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PRIMARY CANCER PREVENTION AND RISK REDUCTION OF CANCER IN VIETNAM Mitra Rado, MN, FNP-C, AOCNP Hematology & Oncology GLOBAL RATE OF CANCER The incidence of cancer worldwide in 2008 was 12.7 million It is estimated to reach 21.4 million by 2030 TOP 10 CAUSES OF DEATHS IN VIETNAM Cancer 25% Stroke 20% Ischemic heart disease 6% Chronic Obstructive Pulmonary Disease 4% Lower Respiratory Infections 4% Tuberculosis 4% Road Injuries 4% Cirrhosis 3% HIV 3% Diabetes 3% CANCER INCIDENCE IN THE US FOR MEN Prostate Lung Bladder Colon Lymphoma CANCER DEATH FOR MEN IN US Cancer Incidence Prostate Lung Bladder Colon Lymphoma Cancer Death Lung Colon Bladder CANCER INCIDENCE IN US FOR WOMEN Breast Lung Uterine Colon Thyroid Lymphoma CANCER DEATH IN US FOR WOMEN Cancer Incidence Breast Lung Uterine Colon Thyroid Lymphoma Cancer Death Lung Breast Colon CANCERS INCIDENCE IN VIETNAM FOR MEN 1. Lung 2. Liver 3. Stomach 4. Colorectal 5. Nasopharynx CANCER INCIDENCE FOR MEN COMPARED Vietnam 2012 1. Lung 2. Liver 3. Stomach 4. Colorectal 5. Nasopharynx US 2015 1. Prostate 2. Lung 3. Bladder 4. Colorectal 5. Lymphoma LEADING CANCERS IN VIETNAM FOR WOMEN 1. Breast 2. Cervix 3. Stomach 4. Liver LEADING CANCERS IN VIETNAM FOR WOMEN Vietnam 2012 1. Breast 2. Cervix 3. Stomach 4. Liver US 2015 1. Breast 2. Lung 3. Uterine 4. Colon 5. Thyroid 6. Lymphoma CANCER IS A GENETIC DISEASE Cancer is caused by certain changes to genes that control the way our cells function, especially how they grow and divide. These changes include mutations in the DNA that makes up our genes. GERMLINE CHANGES Genetic changes that increase cancer risk can be inherited from our parents if the changes are present in germ cells, which are the reproductive cells of the body (eggs and sperm). Such changes are called “Germline changes” and every cell in the body express these inherited changes. SOMATIC CHANGES Genetic changes that occur after conception are called somatic (or acquired) changes. Cancer-causing genetic changes can also be acquired during one’s lifetime, as the result of errors that occur as cells divide during a person’s lifetime or exposure to substances, such as certain chemicals in tobacco smoke, and radiation, such as ultraviolet rays from the sun, that damage DNA, and INFECTION such as hepatitis B or C, human papilloma virus! TYPES OF CANCER PREVENTION Primary Secondary Tertiary HEALTH PROMOTION AND PRIMARY PREVENTION RECOMMENDATIONS IN THE US Nutrition recommendations Alcohol consumption Activity guidelines Tobacco cessation Skin protection HPV prevention HBV vaccine SECONDARY PREVENTION Early Detection, and screening Identify high risk individuals and families Cervical - do a screen and treat approach Breast self exam and Breast mammography Colorectal screening using flexible sigmoidoscopy or colonoscopy Gastric - Endoscopy WHAT IS A RISK FACTOR? Trait or characteristic associated with an increased likelihood of developing a disease. Presence or absence does not dictate whether disease will develop. Risk factors may be: Modifiable (diet, exercise, tobacco use, or other lifestyle factors) Not modifiable (age, sex, family history, or ethnicity). Persons with modifiable risk factors should be encouraged to change lifestyle factors associated with increased risk. BASIC ELEMENTS OF RISK ASSESSMENT Review of personal medical history Review of medications Review of history of personal exposures including ultraviolet light, radiation, and chemicals Detailed family history of at least three generations LAST STEP Based on risk factor assessment, the clinician needs to identify for which cancer(s) the patient is at risk. The clinician needs to explain to the patient for which cancer(s) he or she is at risk. Any modifiable risk factors should be discussed, and the patient should be encouraged and supported in developing a healthier lifestyle. All of this information needs to be communicated to the patient in terms that can be understood. TERTIARY PREVENTION prevention of further disease-related deterioration or recurrence and rehabilitation. PRIMARY PREVENTION Modifiable (diet, exercise, tobacco use, immunization or other lifestyle factors) Not modifiable (age, sex, family history, or ethnicity). PRIMARY PREVENTION In Vietnam tobacco use, infectious disease and chemical exposure are the more common causes of cancer. The average rate of infection as the cause of cancer in the US, Europe, and Australia is about 7% but in Africa, Asia, and South America the average is about 23%. Asia has a 10 fold greater rate of stomach cancer than US and Europe PRIMARY PREVENTION FACTS ABOUT TOBACCO USE • • Smoking increases the risk of cancer of the mouth, nasal cavities, larynx, pharynx, esophagus, stomach, pancreas, kidney, bladder, uterine, and cervix, as well as leukemia. Risk of lung cancer: 23 times higher in male smokers – 13 times higher in female smokers – • • Smoking cessation greatly reduces the risk of death from cancer and other causes. But never reaches “0”. Remember that the risk of lung cancer also is increased by exposure to secondhand smoke. SMOKING EXPOSURE AND LUNG CANCER STUDY IN VIETNAM When lung cancer was used to measure cumulative smoking exposure, 30% of all adult male deaths (>35 years) in Vietnam in 2008 were attributable to smoking. (this did not include second hand smoke) Norman RE, Vos T, Barendregt JJ, et al. Mortality attributable to smoking in Vietnamese men in 2008.Prev Med. 2013; 57(3):232-7 BENEFITS OF TOBACCO CESSATION Short-Term Benefits • Normalization of: Elevated blood pressure, pulse, and body temperature due to nicotine – Blood carbon monoxide and oxygen levels. – • • • • • Taste and smell acuity improves. Shortness of breath decreases. Risk of infection decreases. Coughing and sinus congestion decrease. Energy level and ability to walk improve. Long-Term Benefits Decreased risk of dying from lung cancer by ½ in 10 years Decreased risk of throat, bladder, kidney, or pancreatic cancer by ½ in 5 years Reduced risk of stroke or heart attack TOBACCO CESSATION Cessation is most successful with a combination of behavioral counseling and pharmacotherapy. Tobacco users should be advised to quit at each clinical encounter. Behavioral counseling can be accomplished through group or individualized sessions. START METHOD • • • • • S = Set a quit date. T = Tell family, friends, and coworkers that you plan to quit. A = Anticipate and plan for the challenges you will face while quitting. R = Remove cigarettes and other tobacco products from your home, car, and work. T = Talk to a healthcare provider about getting help to quit. SMOKING CESSATION AIDS Nicotine gum and lozenges Nicotine patch Nicotine inhaler Bupropion (Wellbutrin) Varenicline (Chantix) SOCIAL PRESSURES OF SMOKING HOW CAN WE CREATE A SOCIAL DISLIKE FOR SMOKING? HPV INFECTION AND CANCER PREVENTION • • Vaccination with the HPV vaccine can greatly reduce the risk of developing cervical cancer. HPV vaccination is recommended for females aged 1112. – – • May be given to females as young as age 9 Is also recommended for females aged 1318 to catch up on missed vaccine or to complete the vaccination series HPV vaccination is recommended for males aged 926. Decreases the risk of genital warts and anal cancer – Males can also carry and transmit HPV to their partners. – • Screening for cervical cancer should continue in both vaccinated and unvaccinated women. HOW HPV CAUSES CELL DAMAGE MOST COMMON HPV INFECTIONS IN US HPV VARIANTS IN VIETNAM Can the HPV vaccine be used in Vietnam as a primary prevention of cervical cancer? A 2013 study report of 4500 married women in 5 major cities in Vietnam looked at the HPV infection prevalence and if the HPV vaccine could be used to immunize the population to prevent cervical cancer These woman were selected randomly and interviewed and then underwent a gynecological examination. HPV VARIANTS IN VIETNAM The study found that only 3.1% to 7.4% were infected with the HPV 16 and/or 18. The other 24.5% to 56.8% were infected with other HPV infections that can also lead to cervical cancers. They were 58, 52, 35, and 45. Today, there are no vaccine to prevent all of these. A new agent hit the market December 2014. Which infections does it cover? VACCINE OPTIONS FOR HPV LIVER CANCER Majority of liver cancer world wide is secondary to Hepatitis B Virus infection. (up to 80% worldwide) About 5% due to Hepatitis C Primary prevention with immunization has been available for over 30 years globally. HEPATITIS B INFECTION WORLDWIDE DAMAGE CAUSED BY HEPATITIS B HEPATITIS B VACCINE AS PREVENTION STOMACH CANCER The incidence of Gastric Adenocarcinoma in the world is at 1 million people per year with a mortality of 700,000 deaths per year. It is the 4th most common cancer in the world and the 2nd most common cause of death in the world from cancer. Causes are believed to be related to diet, ethnicity and environment. Nearly 80% of the deaths occur in Asia and only 2% in North America. PREVENTION OF GASTRIC CANCER Better diet, better food conservation including refrigeration and smoking cessation can reduce the incidence of gastric cancer. Smoking also contributes to the development of gastric cancer. H PYLORI DAMAGES THE MUCOSAL LAYER CAN LEAD TO CANCER SO CAN YOU IMPACT THE CULTURE OF HOW FOOD IS PREPARED AND PROCESSED? SECONDARY PREVENTION SECONDARY PREVENTION Early Detection, and screening Identify high risk individuals and families Or do a screen and treat approach Breast mammography Colorectal screening using flexible sigmoidoscopy or colonoscopy Endoscopy to screen for Gastric Cancer - this has been tried in Japan, China and S. Korea with a 75% positivity. Not utilized in asymptomatic patients in the US because of less than 10% positivity. RISK FACTORS: LUNG CANCER Smoking Secondhand smoke Genetic factors Radon exposure Asbestos exposure Chemical exposure LUNG CANCER SCREENING In the US the most recent recommendations are to use Low dose Computed Tomography (CT) for early lung cancer screening. The radiation exposure is reduced by 50% They US guidelines have strict criteria for who should be screened using this method. US CANCER SCREENING GUIDELINES What is the cost of this type of early detection and can it be utilized in Vietnam? RISK FACTORS: CERVICAL CANCER Human papillomavirus (HPV) infection Smoking Weakened immune system Having many pregnancies Young age at the time of first full-term pregnancy SECONDARY PREVENTION OF CERVICAL CANCER Studies have demonstrated that screening by visual inspection of the cervix using acetic acid (VIA) is a simple, affordable, and sensitive test that can identify precancerous changes of the cervix so that treatment such as cryotherapy can be provided. White plaque areas are the early changes for cervical cancer that can be detected RISK FACTORS: BREAST CANCER Being female Increasing age Genetic risk factors Family history Personal history of breast cancer Dense breast tissue Benign breast problems such as atypical hyperplasia RISK FACTORS: BREAST CANCER (CONT.) Total number of menstrual periods Not having children or having them later in life Breast radiation (Hodgkin’s lymphoma) Recent use of birth control pills Using hormone therapy after menopause Alcohol Being overweight or obese TEACH SELF EXAM BREAST MAMMOGRAPHY Digital mammography to detect breast cancer RISK STRATIFICATION FOR COLORECTAL CANCER Colon cancer risk is broken into three groups. Average Moderate High Risk stratification guides screening guidelines. RISK FACTORS: COLORECTAL CANCER AVERAGE RISK Increasing age Ethnic background Race Diet Lack of exercise Overweight Smoking Alcohol Diabetes RISK FACTORS: COLORECTAL CANCER MODERATE RISK Personal history of colorectal cancer Personal history of polyps Personal history of bowel disease Family history of colorectal cancer RISK FACTORS: COLORECTAL CANCER HIGH RISK Hereditary nonpolyposis colorectal cancer (also called HNPCC or Lynch syndrome) Familial adenosis polyposis (FAP) Lynch Syndrome is a hereditary disorder caused by a mutation in a mismatch repair gene in which affected individuals have a higher than normal chance of developing colorectal cancer, endometrial cancer, and various other types of aggressive cancers, often at a young age – also called hereditary nonpolyposis colon cancer. (HNPCC) COLONOSCOPY GASTRIC CANCER SCREENING LATE GASTRIC CANCER HOW CAN YOU REDUCE CANCER AS THE CAUSE OF DEATH? Educate yourself Educate your patient Educate your peers Educate your organization Educate your community Educate your government RESEARCH, RESEARCH, RESEARCH!!!!!! REFERENCES American Cancer Society. (2014). Cancer prevention and early detection facts and figures 2014. Atlanta, GA: Author. Retrieved from http://www.cancer.org/acs/groups/content/@epidemiologysur veilance/documents/document/acspc-042924pdf Centers for Disease Control and Prevention. (2012). Cancer control and prevention. Centers for Disease Control and Prevention. Retrieved April 30, 2012, from http://www.cdc.gov/cancer/ Smokefree.gov. (2011, August). Clearing the air: Quit smoking today. NIH Publication No. 11-1647. Retrieved from http://www.smokefree.gov/pubs/Clearing_the_Air_508.pdf REFERENCES American Cancer Society. (2014). Review causes, risk factors, and prevention topics by tumor types. Retrieved from http://www.cancer.org/search/index National Cancer Institute. (2014). Prevention, genetics, causes. Retrieved from http://www.cancer.gov/cancertopics/preventiongenetics-causes Vu, et al. (2013) Prevalence of cervical infection with HPV type 16 and 18 in Vietnam: implications for vaccine campaign. BMC Cancer 13:53. REFERENCES Miller KD and Simon M (2015) Global Perspectives on Cancer, Incidence, Care and Experience.