Transcript Cancer control and prevention

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
1112.
–
–
•
May be given to females as young as age 9
Is also recommended for females aged 1318 to catch up on
missed vaccine or to complete the vaccination series
HPV vaccination is recommended for males aged 926.
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.