PREVENTIE SI DEPISTARE IN CANCER

Catedra de oncologie, Facultatea de medicina - UMF Carol Davila 2004-2005

Cancer diseases are major causes of death throughout the world

In Europe: 3 million new cases annualy 2 million deaths annualy 6 million people are currently living with cancer 24-27% of all deaths among man 21-28% of all deaths among women

The most common sites at witch cancer appear

Breast in women Prostate and lung in men Colon and rectum in both sexes Lung cancer kills more people than any other cancer Europe: five-year survival rate of cancer patients: 30% -60%.

The fight against cancer is conducted at two levels:

Against gatting cancer Against dying from cancer

NIVELURILE DE PREVENTIE IN CANCER

Preventia primordiala vizeaza impiedicarea aparitiei si stabilirii unor modele sociale, economice si culturale de viata despre care se stie ca pot contribui la cresterea riscului de boala Preventia primara consta in controlul cauzelor si factorilor de risc (expunerea la carcinogenii cunoscuti ) avand ca scop scaderea incidentei cancerelor Preventia secundara consta in tratamentul starilor precanceroase, identificate prin actiuni de depistare sau prin diagnostic precoce. Preventia tertiara este preventia sechelelor terapeutice, reinsertia sociala si profesionala a bolnavilor tratati.

DEPISTAREA DIAGNOSTIC PRECOCE

Depistarea este descoperirea unui cancer inainte de aparitia semnelor clinice ale bolii. Anticipeaza diagnosticul obisnuit printr-un test care separa persoanele aparent sanatoase de cele care pot suferi de boala.
Diagnosticul precoce este identificarea primelor semne clinice de boala prin autoexamen sau examen medical

PREVENTIA PRIMARA: Recomandarile grupurilor de experti cancerologi

Food, Nutrition and the Prevention of Cancer: A Global Perspective WCRF: The World Cancer Reseaech Fund + AICR: American Institute for Cancer Research

Descurajarea productiei,promovarii si utilizarii tutunului Consum moderat de alcool. Evitarea expunerii excesive la soare. Respectarea masurilor de protectie a muncii in activitatea profesionala. Recomandari legate de dieta si stil de viata: - Alimentatie variata, bazata pe fructe si vegetale, - Mentinerea greutatii normale - Mentinerea activitatii fizice - Regim alimentar anticanceros

Tobacco

Tobacco and cancer

35% of deaths of man and 13% of those of woman aged 35-69 in developed countries. Tobacco use currently accounts for 16% of the annual incidence of all cancer cases and 30% of cancer deaths. In 2020 one in three deaths of adults in the world is expected to be due to smoking. Tobacco smoking has been reported to be causally related to deaths from cancers of the oral cavity, oesophagus, pharinx, larinx, lung, pancreas and bladder

Tobacco and cancer

Cancers that have been associated with both active and passive smoking appear to be those of the lung, liver, cervix, nasal sinus and leukemia. Cancers that are associated with active smoking have not been linked to pasive smoking. Passive smoking has be found to be associated with cancers that are not related to active smoking, including those of the brain, endocrin glands, breast and lymphoma.

FCTC: The WHO Framework Convention on Tobacco Control

May 2003: 192 nations approved the text of the worlds first health treaty. 40 nations have ratified the trety. It formally becomes international low. The treaty will regulate relations only between countries that have ratified it.

Actions undertaken to influence peoples use of tobacco

Legislative actions provide the base upon wich social change can bilt. Public awerness and value influence the process that transforms public health into individual health choices. Programmes are set up for individuals or group of individuals, and their succes is facilitate by legislative base and supportive social values
Failure to give priority to tobacco control limits our capacity to fight cancer.

DIET

Carcinogenes substances in food

Policiclic aromatic hydrocarbons in smoked or burnt food; Aflatoxins in nuts N-Nitroso compounds from nitrites in meat and vegetables Acetaldehyde in alcoholic drinks Acrilamide in fried and baked carbohydrate-rich foods The real burden disease is not due to a single carcinogens but to the western style energy dense diet, low in fruits and vegetables.

The scale of benefit

Cancer is mostly a preventable disease. The chief causes of cancer are use of tobacco and innapropiate diets. Between 30% and 40% of all cases of cancer are preventable by fesible and appropiate diets and by physical activity and maintenance of appropiate body weight. On a global basis and at curent rates, this means that a appropiate diets may prevent 3-4 million cases of cancer every year. Diets containing substantial and varied amounts of vegetables and fruits will prevent 20% or more of all cases of cancer.

The scale of benefit

Keeping alcohol intake within the recommended limits will prevent up to 20% or more of all cases of cancer of the aerodigestive tract, colon and rectum, and breast. Cancer of the stomach is mostly preventable by appropiate diets: cancer of the colon and rectum is mostly preventable by appropiate diets and by maintaining or increasing physical activity and maintaining appropiate body weght A feasible intermediate target for the dietary prevention of cancer is the reduction of global incidence by 10% to 20% within 20-25 years.

Goal- centered approch to diet and cancer reduction

Promoted by American Cancer Society: Consuming a varied diet rich in plant foods ( at least five portions of fruit and vegetables per day); Maintening a healthy weight throughout life ( body mass index of 18.5 25 Kg/m2) Adopting a physicaly active lifestyle ( moderate activity for 30 min or more 5 days a week for adults and 60 min or more 5 days of the week for children and adolescents

Summary of dietary recommandations

Food supply and eating: choose predominatly plantbased diets rich in a variety of vegetables and fruits, pulses ( legumes) and minimaly processed starchy staple food. Maintening body weight: avoid being underweight or owerweight and limit weight gain during adulthood to less than 5 kg. Vegetables and fruits: eat 400-800 grms or five or more portions ( servings) a day of a variety of vegetables and fruits, all year round.

Summary of dietary recommandations

Food supply and eating: choose predominatly plantbased diets rich in a variety of vegetables and fruits, pulses ( legumes) and minimaly processed starchy staple food. Maintening body weight: avoid being underweight or owerweight and limit weight gain during adulthood to less than 5 kg. Vegetables and fruits: eat 400-800 grms or five or more portions ( servings) a day of a variety of vegetables and fruits, all year round.

ALCOHOL

ALCOHOL AND CANCER

The link between alcohol use and cancer of the upper digestive tract ( oaral cavity, pharinx, larinx, oesofagus) is well demonstrated and beyond doubt. There is also evidence of a relationship between alcohol use and liver cancer Links between alcohol ingestion and both breast and rectal cancer seems probable. No convincing evidence for a relationship between alcohol drinking and cancer of the urinary baldder and no links have been shown with cancers of the stomach, pancreas, prostate or kidney.

One unit = 10 g alcohol

Varies by country , consisting of 8, 10 or 12 g. Calculating the alcohol content of a drink: % alcohol by volume (ABV) x specific gravity of alcohol (0.78) = grams of alcohol/ 100 ml. Ex.: 13% ABV red wine x 0.78 = 10,14 g of alcohol per 100 ml glass Calculating the number of 10 g units of alcohol per container: % ABV x volume ( ml) 1000 Ex: for red wine, 13% ABV x 750 ml bottle: 13 x 750 = 9,8 units of alcohol 1000

European Code Against Cancer

If you drink alcohol, wether beer, wine, spirits, moderate your consumption to two drinks per day if you are a men or one drink per day if you are a women.

PHYSICAL ACTIVITY

Stay active
Incorporate physical activity into your everday life wherever possible. Try walking or cicling to work or to the shops rather than taking the bus or the car or simply climb the stairs, when out and about, instead of using the lift. Remember that household chores such as making the bed, cleaning and washing can help towards your daily physical activity goal. Adopting a physicaly active lifestyle ( moderate activity for 30 min or more of 5 days a week for adults and 60 min or more 5 days of the week for children and adolescents

PRINCIPII SI STRATEGII DE DEPISTARE

Ce este depistarea ?
Depistare = screening = triaj Depistarea = identificarea unui cancer inaintea aparitiei semnelor clinice ale bolii Depistarea Diagnostic Diagnosticul = ansamblul de mijloace utilizate n stabilirea etiologiei precise, pornind de la un simptom Tipuri de depistare: Depistare in masa = act de sanatate publica Se aplica populatiei dintr-o anumita arie geografica Scop: mpartirea populatiei n 2 grupe - Grupa cu testul (-) - Grupa cu testul (+): necesitatea altor investigatii pentru afirmarea sau infirmarea dg. de cancer Depistare individuala (oportunista)- orientata de factori de risc - se limiteaza la pacientii care se adreseaza medicului pentru alt motiv, - este recomandata de medicul specialist

Criterii de indeplinit pentru instituirea unui program de depistare: Boala grava dar curabila Prevalenta inalta in stadiu preclinic Istoria naturala a bolii este cunoscuta Perioada de timp indelungata intre primele semne de boala si boala declarata

Testul de diagnostic: - sensibil si specific

- simplu si ieftin - lipsit de risc - sigur (fiabil)

Diagnostic si tratament: - Sa existe tratament eficient, acceptabil si lipsit de riscuri

- Tratamentul precoce trebuie sa fie mai eficient in reducerea mortalitatii sau morbiditatii decat tratamentul inceput dupa manifestarea evidenta a bolii

TESTUL DE TRIAJ - Calitati impuse de OMS

Sensibilitate = numar mic de rezultate fals negative la bolnavi - probabilitatea ca un test sa fie (+) la persoanele bolnave Specificitate = numar mic de rezultate fals pozitive - probabilitatea ca un test sa fie (-) la persoanele care nu sunt bolnave Fiabilitate = rezultate valide; Clasificarea corecta a populatiei investigate n persoane cu/ fr boal Acceptat de populatie, simplu, nedureros Valoare de predictie pozitiva: - probabilitatea ca persoana sa fie bolnava cand testul este pozitiv Valoare de predictie negativa: - probabilitatea ca persoana sa nu fie bolnava cand testul e negativ Randament bun: - Scaderea mortalitatii prin cancerele depistate in grupul populational in care a fost aplicat

PRINCIPALELE MIJLOACE DE DEPISTARE

Clinice: autoexamen ; examenul clinic medical (+ dg.precoce) Ex.: autoexamenul si ex. clinic al sanului, tuseul rectal pentru cancerul de prostata, inspectia leziunilor cutanate Metode radiologice: mamografia Metode endoscopice : eficacitate mare; acceptabilitate mica Metodele biologice - interes public mare; interes medical redus - Markerii biologici nu au nuvele crescute paralel cu stadiul evolutiv al bolii Examenele citologice: - au permis realizarea celui mai fiabil test de depistare: ex.citologic cervico-vaginal n depistarea cancerului de col uterin - citologia exfoliativa c. bronsic, vezical, EVALUAREA (ECONOMICA) A ACTIUNII DE DEPISTARE Dificil de facut un raport cost/ eficienta Mamografia a redus cu 37% mortalitatea prin cancer mamar Citologia cervico-vaginala a redus cu 90% mortalitatea prin cancer de col uterin

ATITUDINI PRACTICE DE PREVENTIE SI DEPISTARE IN PRINCIPALELE LOCALIZARI ALE CANCERELOR

Screening for which cancers?

The effectiveness of screening for cancers of the breast, cervix and colo-rectum is well documented. There is no evidence that population- based screening for cancers of the prostate or head and neck or skin melanoma reduces the number of deaths from cancers at these sites. No evidence that screening for lung cancer is effective; primary prevention ( NO SMOKING) can reduce the incidnce by 90%.

Breast cancer

Breast cancer
There no clear possibility of primary prevention. Screening: Mammograms Clinical breast exams ( breast exams by doctor) Breast self-examination

Breast cancer
There no clear possibility of primary prevention. Screening: Mammograms Clinical breast exams ( breast exams by doctor) Breast self-examination

Breast cancer
Clinical breast exam (breast exams by doctor): - 20- 25% reduction in mortality from breast cancer - is usualy part of the regular medical checkup - is no substitute for regular mammography (over 40) - each womens breasts change because of aging, the menstrual cicle, pregnancy, menopause, or taking birth control pils or other hormones Self-exam: - 10- 15% reduction in mortality from breast cancer - a women should contact her doctor about any unusual changes in her breasts - is no substitute for regular mammography (over 40)

Cervical cancer

Cervical cancer
Cause and primary prevention: - Early sexual activities - Many sexual parteners ( more likely to get a sexuality transmited virus) - Sexually transmitted viruses: (HPV- human papillomaviruses , the genital herpes virus may cause the growth af abnormal cells in the cervix; they act together with other factors) At present: early detection and treatment of precancerous tissue remain the most effective ways of preventing cervical cancer.

Cervical cancer
Papanicolaou test ( Pap smears): - is a simple, painless test to detect abnormal cells in and around the cervix; - a wooden scraper and/or a small brush is used to collect a sample of cells from the cervix and upper vagina; - the cells are placed on a glass slide and send to a medical laboratory to be checked for abnormal changes Sensitivity: 51% Specificity: 98% 90% reduction in mortality from cervical cancer.

The original Papanicolaou classification

Class Description

I II
III

Absence of atypical or abnormal cells Atypical cytology, but no evidence for malignancy
Cytology suggestive of, but not conclusive for, malignancy

IV
V

Cytology strongly suggestive of malignancy

Cytology conclusive for malignancy

From Papanicolaou, 1954

Comparison of different terminologies used for cytologic reporting

Papanicolaou class system
Class I Class II Class III
Mild dysplasia Moderate dysplasia Severe dysplasia

World Health Organization

CIN

Bethesda System
Within normal limits Benign cellular changes ASC

CIN 1 CIN2 CIN 3

Low grade SIL

High-grade SIL

Class IV Class V

Carcinoma in situ
Microinvasive carcinoma Invasive carcinoma

CIN 3 Invasive Invasive carcinoma carcinoma

Abbreviations: CIN, Cervical intraepithelial neoplasia; ASC, Atypical squamous cells; SIL, Squamous intraepithelial lesions From Papanicolau (1954), Riotton et al. (1973), Richart (1968, 1973), Solomon et al (2002)

Cervical cancer
If all women had pelvic exams and Papanicolaou (Pap) tests regulary, most precancerous conditions would be detected and treated before cencer develops; The screening interval should be 3 years; Women should have regular checkups, if they are or have been sexually active Upper limit: preferable not under 60.

Colon and rectal cancer

Faecal occcult blood testing

Well-organised mass screening Every 2 years in asimptomatic people over 50 years of age and without familial risk. Removal of polyps identified at screening prevents colo-rectal cancer

Who is at risc from colorectal cancer ?

The exact causes of colorectal cancer are not yet known. Some groups of people may have an increased risk: 50 + age group People who tend to develop polips Sufferers from ulcerative colitis, in wich the lining of the colon becomes inflamed Those who consume a poor diet, high in fat and meat but low in vegetables and fibre Smokers Those with a family history of colorectal cancer
( particulary those with relatives diagnosed under the age of 45)

To prevent colorectal cancer

Colorectal cancer is the most likely of all cancers to be prevented thruogh a helthy diet and life style. 66%-75% of cases of colorectal cancer could be avoided if we folloowed the tipe of diet and life style recommended.

CANCERUL DE PROSTATA
Incidenta: locul III; Mortalitate: locul III Incidenta in crestere in acord cu cresterea sperantei de viata Preventia primara: necunoscuta Depistarea: Tuseul rectal: depistare individuala - anual la barbati ntre 60-70 ani - poate depista tumori corespunzatoare unui stadiu B de cancer - n caz de suspiciune clinica: dozarea PSA, ecografie transrectala, biopsie prostatica transrectala PSA Antigenul specific prostatic - marker biologic foarte sensibil - nu este specific cancerului de prostata - creste si in hipertrofiile benigne (75%) - nu poate fi utilizat n depistarea n mas Ecografia transrectala: - nu poate fi utilizata ca metoda de depistare n mas - util pentru orientarea punctiei bioptice

CANCERELE CUTANATE
Epitelioamele bazocelulare strict localizate Melanoamele tumora grava , curabilitate mica in std. metastazat

Preventia primara: - evitarea expunerii prelungite la soare, la ore cu nocivitate maxima a radiatilor UV, utilizarea cremelor cu factori de protectie - Examen clinic: recunoasterea leziunilor cutanate cu risc de malignizare Preventia secundara: tratarea leziunilor precanceroase in formele lor incipiente Leziuni nevice preexistente (Melanom) - Semne de malignitate: cresterea in dimensiuni, modificarea culorii, halou inflamator, neregularitati ale marginilor - Biopsia incizionala prohibit!! - Corect: Excizie chirurgical = vindecare 100% din cazurile cu adancimea leziunii < 0,75 mm = vindecare 75% din cazurile cu adancimea de < 2 mm Alunitele risc de malignizare, daca isi modifica caracterele sau sunt in zone expuse traumatismelor mici si repetate