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Introduction to Cancer basics? Candy Cooley, Manager National Genetics Education and Development Centre cancernursing.org online lecture March 2009 Statistics >9.7 million cases are detected each year 6.7 million people will die from cancer Every day, around 1700 Americans die of the disease 20.4 million people living with cancer in the world today 1 in 3 people will be diagnosed with cancer in the UK and 1 in 4 will die from their disease The Global Burden of Cancer 2000 Women Men 4.7 million cases 2.7 million deaths 5.3 million cases 3.5 million deaths Lung 902 337 293 810 Breast 499 Colon/Rectum 255 234 558 Stomach 318 405 398 384 Liver Prostate 105 0 370 446 241 166 165 543 204 Cervix uteri 471 233 Oesophagus 279 227 260 Bladder 99 Non-Hodgkin 167 Lymphoma 93 144 109 170 81 116 112 Leukaemia Oral cavity Pancreas 119 Kidney 57 133 111 76 33 121 68 113 86 97 47 101 101 71 34 Mortality 192 Ovary 114 1000 0 Incidence 800 600 400 200 0 (Thousands) From: D.M. Parkin The Lancet Oncology 2: 533-543 (2001) 200 400 600 800 100 WHO Statistics 2020 15 million people will die from cancer Causes Ageing population Obesity Smoking The burden of cancer 6% of NHS hospital expenditure $/€/£ etc millions spent on research Substantial financial burdens upon families and carers Physical and emotional burden Personal views of cancer “in the popular imagination cancer equals death” “Cancer forces us to confront our lack of control over our own or others death” Kleinman (1988) (Susan Sontag,1977) What is Cancer? Division – uncontrolled cell division Growth – formation of a lump (tumour) or large numbers of abnormal white cells in the blood Mutation – changes to how the cell is viewed by the immune system Spread – ability to move within the body and survive in another part Division – uncontrolled cell division Oncogenes Tumour suppressor genes – p53 Suicide genes – apoptosis DNA repair genes Growth Tumour Pressure on nerves Blocking organs Stopping normal function Altering nerve signals Fungating Mutation and Spread Invasion Angiogenesis Types of Cancer Carcinomas Sarcomas Lymphomas Leukaemias Adenomas Often prefixed by the specific cell What are the differences in the features of normal and cancer cells? Malignant versus benign tumours Normal and abnormal cell growth Normal cell growth Cancerous growth Metastatic cancer What causes cancer? Carcinogenesis. Some factors to consider… Heredity Immunity Chemical Physical Viral Bacterial Lifestyle Heredity 5-10% of Cancers ?15% of all cancers Molecular biology and Human Genome Project Heredity Genes isolated for several classic familial cancer syndromes: RB1 (retinoblastoma) APC (familial polyposis) Human Non Polyposis Colon Cancer (HNPCC) BRCA 1&2 (breast cancer) p53 (many cancers) Immunity HIV / AIDS Immunosuppression Virus’s Hepatitis B Human T-cell Leukaemia virus Epstein Barr Virus Human Papilloma Virus (HPV) Bacterial H. pylori Other Parasites: Schistosoma spp Clonorchis sinensis Estimated Burden of Cancer from Infection Worldwide in 2000 No. of cases Agent % World cancer Liver 509,000 HBV, HCV, flukes 5.1 Cervix 471,000 HPV 4.7 Stomach 442,000 H. pylori 4.4 Kaposi’s (HIV related) 134,000 HHV-8 1.3 Non Hodgkin lymphoma 72,000 H. pylori, EBV, HIV 0.7 Ano-genital 65,000 HPV 0.6 Nasopharyngeal 63,000 EBV 0.6 Hodgkin disease 33,000 EBV, HIV 0.3 Bladder 10,000 Schistosoma 0.1 HTLV1 0.03 Leukaemia Total 3,000 1,801,000 17.9 Chemical Alcohol Asbestos Wood dust Rubber, plastics, dyes Tar / bitumen Aflatoxin Alkylating agents Tobacco Smoking Single biggest cause of cancer 25-40% smokers die in middle age 9 in 10 lung cancers Know to cause cancer in 1950 Smoking and alcohol Industrial pollution Physical causes Ultraviolet radiation Sunlight Certain industrial sources Radiation Radon Cancer treatment Obesity Lifestyle: - Highly caloric diet, rich in fat, refined carbohydrates and animal protein - Low physical activity Consequences: - Cancer - Diabetes - Cardiovascular disease - Hypertension Lifestyle Age Occupation Ethnicity Deprivation Survival variations CONCORD Study (1.9 million survivors) demonstrated a clear relationship to income not only between countries but also between the ethnic groups in those countries (Coleman et al Lancet Oncology 2008) Diagnosis and staging Clinical History Normal diagnostic procedures Scans, xrays Blood tests Biopsy Pathological staging Staging Size Invasion Lymph nodes Metastasises TNM Staging T (a,is,(0),1-4): size or direct extent of the primary tumor N (0-3): degree of spread to regional lymph nodes N0: tumor cells absent from regional lymph nodes N1: tumor cells spread to closest or small number of regional lymph nodes N2: tumor cells spread to an extent between N1 and N3. N3: tumor cells spread to most distant or numerous regional lymph nodes M (0/1): presence of metastasis M0: no distant metastasis M1: metastasis to distant organs (beyond regional lymph nodes) Other parameters G (1-4): the grade of the cancer cells (i.e. they are "low grade" if they appear similar to normal cells, and "high grade" if they appear poorly differentiated) R (0/1/2): the completeness of the operation (surgeryboundaries free of cancer cells or not) L (0/1): invasion into lymphatics V (0/1): invasion into vein C (1-4): a modifier of the certainty (quality) of the last mentioned parameter Examples Small, low grade cancer, no metastasis, no spread to regional lymph nodes, cancer completely removed, resection material seen by pathologist - pT1 pN0 M0 R0 G1; this would be considered Stage I. Large, high grade cancer, with spread to regional lymph nodes and other organs, not completely removed, seen by pathologist - pT4 pN2 M1 R1 G3; this would be considered Stage IV. Most Stage I tumors are curable; most Stage IV tumors are not. Staging for Chronic Lymphocytic Leukemia (CLL) There are two different systems for staging chronic lymphocytic leukemia. The Rai classification is used more often in the United States, whereas the Binet system is used more widely in Europe Stages of Leukemia: Acute Lymphocytic Leukemia (ALL) For adults, ALL is classified as untreated, in remission, or recurrent. For childhood ALL, risk groups are used instead of stages to describe cases of the disease. Risk groups for childhood ALL include: Standard (low) risk High risk Recurrent. Other staging Lymphoma: uses Ann Arbor staging Hodgkin's Disease: follows a scale from I-IV and can be indicated further by an A or B, depending on whether a patient is non-symptomatic or has symptoms such as fevers. It is known as the "Cotswold System" or "Modified Ann Arbor Staging System". Duke Staging System Modified Duke A The tumor penetrates into the mucosa of the bowel wall but no further. Modified Duke B B1: tumor penetrates into, but not through the muscularis propria (the muscular layer) of the bowel wall. B2: tumor penetrates into and through the muscularis propria of the bowel wall. Modified Duke C C1: tumor penetrates into, but not through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. C2: tumor penetrates into and through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. Modified Duke D The tumor, which has spread beyond the confines of the lymph nodes (to organs such as the liver, lung or bone). Summary Cancer is a disease of Division, growth and spread It has a number of causes many of them preventable The survival of the patient is determined by the stage of the disease, the earlier the detection or the smaller the tumour the better the survival 10 Rules to Avoid Cancer 1. 2. 3. 4. Don’t smoke Don’t smoke. Don’t smoke. Avoid exposure to other known carcinogens, including aflatoxin, asbestos and UV light. 5. Enjoy a healthy diet, moderate in calories, salt and fat, and low in alcohol. 6. Eat fresh fruit and vegetables several times a day. 7. Be physically active and avoid obesity. 8. Have vaccination against, or early detection/treatment of, cancer causing chronic infections. 9. Have the right genes. 10. Have good luck !