Detection: Rabab Gaafar,MD. Prof. Medical Oncology NCI,Cairo, Cairo University

Cancer Prevention and Early Detection: Rabab Gaafar,MD Prof. Medical Oncology NCI,Cairo, Cairo University Director Early Detection Unit

Prevention and Early Detection Definition Goals of Cancer Prevention and Control Magnitude of the Problem Local Strategies to fight Cancer Breast Cancer early detection Breast cancer Prevention Elderly

Definition "primary" prevention (intervention for relatively healthy individuals with no invasive cancer and an average risk for developing cancer). "secondary" " prevention (intervention ti for patients t determined d by early detection to have asymptomatic, subclinical cancer). "tertiary" prevention (symptom control rehabilitation or other tertiary prevention (symptom control, rehabilitation, or other issues in patients with clinical cancer.

Cancer prevention science and practice are just beginning to gain public, academic, government and industry recognition as a major aspect of oncology. Cancer prevention spans a wide range of disciplines, including population, behavioral, and social sciences; diagnostics; and clinical therapeutics (chemoprevention, risk reduction). Diverse training and skills are required to fully address the spectrum of carcinogenesis and its control. Risk-based management is the process of determining the best cancer prevention approaches for specific cancer risks

Prevention -Cancer can be caused by a number of factors -May develop over a number of years. -Some risk factors can be controlled. -Choosing the right health behaviors -preventing exposure to certain environmental risk factors can help prevent the development of cancer. -For this reason, it is important to follow national trends data to monitor the reduction of these risk factors.

Early Detection The use of screening tests to detect cancers early may allow patients to obtain more effective treatment with fewer side effects. Patients whose cancers are found early and treated in a timely manner are more likely to survive these cancers than are those whose cancers are not found until symptoms appear.

ASCO Strategic Plan 2004 2007: Goal Cancer Prevention and Control Advocate for rapid, worldwide reduction and ultimate elimination of tobacco products and exposure to environmental tobacco smoke, in collaboration with other organizations and professional societies Increase core knowledge about cancer risk and risk reduction through new education initiatives Promote clinical, behavioral, and translational research, and education and training in cancer prevention and control Work to eliminate healthcare disparities in cancer risk assessment and early detection Provide prevention-oriented messages for individuals with a prior history of cancer and for the general public

Economic Benefit of Cancer Prevention / Early Detection Improves beneficiary health Averts direct medical costs Reduces lost productivity Reduces disability Reduces employee turnover Reduces excess medical costs from related conditions, complications, or sequelae

Leading causes of death Heart Diseases 31.0 Cancer Cerebrovascular Diseases Chronic Obstructive Lung Diseases Accidents Pneumonia & Influenza Diabetes Mellitus Suicide 6.8 4.8 42 4.2 3.9 2.8 1.3 23.2 Nephritis 1.1 Cirrhosis of the Liver 11 1.1 Percentage of Total Deaths, US

Developed Countries

2006 Estimated US Cancer Cases* Prostate 33% Lung & bronchus 13% Colon & rectum 10% Urinary bladder 6% Men 720,280 Women 679,510 31% Breast 12% Lung & bronchus 11%Colon & rectum 6% Uterine corpus Melanoma of skin 5% 4% Non-Hodgkin lymphoma Non-Hodgkin 4% lymphoma 4% Melanoma of skin Kidney 3% 3% Thyroid Oral cavity 3% 3% Ovary Leukemia 3% 2% Urinary bladder Pancreas 2% 2% Pancreas All Other Sites 18% 22% All Other Sites *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2006.

Lifetime Probability of Developing Cancer, by Site, Men, 2000-2002* Site Risk All sites 1 in 2 Prostate 1 in 6 Lung and bronchus 1 in 13 Colon and rectum 1 in 17 Urinary bladder 1 in 28 Non-Hodgkin lymphoma 1 in 46 Melanoma 1 in 52 Kidney 1 in 64 Leukemia 1 in 67 Oral Cavity 1 in 73 Stomach 1 in 82 * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002. All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder. Includes invasive and in situ cancer cases Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

Lifetime Probability of Developing Cancer, by Site, Women, US, 2000-2002* Site Risk All sites 1 in 3 Breast 1 in 8 Lung & bronchus 1 in 17 Colon & rectum 1 in 18 Uterine corpus 1 in 38 Non-Hodgkin lymphoma 1 in 55 Ovary 1 in 68 Melanoma 1 in 77 Pancreas 1 in 79 Urinary bladder 1 in 88 Uterine cervix 1 in 135 * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002. All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder. Includes invasive and in situ cancer cases Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

U.S. Cancer Mortality Lung & bronchus 32% 25% Lung & bronchus Prostate 10% 15% Breast Colon & rectum 10% 10% Colon & rectum Pancreas 5% 6% Ovary Leukemia 5% 6% Pancreas NH lymphoma 4% 4% Leukemia Esophagus 4% 3% NH lymphoma Liver & bile duct 3% 3% Uterine corpus Urinary bladder 3% 2% Multiple myeloma Kidney 3% 2% Brain/ONS All other sites 21% 24% All other sites American Cancer Society, 2004

Cancer Death Rates*, for Men, US,1930-2002 100 Rate Per 100,000 80 Lung 60 Stomach 40 Colon & rectum Prostate 20 Pancreas 0 Leukemia Liver 19 930 19 935 19 940 19 945 19 950 19 955 19 960 19 965 19 970 19 975 19 980 19 985 19 990 19 995 20 000 *Age-adjusted to the 2000 US standard population. Source: US Mortality Public Use Data Tapes 1960-2002, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2005.

Cancer Death Rates*, for Women, US,1930-2002 100 Rate Per 100,000 80 60 40 Uterus Breast Lung 20 Stomach Colon & rectum Ovary 0 Pancreas 19 930 19 935 19 940 19 945 19 950 19 955 19 960 19 965 19 970 19 975 19 980 19 985 19 990 19 995 20 000 *Age-adjusted to the 2000 US standard population. Source: US Mortality Public Use Data Tapes 1960-2002, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2005.

Tobacco Use in the US, 1900-2002 apita Cigarette Co onsumption Per C Male lung cancer death rate 5000 100 4500 4000 3500 3000 2500 2000 1500 1000 500 Per capita cigarette consumption Female lung cancer death rate 90 80 70 60 50 40 30 20 10 Age-A Adjusted Lung Ca ancer Death Rates* 0 1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year 2000 0 *Age-adjusted to 2000 US standard population. Source: Death rates: US Mortality Public Use Tapes, 1960-2002, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2005. Cigarette consumption: US Department of Agriculture, 1900-2002.

Five-year Relative Survival (%)* during Three Time Periods By Cancer Site Site 1974-1976 1983-1985 1995-2001 All sites 50 53 65 Breast (female) 75 78 88 Colon 50 58 64 Leukemia 34 41 48 Lung and bronchus 12 14 15 Melanoma 80 85 92 Non-Hodgkin lymphoma 47 54 60 Ovary 37 41 45 Pancreas 3 3 5 Prostate 67 75 100 Rectum 49 55 65 Urinary bladder 73 78 82 *5-year relative survival rates based on follow up of patients through 2002. Recent changes in classification of ovarian cancer have affected 1995-2001 survival rates. Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control and Population Sciences, National Cancer Institute, 2005.

Why? Better screening for prevention and early detection Better diagnostics/imaging technology Better treatments Better drugs and understanding how to use them and how not to use them Better availability of care

Scientists estimate that as many as 50 to 75 percent of cancer deaths in USA are caused by human behaviors such as smoking, physical inactivity, and poor dietary choices. Not using cigarettes or other tobacco products: Not drinking too much alcohol Eating five or more daily servings of fruits and vegetables Eating a moderate-fat diet Consuming a diet in which total calories eaten are balanced with calories expended by physical activity Maintaining or reaching a healthy weight Being physically active Protecting skin from sunlight

Future 19 % decline in the rate at which new cancer cases occur 29 % decline in the rate of cancer deaths could potentially be achieved by 2015 if efforts to help ppeople p change their behaviors that put them at risk were stepped up and if behavioral change were sustained. This would equate to the prevention of approximately 100,000000 cancer cases and 60,000 cancer deaths each year by the year 2015.

Developing Countries

Estimated cancer incidences in the EM region

Most common sites in Males Females Bladder Liver Lymphoma Leukemia Lung Colorectal Soft tissue Skin Larynx Bones 17 16 17 12 11 10 10 11 10 9 8 6 6 2003 2002 5 4 5 2001 4 3 7 4 3 3 3 3 3 2 3 3 38 Breast 38 35 6 Leukemia 6 5 6 Lymphoma 7 6 5 Bladder 4 5 4 Ovary 2003 4 2002 4 Colorectal 4 4 2001 4 Liver 4 4 3 Soft tissue 2 6 3 Cervix 3 0 5 10 15 20 Thyroid Percent of cases 2 2 0 10 20 30 40 50 Percent of cases NCI, Cairo

Causes of the Growing Cancer Burden Aging populations Impact of infectious diseases Increased tobacco use and pollution Nutrition and lack of physical activity

Aging Populations 2050 2000 1950 5% 10% 15% 20% Percentage of global population 60 and older

Cancer and the Environment Tobacco 10 8 3000 2500 2000 1500 1000 500 6 4 2 0 Developed Developing 2000 2030 Annual deaths from tobacco Developing Nations Developedeloped Nations 0 1970-72 1980-82 1990-92 Annual number of cigarettes consumed per adult

Chicha in the 90 s : new flavored tobacco + satellites/electronic media = new fashion 1h chicha session = 70 to 200 cigarettes Water does not filtrate carcinogens (carbon monoxide, heavy metals, other carcinogens) charcoals produce their own toxicants Second hand smoke = tobacco smoke + charcoals smoke

Pollution

Etiologic Factors of HCC

Prevalence of schistosomiasis in Egypt: 1935-2003 % 40 35 30 25 20 15 10 5 0 1980 1985 1990 1995 2000 2005

Action needed Study of the viral etiology of HCC and the role played by HBV and HCV (possibly a multinational l comparative study). HBV vaccination specially children and high risk groups. Proper follow up of hepatitis patients, specially cirrhotic for early detection of HCC.

The National Cancer Institute Cairo University www.nci.cd.edu.eg Cairo University National Cancer Institute

Main Strategies NCI, Cairo University Management: Diagnosis and Treatment Cancer Registry Education: Training and degree-granting g g programs Research: Basic science, Population, and Clinical studies of National Interest Prevention and early detection

Key Point Detecting cancer in its initial stages presents the opportunity to treat disease before it spreads. the ability to reduce a person s risk of developing cancer opens the way for optimum prevention strategies. The NCI Cairo University is committed to progress in cancer detection and risk assessment that allows interventions to focus on the earliest stages of disease.

Secondary Prevention Breast Referred cases for management Soft tissue Colon Breast Ovary Thyroid Liver Prostate thymoma scapula mass

With limited advertising, matching with our resources 1500 New Cases visit our clinic with dramatically rising curve

400 2006 No. 300 200 2003 2004 2005 100 0 Total cases 1

Secondary Prevention Triage for every patient Accurate history taking. Pedigree design. Meticulous clinical examination

We provide Lectures & Outdoor Campaign

Primary Prevention We provide support services to cancer patients t and their families.

Primary Prevention We support and encourage research and studies related to prevention and early detection ti of cancer. 1. Early Detection & classification of Lymphoma 2. Pilot Study of Inflammatory Breast Cancer in Egypt and Tunisia in collaboration with National Cancer Institute U.S.A. 3. IBIS II Prevention protocol an international multi-center study of anastrazole vs placebo in postmenopausal women at increased risk of breast cancer

We are trying to prevent malpractice which is vital issue in management of cancer patient by establishing training programs to the GPs and junior staff to know well. How to suspect cancer? How to deal with cancer patients and when they should refer to cancer centre?

Screening Guidelines for the Early Detection of Breast Cancer, American Cancer Society Yearly mammograms are recommended starting at age 40. A clinical breast exam should be part of a periodic health exam, about every three years for women in their 20s and 30s, and every yyear for women 40 and older. Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self-exam is an option for women starting in their 20s. Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting ti mammography screening earlier, having additional tests t (i.e., breast ultrasound and MRI), or having more frequent exams.

High risk groups factors RR Nb of 1st degree relatives with BC 1 vs none 2 2 vs none 3-5 First child age >30 vs <20 2-3 Breast feeding none vs 4 children 2.5 Menarche <11 vs >15 1.5 Number of child none vs 3 1.5

Breast cancer screening tests Breast self examination (BSE) Clinical breast examination (CBE) Mammography Ultrasonography Electrical impedance imaging Magnetic resonance imaging Positron emission tomography (PET) Scinti-mammography Digital ii mammography *IARC handbook of cancer prevention

Clinical Breast Examination Sensitivity (western countries) From 40% to 70%* # in western countries Specificity From 85% to95%* in western countries Advantages Low cost technique Performable by non medical staff Efficiency for screening is under evaluation (No RT results to date) Duffy et Al. BHGI 2006: Modelisations suggest that the benefit of CBE is a little more than half of the benefit of Mammography *IARC handbook of cancer prevention, # BHGI guidelines

Mammography Sensitivity From 53% to 92% in western countries* Low in pre-menopausal women (from 44% to 76 % in women <50*) Specificity From 82% to 98% in western countries* Mammography requires quality control Continuous Training i and Monitoring, i Double reading *IARC handbook of cancer prevention

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