cancer: a global concern the epidemiology of cancer farid najafi school of population health...
TRANSCRIPT
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Cancer: A global concern
The epidemiology of CancerFarid Najafi
School of Population HealthKermanshah University of Medical Sciences
(KUMS)2008
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What is cancer?
• A generic term for a group of more than 100 diseases
• ‘Malignant tumours’ and ‘Neoplasm’ are other names
• Charecterized by followings:– Rapid creation– Metastasis
Oncogenesis: The process whereby normal cells become cancer cells
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cancer...
• unrestrained cell division +• disordered tissue growth
• local invasion• distant spread
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cancer...
• failure to control growth• genetic imbalance:
• excess stimulus (oncogene activation)• loss of tumour suppression
• act via various factors (eg loss of telomerase, angiogenesis)
DNA errors: may be inherited;
or acquired
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Functional properties of tumor cells
1. Contact inhibition of cell movement
2. Immortality of cells
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Primary vs. Secondary tumors
• The original tumor is called a primary tumor and all cells derive from single aberrant cell
• As tumors metastasize the new colonies or foci are refferred to as secondary tumors or metastatic centers
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Malignant transformation
• Initiation: a change in the cell’s genetic material primes the cell to become cancerous. Change may be spontanous or by an agent that cause cancer (carciongen)
• Promotion: Unlike carcinogens, promoters do not cause cancer by themselves. They allow a cell that has undergone initiation to become cancerous
• Spread:
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Biology of cancer
1. Healthy cells
2. Dysplasia: subtle morphological abnormalities
3. Carcinoma in Situ: abnormality in proliferation but no invasion into the underlying basement membrane
4. Localize cancer (I): invasion to the local tissues
5. Regional spread (II & III): invasion to the regional or extended regional lymph nodes
6. Generalized disease (IV): blood-borne metastasis
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Cancer burden indicators
• Cancer control policies are based on the availability of statistical measures of the impact of cancer in a population
• Main epidemiological indicators are cancer mortality, incidence, prevalence, and survival
• These four indicators describe different aspects of the disease impact and of the efficacy of health care system in controlling the disease
• They are related each other and overall they are a complete set of indicators to describe cancer burden
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A B
cancer
other causes
exposure
Onset of disease
Diagnosis TreatmentFollow-up
Pre-clinical phase Clinical phase
Survival
Incidence Mortality
The disease process
C
Events
Cancer burden indicators
Prevalence
Death
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• Mortality - Number of cause-specific deaths occurring in a defined population in the unit of time. Usually expressed as rate per 100,000 persons/year
• Classification: ICD-9 or 10
• Availability: cause specific mortality data from official statistics in almost all countries. Local/regional/national geographical detail.
Cancer burden indicators: Mortality
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Cancer burden indicators: Incidence
• Incidence – Number of new cancer cases diagnosed in a defined population in the unit of time. Usually expressed as rate per 100,000 persons/year.
• Classification: ICD-O (3° revision) topography and morphology
• Availability: in areas covered by population-based Cancer Registries (CR). Good quality data.
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Cancer burden indicators: Survival
– Cause of death known Cancer Specific Survival probability of surviving cancer after x years from diagnosis in a cohort of patients diagnosed in a period of time t
– Cause of death unknown Relative Survival (RS) ratio of the observed survival in the patients group to the expected survival in a similar group in the population (same age, sex, year, area, socio-economic class etc…)
– RS measures the extra-risk of dying of cancer patients by removing the competitive mortality due to causes other than cancer.
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Cancer burden indicators: Prevalence• Prevalence
– The number of surviving cancer patients in a population at a defined index date.
– Usually expressed as count or proportion x 100.000
– Total (or complete) prevalence involves all survivors irrespectively of the date of diagnosis.
– Partial prevalence by years from diagnosis represents the number of survivors by limited disease duration.
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Some facts about cancer
• A leading cause of death (13% of all deaths in 2005 worldwide)
• >70% of cancer deaths in 2005 occurred in developing countries
• Common types of cancers:– Men: Lung, stomach, liver, colorectal,
oesophagus and prostate– Women: Breast, lung, stomach, colorectal and
cervical
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the cancer burden
2000: 10 million new cases (world)
2020: 20 million new cases -70% in countries with < 5% cancer
control resources
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Some facts about cancer
• 40% of cancer can be prevented• Smoking is the single largest preventable cause
of cancer in the world• 1/5 of cancers are due to chronic infections:
– HBV: liver cancer– HPV: cancer of cervix– Helicobacter pylori: stomach cancer– Schistosomes: cancer of bladder– HIV infection: kaposi sarcoma and lymphomas
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Cancers in developed and developing countries
• Developed countries– Cancer is the second-biggest cause of death after
CVD– Prostate, breast and colon cancer are the most
common types
• Developing countries– Death due to cancer is going to mimic developed
countries– Stomach, lung and cervical cancer are more common
• World– Lung cancer kills more people than any other cancer
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Some other facts about cancer
The rule of Thirds 1/3 preventable; 1/3 curable (1/2 in developed
countries
The importance of screening Earlier diagnosis means more curability
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Cause of cancers
1. Physical agents• Ionizing radiation: X-rays & Radioactivity• Nonionizing radiation: Sunlight• Physical substances: Asbestos & pollution
2. Chemical agents• Promotion and initiation• Industrial exposure
• Benzene, benzidine, cadmium, nickel or vinyl choloride
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Cause of cancers
Biological agents• Viruses• Parasites
Diet• Dietary fat• Food preservation• Protective substances in the diet
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Cause of cancers
Social factors• Social class• Occupation
• Industrial hazard
• Medical Services and care• Radiation and medications
• Lifestyle• Habits and food hadling
• Air and water pollution
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avoidable cancer causes
• smoking (30%)• diet (20-50%)
• infection (10-20%)• radiation (6%)• alcohol (5%)• occupation (3%)• pollution (1-5%)• (reproductive hormones 10-20%)
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Global action against cancer, WHO, 2005
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Causes of cancer
• Tobacco consumption is the world’s most avoidable cause of cancer
• 30% of all cancer deaths in developed countries
• The contribution of diet and inactive lifestyle to cancer is similar to smoking in developed countries
• One-fifth of cancers worldwide are due to chronic infections
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smoking and cancer
• mouth
• pharynx
• oesophagus
• larynx
• lung
• pancreas
• kidney
• bladder
lip, nose, stomach. myeloid leukaemia
(liver, large bowel, cervix)
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infection and cancer
• parasites: bladder, bowel, liver, bile ducts (Asia, Africa)
• bacteria: stomach (? bladder, bowel)
• viruses: numerous
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viruses and cancer
• Hepatitis B,C liver• Human papilloma cervix, vulva, vagina,
penis, anus
• EBV Burkitt’s lymphoma, Hodgkin’s lymphoma, naso-pharyngeal ca
• Human herpes (8) Kaposi’s sarcoma• various T-cell leukaemia,
mesothelioma..
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diet and cancer
aflatoxin liver cancer
‘salted fish” NPC(salted foods stomach cancer)
overeating/ gall bladder, uterus, obesity breast (post-menopause)
vegetables/ lung, stomach,
fruit oesophagus, mouth, pharynx, colon, breast,
pancreas, bladder
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treatment strategies (i)
screening: breast large bowel cervix
prostate lung
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treatment strategies (ii)
cures (chemoRx, hormone Rx, XRx)
• extend life (as above + lifestyle change)
• palliate always
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The role of epidemiological knowledge in disease control: a case of two cancers
Intervntion Accepted utility for widescale use
Lung cancer Breast cancer
Prevention YES. Smoking cigarettes is the strong risk factor; and exposure is modifiable by actions at personal and community levels
NO. Many weak risk factors, most not readily modifiable
Screening NO. Even the newest tests (CT lung scans) yield very limited survival benefits
YES. Substantial good evidence (RCTs) of lower mortality due to population screening programs for over 50s
Improved treatment
NO. Minor survival improvements only with newer treatments
YES. RCT results show survival advantage with appropriate chemotherapy/radiotherapy
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Cancer in Iran
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Causes of deathsIran (2005, 2030)
WHO, 2007
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Some facts about cancer in Iran
• In 2005 cancer killed 47,000 people in Iran, 27,000 of those people were under the age of 70
• In 2002 stomach cancer was the most common cancer found in men in Iran
• In 2005 stomach cancer was the leading cause of cancer deaths in women and men
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Incidence of cancer(Iran, 2002)
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Cancer deaths(Iran, 2005)
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Incidence of cancer(Iran, United States)
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Incidence of cancer(Iran, United State)
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Gastric Cancer
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Biology
• Several Hystological types of gastric cancer of which adenocarcinoma is by the most frequent
• Sarcomas and lymphomas are other types
• This lecture mainly focous on adenocarcinoma
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Epidemiology
• Infrequent before 40 years of age
• Twice as frequent in men than in women
• Leading cause of death from cancer worldwide and in Iran
• Highest incidence in Japan, South America and Eastern Europe
• Adjusted rate worldwide is 15.62% per 100,000
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EUROCARE-4 EUROCARE-4 STOMACHSTOMACHAge standardized 5-year relative survival, by country (both sexes)Age standardized 5-year relative survival, by country (both sexes)
Sant et al EJC, 2009
0 20 40 60 80 100
EUROCARE-4 POOL
Poland
Czech Republic
Spain
Slovenia
Portugal
Malta
Italy
Switzerland
Netherlands
Germany
France
Belgium
Austria
UK Wales
UK Scotland
UK Northern Ireland
UK England
Ireland
Sweden
Norway
Iceland
Finland
Denmark
5-year relative survival (%)0 20 40 60 80 100
EUROCARE-4 POOL
Poland
Czech Republic
Spain
Slovenia
Portugal
Malta
Italy
Switzerland
Netherlands
Germany
France
Belgium
Austria
UK Wales
UK Scotland
UK Northern Ireland
UK England
Ireland
Sweden
Norway
Iceland
Finland
Denmark
5-year relative survival (%)
Colon and Rectum Stomach
Incidence ASRx100,000Incidence ASRx100,000Tehran M 20Tehran M 20Tehran F 10Tehran F 10Europe M Europe M W <5W <5 E 30E 30 N <5N <5 S 18S 18
5-year survival 25%5-year survival 25%Range= 14-32%Range= 14-32%
Northern EuropeUK and IrelandCentral EuropeSouthern EuropeEastern Europe
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Risk factor of gastric cancer
• Chronic Atrophic Gasteritis is the first step in the development of most gastric cancer, associated with:– Tobacco– H.pylori infection– Diet with high level of nitrites, nitrates, salt
and smoked food– Previous gastric surgery– Pernicious anemia (B12 deficiency due to
absence of interinsic factor+atrophic gastritis
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tobacco
• Increases the risk of gastric cancer by 50%
• Responsible for 11% of all Stomach Cancer
• Decreases the level of carotenoids and Vitamin c
• Increases the risk of H.pylori
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Helycobacter pylori
• Associated with a two to sixfold increase in the risk of developing Gastric Cancer
• In 1994 the WHO designated H.pylori a group 1 carcinogen
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Dietary factors
• Consumption of fruit, vegetables and fiber have a protective effect against Gastric Cancer
• Their effect is probably associated with Vitamin C or carotenes
• Nitrates and nitrites are usually found in salted, smoked and dried foods
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Genetic factors
• Blood type A
• A first degree relative with Gastric Cancer
• Hereditary non-polyposis colorectal cancer
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Secondary prevention
• Early detection: difficult due to lack of symptoms
• Screening might be effective where the disease is a major health problem (such as Japan)– Gas-contrast Stomach Fluorography – Further paraclinical tests (endoscopy and
biopsy) if the result is abnormal
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Conclusion
• High mortality rate
• The best primary prevention strategies are:– Smoking cessation– Healthy diet– Avoidence of salted, smoked and poorly
preserved foods– Erradication of H.pylori
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Lung cancer
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Some facts about lung cancer
• Lung cancer is the third most common cancer in the western world, after prostate and breast cancer
• One of the most preventable kinds of cancer
• Four out of five cases are associated with smoking
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EUROCARE-4 EUROCARE-4 LUNG CANCERAge-standardized 5-year relative survival by Age-standardized 5-year relative survival by countrycountry
Sant et al. EJC 20090 20 40 60 80 100
EUROCARE-4 POOL
Poland
Czech Republic
Spain
Slovenia
Portugal
Malta
Italy
Switzerland
Netherlands
Germany
France
Belgium
Austria
UK Wales
UK Scotland
UK Northern Ireland
UK England
Ireland
Sweden
Norway
Iceland
Finland
Denmark
5-year relative survival (%)
Incidence ASRx100,000Incidence ASRx100,000Tehran M 15Tehran M 15Tehran F 7Tehran F 7Europe MEurope M between 42-65between 42-65
5-year survival 12%5-year survival 12%Range = 8-15%Range = 8-15%
Northern EuropeUK and IrelandCentral EuropeSouthern EuropeEastern Europe
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Risk factors
• Tobacco and passive smoking– Smokers have a 10-25 times higher risk compared to
non-smokers– 10%-20% of all lung cancers in non smokers are due
to passive smoking• Air pollution
– Exposure to air pollution increase the risk of lung cancer by 100%
• Chronic obstructive lung disease (COPD)• Occupational exposure
– Asbestos, glass-wool and ceramic fibres• Genetic factors
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Taylor R et al 2007
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Prevention of lung cancer
• 80%-85% of lung cancers are associated with smoking
• 10% are associated with occupational carcinogens
• 1% are associated with passive smoking
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Histological types of lung cancer
• Two major types:– Small-cell lung cancer– Nonsmall-cell lung cancer
• Squamous cell carcinoma• Adenocarcinoma• Large-cell carcinoma
• Squamous cell carcinoma is the most commonest type in males and adenocarcinoma is the most commonest type in females
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Early detection of lung cancer
• Low cure rate (13%)
• Low cure rate is related to lack of early detection measures
• There is no successful screening test
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Minami, H. et al. Chest 2000;118:1603-1609
Actual survival curves of 647 patients >= 60
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Conclusion
• NO currently established means for the screening or early detection of lung cancer
• 85-88% of all lung cancer are caused by active or passive smoking
• Reduction of tobacco consumption still is the most important strategy