CANCER

Dr. Sonkar v k
 Intro
Cancer may be regarded as a group of diseases
characterized by an
(i) abnormal growth of cells
(ii) ability to invade adjacent tissues and even
distant organs, and
(iii) the eventual death of the affected patient if
the tumour has progressed beyond that stage
when it can be successfully removed.
Cancer can occur at any site or tissue of the body
and may involve any type of cells.
 The major categories of cancer are
(a) Carcinomas, which arise from epithelial cells
lining the internal surfaces of the various organs
(e.g. mouth, oesophagus, intestines, uterus) and
from the skin epithelium;
(b) Sarcomas, which arise from mesodermal cells
constituting the various connective tissues (e.g.
fibrous tissue, fat and bone); and
(c) Lymphomas, myeloma and Ieukaemias arising
from the cells of bone marrow and immune
systems:
 The term primary tumour is used to denote cancer in
the organ of origin,
while secondary tumour denotes cancer that has
spread to regional lymph nodes and distant organs.
When cancer cells multiply and reach a critical size,
the cancer is clinically evident as a lump or ulcer
localized to the organ of origin in early stages.
As the disease advances, symptoms and signs of
invasion and distant metastases become clinically
evident.
 Problem statement: WORLD
In 2012, the worldwide burden of cancer rose to an
estimated 14 million new cases per year, a figure
expected to rise to 22 million annually within the next
two decades.
Over the same period, cancer deaths are predicted to
rise from an estimated 8.2 million annually to 13
million per year.
Globally, during 2012, the most common cancers
diagnosed were those of the lung (1.8 million), breast
(1.7 million) and colorectal (1.4 million).
The most common causes of cancer deaths were
cancer of lung (1.6 million), liver (0.8 million) and
stomach (0.7 million).
 As a consequence of growing and ageing
populations, developing countries are
disproportionately affected by the increasing
numbers of cancers.
More than 60 per cent of the worlds total cases
occur in Africa, Asia, and Central and South
America, and these regions account for about 70
per cent of the worlds cancer deaths.
Situation is made worse by the lack of early
detection and access to treatment.
 The Westernization trends As low human-
development index (HDI) countries become more
developed through rapid societal and economic
changes, they are likely to become westernized.
As such, the pattern of cancer incidence is likely
to follow that seen in high HDI settings, with
likely decline in cancer incidence rate of cervix
uteri and stomach, and increasing incidence rates
of breast, prostate and colorectal cancers.
This westernization effect is a result of reduction
in infection-related cancers and increase in
cancers associated with reproductive, dietary and
hormonal risk factors.
 Large variations in both cancer frequency and
case fatality are observed, even in relation to
the major forms of cancer in different regions
of the world for men and women.
Table 1 and 2 show the age standardized
incidence and mortality of most common
cancers in men and women worldwide.
 For any disease, the relationship of incidence
to mortality is an indication of prognosis.
Similar incidence and mortality rates being
indicative of an essentially fatal condition.
Thus, lung cancer accounts for most deaths
from cancer in the world :(1.6 million)
annually, since it is most invariably associated
with poor prognosis.
 On the other hand, appropriate intervention is
often effective in avoiding fatal outcome
following diagnosis of breast cancer.
Hence this particular cancer, which rank
second in terms of incidence, is not among
the top three causes of death from cancer,
which are respectively cancers of the lung,
stomach, and liver.
 The most conspicuous feature of the distribution
of cancers between the sexes is the male
predominance of lung cancer.
Prostate, colorectal, stomach and liver cancer are
also much more common in males (Table 1).
Cancer of breast, colorectum, cervix, uteri, lung
and stomach are common in females.
For the most part, differences in distribution
between the sexes are attributable to differences
in exposure to causative agents rather than to
variation in the susceptibility.
 For other tumour types, including cancers of
pancreas and colorectum, there is little
difference in the sex distribution.
Generally speaking, the relationship of
incidence to mortality is not affected by sex.
Thus for example, the prognosis following
diagnosis of liver or pancreatic cancer is
dismal for both males and females.
 Many other tumour types are more
responsive to therapy, so that cancers of
breast, prostate and uterine cervix are the
cause of death in only a minority of patients
diagnosed.
The burden of cancer is distributed unequally
between developed and developing countries,
with particular cancer types exhibiting
different patterns of distribution.
 Problem statement: INDIA
In India, the National Cancer Registry Programme of the
ICMR provides data on incidence, mortality and distribution
of cancer from 25 population-based registries and 5
hospital based registries.
It is estimated that during the year 2012, 10.15 lac new
cancer cases occurred in the country, of these 4.77 lac were
males and 5.37 lac females.
It gives an incidence rate of 92.4 per lac population.
Same year about 6.83 lac persons died of cancer, (3.57 lac
males and 3.26 lac females), a mortality rate of 69.7 per lac
population.
Table 3 and 4 show the age standardized incidence and
mortality due to cancer in India.
 The five most frequent cancers in men were cancer
lung, lip and oral cavity, stomach, colorectum and
other pharynx, and
in women, cancer breast, cervix uteri, colorectum,
ovary, lip and oral cavity. Cancer in males were mostly
tobacco related.
In women, cervical cancer is closely associated with
poor genital hygiene, early consummation of marriage,
multiple pregnancies, and contact with multiple sexual
partners.
It is also reported that breast cancer is proportionately
on the increase in a few metropolitan areas of India.
 This appears to be related to late marriage, birth of the
first child at a late age, fewer children, and shorter
periods of breast-feeding, which are increasingly
common practice among the educated urban women.
Facilities for screening and proper management of
cancer patients are grossly limited in India.
More than two-thirds of cancer patients are already in
an advanced and incurable stage at the time of
diagnosis.
Appropriate strategies are being developed, including
creating public awareness about cancer, tobacco
control and application of self or assisted screening
technique for oral, cervical, and breast cancers.
 Time trends
Few decades ago, cancer was the sixth leading cause of
death in industrialized countries;
today, it is the second leading cause of death.
There are a number of reasons for this increase, the three
main ones being a longer life expectancy, more accurate
diagnosis and the rise in cigarette smoking, especially
among males.
The overall rates do not reflect the different trends
according to the type of cancer.
For example, there has been a large increase in lung cancer
incidence and the stomach cancer has shown a declining
trend in most developed countries for reasons not
understood.
 Cancer patterns
There are wide variations in the distribution of cancer
throughout the world.
That cancer of the stomach is very common in Japan,
and has a low incidence in United States.
The cervical cancer is high in Columbia and has a low
incidence in Japan.
In the South-East Asia Region of WHO, the great
majority are cancers of the oral cavity and uterine
cervix.
These and other international variations in the pattern
of cancer are attributed to multiple factors such as
environmental factors, food habits, lifestyle, genetic
factors or even inadequacy in detection and reporting
of cases.
 Hospital data clearly indicates that the two
organ sites most commonly involved are:
(I) the uterine cervix in women, and
(ii) the oropharynx in both sexes.
These two sites represent approximately 50
per cent of all cancer cases.
Both these cancers are predominantly
environment related and have a strong socio-
cultural relationship.
 It is also important to note that these two kinds of
cancer are easily accessible for physical examination
and amenable to early diagnosis by knowledge already
available.
i.e., good clinical examination and exfoliative cytology.
The cure rate for these neoplasma is also very high if
they are treated surgically at stages I and II.
But unfortunately, in most cases, the patients present
themselves to a medical facility when the disease is far
advanced and is not amenable to treatment.
This is the crux of the problem.
 Causes of cancer
As with other chronic diseases, cancer has a
multifactorial aetiology.
1. ENVIRONMENTAL FACTORS
2. GENETIC FACTORS
 1. ENVIRONMENTAL FACTORS
Environmental factors are generally held responsible
for 80 to 90 per cent of all human cancers. The major
environmental factors identified so far include
(a) TOBACCO : Tobacco in various forms of its usage
(e.g., smoking, chewing) is the major environmental
cause of cancers of the lung, larynx, mouth, pharynx,
oesophagus, bladder, pancreas and probably kidney.
It has been estimated that, in the world as a whole,
cigarette smoking is now responsible for more than
one million premature deaths each year.
 (b) ALCOHOL : Excessive intake of alcoholic
beverages is associated with oesophageal and
liver cancer.
Some recent studies have suggested that beer
consumption may be associated with rectal
cancer.
It is estimated that alcohol contributed to
about 3 per cent of all cancer deaths.
 (c) DIETARYFACTORS : Dietary factors are also
related to cancer.
Smoked fish is related to stomach cancer,
dietary fibre to intestinal cancer, beef
consumption to bowel cancer and a high fat
diet to breast cancer.
A variety of other dietary factors such as food
additives and contaminants have fallen under
suspicion as causative agents.
 (C) OCCUPATIONAL EXPOSURES:
These include exposure to benzene, arsenic,
cadmium, chromium, vinyl chloride, asbestos,
polycyclic hydrocarbons, etc.
Many others remain to be identified.
The risk of occupational exposure is considerably
increased if the individuals also smoke cigarettes.
Occupational exposures are usually reported to
account for 1 to 5 per cent of all human cancers.
 (e) VIRUSES : An intensive search for a viral origin
of human cancers revealed that hepatitis B and C
virus is causally related to hepatocellular
carcinoma.
The relative risk of Kaposis sarcoma occurring in
patients with HIV infection is so high that it was
the first manifestation of the AIDS epidemic to be
recognized.
NonHodgkins lymphoma, a cancer of the
lymph nodes and spleen is a late complication of
AIDS.
 The Epstein-Barr virus (EBV) is associated with 2 human
malignancies, viz. Burkitts lymphoma and
nasopharyngeal carcinoma.
Cytomegalovirus (CMV) is a suspected oncogenic agent
and classical Kaposis sarcoma is associated with a
higher prevalence of antibodies to CMV.
Human papiloma virus (HPV) is a chief suspect in
cancer cervix.
Hodgkins disease is also believed to be of viral origin.
The human Tcell leukaemia virus is associated with
adult Tcell leukaemia / lymphoma in the United
States and southern parts of Japan.
 (f) PARASITES : Parasitic infections may also
increase the risk of cancer, as for example,
schistosomiasis in Middle East producing
carcinoma of the bladder.
(g) CUSTOMS, HABITS AND LIFESTYLES : To the
above causes must be added customs, habits and
lifestyles of people which may be associated with
an increased risk for certain cancers.
The familiar examples are the demonstrated
association between smoking and lung cancer,
tobacco and betel chewing and oral cancer, etc.
 (h) OTHERS : There are numerous other
environmental factors such as sunlight,
radiation, air and water pollution, medications
(e.g., oestrogen) and pesticides which are
related to cancer.
 2. GENETIC FACTORS
Genetic influences have long been suspected.
For example, retinoblastoma occurs in children of
the same parent.
Mongols are more likely to develop cancer
(leukaemia) than normal children.
However, genetic factors are less conspicuous
and more difficult to identify.
There is probably a complex interrelationship
between hereditary susceptibility and
environmental carcinogenic stimuli in the
causation of a number of cancers.
 Cancer control
Cancer control consists of a series of measures
based on present medical knowledge in the fields
of prevention, detection, diagnosis, treatment,
after care and rehabilitation, aimed at reducing
significantly the number of new cases, increasing
the number of cures and reducing the invalidism
due to cancer.
The basic approach to the control of cancer is
through primary and secondary prevention. It is
estimated that at least one-third of all cancers are
preventable.
 1. PRIMARY PREVENTION
Cancer prevention until recently was mainly
concerned with the early diagnosis of the disease
(secondary prevention), preferably at a
precancerous stage.
Advancing knowledge has increased our
understanding of causative factors of some
cancers and it is now possible to control these
factors in the general population as well as in
particular occupational groups.
They include the following:
 (a) CONTROL OF TOBACCO AND ALCOHOL
CONSUMPTION : Primary prevention offers
the greatest hope for reducing the number of
tobaccoinduced and alcohol related cancer
deaths. It has been estimated that control of
tobacco smoking alone would reduce the total
burden of cancer by over a million cancers
each year.
 (b) PERSONAL HYGIENE: Improvements in
personal hygiene may lead to declines in the
incidence of certain types of cancer, e.g.,
cancer cervix.
(c) RADIATION: Special efforts should be made
to reduce the amount of radiation (including
medical radiation) received by each individual
to a minimum without reducing the benefits.
 (d) OCCUPATIONAL EXPOSURES : The
occupational aspects of cancer are frequently
neglected. Measures to protect workers from
exposure to industrial carcinogens should be
enforced in industries.
(e) IMMUNIZATION: In the case of primary liver
cancer, immunization against hepatitis B virus and
for prevention of cancer cervix immunization
against HPV presents an exciting prospect.
 (f) FOODS, DRUGS AND COSMETICS: These should
be tested for carcinogens.
(g) AIR POLLUTION : Control of air pollution is
another preventive measure.
(h) TREATMENT OF PRECANCEROUS LESIONS :
Early detection and prompt treatment of
precancerous lesions such as cervical tears,
intestinal polyposis, warts, chronic gastritis,
chronic cervicitis, and adenomata is one of the
cornerstones of cancer prevention.
 (I) LEGISLATION : Legislation has also a role in primary
prevention. For example, legislation to control known
environmental carcinogens (e.g., tobacco, alcohol, air
pollution).
(j) CANCER EDUCATION: An important area of primary
prevention is cancer education. It should be directed at
high-risk groups. The aim of cancer education is to
motivate people to seek early diagnosis and early
treatment. Cancer organizations in many countries
remind the public of the early warning signs (danger
signals) of cancer.
 These are:
a. a lump or hard area in the breast
b. a change in a wart or mole
c. a persistent change in digestive and bowel habits
d. a persistent cough or hoarseness
e. excessive loss of blood at the monthly period or loss
of blood outside the usual dates
f. blood loss from any natural orifice
g. a swelling or sore that does not get better
h. unexplained loss of weight.
 There is no doubt that the possibilities for primary
prevention are many.
Since primary prevention is directed at large
population groups (e.g., high risk groups, school
children, occupational groups, youth clubs), the cost
can be high and programmes difficult to conduct.
Primary prevention, although a hopeful approach, is
still in its early stages.
Major risk factors have been identified for a small
number of cancers only and far more research is
needed in that direction.
 2. SECONDARY PREVENTION
Secondary prevention comprises the following
measures
i) CANCER REGISTRATION
ii) EARLY DETECTION OF CASES
iii) TREATMENT
 i) CANCER REGISTRATION
Cancer registration is a sine qua non for any
cancer control programme.
It provides a base for assessing the magnitude
of the problem and for planning the necessary
services.
Cancer registries are basically of two types
hospitalbased and population based.
 (a) HOSPITAL-BASED REGISTRIES: The hospital-based
registry includes all patients treated by a particular
institution, whether in- patients or out-patients.
Registries should collect the uniform minimum set of
data recommended in the WHO Handbook for
Standardized Cancer Registers.
If there is a long-term follow-up of patients, hospital-
based registries can be of considerable value in the
evaluation of diagnostic and treatment programmes.
Since hospital population will always be a selected
population, the use of these registries for
epidemiological purposes is thus limited.
 (b) POPULATION-BASED REGISTRIES : A right step is to
set up a hospitalbased cancer registry and extend
the same to a population-based cancer registry.
The aim is to cover the complete cancer situation in a
given geographic area.
The optimum size of base population for a population
based cancer registry is in the range of 27 million.
The data from such registries alone can provide the
incidence rate of cancer and serve as a useful tool for
initiating epidemiological enquiries into causes of
cancer, suveillance of time trends, and planning and
evaluation of operational activities in all main areas of
cancer control.
 ii) EARLY DETECTION OF CASES
Cancer screening is the main weapon for early
detection of cancer at a pre-invasive (in situ) or
pre-malignant stage.
Effective screening programmes have been
developed for cervical cancer, breast cancer and
oral cancer. Like primary prevention, early
diagnosis has to be conducted on a large scale;
however, it may be possible to increase the
efficiency of screening programmes by focussing
on high-risk groups.
 Clearly, there is no point in detecting cancer at
an early stage unless facilities for treatment
and after-care are available.
Early detection programmes will require
mobilization of all available resources and
development of a cancer infrastructure
starting at the level of primary health care,
ending with complex cancer centres or
institutions at the state or national levels.
 iii) TREATMENT
Treatment facilities should be available to all
cancer patients. Certain forms of cancer are
amenable to surgical removal, while some others
respond favourably to radiation or chemotherapy
or both. Since most of the known methods of
treatment have complementary effect on the
ultimate outcome of the patient, multi-modality
approach to cancer control has become a
standard practice in cancer centres all over the
world.
 In the developed countries today, cancer
treatment is geared to high technology.
For those who are beyond the curable stage, the
goal must be to provide pain relief.
A largely neglected problem in cancer care is the
management of pain.
The WHO has developed guidelines on relief of
cancer pain.
Freedom from cancer pain is now considered a
right of cancer patients.
 CANCER SCREENING
In the light of present knowledge, early detection
and prompt treatment of early cancer and
precancerous conditions provide the best
possible protection against cancer for the
individual and the community.
Now a good deal of attention is being paid to
screening for early detection of cancer.
This approach, that is, cancer screening may be
defined as the search for unrecognized
malignancy by means of rapidly applied tests.
 Cancer screening is possible because
(a) in many instances, malignant disease is
preceded for a period of months or years by a
premalignant lesion, removal of which prevents
subsequent development of cancer;
(b) most cancers begin as localized lesions and if
found at this stage a high rate of cure is
obtainable; and
(c) as much as 75 per cent of all cancers occur in
body sites that are accessible.
METHODS OF CANCER SCREENING
(a) Mass screening by comprehensive cancer detection
exami nation: A rapid clinical examination, and examination
of one or more body sites by the physician is one of the
important approaches for screening for cancer.
(b) Mass screening at single sites : This comprises
examination of single sites such as uterine cervix, breast or
lung.
(c) Selective screening : This refers to examination of those
people thought to be at special risk, for example, parous
women of lower socio-economic strata upwards of 35 years
of age for detection of cancer cervix, chronic smokers for
lung cancer, etc.
 1. Screening for cancer cervix
Screening for cervical cancer has become an accepted
clinical practice. The prolonged early phase of cancer in
situ can be detected by the Pap smear.
Current policy suggests that all women should have a
Pap test (cervical smear) at the beginning of sexual
activity, and then every 3 years thereafter.
A periodic pelvic examination is also recommended.
Organized population based screening programmes
have reduced the incidence and mortality from cervical
cancer in many developed countries.
 However, screening for cancer cervix using Pap smear
requires excessive resources in terms of laboratories,
equipments and trained personnels.
This has led to search for an alternative screening
method that can be more cost- effective.
Visual inspection based screening tests such as visual
inspection with 5 per cent acetic acid (VIA), VIA with
magnification (VIAM), and visual inspection post
application of Lugols iodine (VILI) are some of the
alternative screening tests, which have been studied
for their effectiveness in India.
Sensitivity of VIA tends to be similar to cytology based
screening. It is easy to carry out and easy to train
appropriate health workers.
 The present strategy is to screen women using visual
inspection after application of freshly prepared 5 per
cent acetic acid solution (5 ml of glacial acetic acid
mixed with 95 ml distilled water).

Detection of well-defined opaque acetowhite lesions

close to the squamo-columnar junction, well defined
circum-orificial acetowhite lesion or dense
acetowhitening of ulceroproliferative growth on the
cervix constiute a positive VIA or VIAM.
The test is followed by a single visit approach for
further investigation and management at district
hospital.
 The management at district hospital is planned in
such a way that the treatment based on
colposcopy is offered in the same visit.
Pap smear and biopsy are the investigations that
are done to ensure that there are cytological and
histopathological back-up for the interventions.
Intensive information, education and
communication activities are required to sensitize
the community about the significance of the
disease and its early detection through screening.
 2. Screening for breast cancer
There is evidence that screening for breast
cancer has a favourable effect on mortality
from breast cancer. The basic techniques for
early detection of breast cancer are
(a) breast self-examination (BSE) by the
patient (b) palpation by a physician (c)
thermography, and (d) mammography.
 All women should be encouraged to perform
breast self- examination.
Breast cancers are more frequently found by
women themselves than by a physician during a
routine examination.
Although the effectiveness of BSE has not been
adequately quantified, it is a useful adjuvant to
early case detection. In many countries, BSE will
probably be the only feasible approach to wide
population coverage for a long time to come.
Palpation is unreliable for large fatty breasts.
 Thermography has the advantage that the patient
is not exposed to radiation.
Unfortunately, it is not a sensitive tool.
Mammography is most sensitive and specific in
detecting small tumours that are sometimes
missed on palpation.
The use of mammography has three potential
drawbacks: (i) exposure to radiation. This may
amount to a dose of 500 milliroentgen compared
to a 3040 milliroentgen dose received in chest
X-ray.
 Therefore, there has been concern about exposure to
radiation from repeated mammographies and the risk
of breast cancer developing as a result
(ii) mammography requires technical equipment of a
high standard and radiologists with very considerable
experience these two factors limit its more
widespread use for mass screening purposes, and
(iii) biopsy from a suspicious lesion may end up in a
false-positive in as many as 510 cases for each case
of cancer detected.
 Although recent evidence points to the
superiority of mammography over clinical
examination in terms of sensitivity and
specificity, medical opinion is against routine
mammography on the very young. Women
under 35 years of age should not have X-rays
unless they are symptomatic or a family
history of early onset of breast cancer.
 3. Screening for lung cancer
At present there are only two techniques for
screening for lung cancer, viz, chest radiograph
and sputum cytology. Mass radiography has been
suggested for early diagnosis at six monthly
intervals, but the evidence in support of this is
not convincing. So it is not recommended. It is
doubtful whether the disease satisfies the criteria
of suitability for screening.