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Module 6 - Cancer as a chronic disease
Terms in this set (28)
What are some smoking trends? Why is it hard to control?
Men smoke more than women
Smoking is more popular in certain countries like Chile, Bolivia and the United States
It is hard to control because of the act of freedom. Constant battle between public health and cigarette companies
What is passive smoke? Why is it public smoking banned now?
Passive smoking is secondhand smoke is released in the air from cigarettes that can be inhaled by people that do not smoke. Smoking indoors including in buildings and in cars if someone is there, is now banned. This is because of the unfair passive smoke that is inhaled by children.
What are the steps to developing COPD?
2. Chronic bronchitis - permanent damage to lungs
3. Emphysema (alveolar tissue is destroyed)
4. Chronic Hypoxemia - damages heart
5. Cor pulmonale
Active smoking in 80-90% of individuals with COPD
50% of smokers have sub-clinical COPD
Based on spirometry, what you should your forced expiratory volume be?
Normal FEV1, your expiratory volume should be 4L
Explain how lung cancer can go undetected?
There are masses in the lung, and primary lung cancer starts as one mass
If you do not do an X-ray, you will be asymptomatic
Most of the lungs are in tact, its just the one mass, and that is why you wouldn't know, for a while
The only sign that most people see is when they cough blood, and that is because the cancer is highly vascularized (hemoptysis)
What are some physical things that would occur in someone with lung cancer?
Weight loss is something that occurs with cancer, it is called cachexia
There are no pain receptors in the lungs, and cancer of the lungs causes inflammation but people do not feel it
Cancer can also cause immunosuppression as well as the treatment
What are some ways to diagnose lung cancer? What is the treatment?
Chest x-ray, CT scan, sputum cytology, bronchoscopy, CT guided fine needle aspiration
Treatment: Stage I lung cancer treated with lobectomy & follow-up chemotherapy
What is the global epidemiology of cervical cancer?
Nearly 500,000 women diagnosed as new cases every year
About 270,000 women die from cervical cancer each year
Globally, 80 to 85% of deaths occur in low-income or middle-income countries
Where does cervical cancer occur most?
Public Health: looking at the epidemiology of cancer, cervical cancer is highly prevalent in certain countries and barely exists in others
It occurs in low to middle-income countries because a country needs to have money to afford the treatments and the Public Health in order to create a prevention strategy
What is the incidence and mortality rate of cervical cancer in Canada?
550 women per year
175 women per year
Where does cervical cancer start? Where does a pap smear look for cancer cells?
It occurs in when the exo and the endo cervix meets
In the histology photo the exo is the stratified squamous portion on the right and the endo is the epithelium on the left
If you do a pap smear, you have to look for the transformation zone
What are the warning signs of cervical cancer? What are the risk factors?
Most common type is squamous cell carcinoma
Human papilloma virus (types 16 & 18) - Koilocytes (causes dysplasia)
Early age at first intercourse
Multiple sexual partners
History of STDs
What did George N. Papanicolaou propose?
Believed that we needed a cheap method of screening
Came up with us swabbing the cervix to determine cervical cancer
An "Adequate Specimen"
Squamous-Columnar Transition Endocervix Exocervix
Haematoxylin - nuclear stain Orange G - keratin stain Eosin Azure - cytoplasmic stains
What is the difference in HPV strains?
The premise is that we know how HPV causes cancer
It takes 10-30 years for it to turn into cancer
Global health differences - have to look for certain journals
The patterns of HPV are different
HPV-45 was much more prevalent in Sub-Saharan Africa
Same cancer comparing from new England and somewhere in Africa? But the genomics of the cancer were completely different
What is the leading cause of death in Canada?
Cancer is the leading cause of death in Canada
In 1994, cardiovascular disease was the leading cause of death and that was the case for a long time, but with the emphasis of health, fitness and diet, this has decreased and cancer has becoming the leading cause of death and it may be like this for a while
What are the important stats about cancer in Canada?
196,900 Canadians will be diagnosed with cancer in a year, that is 540 a day. 78,000 Canadians will die of cancer in a year, and that is 214 a day.
It changes the way that we think, it changes health care priorities and our families and how we think about them and vice versa
Incidence is always higher than mortality but as incidence gets higher, mortality will also increase
What is the difference between acute and chronic cancer?
Cancer can be acute or chronic depending on the type , cancer has a common denominator for many diseases
Pancreatic cancer is a very acute disease the survival rate is low
The reason for that is that it gets diagnosed very late in its stages and because of the function of the pancreas, it produces very few symptoms
The same as liver, esophageal and lung cancer, the survival is very small
But at the top you can see cancers like thyroid or prostate have a very high survival rate and people can live very long with it for many years, and you can understand the chronicity of it
This data is independent of treatment, and have been treated
What is the difference between men and women when it comes to cancer?
When looking at longitudinal data, cancer mortality overall has been decreasing , and you can see the trends
The three common cancers in men, lung colorectal and prostate, you can see between 1986 and now there is a decrease in mortality
Diagnosis has improved as well as treatment
In women, you can see that with breast and colorectal cancer, the mortality rate has also decreased but that is not the case for lung cancer
More women are dying of lung cancer and this is because men started smoking a lot sooner before women, men started smoking in the 60s or 70s and because it takes decades to develop lung cancer, it peaked a few decades later, but for women it hasn't peaked yet but is projected to peak in the next decade or so and the mortality rate will hopefully start to go down
When was the first successful decrease in cancer mortality?
Cancer treatments did not exist before 1948, so anyone who had a cancer diagnosis before then would just have to let the cancer advance
There was surgery but of course surgery is not enough
We are a good place with cancer with all this advancement
This paper was the first public success in 1948, published by a Boston paper that showed that there was a drug used for anemia that could actually slow down leukemia in children and if you look at the graph on the right hand side and it shows the five year survival rate for people with leukemias
You can see how dramatic the change has been, in the 1950s you can see it was very low, and then as new treatments were developed by the 1990s, the survival rate was a lot higher
Explain the timelines of cancer
For us to develop cancer, if we have a genetic disease, then there is a genetic alteration that develop at any time and if there is something to promote that alteration then the cancer can develop very fast
But if it is caused by an environmental agent then it can take decades for the cancer to develop
So the first step to cancer is initiation can occur 10 years before the person develops cancer , so there is a huge latency period between the exposure to carcinogens and the development of cancer
Once the person has cancer, it can take years for the cancer to spread and develop metastases
So it can be seen as a chronic disease, and it does not start at diagnosis but at tumor initiation which you can see at the beginning of the slide
Explain dormancy in cancer
When we get diagnosed, we see a tumor mass, we get treated and the treatment gets rid of the tumor mass
But this is not a cure, but this is called remission because we know that sometimes the cells may not be completely gone
There is something called micro-metastases which is when some of the cancer cells break away from the original tumor and spread through the bloodstream
Clinically, if they do not see a tumor then we can say that the patient is remission, but the patient must be monitored very closely so that the person stays in the remission phase forever
Something called recurrence which is demonstrated by the red lines,
If you have cancer and you go into remission that is great, but we know that is likely that there may be some cancer cells that will remain dormant - so it will go to another organ, fall asleep and stay dormant for a long time
We want to keep these cancer cells asleep and hope that they do not awake again and form metastases because this is called recurrence
What is the clinical evolution of cancer?
If you look at the top, you see that there is a tumor burden that increases until it reaches initial diagnosis, and then there is a therapy or management
If the therapy helps to reduce the rumor burden then this is called a response, if it maintains it, then we call this a stable disease but if it does not lessen or maintain the tumor burden then it is called progression
If the tumor burden responds to the treatment and goes down then we must wait for the threshold for diagnosis of recurrence which hopefully does not happen
In the lower part of the diagram, we see the interventions that we can do, which are important for prevention
For example we do risk assessment to prevent cancer from occurring in the first place and we do periodic screenings for early detection
Once it is detected, we classify, stage and grade which helps with prognosis and treatment
And then there is monitoring for recurrence for early intervention
How does cancer start?
We get exposed to carcinogens which is the first hit or initiation and then there is
We want the carcinogen to kill the cell, but for carcinogenesis to occur, the carcinogen has to damage the cell and the cell survives the sublethal damage and this creates an initiated cell
And then the cell can get promoted which is the second hit and this promotes the growth of the initiated cell and that's when things can go wrong
The cell is already genomically unstable, but when is promoted, the genomic instability is passed on
This diagram is important because it shows you initiation and promotion of cancer which is important but it also shows you the two hits because just being exposed to a carcinogen is not sufficient
It needs to cause enough damage to a cell to create an initiated cell and something must promote it to grow
For example, you can eat a lot of processed foods which will cause initiation in a liver cell but you need something to promote the growth of this initiated cell which could be hepatitis
What is a carcinogen?
Any substance that induces cancer in animals
Carcinogens in general attack the DNA and it acts as a mutagen
It can cause a mutation as it damages the cell DNA and causes mutagenesis
Many carcinogens are mutagens
Ionizing radiation, tobacco, asbestos etc are carcinogens
What are the IARC classifications of carcinogens?
The agent is carcinogenic to humans.
E.g. Asbestos, Solar radiation, tobacco
The agent is probably carcinogenic to humans.
E.g. Chemotherapy drugs, Diesel engine exhaust, PCBs
The agent is possibly carcinogenic to humans.
E.g. Lead, Mercury, Gasoline engine exhaust
The agent is not classifiable as to its carcinogenicity to humans.
The agent is probably not carcinogenic to humans.
What are some examples of carcinogens?
Hepatitis B virus
Which environmental factors alter the risk of developing cancer?
Environmental tobacco smoke
Explain prevention as it applies to cancer
Primordial prevention is looking at creating economic, environmental and social conditions that are conducive to health and that minimize the likelihood of developing a disease - socioeconomic and environmental factors contributing to cancer?
Primary prevention is addressing specific causal factors - Can human exposure to carcinogens be eliminated or minimized?
Secondary prevention is targeting people with the disease which is established at an early stage in order to limit or exacerbate the disease - can we diagnose human cancer at its earliest stages
Tertiary prevention is concerned with patients with well-established diseases and its aim to to minimize suffering and complications - can oncologists decrease mortality rate?
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