Transcript Cancer: Basic Facts

Cancer: Basic Facts
Presented By: Nancy Barrett & Krista
Davidson
Objectives
• 1. Describe the basic characteristics of cancer.
• 2. Examine the different types of cancers.
Basic Facts
• What is Cancer?
– Cancer is a group of diseases characterized by uncontrolled growth
and spread of abnormal cells. If the spread is not controlled, it can
result in death.
– Cancer is treated with: surgery, radiation, chemotherapy, hormone
therapy, biological therapy, and targeted therapy.
– All cancers involve the malfunction of genes that control cell
growth and division. Most cancers don’t result from inherited
genes but from damage to genes occurring during one’s life.
Cancer Can be Prevented!
• The American Cancer Society estimated that
in 2011 about 171,600 cancer deaths would
be caused by tobacco use.
• Scientific evidence suggests that about 1 in 3
of the 571,950 cancer deaths expected to
occur in 2011 would be related to physical
inactivity, poor nutrition, or being
overweight/obese and thus could be
prevented.
Cancer Can be Prevented!
• Regular screening exams by a health care
professional can result in the detection and
removal of precancerous growths, as well as
the diagnosis of cancers at an early stage,
when they are most treatable.
Who’s At Risk?
• Anyone can develop cancer.
– Most cases occur in adults who are middle aged or
older.
• Women who have a first degree relative (mother, sister,
daughter…) with a history of breast cancer have about
twice the risk of developing breast cancer, compared to
women who don’t have this family history.
How Many People Have Ever Had Cancer?
• The National Cancer Institute
estimates that approximately 11.4
million Americans with a history of
cancer were alive in January of 2006.
How Many New Cases this Year?
• About 1,596,670 new cancer cases are
expected to be diagnosed in 2011.
Cancer Deaths Expected this Year?
• This year, about 571,950 Americans are
expected to die of cancer, more than 1,500
people per day.
– Cancer is the second most common cause of
death in the US, exceeded only by heart disease.
In the US, cancer accounts for nearly 1 of every 4
deaths.
How Many Will Survive?
• The five year relative survival rate for all
cancers diagnosed between 1999-2005 is 68%,
up from 50% in 1975-1977.
What Does Cancer Cost?
• The National Institute of Health estimates
overall costs of cancer in 2010 at $263.8
billion:$102.8 billion for direct medical costs
(total of all health expenditures); $20.9 billion
for indirect morbidity costs (cost of lost
productivity due to illness); and $140.1 billion
for indirect mortality costs (cost of lost
productivity due to premature death).
What Does Cancer Cost?
• Uninsured patients and those from ethnic
minorities are substantially more likely to be
diagnosed with cancer at a later stage, when
treatment can be more extensive and costly.
Estimated New Cancer Cases for Ohio
in 2011
All Sites
Female
Breast
Uterine
Cervix
Colon &
Rectum
Uterine
Corpus
Leukemia
Lung &
Bronchus
Melanoma
of the skin
NonHodgkin
Lymphoma
Prostate
Urinary
Bladder
65,060
8,970
480
5,850
2,080
1,690
10,060
2,620
2,660
9,190
2,890
Estimated Cancer Deaths for 2011
All Sites
Brain/Nervo
us System
Female
Breast
Colon &
Rectum
Leukemia
Liver
Lung &
Bronchus
NonHodgkin
Lymphoma
Ovary
Pancreas
Prostate
24,900
540
1,730
2,170
910
700
7,210
830
600
1,550
1,260
Cancer Death Rates: Male vs. Female
All Sites
Breast
Colon &
Rectum
Lung &
Bronchus
NonHodgkin
Lymphoma
Pancreas
Prostate
Male
Female
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
249.1
168.3
26.6
23.6
16.8
80.3
45.3
9.6
5.9
12.9
9.6
26.3
Selected Cancers
Breast Cancer
• Breast cancer is the most frequently
diagnosed cancer in women.
• New Cases
– An estimated 230,480 cases of invasive breast
cancer are expected to occur among women in
the US during 2011; about 2,140 new cases are
expected in men.
Breast Cancer
• Breast cancer rates second as a cause of cancer death in
women (after lung cancer).
• Deaths
– An estimated 39,970 breast cancer deaths (39,520 women, 450
men) are expected in 2011.
– Death rates for breast cancer in women have steadily decreased
since 1990, with larger decreases in women younger than 50 (a
decrease of 3.2% per year) than in those 50 and older (2% per
year).
Breast Cancer
• Risk Factors
– Aside from being female, age is the most
important risk factor for breast cancer.
– Potentially modifiable risk factors include: weight
gain after age 18, being overweight or obese (for
postmenopausal breast cancer), use of combined
estrogen and progestin MHT, physical inactivity,
and consumption of one or more alcoholic
beverages per day.
Breast Cancer
• Signs and Symptoms
– The earliest sign of breast cancer is often an
abnormality detected on a mammogram before it
can be felt by the woman or a health care
professional.
– Mammography can detect breast cancer at an
early stage, when treatment is more effective and
a cure is more likely.
Breast Cancer
• Treatments
– Treatment may involve lumpectomy (surgical removal of the tumor
with clear margins) or mastectomy (surgical removal of the breast).
– Removal of some of the axillary (underarms) lymph nodes is usually
also recommended to obtain accurate information on the stage of
the disease.
– Treatment may also involve radiation therapy, chemotherapy
(before or after surgery), hormone therapy (tamoxifen, aromatase
inhibitors), or targeted therapy.
Breast Cancer
• Survival
– The survival rate for women diagnosed with
localized breast cancer (cancer that has not spread
to the lymph nodes or other locations outside the
breast) is 98%.
Colon & Rectum
• New Cases: An estimated 101,340 cases of
colon and 39,870 cases of rectal cancer are
expected to occur in 2011.
• Colorectal cancer is the third most common
cancer in both men and women.
Colon & Rectum
• Deaths: An estimated 49,380 deaths
from colorectal cancer are expected to
occur in 2011, accounting for 9% of all
cancer deaths.
Colon & Rectum
• Risk Factors
– The risk of colorectal cancer increases with age.
– 91% of cases are diagnosed in individuals ages 50
and older.
– Other risk factors include: obesity, physical
inactivity, a diet high in red processed meat, heavy
alcohol consumption, long term smoking, and
possibly inadequate intake of fruits and
vegetables.
Colon & Rectum
• Signs and Symptoms
– Early stage colorectal cancer does not usually have
symptoms; therefore, screening is often necessary
to detect colorectal cancer in early stages.
– Advanced disease may cause rectal bleeding,
blood in the stool, a change in bowel habits, and
cramping pain in the lower abdomen.
Colon & Rectum
• Early Detection
– Beginning at age 50, men and women who are at
average risk for developing colorectal cancer
should begin screening. Screening can result in the
detection and removal of colorectal polyps before
they become cancerous, as well as the detection
of cancer that is at an early stage.
Colon & Rectum
• Treatment
– Surgery is the most common treatment for
colorectal cancer. A permanent colostomy is rarely
needed for colon cancer and is infrequently
required for rectal cancer.
– Chemotherapy alone or in combination with
radiation (for all rectal cancer) is given before or
after surgery to most patients whose cancer has
penetrated the bowel wall deeply or spread to
lymph nodes.
Colon & Rectum
• Treatment
– A chemotherapy combination as FOLFOX (oxaliplatin,
fluorouracil, and leucovorin) is often used to treat
persons with metastatic carcinoma of the colon or
rectum.
– Three targeted monoclonal antibody therapies are
approved by the FDA to treat metastatic colorectal
cancer: bevacizumab (Avastin) blocks the growth of
blood vessels to the tumor, and cetuxmab (Erbitux) and
panitumumab (Vectibix) both block the effects of
hormone-like factors that promote cancer cell growth.
Colon & Rectum
• Survival
– The 1 and 5 year
relative survival for
persons with
colorectal cancer is
83% and 65%,
respectfully.
Leukemia
• New Cases
– Leukemia is diagnosed 10 times more often in
adults than children.
– An estimated 44,600 new cases of leukemia are
expected in 2011.
– In adults, the most common types are acute
myeloid leukemia (AML), and chronic lymphocytic
leukemia (CLL).
Leukemia
• Deaths
– An estimated 21,780 deaths are expected to occur
in 2011.
Leukemia
• Risk Factors
– Exposure to ionized radiation increases risks of several types of
leukemia.
– Leukemia may also occur as a side effect of chemotherapy.
– Family history is one of the most common factors for CLL.
– Cigarette smoking and exposure to certain chemicals such as
benzen (a component in gasoline and cigarette smoke) are risk
factors for myeloid leukemia.
Leukemia
• Signs and Symptoms
– Symptoms may include fatigue, paleness, weight
loss, repeated infections, fever, bruising easily, and
nose bleeds or other hemorrhages.
– Chronic leukemia can progress slowly with few
symptoms and is often diagnosed with routine
blood tests.
Leukemia
• Early Detection
– Leukemia can be difficult to diagnose early
because symptoms often resemble those of other
less serious conditions.
– When a physician does suspect leukemia,
diagnosis can be made using blood tests and a
bone marrow biopsy.
Leukemia
• Treatments
– Chemotherapy is the most effective method of
treating leukemia.
– Imatinib (Gleevec) is a highly specific drug used for
treatment of chronic myleloid (or myelogenous)
leukemia (CML).
Leukemia
• Treatments
– Two related drugs, nilotinib (Tasigna) and dastinib (Sprycel), are
often effective if imatinib stops working.
– Imatinib is also sometimes used to treat ALL.
– Gemtuzumab ozogamicin (Mylotarg) is a targeted drug approved
for treatment in older AML patients whose cancer has relapsed or
who are not able to receive other chemotherapy.
– Under appropriate conditions stem cell transplantation may be
useful in treating certain types of leukemia.
Leukemia
• Survival
– Survival in leukemia varies by type, ranging from a
5 year relative survival of 24% for people with
AML or 80% with CLL.
– In large part due to the discovery of the targeted
cancer drug Gleevec, survival rates for CML, have
more than doubled since 1975-1977, from 24% to
55% today.
Liver
• New Cases
– An estimated 26,190 new cases of liver cancer
(including intrahepatic bile duct) are expected to
occur in the US during 2011.
– Incident rates are highest among Asian
Americans/Pacific Islanders and Hispanic
Americans.
Liver
• Deaths
– An estimated 19,590 liver cancer deaths (6,330 in
women, 13,260 in men) are expected in 2011.
Liver
• Risk Factors
– In the US and other western countries, alcohol
related cirrhosis and possibly non-alcoholic fatty
liver disease associated with obesity accounts for
the majority of liver cancer cases.
– Chronic infections with hepatitis B virus (HBV) and
hepatitis C virus (HCV) are associated with less
than half of liver cancer cases in the US.
Liver
• Signs and Symptoms
– Common symptoms include abdominal pain
and/or swelling, weight loss, weakness, loss of
appetite, jaundice (a yellowish discoloration of the
skin and eyes) and fever.
– Enlargement of the liver is the most common
physical sign occurring in 50-90% of patients.
Liver
• Early Detection
– At present, the best strategy to reduce the burden
of cancer is the adoption of preventative
measures of vaccinations against HBV and the
avoidance of high risk behaviors such as
intravenous drug use and alcohol abuse.
Liver
• Treatment
– The treatment of cirrhosis (a disease state that precedes liver
cancer in the majority of cases) with interferon may reduce the risk
of progression to cancer and is the subject of ongoing research.
– Early stage liver cancer in patients with sufficient liver tissue can
sometimes be successfully treated with surgery or, less often, liver
transplantation.
– Sorafenib (Nexavar) is a drug approved for the treatment of HCC in
patients who are not candidates for surgury.
Liver
• Survival
– The 5 year relative survival rate for patients with
liver cancer is 14%.
– 5 year survival is 26% among patients in whom
cancer is found at an early stage, compared to
only 3% when it’s found after spreading to distant
organs.
Lung & Bronchus
• New Cases
– An estimated 221,130 new cases of lung cancer
are expected in 2011, accounting for about 14% of
cancer diagnoses.
– Lung cancer is classified clinically as small cell
(14%) or non-small cell (85%) for the purpose of
treatment.
Lung & Bronchus
• Deaths
– Lung cancer accounts for more deaths than any
other cancer in both men and women.
– An estimated 156,940 deaths, accounting for
about 27% of all cancer deaths, are expected to
occur in 2011.
Lung & Bronchus
• Risk Factors
– Cigarette smoking is by far the most important
factor for lung cancer.
– Other factors include: occupational or
environmental exposure to second hand smoke,
radon, asbestos (particularly among smokers),
certain metals (chromium, cadmium, arsenic),
some organic chemicals, radiation, air pollution,
and a history of tuberculosis.
Lung & Bronchus
• Signs and Symptoms
– Symptoms may include persistent cough, sputum
streaked with blood, chest pain, blood, voice
change, and recurrent pneumonia or bronchitis.
Lung & Bronchus
• Early Detection
– Screening for early lung cancer detection has not
yet been proven to reduce mortality.
– The National Lung Screening Trial is a clinical trial
to assess whether screening individuals at high
risk for lung cancer with spiral CT or standard
chest x-ray can prevent cancer deaths.
Lung & Bronchus
• Treatment
– Treatment options are determined by the type
(small cell or non-small cell) and stage of cancer
and include: surgery, radiation therapy,
chemotherapy, and targeted therapies such as
bevacizumab (Avastin) and erlotinib (Tarceva).
– For localized cancers, surgery is usually the
treatment of choice.
Lung & Bronchus
• Treatment
– Because the disease has usually spread by the time it has been
discovered, radiation therapy and chemotherapy are often used,
sometimes in combination with surgery.
– A recent clinical trial showed a survival advantage for advancedstaged non-small cell lung cancer patients when cetuximab
(Erbitux), a monoclonal antibody (was combined with the
traditional chemotherapeutic regimen).
– Chemotherapy alone or combined with radiation is the usual
treatment for small cell lung cancer.
Lung & Bronchus
• Survival
– The 1 year relative survival for lung cancer
increased from 35% in 1975-1979 to 43% in 20032006. However, the 5 year survival rate for all
stages combined is only 16%. The 5 year survival
rate is 53% for cases detected when the disease is
still localized.
Lymphoma
• New Cases
– An estimated 75,190 new cases of lymphoma will
occur in 2011, including 8,830 cases of Hodgkin's
lymphoma and 66,360 cases of non-Hodgkin’s
lymphoma.
Lymphoma
• Deaths
– An estimated 20,620 deaths from lymphoma will occur in 2011
(Hodgkin’s lymphoma 1,300; non-Hodgkin’s lymphoma 19,320).
– Death rates for Hodgkin’s lymphoma have been decreasing in both
men and women for more than three decades, though the
decrease in men has slowed since 2000.
– Death rates for NHL have been decreasing since 1997 by 3% per
year in men and by 3.6% per year in women after increasing for
most of the previous two decades.
Lymphoma
• Risk Factors
– The risks of developing NHL include: age, organ
transplant patients who receive immuno
suppressants to prevent rejection, patients with
autoimmune conditions, patients who have HIV,
human T-cell leukemia virus type 1 (HTLV-1), and
patients with hepatitis C virus (HCV).
Lymphoma
• Risk Factors
– Hodgkin’s lymphoma risks include: patients with Epstein-Barr virus
(EBV), H. pylori infections have increased the risk of gastric
lymphoma.
– Family history of lymphoma and certain common genetic variations
in immune response genes are associated with a modestly
increased risk.
– Occupational exposure to herbicides, chlorinated organic
compounds, and certain other chemicals also increase risk.
Lymphoma
• Signs and Symptoms
– Symptoms may include swollen lymph nodes,
itching, night sweats, fatigue, unexplained weight
loss, and intermittent fever.
Lymphoma
• Treatments
– Hodgkin’s lymphoma is usually treated with
chemotherapy, radiation therapy, bone marrow or
stem cell transplantation, or any combination
thereof, depending on the stage and cell type of
the disease.
– Non-Hodgkin’s lymphoma patients are usually
treated with chemotherapy or radiation.
Lymphoma
• Treatments
– Highly specific monoclonal antibodies, such as
rituximab (Rituxan) and alemtuzumab (Campath),
directed at lymphoma cells are used for initial
treatment and recurrence of some types of NHL,
as are antibodies linked to radioactive atoms, such
as, ibritumomab tiuxetan (Zevalin) and
tositumomab (Bexxar).
Lymphoma
• Survival
– Survival varies widely by cell type and stage of
disease. 1 year relative survival for Hodgkin’s and
non-Hodgkin’s lymphoma is 92% and 80%,
respectively; the 5 year survival is 85% and 67%
respectively.
– Ten years after diagnosis, survival for Hodgkin’s
and non-Hodgkin’s lymphoma declines to 81% and
57%, respectively.
Ovary
• New Cases
– An estimated 21,990 new cases of ovarian cancer
are expected in the US in 2011.
– Ovarian cancer accounts for about 3% of cancer in
women and ranks second to gynecologic cancers,
following cancer of uterine corpus.
Ovary
• Deaths
– An estimated 15,460 deaths are expected in 2011.
Ovarian cancer causes more deaths than any
other cancer in the female reproductive system.
Ovary
• Risk Factors
– The most important risk factor is a strong family
history of breast or ovarian cancer. Women who
have had breast cancer or who have tested
positive for inherited mutations in BRCA 1 or BRCA
2 genes are at increased risk.
Ovary
• Signs and Symptoms
– Early ovarian cancer usually has no obvious
symptoms.
– The most common sign is enlargement of the
abdomen which is caused by the accumulation of
fluid.
– Abnormal vaginal bleeding is rarely a symptom of
ovarian cancer.
Ovary
• Early Detection
– There is currently no sufficiently accurate screening test proven to
be effective in the early detection of ovarian cancer. Pelvic exams
only occasionally detect ovarian cancer, generally when the disease
is advanced.
– However, for women who are at high risk of ovarian cancer and
women who have persistent, unexplained symptoms, the
combination of a thorough pelvic exam, transvaginal ultrasound,
and blood tests for the tumor marker CA125 may be offered.
Ovary
• Early Detection
– For women at average risk, transvaginal
ultrasound and testing for the tumor marker
CA125 may help in diagnosis but are not used for
routine screening.
Ovary
• Treatments
– Treatments includes surgery and usually
chemotherapy. Surgery usually involves removal of
one or both ovaries and fallopian tubes (salpingooophorectomy), and the uterus (hysterectomy).
Ovary
• Survival
– Relative survival varies by age; women younger than 65 are almost
twice as likely to survive 5 years (57%) following diagnosis as
women 65 and older (29%).
– Overall, the 1 and 5 year relative survival of ovarian cancer patients
is 75% and 46%, respectively.
– If diagnosed at the localized stage, the 5 year survival rate is 94%;
however, only 15% of all cases are detected at this stage, usually
during another medical procedure.
Pancreas
• New Cases
– An estimated 44,030 new cases of pancreatic
cancer are expected to occur in the US in 2011.
– Since 1998, incidence rates of pancreatic cancer
have been increasing by 0.8% per year in men and
by 1% per year in women.
Pancreas
• Deaths
– An estimated 37,660 deaths are expected to occur
in 2011. The death rate for pancreatic cancer
increased from 2003-2007 by 0.7% per year in
men and 0.1% per year in women.
Pancreas
• Risk Factors
– Tobacco smoking increases the risk of pancreatic
cancer; incident rates are about twice as high for
cigarette smokers as for nonsmokers.
– Risk also increases with family history of
pancreatic cancer and a personal history of
pancreatitis, diabetes, obesity, and possibly the
use of smokeless tobacco.
Pancreas
• Risk Factors
– Individuals with Lynch syndrome are at increased
risk.
– Though evidence is still accumulating,
consumption of red meat may also increase risk.
Pancreas
• Signs and Symptoms
– Cancer of the pancreas often develops without early symptoms.
– Symptoms may include: weight loss, pain in upper abdomen that
may radiate to the back, and occasionally glucose intolerance (high
blood glucose levels).
– Tumors that develop near the common bile duct may cause a
blockage that leads to jaundice (yellowing of the skin and eyes),
which can sometimes allow the tumor to be diagnosed at an early
stage.
Pancreas
• Early Detection
– At present, there is no method for the early
detection of pancreatic cancer. Though, research
is underway to establish a method of early
detection.
Pancreas
• Treatments
– Less than 20% of all patients are candidates for
surgery.
– Surgery, radiation therapy, and chemotherapy are
treatment options that may extend survival
and/or relieve symptoms in many patients but
seldom produce a cure.
Pancreas
• Treatments
– Clinical trials have shown that for patients who undergo surgery,
adjuvant treatment with the chemotherapeutic drug gemcitabine
lengthens survival.
– Erlotinib (Tarceva) has been approved by the FDA for the treatment
of advanced pancreatic cancer. This targeted anti cancer drug
blocks tumor cell growth and has demonstrated a minimal
improvement in pancreatic cancer survival when used along with
gemcitabine.
Pancreas
• Survival
– For all stages combined, the 1 and 5 year relative
survival rates are 26% and 6%, respectively. Even
for those people diagnosed with local disease, the
5 year survival is only 23%.
– Obesity is associated with lower survival rates
with pancreatic cancer.
Special Section
Prostate Cancer
Prostate
• Excluding skin cancer, prostate cancer is the
most commonly diagnosed cancer among
men in the US and the second most common
cause of cancer death among men. It’s
estimated that about 1 in 6 men in the US will
be diagnosed with prostate cancer during
their life and 1 in 36 will die from the disease.
Prostate
• New Cases
– In 2011, an estimated 240,890 new cases of
prostate cancer will be diagnosed in the US.
Prostate
• Deaths
– Approximately 33,720 men are expected to die of
prostate cancer in 2011.
– Only lung cancer accounts for more cancer deaths
in US men.
Prostate
• Who gets prostate cancer?
– Age: Age is the most important risk factor in
prostate cancer.
– Prostate cancer incident rates increase in men
until about age 70 and decline thereafter.
Prostate
• Who gets prostate cancer?
– Race/Ethnicity: African American men have a higher incidence of
prostate cancer and are more likely to die from the disease than
white men in every age group.
– In 2002-2006, the overall age adjusted incidents rate for white men
was 146.3/100,000 and for African American men was
231.9/100,000. During the same time, the mortality rate for white
men was 23.6/100,000 and for African American men was
56.3/100,000.
Prostate
• Who gets prostate cancer?
– Socioeconomic Position: Prostate cancer death
rates vary by level of education. American Cancer
Society research has found that men with 12+
years of education are at less risk of developing
prostate cancer than those with fewer than 12
years of educational background.
Prostate
• Can prostate cancer be prevented?
– Although many epidemiological studies have been
done to investigate the causes of prostate cancer,
few modifiable risk factors have been identified.
– Studies have investigated the role of family
history, genetic factors, nutrition, dietary
supplements, obesity, physical activity, infection,
medications, and hormonal factors in prostate
cancer risk.
Prostate
• Can prostate cancer be detected early?
– Early prostate cancer usually has no symptoms. With more
advanced disease, individuals may experience weak or interrupted
urine flow, inability to urinate, or difficulty starting or stopping the
urine flow; the need to urinate frequently especially at night; blood
in the urine; or pain or burning with urination.
– Advanced prostate cancer commonly spreads to the bones which
can cause pain in the hips, spine, ribs, and other areas.
Prostate
• Early Detection
– Most prostate cancers are diagnosed before
symptoms develop through PSA screening or a
digital rectal exam (DRE). If it’s suspected, a biopsy
may be performed.
– PSA levels of less than 10 ng/mL, are considered
to be low risk; 10-20 ng/mL, is considered
intermediate risk; and greater than 20 ng/mL is
considered high risk.
Prostate
• What factors influence prostate cancer
survival?
– Prostate cancer survival rates are strongly related
to stage with a 5 year relative survival rate
approaching 100% among patients diagnosed with
localized or regional disease and 31% among men
diagnosed at a distant stage.
Prostate
• Treatments
– The major treatments for clinically localized
prostate cancer are active surveillance, radical
prostatectomy, and radiation therapy with active
surveillance more likely to be recommended for
men of any age with low risk cancer and for those
with less than 10 years of life expectancy.
Prostate
• Prostate Treatment Options
– Active surveillance, radical prostatectomy, brachytherapy,
androgen deprivation therapy (ADT).
– Chemoprevention: Two drugs of interest- finasteride and
dutasterid- reduce the amount of certain male hormones in the
body and are already used to treat symptoms of an enlarged
prostate.
– Reduction by Dutasteride of prostate cancer events (REDUCE)
clinical trial found that men who receive dutasteride had a 23%
lower risk of developing prostate cancer.
Prostate
• Survival
– The National Cancer Institute estimates that
approximately 2.2 million men with a history of
prostate cancer were alive in January of 2006.
References
• All information was provided from the
American Cancer Society’s Cancer Facts and
Figures of 2010 and 2011.
– American Cancer Society. Cancer Facts & Figures
2010. Atlanta: American Cancer Society; 2010.
– American Cancer Society. Cancer Facts & Figures
2011. Atlanta: American Cancer Society; 2011.
Created By Katie Barrett