms. But ultrasound should not be used instead of mammograms. It also helps to tell the difference between cysts and solid masses without using a needle to draw out fluid. Ductogram (also called a galactogram): This is a special kind of x-ray that is sometimes helpful in finding the cause of a nipple discharge. A fine plastic tube is placed into the opening of the duct at the nipple. A substance is injected to outline the shape of the duct on an x-ray picture. It will show if there is a mass inside the duct. If there is a discharge, the fluid can be tested for cancer cells.

19 BREAST CANCER - DIAGNOSIS Biopsy Fine needle aspiration biopsy (FNAB): For this test, a very thin (fine) needle is used to withdraw fluid or tissue from the lump, sometimes guided by ultrasound imaging. If the fluid drawn out is clear, the lump is most likely a benign cyst. Bloody or cloudy fluid can mean either a cyst or, rarely, cancer. If the lump is solid, small pieces of tissue are removed. These will be looked at under a microscope to see if they are cancer. If the biopsy does not provide a clear answer, or your doctor is still not sure, a second biopsy or a different type of biopsy may be needed. Stereotactic core needle biopsy: The needle used for this test is larger than the one for fine needle biopsy. It is used to remove several cylinders of tissue. The biopsy is done with local anesthesia (the area is numbed) on an outpatient basis. Surgical biopsy: Sometimes surgery is needed to remove all or part of a lump so it can be looked at under a microscope. The entire lump as well as some normal tissue around it may be removed. Most often this is done in the hospital on an outpatient basis. Local anesthesia (the area around the lump is numbed) is used and sedation may also be given to relax you and make you less aware of the process. Biopsy lab tests: The tissue removed during a biopsy is looked at in the lab to see whether it is benign (not cancer) or cancerous. If it is not cancer, then no further treatment is needed. If it is cancer, the biopsy can help to tell the type of cancer you have and show whether it is invasive or not.

20 BREAST CANCER HIGH RISK FOR RECURRENCE/ METASTASIS Breast Cancer Grade Cancers that look more like normal breast tissue tend to grow and spread more slowly. In general, a lower grade number means a slower-growing cancer, while a higher number means a faster-growing cancer. The tumor grade is most important in women with small tumors without lymph node involvement. These women may not need further treatment after the tumor is removed, while women with higher grade tumors usually get hormonal therapy or chemotherapy. Hormone Receptor Status Receptors are proteins on the outside surfaces of cells that can attach to hormones in the blood. The biopsy sample can be tested to see whether it has receptors for the hormones estrogen and progesterone. If it does, it is often referred to as ER-positive or PR-positive. Such cancers tend to have a better outlook than cancers without these receptors because they are much more likely to respond to hormone treatment. About 2 out of 3 breast cancers have at least one of these receptors. HER2/neu Status About 1 out of 5 breast cancers have too much of a protein called HER2/neu. Tumors with increased levels of HER-2/neu are referred to as "HER2-positive." These cancers tend to grow and spread more than other breast cancers. HER2/neu testing should be done on all newly diagnosed breast cancers. HER2-positive cancers can be treated with drugs that target the HER2/neu protein, such as trastuzumab

21 BREAST CANCER Staging Staging is the process of finding out how widespread the cancer is at the time it is found. The stage of a cancer is the most important factor in choosing among treatment options. The stage is based on the results of the physical exam, biopsy, and other tests the doctor may have ordered. Tests to Find Breast Cancer Spread Chest x-ray - to see whether the cancer has spread to the lungs. Mammogram - to view other breast. Bone scan - whether the cancer has spread to the bones. CT scan (computed tomography) - detailed x-ray picture of the internal organs ( liver or other organs). MRI (magnetic resonance imaging) - takes pictures using radio waves and strong magnets instead of x-rays, used for looking at the brain and spinal cord. PET scan (positron emission tomography) - uses a form of sugar that contains a radioactive atom. Cancer cells absorb high amounts of this sugar. A special camera can then spot these cells. PET is useful when the doctor thinks the cancer has spread but doesn t know where. It may also be useful in checking lymph nodes for cancer before they are removed. Some of the newer machines are able to do both a PET and CT scan at the same time. This test can be used along with a mammogram, especially when looking for cancer in axillary lymph nodes

22 BREAST CANCER Survival by Stage The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is found. This means that they may or may not be cancer-free during this 5 year period. Of course, many people live much longer than 5 years. Five-year relative survival rates leave out patients dying of other diseases. This means that anyone who died of another cause, such as heart disease, is not counted. The numbers below are based on the precise stage of the cancer. The numbers are also based on women treated a number of years ago and if we find more cancers early and use newer, better treatments Stage 5-year Relative Survival Rate 100% I 100% IIA 92% IIB 81% IIIA 67% IIIB 54% IV While these numbers provide an overall picture, keep in mind that every woman s situation is unique and the statistics can t predict exactly what will happen in your case.

23 BREAST CANCER General Treatment Types Local vs. Systemic Treatment The purpose of local treatment is to treat a tumor without affecting the rest of the body. Surgery and radiation are examples of local treatment. Systemic treatment is given into the bloodstream or by mouth to go throughout the body and reach cancer cells that may have spread beyond the breast. Chemotherapy, hormone therapy, and immunotherapy are systemic treatments. Adjuvant and Neoadjuvant Therapy When people who seem to have no cancer left after surgery are given more treatment it is referred to as adjuvant therapy. Doctors now think that cancer cells can break away from the main tumor and begin to spread through the bloodstream in the early stages of the disease. It s very hard to tell if this has happened. But if it has, the cancer cells can start new tumors in other organs or the bones. The goal of adjuvant therapy is to kill these hidden cells. But not every patient needs adjuvant therapy. Some people are given systemic treatment (most likely chemotherapy) before surgery to shrink a tumor. This is called neoadjuvant therapy.

24 BREAST CANCER Surgery Most women with breast cancer will have some type of surgery to treat the main breast tumor. The purpose of surgery is to remove as much of the cancer as possible. Surgery can also be done to find out whether the cancer has spread to the lymph nodes under the arm (axillary dissection), to restore the breast's appearance after a mastectomy (mas-tek-tuh-me), or to relieve symptoms of advanced cancer. Breast-conserving Surgery involves removal of only a part of the breast tissue Lumpectomy: This surgery involves removing only the breast lump and some normal tissue around it. Radiation treatment is usually given after this type of surgery. If chemotherapy is also going to be used, the radiation may be delayed until the chemo is finished. Partial (segmental) mastectomy (quadrantectomy): This surgery involves removing more of the breast tissue than in a lumpectomy. It is usually followed by radiation therapy. Again, this may be delayed if chemotherapy is also going to be given. Mastectomy - involves removal of all of the breast tissue, sometimes along with other nearby tissues. Simple or total mastectomy: entire breast is removed but not the lymph nodes under the arm or the muscle tissue beneath the breast. Sometimes both breasts are removed, especially when mastectomy is done as a preventive measure. Most women, if they are hospitalized, can go home the next day. Modified radical mastectomy: removes the entire breast and some of the lymph nodes under the arm. This is the most common surgery for women with breast cancer who are having the whole breast removed. Radical mastectomy: extensive removal of entire breast, lymph nodes, and the chest wall muscles under the breast.

25 BREAST CANCER Radiation Therapy Radiation therapy is treatment with highenergy rays (such as x-rays) to kill or shrink cancer cells. This treatment may be used after breast-conserving surgery. External Beam Radiation Brachytherapy

26 BREAST CANCER Chemotherapy Chemotherapy (commonly called just "chemo") is the use of cancerkilling drugs injected into a vein, given as a shot, or taken as a pill or liquid. These drugs enter the bloodstream and go throughout the body, making the treatment useful for cancers that have spread to distant organs. While these drugs kill cancer cells, they also damage some normal cells, which can lead to side effects. Adjuvant chemotherapy: Treatment given to patients after surgery who do not seem to have any spread of cancer is called adjuvant therapy. When used this way after breast-conserving surgery or mastectomy, chemo reduces the risk of the breast cancer coming back. Even in the early stages of the disease, cancer cells can break away from the first breast tumor and spread through the bloodstream. These cells don t cause symptoms, they don t show up on an x-ray, and they can t be felt during a physical exam. But if they are allowed to grow, they can form new tumors in other places in the body. Adjuvant chemo can be given to find and kill these cells. Neoadjuvant chemotherapy: Chemotherapy given before surgery is called neoadjuvant therapy. Can shrink large cancers so that they are small enough to be removed by lumpectomy instead of mastectomy. Chemo for advanced breast cancer: Chemo can also be used as the main treatment for women whose cancer has already spread outside the breast and underarm area at the time it is found, or if it spreads after the first treatments. In most cases chemo works best if more than one drug is used. Chemo is given in cycles, with each period of treatment followed by a rest period. The time between giving the drugs is generally 2 or 3 weeks and varies according the drug or combination of drugs being used. The total course of treatment usually lasts for 3 to 6 months. Treatment may be longer for advanced breast cancer.

27 BREAST CANCER Hormone Therapy Hormone therapy is another form of systemic therapy. It is most often used to help reduce the risk of the cancer coming back after surgery, though it may also be used for more advanced breast cancers. The female hormone estrogen promotes the growth of breast cancer cells in some women (those who have ER-positive cancers). For these women, several methods to block the effect of estrogen or to lower its levels are used to treat breast cancer. Tamoxifen: A drug such as tamoxifen can be given to counter the effects of estrogen. Tamoxifen is taken in pill or liquid form, usually daily for 5 years after surgery, to reduce the risk the cancer will come back. This drug does have known side effects. The most common side effects include fatigue, hot flashes, vaginal discharge, Fulvestrant: A drug that acts by damaging the estrogen receptor instead of blocking it. It often works even if the breast cancer is no longer responding to tamoxifen. It is given by injection once a month. Right now it is only approved for use in women with advanced breast cancer. Aromatase inhibitors: These are drugs that stop the body from making estrogen. They only work for women who are past menopause and whose cancers are hormone-receptor positive. These drugs may be used after, or even instead of, tamoxifen to reduce the risk of the breast cancer coming back. They don t cause uterine cancer and very rarely cause blood clots. They can, however, cause bone thinning and fractures because they remove estrogens from the body.

28 BREAST CANCER Targeted Therapy As we have learned more about the gene changes that cause cancer, researchers have been able develop newer drugs that are aimed directly at these changes. These targeted drugs work differently than standard chemo drugs. They often have different and less severe side effects. At this time, they are most often used along with chemo. Trastuzumab: This is a monoclonal antibody that attaches to a growth-promoting protein called HER2/neu. This protein is found in small amounts on the surface of normal breast cells and most breast cancer cells. Some breast cancers have too much of this protein, which can cause the cancer to grow and spread faster. Trastuzumab can stop this protein from causing breast cancer cell growth. It may also help the immune system to better attack the cancer. (Monoclonal antibodies are man-made versions of immune system proteins the body makes to fight diseases.) Lapatinib: This is another drug that targets the HER2/neu protein. This drug is given as a pill, most often along with chemo. It is used for some women with cancer that is no longer helped by chemo and trastuzumab. Bevacizumab: This is another monoclonal antibody that may be used in patients with breast cancer that has spread. It is always used along with other chemo drugs. This antibody helps to prevent tumors from forming new blood vessels to feed the tumor. Bevacizumab is given by intravenous infusion.