Cancer A Superficial Introduction

Cancer A Superficial Introduction Gabor Fichtinger, Queen s University

Cancer some definitions Medical term: malignant neoplasm Class of diseases in which a group of cells display: uncontrolled growth (division beyond the normal limits) invasion (intrusion on and destruction of adjacent tissues) sometimes metastasis (spread to other locations in the body via lymph or blood) The above differentiate cancer from non-malignant (benign) growth Most cancers are solid and form a tumor. Some, like leukemia, do not. This course deals mostly solid cancer i.e. tumor.

Cancer known causes Mutation: chemical carcinogens tobacco smoke, some artificial sweeteners, some food preservatives Mutation: ionizing radiation Viral or bacterial infection Hormonal imbalances Immune system dysfunction Heredity Other causes

Cancers in this course Prostate Breast Gynecological Liver Bone / spine Head and Neck Brain Kidney Leukemia Lymph nodes

Cancer diagnosis Non-invasive: Blood serum Palpation (i.e. feel a lump under your finger) Imaging (CT, MRI, Ultrasound, PET, SPECT) Tissue biopsy Pathologist the doctor who examines it Histology or histopathology the process Pattern classification problem Diagnosis Staging of the disease Treatment options

Cancer imaging CT Liver cancer Kidney cancer Prostate cancer

Cancer imaging CT Glioblastoma multiform Metastatic brain lesions Metastatic spine cancer

Cancer imaging MRI prostate breast

Cancer imaging contrast imaging Issues: Toxicity Uptake Washout

Cancer imaging ultrasound Prostate - Transrectal Ultrasound (TRUS) Liver - Transcutaneous Ultrasound

Cancer imaging SPECT

Biopsy - the tools - cutting

Biopsy - the tools - suction Aspiration for serial semen analyses

Biopsy - drilling & suction Bone marrow biopsy needle Bone biopsy needle

Biopsy - the tissue (examples) Primary liver cancer in laparoscopy camera and pathology Liver mets from testicular (left) and breast cancer (right)

Cancer Diagnosis specificity and sensitivity sensitivity no yes specificity no BAD? yes? IDEAL Sensitivity = can I see it if it is there? Specificity = can I recognize it if I see it?

Cancer treatment Chemotherapy (realm of medical oncology) Surgery Resection Growth inhibition Thermal Ablation Cryotherapy (freezing) Injection Embolization Radiation therapy External beam (EBRT) Implanted sources (brachytherapy)

Cancer MIS tools - RFA

Cancer MIS tools - cryo

Cancer MIS tools - microwave

2 8 2 9 2 7 30 2 6 3 1 2 5 32 24 33 23 3 4 2 2 3 5 2 1 36 2 0 1 1 9 2 1 8 3 17 4 1 6 5 1 5 6 1 4 7 13 8 1 2 9 1 1 10 Cancer MIS tools HIFU needle a ) C o n t r o l l e d U l t r a s o u n d O u t p u t U l t r a s o u n d T r a n s d u c e r s ( T u b u l a r ) O u t e r S u p p o r t S h a f t coagulation boundary 3 ACOUSTTiC Needles ACOUSTTiC 3 Needles + Catheter 3 Needles + Catheter-cooling C o o l i n g F l o w I n s e r t i o n T i p T e m p e r a t u r e S e n s o r s P o w e r L e a d W i r e s 30 9 8 7 26 31 25 32 24 33 23 34 22 15 12 9 6 3 0 3615 2 35 21 20 90 o sector 12 9 6 3 0 270 o sector 18 3 17 4 5 6 7 8 9 1 1 12 13 14 15 16 R di ld h f 35 36 15 2 3 4 12 5 32 3334 6 9 31 7 30 6 8 29 3 9 28 0 10 27 11 26 200 o 12 25 sector 13 24 14 23 15 22 16 21 20 18 17 1 19 35 3615 2 3 34 4 33 12 5 32 6 9 31 7 30 6 8 29 3 9 28 0 10 27 11 26 12 25 360 o 13 24 sector 14 23 15 22 16 21 20 18 17 Acousticx Acoustic Medsystems, Inc

Cancer HDR brachytherapy

Cancer Statistics 2007 A Presentation From the American Cancer Society 2007, American Cancer Society, Inc.

US Mortality, 2004 Rank Cause of Death No. of deaths % of all deaths 1. Heart Diseases 652,486 27.2 2. Cancer 553,888 23.1 3. Cerebrovascular diseases 150,074 6.3 4. Chronic lower respiratory diseases 121,987 5.1 5. Accidents (Unintentional injuries) 112,012 4.7 6. Diabetes mellitus 73,138 3.1 7. Alzheimer disease 65,965 2.8 8. Influenza & pneumonia 59,664 2.5 9. Nephritis 42,480 1.8 10. Septicemia 33,373 1.4 Source: US Mortality Public Use Data Tape 2004, National Center for Health Statistics, Centers for Disease Control Laboratory and Prevention, for Percutaneous 2006. Surgery The Perk Lab

600 500 Change in the US Death Rates* by Cause, 1950 & 2004 Rate Per 100,000 586.8 1950 2004 400 300 200 217.0 180.7 193.9 185.8 100 50.0 48.1 19.8 0 Heart Diseases Cerebrovascular Diseases Pneumonia/ Influenza Cancer * Age-adjusted to 2000 US standard population. Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised. 2004 Mortality Data: US Mortality Public Use Data Tape, 2004, NCHS, Centers for Disease Control and Laboratory Prevention, for Percutaneous 2006 Surgery The Perk Lab

2007 Estimated US Cancer Deaths* Lung & bronchus 31% Prostate 9% Men 289,550 Women 270,100 26% Lung & bronchus 15% Breast Colon & rectum 9% 10% Colon & rectum Pancreas 6% 6% Pancreas Leukemia 4% 6% Ovary Liver & intrahepatic 4% bile duct Esophagus 4% 4% Leukemia 3% Non-Hodgkin lymphoma Urinary bladder 3% 3% Uterine corpus Non-Hodgkin 3% lymphoma Kidney 3% 2% Brain/ONS 2% Liver & intrahepatic bile duct All other sites 24% 23% All other sites ONS=Other nervous system. Laboratory Source: for Percutaneous American Cancer Surgery Society, The Perk 2007. Lab

Trends in the Number of Cancer Deaths Among Men and Women, US, 1930-2004 300,000 290,000 Men 285,000 Men 250,000 280,000 Number of Cancer Deaths 200,000 150,000 100,000 Women 275,000 270,000 Women 265,000 2000 2001 2002 2003 2004 50,000 0 1930 1940 1950 1960 1970 1980 1990 2000 Source: US Mortality Public Use Data Tape, 2004, National Center for Health Statistics, Centers for Disease Laboratory Control for and Percutaneous Prevention, Surgery 2006. The Perk Lab

Cancer Death Rates*, All Sites Combined, All Races, US, 1975-2003 300 Rate Per 100,000 Men 250 200 150 Both Sexes Women 100 50 0 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 *Age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Mortality - All COD, Public-Use With State, Total U.S. (1969-2003), National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 2006. Underlying mortality data Laboratory provided for Percutaneous by NCHS (www.cdc.gov/nchs). Surgery The Perk Lab

Cancer Death Rates*, for Men, US,1930-2003 100 Rate Per 100,000 Lung & bronchus 80 60 Stomach 40 Colon & rectum Prostate 20 Pancreas 0 Leukemia Liver 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 *Age-adjusted to the 2000 US standard population. Source: US Mortality Public Use Data Tapes 1960-2003, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

Cancer Death Rates*, for Women, US,1930-2003 100 Rate Per 100,000 80 60 40 Uterus Breast Lung & bronchus 20 Stomach Colon & rectum Ovary 0 Pancreas 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 *Age-adjusted to the 2000 US standard population. Source: US Mortality Public Use Data Tapes 1960-2003, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

Cancer Death Rates*, by Race and Ethnicity, US,1999-2003 400 Men Women 350 331.0 300 250 239.2 200 150 100 163.4 192.4 144.9 98.8 153.4 166.4 111.6 108.8 50 0 White African American Asian/Pacific Islander American Indian/ Alaskan Native Hispanic *Per 100,000, age-adjusted to the 2000 US standard population. Persons of Hispanic origin may be of any race. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control and Population Sciences, National Cancer Institute, 2006.

Cancer Sites in Which African American Death Rates* Exceed White Death Rates* for Men, US, 1999-2003 Site African American White Ratio of African American/White All sites 331.0 239.2 1.4 Prostate 65.1 26.7 2.4 Larynx 5.1 2.2 2.3 Stomach 12.4 5.4 2.3 Myeloma 8.6 4.4 2.0 Oral cavity and pharynx 6.9 3.8 1.8 Esophagus 10.7 7.6 1.4 Liver and intrahepatic bile duct 9.6 6.3 1.5 Small intestine 0.7 0.4 1.8 Colon and rectum 33.6 23.7 1.4 Lung and bronchus 98.4 73.8 1.3 Pancreas 15.7 12.0 1.3 *Per 100,000, age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control Laboratory and Population for Percutaneous Sciences, Surgery National The Perk Cancer Lab Institute, 2006.

Cancer Sites in Which African American Death Rates* Exceed White Death Rates* for Women, US, 1999-2003 Site African American White Ratio of African American/White All sites 192.4 163.4 1.2 Stomach 6.0 2.7 2.2 Myeloma 6.4 2.9 2.2 Uterine cervix 5.1 2.4 2.1 Esophagus 3.0 1.7 1.8 Larynx 0.9 0.5 1.8 Uterine corpus 7.1 3.9 1.8 Small intestine 0.5 0.3 1.7 Pancreas 12.5 9.0 1.4 Colon and rectum 23.7 16.4 1.4 Liver and intrahepatic bile duct 3.8 2.8 1.4 Breast 34.4 25.4 1.4 Urinary bladder 2.9 2.3 1.3 Gallbladder 1.0 0.8 1.3 Oral cavity and pharynx 1.8 1.5 1.2 *Per 100,000, age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control Laboratory and Population for Percutaneous Sciences, Surgery National The Perk Cancer Lab Institute, 2006.

Cancer Death Rates* by Sex and Race, US, 1975-2003 500 450 400 350 300 250 200 150 100 50 Rate Per 100,000 African American men White men African American women White women 0 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 *Age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control and Laboratory Population for Percutaneous Sciences, Surgery National The Cancer Perk Lab Institute, 2006.

2007 Estimated US Cancer Cases* Men 766,860 Women 678,060 Prostate 29% Lung & bronchus 15% Colon & rectum 10% Urinary bladder 7% Non-Hodgkin 4% lymphoma Melanoma of skin 4% Kidney 4% Leukemia 3% Oral cavity 3% Pancreas 2% All Other Sites 19% 26% Breast 15% Lung & bronchus 11% Colon & rectum 6% Uterine corpus 4% Non-Hodgkin lymphoma 4% Melanoma of skin 4% Thyroid 3% Ovary 3% Kidney 3% Leukemia 21% All Other Sites *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Laboratory Source: for American Percutaneous Cancer Surgery Society, The Perk 2007. Lab

Cancer Incidence Rates*, All Sites Combined, All Races, 1975-2003 700 Rate Per 100,000 600 Men 500 Both Sexes 400 Women 300 200 100 0 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 *Age-adjusted to the 2000 US standard population and adjusted for delay in reporting. Source: Surveillance, Epidemiology, and End Results Program, 1973-2003, Division of Cancer Control and Laboratory Population for Percutaneous Sciences, Surgery National The Cancer Perk Lab Institute, 2006.

Cancer Incidence Rates* for Men, 1975-2003 250 Rate Per 100,000 200 Prostate 150 100 Lung & bronchus 50 Colon and rectum Urinary bladder 0 Non-Hodgkin lymphoma Melanoma of the skin 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 *Age-adjusted to the 2000 US standard population and adjusted for delays in reporting. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control and Population Sciences, National Cancer Institute, 2006.

Cancer Incidence Rates* for Women, 1975-2003 250 Rate Per 100,000 200 150 Breast 100 50 0 Colon and rectum Lung & bronchus Uterine Corpus Ovary Non-Hodgkin lymphoma 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 *Age-adjusted to the 2000 US standard population and adjusted for delays in reporting. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control and Population Sciences, National Cancer Institute, 2006.

Cancer Incidence Rates* by Race and Ethnicity, 1999-2003 Rate Per 100,000 800 Men Women 700 639.8 600 555.0 500 400 300 421.1 383.8 385.5 359.9 303.3 305.0 444.1 327.2 200 100 0 White African American Asian/Pacific Islander American Indian/ Alaska Native Hispanic *Age-adjusted to the 2000 US standard population. Person of Hispanic origin may be of any race. Sources: Howe HL, et al. Annual report to the nation on the status of cancer 1975-2003; SEER, 1975-2003, Division of Cancer Control and Population Sciences, National Cancer Institute, 2006.

900 800 Cancer Incidence Rates* by Sex and Race, All Sites, 1975-2003 Rate Per 100,000 700 African-American men 600 500 400 300 200 100 White women White men African-American women 0 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 *Age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control and Laboratory Population for Percutaneous Sciences, Surgery National The Cancer Perk Lab Institute, 2006.

Lifetime Probability of Developing Cancer, by Site, Men, 2001-2003* Site Risk All sites 1 in 2 Prostate 1 in 6 Lung and bronchus 1 in 12 Colon and rectum 1 in 17 Urinary bladder 1 in 28 Non-Hodgkin lymphoma 1 in 47 Melanoma 1 in 49 Kidney 1 in 61 Leukemia 1 in 67 Oral Cavity 1 in 72 Stomach 1 in 89 * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2001 to 2003. 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 6.1.1 Statistical Research and Laboratory Applications for Percutaneous Branch, Surgery NCI, 2006. The http://srab.cancer.gov/devcan Perk Lab

Lifetime Probability of Developing Cancer, by Site, Women, US, 2001-2003* Site Risk All sites 1 in 3 Breast 1 in 8 Lung & bronchus 1 in 16 Colon & rectum 1 in 19 Uterine corpus 1 in 40 Non-Hodgkin lymphoma 1 in 55 Ovary 1 in 69 Melanoma 1 in 73 Pancreas 1 in 79 Urinary bladder 1 in 87 Uterine cervix 1 in 138 * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2001 to 2003. 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 6.1.1 Statistical Research and Applications Branch, NCI, 2006. http://srab.cancer.gov/devcan

Cancer Survival*(%) by Site and Race,1996-2002 Site White African American % Difference All Sites 68 57 11 Breast (female) 90 77 13 Colon 66 54 12 Esophagus 17 12 5 Leukemia 50 39 11 Non-Hodgkin lymphoma 64 56 8 Oral cavity 62 40 22 Prostate 100 98 2 Rectum 66 59 7 Urinary bladder 83 65 18 Uterine cervix 75 66 9 Uterine corpus 86 61 25 *5-year relative survival rates based on cancer patients diagnosed from 1996 to 2002 and followed through 2003. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control and Laboratory Population for Percutaneous Sciences, Surgery National The Cancer Perk Lab Institute, 2006.

Five-year Relative Survival (%)* during Three Time Periods By Cancer Site Site 1975-1977 1984-1986 1996-2002 All sites 50 53 66 Breast (female) 75 79 89 Colon 51 59 65 Leukemia 35 42 49 Lung and bronchus 13 13 16 Melanoma 82 86 92 Non-Hodgkin lymphoma 48 53 63 Ovary 37 40 45 Pancreas 2 3 5 Prostate 69 76 100 Rectum 49 57 66 Urinary bladder 73 78 82 *5-year relative survival rates based on follow up of patients through 2003. Recent changes in classification of ovarian cancer have affected 1996-2002 survival rates. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control and Laboratory Population for Percutaneous Sciences, National Surgery Cancer The Perk Institute, Lab 2006.

Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2003 18 Rate Per 100,000 16 Incidence 14 12 10 8 6 4 Mortality 2 0 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 *Age-adjusted to the 2000 Standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control and Laboratory Population for Percutaneous Sciences, Surgery National The Cancer Perk Institute, Lab 2006.

Tobacco Use in the US, 1900-2003 5000 100 4500 90 Per Capita Cigarette Consumption 4000 3500 3000 2500 2000 1500 1000 500 0 Per capita cigarette consumption Male lung cancer death rate Female lung cancer death rate 80 70 60 50 40 30 20 10 0 Age-Adjusted Lung Cancer Death Rates* 1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 Year *Age-adjusted to 2000 US standard population. Source: Death rates: US Mortality Public Use Tapes, 1960-2003, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2005. Cigarette consumption: US Department of Agriculture, 1900-2003.

Trends in Cigarette Smoking Prevalence* (%), by Gender, Adults 18 and Older, US, 1965-2005 60 50 Prevalence (%) 40 30 20 Women Men 10 0 1965 1974 1979 1983 1985 1990 1992 1994 1995 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year *Redesign of survey in 1997 may affect trends. Source: National Health Interview Survey, 1965-2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

Trends in per capita cigarette consumption for selected states and the average consumption across all states, 1980-2003 140 120 Per Capita Sales (# of Packs) 100 80 60 40 California United States Massachusetts 20 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 Year Data from: Orzechowski W, Walker RC. The tax burden on tobacco: historical compilation 2003: Volume 36. Arlington (VA): Orzechowski and Walker; 2003.

Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment, Adults 18 and Older, US, 1992-2005 Prevalence (%) 60 55 50 45 40 35 30 25 20 15 10 5 0 Adults with less than a high school education All adults 1992 1994 1996 1998 2000 2002 2003 2004 2005 Year Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for adults 25 and older. Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2002, 2004, 2005), National Center for Chronic Disease Prevention and Health Promotion, Centers for Laboratory Disease for Percutaneous Control and Surgery Prevention, The 1997, Perk Lab 1999, 2000, 2001, 2003, 2005, 2006.

Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, 1960-2004 45 Prevalence (%) 40 35 30 25 20 15 10 13 15 15 23 31 33 11 12 13 21 28 32 16 17 17 26 34 35 5 0 Both sexes Men Women NHES I (1960-62) NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94) NHANES 1999-2002 NHANES 2003-2004 *Obesity is defined as a body mass index of 30 kg/m 2 or greater. Age adjusted to the 2000 US standard population. Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2004: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, National Center for Health Laboratory Statistics, for Percutaneous Centers for Surgery Disease The Control Perk and Lab Prevention, 2006.

Trends in Overweight* Prevalence (%), Adults 18 and Older, US, 1992-2005 1992 1995 1998 2005 Less than 50% 50 to 55% More than 55% State did not participate in survey *Body mass index of 25.0 kg/m 2 or greater. Source: Behavioral Risk Factor Surveillance System, CD-ROM (1984-1995, 1998) and Public Use Data Tape (2004, 2005), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 2000, 2005, 2006.