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Cancer Prevention and Early Cancer Prevention and Early Detection:
Rabab Gaafar,MD
Prof. Medical OncologyNCI,Cairo, Cairo University
Director Early Detection UnitDirector Early Detection Unit
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Prevention and Early DetectionPrevention 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
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Prevention and Early DetectionPrevention and Early DetectionDefinition
Goals of Cancer Prevention and Control
Magnitude of the Problem
Local Strategies to fight Cancer
Breast Cancer early detection
Breast cancer Prevention Elderly
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DefinitionDefinition"primary" prevention (intervention for relatively healthy individuals with no invasive cancer and an average risk for developing cancer).
" d " ti (i t ti f ti t d t i d b "secondary" prevention (intervention for patients determined 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 .
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Cancer prevention science and practice are just beginning to gain public, academic, t d i d t iti j t f l 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
d ti ) 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
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PreventionPrevention
-Cancer can be caused by a number of factors-May develop over a number of years.-Some risk factors can be controlledSome risk factors can be controlled.-Choosing the right health behaviors-preventing exposure to certain environmental risk factorscan help prevent the development of cancercan 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.
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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 until symptoms appear.
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Prevention and Early DetectionPrevention and Early DetectionDefinition
Goals of Cancer Prevention and Control
Magnitude of the Problemg
Local Strategies to fight Cancer
Breast Cancer early detection
Breast cancer Prevention Elderly
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ASCO Strategic Plan 2004–2007: Goal C P ti d C t l Cancer Prevention and Control
Advocate for rapid worldwide reduction and ultimate elimination of tobacco products 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 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 controlcancer 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
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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
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Prevention and Early DetectionPrevention and Early DetectionDefinition
Goals of Cancer Prevention and Control
Magnitude of the Problem
Local Strategies to fight Cancer
Breast Cancer early detection
Breast cancer Prevention Elderly
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Leading causes of death
23.2
31.0Heart Diseases
Cancer
4 2
4.8
6.8Cerebrovascular Diseases
Chronic Obstructive Lung Diseases
A id t
2.8
3.9
4.2Accidents
Pneumonia & Influenza
Diabetes Mellitus
1 1
1.1
1.3Suicide
Nephritis
Cirrhosis of the Liver 1.1
Percentage of Total Deaths, USPercentage of Total Deaths, US
Cirrhosis of the Liver
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Developed CountriesDeveloped Countries
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2006 Estimated US Cancer Cases*
Men720,280
Women679,510
31% Breast31% Breast
12% Lung & bronchus
11%Colon & rectum
Prostate 33%
Lung & bronchus 13%
Colon & rectum 10%6% Uterine corpus
4% Non-Hodgkinlymphoma
4% M l f ki
Urinary bladder 6%
Melanoma of skin 5%
Non-Hodgkin 4% l h 4% Melanoma of skin
3% Thyroid
3% Ovary
lymphoma
Kidney 3%
Oral cavity 3%2% Urinary bladder
2% Pancreas
22% All Other Sites
Leukemia 3%
Pancreas 2%
All Other Sites 18%
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2006.
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Lifetime Probability of Developing Cancer, by Site, Men, 2000-2002*
Site RiskAll sites† 1 in 2Prostate 1 in 6Lung and bronchus 1 in 13Colon and rectum 1 in 17Urinary bladder‡ 1 in 28Non-Hodgkin lymphoma 1 in 46Melanoma 1 in 52Melanoma 1 in 52Kidney 1 in 64Leukemia 1 in 67Oral Cavity 1 in 73Stomach 1 in 82
* For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002.
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
‡ Includes invasive and in situ cancer cases† All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder.
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Lifetime Probability of Developing Cancer, by Site, Women, US, 2000-2002*
Site RiskAll sites† 1 in 3Breast 1 in 8Lung & bronchus 1 in 17Colon & rectum 1 in 18Uterine corpus 1 in 38Non-Hodgkin lymphoma 1 in 55Ovary 1 in 68Ovary 1 in 68Melanoma 1 in 77Pancreas 1 in 79Urinary bladder‡ 1 in 88Uterine cervix 1 in 135
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
* 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
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U S Cancer MortalityU.S. Cancer Mortality
Lung & bronchus 32% 25% Lung & bronchusLung & bronchus 32%Prostate 10%Colon & rectum 10%P 5%
25% Lung & bronchus15% Breast10% Colon & rectum6% OvaryPancreas 5%
Leukemia 5%NH lymphoma 4%E h 4%
6% Ovary6% Pancreas4% Leukemia3% NH l hEsophagus 4%
Liver & bile duct 3%Urinary bladder 3%
3% NH lymphoma3% Uterine corpus2% Multiple myeloma2% B i /ONSKidney 3%
All other sites 21%2% Brain/ONS24% All other sites
American Cancer Society, 2004
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Cancer Death Rates*, for Men, US,1930-2002
100 Rate Per 100,000
80 Lung
40
60
StomachProstate
20
40Colon & rectum
Pancreas
0
930
935
940
945
950
955
960
965
970
975
980
985
990
995
000
Pancreas
LiverLeukemia
*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.
19 19 19 19 19 19 19 19 19 19 19 19 19 19 20
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Cancer Death Rates*, for Women, US,1930-2002
100Rate Per 100,000
80
40
60
LungUt
20
40
Colon & rectum
Uterus
Stomach
Breast
0
930
935
940
945
950
955
960
965
970
975
980
985
990
995
000
Ovary
Pancreas
*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.
19 19 19 19 19 19 19 19 19 19 19 19 19 19 20
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Tobacco Use in the US, 1900-2002
5000 100Male lung cancer
3000
3500
4000
4500
5000
onsu
mpt
ion
60
70
80
90
100
ance
r Dea
th
Per capita cigarette consumption
death rate
1500
2000
2500
3000
apita
Cig
aret
te C
o
30
40
50
60
Adj
uste
d Lu
ng C
aRa
tes*
Female lung cancer death rate
0
500
1000
1900
1905
1910
1915
1920
1925
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
Per
C
0
10
20
Age
-A
2
Year
*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.
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Five-year Relative Survival (%)* during Three Time Periods By Cancer Site
All sites 50 53 65
Site 1974-1976 1983-1985 1995-2001
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 60Non-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 82y
*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 andPopulation Sciences, National Cancer Institute, 2005.
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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
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Scientists estimate that as many as 50 to 75 percent of cancer deaths in USA are caused by human behaviorssuch as smoking, physical inactivity, and poor dietary choices.
Not using cigarettes or other tobacco products: Not drinking too much alcoholNot drinking too much alcoholEating five or more daily servings of fruits and vegetablesEating a moderate-fat dietConsuming a diet in which total calories eaten are balanced with calories expended by physical activityMaintaining or reaching a healthy weightg g y gBeing physically activeProtecting skin from sunlight
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Future
19 % decline in the rate at which new cancer cases occur 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 people change their behaviors that y p p p gput them at risk were stepped up and if behavioral change were sustained.
Thi ld t t th ti f i t l 100 000 This would equate to the prevention of approximately 100,000 cancer cases and 60,000 cancer deaths each year by the year 2015.
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Developing CountriesDeveloping Countries
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Estimated cancer incidences in the EM region
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Most common sites in Males Females
10
10
17
8
11
11
16
9
10
12
17
Leukemia
Lymphoma
Liver
Bladder
6
5
35
7
6
38
6
6
38
Lymphoma
Leukemia
Breast
7
5
6
8
3
4
6
8
4
4
5
6
Soft tissue
Colorectal
Lung
Leukemia
20032002
2001
4
4
5
6
4
4
4
4
4
4
5
Colorectal
Ovary
Bladder
20032002
2001
3
3
3
3
3
3
2
3
4
0 5 10 15 20
Bones
Larynx
Skin
3
6
4
2
3
2
4
2
3
3
4
Thyroid
Cervix
Soft tissue
Liver
Percent of cases 22
0 10 20 30 40 50
Thyroid
Percent of cases
NCI, Cairo
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Causes of the Growing Cancer BurdenCauses of the Growing Cancer Burden
Aging populations
Impact of infectious diseases
Increased tobacco use and pollutionp
Nutrition and lack of physical activity
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Aging Populations
2050
2000
1950
5% 10% 15% 20%
Percentage of global population 60 and olderPercentage of global population 60 and older
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Cancer and the Environment
Tobacco10
4
6
8
10
DevelopingNationsDe eloped
0
2
4
2000 2030
DevelopedNations
1500
2000
2500
3000
Developed
Annual deaths from tobacco
0
500
1000
1500
1970-72 1980-82 1990-92
Developing
Annual number of cigarettes consumed per adult
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ChichaChichain the 90’s :
new flavored tobacco + satellites/electronic media = new fashion
1h chicha session = 70 to 200 cigarettes
Water does not filtrate carcinogens g(carbon monoxide, heavy metals, other carcinogens)
h l d h charcoals produce their own toxicants
Second hand smoke = tobacco smoke + charcoals smoke
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Pollution
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Etiologic Factors of HCCEtiologic Factors of HCC
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Prevalence of schistosomiasisin Egypt: 1935-2003
40%
25
30
35
15
20
25
0
5
10
01980 1985 1990 1995 2000 2005
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Action needed
Study of the viral etiology of HCCand the role played by HBV and HCV (possibly a
lti ti l ti t d )multinational comparative study).
• HBV vaccination specially children and high risk groups.
• Proper follow up of hepatitis patients, specially cirrhotic for early detection of p y yHCC.
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Prevention and Early DetectionPrevention and Early DetectionDefinition
Goals of Cancer Prevention and Control
Magnitude of the Problem
Local Strategies to fight Cancer
Breast Cancer early detection
Breast cancer Prevention Elderly
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The National Cancer InstituteCairo UniversityCairo University
www.nci.cd.edu.eg
Cairo University National Cancer Institute
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Main StrategiesNCI Cairo UniversityNCI , Cairo University
Management: Diagnosis and TreatmentCancer RegistryEducation: Training and degree-granting g g g gprogramsResearch: Basic science, Population, and Clinical studies of National InterestPrevention and early detection
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Key PointKey Point
Detecting cancer in its initial stages presents the opportunity to treat diseasebefore it spreadsbefore it spreads.the ability to reduce a person’s risk of developing cancer opens the way foroptimum prevention strategies.
The NCI – Cairo University is committed to progress in cancer detection andrisk assessment that allows interventions to focus on the earliest stages ofdisease.
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Secondary Preventiony
Referred cases for managementBreast
Soft tissuef f g Soft tissue
Colon
Ovary
ThyroidBreast
Liver
Prostate
thymoma
scapula mass
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With limited advertising, matching with our resourcesour resources
1500 New Cases visit our clinic with dramatically rising curvedramatically rising curve
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400 2006
300
400
20032004
2005300
No.
2003200
100
01Total cases
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Secondary Prevention
Triage for every patient
Accurate history taking .y g
Pedigree designPedigree design .Meticulous clinical examination
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We provide Lectures & Outdoor Campaignp p g
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Primary Preventiony
We provide support services to ti t d th i f ilicancer patients and their families.
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Primary Preventiony
We support and encourage research and studies l t d t ti d l d t ti frelated to prevention and early detection of
cancer.
1. Early Detection & classification of Lymphoma
2. Pilot Study of Inflammatory Breast Cancer in2. Pilot Study of Inflammatory Breast Cancer in Egypt and Tunisia in collaboration withNational 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
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We are trying to prevent malpractice i i i i iwhich is vital issue in management
of cancer patient by establishing training programs to the GPs and junior staff to know welljunior staff to know well.
How to suspect cancer ?How to deal with cancer patients and when they should refer to cancer centre ?
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Prevention and Early DetectionPrevention and Early DetectionDefinition
Goals of Cancer Prevention and Control
Magnitude of the Problem
Local Strategies to fight Cancer
Breast Cancer early detection
Breast cancer Prevention Elderly
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Screening Guidelines for the Early Detection of g yBreast 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 year for women 40 y , y yand 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 t ti h i li h i dditi l t t (i b t starting mammography screening earlier, having additional tests (i.e., breast
ultrasound and MRI), or having more frequent exams.
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High risk groups
factors RRfactors RR
Nb of 1st degree relatives with BC1 vs none 21 vs none2 vs none
23-5
First child age >30 vs <20 2-3
Breast feeding none vs 4 children 2.5
M h <11 >15 1 5Menarche <11 vs >15 1.5
Number of child none vs 3 1.5
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Breast cancer screening testsBreast cancer screening tests
• Breast self examination (BSE)
• Clinical breast examination (CBE)
• Mammography
• Ultrasonography• Ultrasonography
• Electrical impedance imaging
• Magnetic resonance imaging
• Positron emission tomography (PET)
• Scinti-mammography
i i l h• Digital mammography
*IARC handbook of cancer prevention
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Clinical Breast ExaminationClinical Breast ExaminationSensitivity (western countries)
• From 40% to 70%* # in western countries
Specificity• From 85% to 95%* in western countriesFrom 85% to 95% in western countries
AdvantagesAdvantages
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
*IARC handbook of cancer prevention, #BHGI guidelines
more than half of the benefit of Mammography
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MammographyMammographySensitivity
• From 53% to 92% in western countries*
• Low in pre-menopausal women (from 44% to 76 % in women <50*)to 76 % in women <50 )
Specificity• From 82% to 98% in western countries*
Mammography requires quality control
C ti T i i d M it iContinuous Training and Monitoring,
Double reading
*IARC handbook of cancer prevention
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Prevention and Early DetectionPrevention and Early DetectionDefinition
Goals of Cancer Prevention and Control
Magnitude of the Problemg
Local Strategies to fight Cancer
Breast Cancer early detection
Breast cancer Prevention Elderly
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THANK YOUYOU