Cancer

Group 6

III-1

REPORT OBJECTIVES To briefly introduce cancer as one of the killer diseases in the Philippines To identify the most common cancer sites in Filipinos To present the cancer sites with the most new cases and the most deaths in the Philippines, based on GLOBOCAN data To identify measures taken by the DOH for prevention, early detection, and treatment of different cancers in the Philippines To identify risk factors, warning signs, and available detection and treatment options for particular cancers INTRODUCTION The most essential information necessary to win a successful war against cancer are INCIDENCE, MORTALITY and SURVIVAL Incidence indicates success of prevention Survival indicates curability of some cancers, and health system performance in early diagnosis and proper treatment Mortality sum effect of incidence and survival Best information population-based data Hospital-based data should be used with caution Data Sources in the Philippines 1. Philippine Cancer Society Manila Cancer Registry (PCS-MCR) 2. Department of Health Rizal Cancer Registry (DOH-RCR) Data from these two registries have been published by the International Agency for Research on Cancer (IARC) and by the PCS

Usual non-genetic/epigenetic factors implicated include: Cigarette smoking Obesity Unhealthy diet Hormones Alcohol drinking Viruses Physical inactivity Ionizing Radiation Cancer is NOT inevitable for people who are genetically predisposed to develop it if they develop a healthy lifestyle and avoid carcinogenic substances. Cancer risk increases with age

Table 1. Estimated New Cancer Cases in 2002 By Age-Groups, All Sites, Philippines (GLOBOCAN 2002) AGE GROUP MALES FEMALES Rate per No. of Rate per 100,000 Cases 100,000 0-14 12.8 1,884 10.4 15-44 34.7 6,486 62.6 45-54 222.2 6,734 352.4 55-64 605.1 11,006 590.3 65+ 1,415.0 17,962 937.1 All Ages 112.0 44,072 129.0 Table 2. Estimated New Cancer Deaths in 2002 By Age-Groups, All Sites, Philippines (GLOBOCAN 2002) AGE MALES FEMALES GROUP Rate per No. of Rate per 100,000 Cancer 100,000 0-14 8.7 1,277 6.9 15-44 23.2 4,343 36.8 45-54 176.0 5,333 215.1 55-64 475.0 8,639 404.4 65+ 1,155.0 14,660 710.1 All Ages 87.0 34,252 86.0

No. of Cases 1,454 11,465 10,844 11,246 15,047 50,056

Philippine Cancer Facts and Estimates Series The calculation of national cancer incidence and mortality estimates for the years 1988, 1993 and 1998 were done by the authors. IARC helps to develop and sustain population-based cancer registries worldwide GLOBOCAN has greatly facilitated national estimation of cancer incidence every 5 years and comparisons between countries 2005 Incidence and Mortality Estimates derived from GLOBOCAN 2000 data on Cancer Incidence, Mortality and Prevalence Worldwide V. 1.00; produced by Descriptive Epid Group of IARC (data is OVERESTIMATED) 2010 Incidence and Mortality Estimates based on GLOBOCAN 2008 data closer to real situation d/t age-standardized incidence and mortality rates, as well as cumulative incidence and cumulative mortality rates in 2008 for the Philippines and selected countries. CANCER: BASIC DATA Malignant neoplasm Third leading cause of morbidity and mortality in the Philippines Caused by genetic mutations, leading to disruption of normal arrest of multiplication of non-functional or dysfunctional cells Carcinogens cause these mutations.

No. of Cases 963 6,740 6,620 7,705 11,402 33,430

According to rates in 2008: 13/100 males and 12/100 females will have had some type of cancer by age 75 10/100 males and 7/100 females will have died of cancer before 75 PREVENTION At least 1/3 of all cancers are preventable From childhood, a HEALTHY LIFESTYLE must be the rule Healthy Diet High carb, low fat, starch-rich, substantial intake of fruits and vegetables Physical Fitness lifelong active lifestyle Support family and community to help cope with stress

THE CURRENT SITUATION PREVENTION Smoking Decreased prevalence 1989 2003-2004 Males 64% 56% Females 19% 12% Large need for strong and sustained ban on tobacco advertising and sponsorship, prohibition of sales to minors, and prevention of 2nd hand smoke exposure Fruit and Vegetable Consumption Decline, with concomitant increase in overweight/obesity from 24% (2003) to 26.6% (2008) 7th National Nutrition and Health Survey Resultant increase in hypertension in adults 22% (1993) to 25.3% (2008) Resultant increase in FBS 3.9% (1998) to 4.8% (2008) Physical Activity In Luzon, 57% of adults aged 20-65 years old had SOME form of physical activity Alcohol Consumption Regular drinking (>4d/wk) 13% of males, 6% of females More than 50% increase of per capita alcohol consumption from 1970 until 1996 HBV Vaccines Available since 1984 Included in DOH EPI in 1992, but with insufficient funding Widely promoted and accepted since 1992 for those who can afford it Safe(r) Sex Condom use widely advocated by previous DOH Sec d/t increased HIV-AIDS incidence Opposed by Catholic Church In order to promote health and prevent cancer, and other major diseases successfully, and INTEGRATED and COMPREHENSIVE effort that is doable and sustainable must be undertaken simultaneously by all sectors of the society

Philippine drug regulation is NOT IN KEEPING with the principle of BALANCE that the WHO and International Narcotics Control Board have been advocating globally. Comprehensive Dangerous Drugs Act of 2002 - the government shall however claim to achieve a balance in the national drug control program so that the people with legitimate medical needs are not prevented from being treated with adequate amounts of appropriate medications, which include the use of dangerous drugs The Dangerous Drugs Board (DDB) shall develop and adopt a comprehensive, integrated, unified, and balanced national drug abuse prevention and control strategy. shall also establish a regular and continuing consultation with concerned government agencies and medical professional organizations if balance exists in policies, procedures, rules and regulations on dangerous drugs and to provide recommendation on how the lawful use of dangerous drugs can be improved and facilitated. THE DOH INITIATIVE CARE REGISTRATION PCS-MCR as the lead partner organization for population-based cancer registration Cancer incidence, mortality and survival data will be the basis for formulating, implementing, monitoring, and assessment of cancer control programs Linkage with NSO (death certificates for cancer survival info) Financial assistance for PCS-MCR Active relations with existing and potential benefactors of other cancer registries HEALTHY LIFESTYLE Strengthen the Integrated Program for Non-Communicable Diseases Focus on a. Avoidance of cigarette smoking and exposure to 2nd hand smoke b. Healthy diet and avoidance of obesity (huhuhu) c. Increased physical activity, and d. Avoidance of excessive alcohol consumption ACUTE LYMPHOCYTIC LEUKEMIA IN CHILDREN ALL is the most common cancer in children and is highly curable Continue and improve systems and methods of medicine access program for children with ALL From 2009 program has benefited around 300 children in 14 government hospitals PILOT PROJECT OF INTEGRATED BREAST CANCER DETECTION AND TREATMENT IN METRO MANILA Medicines access program extended for breast cancer Patient Navigation System assistance for patients to surpass socioeconomic obstacles which hinder early detection and treatment TOP 10 CANCER SITES IN THE PHILIPPINES

1.

2.

3.

EARLY DETECTION AND TREATMENT Majority of cancers (breast, cervix, colorectal) are not diagnosed early despite nearly two decades-worth of Awareness Campaigns Need for a more Filipino-tailored approach, since methods used are similar to those for high-income countries MYTH Most Filipinos lack awareness that certain common cancers are curable when detected and treated early. FACT Majority have no choice d/t socio-economic realities PALLIATIVE CARE 1991 Philippine Cancer Society, Incorporated started the Patient Outreach Services 35 registered facilities (18 outside Metro Manila), according to 2007 Directory of the Asia Hospice Palliative Care Network Excessive regulation of prescription of morphine and other strong opioids is the MAJOR BARRIER to effective treatment of pain (caused by cancer, post-surgical, or other painful conditions)

4.

Top 10 Sites of Cancer in BOTH MEN AND WOMEN in 2010 (GLOBOCAN 2008) New Cases Deaths 1. Breast (15%) 1. Lung (18%) 2. Lung (14%) 2. Liver (13%) 3. Liver (9%) 3. Colon/Rectum (8%)

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4. 5. 6. 7. 8. 9. 10.

Colon/Rectum (7%) Cervix Uteri (6%) Leukemia (4%) Stomach (4%) Prostate (3%) Brain/Nervous System (3%) Ovary (3%)

4. 5. 6. 7. 8. 9.

Prostate (6%) Stomach (5%) Leukemia (4%) Brain/Nervous System (4%) Other Pharynx (4%) Non-Hodgkins Lymphoma (3%) 10. Kidney (3%)

Top 10 Sites of Cancer in MEN in 2010 (GLOBOCAN 2008) New Cases Deaths 1. Lung (22%) 1. Lung (25%) 2. Liver (15%) 2. Liver (18%) 3. Colon/Rectum (8%) 3. Colon/Rectum (6%) 4. Prostate (7%) 4. Prostate (5%) 5. Stomach (5%) 5. Leukemia (5%) 6. Leukemia (4%) 6. Stomach (5%) 7. Brain/Nervous System (3%) 7. Brain/Nervous System (4%) 8. Other Pharynx (3%) 8. Other Pharynx (3%) 9. Non-Hodgkins Lymphoma 9. Pancreas (2%) (3%) 10. Non-Hodgkins Lymphoma 10. Kidney (2%) (2%) Top 10 Sites of Cancer in WOMEN in 2010 (GLOBOCAN 2008) New Cases Deaths 1. Breast (28%) 1. Breast (18%) 2. Cervix uteri (11%) 2. Lung (9%) 3. Lung (6%) 3. Cervix uteri (8%) 4. Colon/Rectum (6%) 4. Liver (7%) 5. Ovary (5%) 5. Colon/Rectum (6%) 6. Liver (4%) 6. Leukemia (5%) 7. Corpus Uteri (4%) 7. Ovary (4%) 8. Leukemia (3%) 8. Stomach (4%) 9. Thyroid (3%) 9. Corpus uteri (3%) 10. Stomach (3%) 10. Brain/Nervous System (3%) Figures 1, 2 and 3 compare the frequency of new cases to deaths per cancer site, as projected for 2010 from the 2008 data. Cancers with high incidence but low mortality indicate that these cancers have EFFECTIVE EARLY DETECTION AND TREATMENT strategies.

THYROID CANCER INCIDENCE AND MORTALITY 11th most common cancer in 2010 (2%) 17th most common in men (1%), 9th in women (3%) For most women It is the most common cancer in the 15-24 age group Incidence starts to rise at age 30 In men, incidence increases at age 60 Estimated age-standardized national incidence was 5.7 per 100,000 Estimated national standardized mortality rate in 2008 was 2.8 per 100,000 More than 90% are well-differentiated, indicating good prognosis following treatment 5-years survival rate of Metro Manila residents (82%) was lower than Fil-Caucasians (91.3%) and Caucasians (92%) RISK FACTORS History of neck irradiation during childhood Filipino females residing in the Philippines Females of Filipino descent from Hawaii or the US West Coast History of iodine deficiency and goiter WARNING SIGNALS Hard anterior neck mass Thyroid nodules in men Rapid enlargement of longstanding goiter in older patients Enlarged neck nodes Hoarseness, dysphagia, dyspnea associated with goiter EARLY DETECTION FNAB of thyroid nodule is recommended in the following Nodule of hard consistency Solitary nodule with non-enlarged thyroid

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Rapidly growing nodule in benign multinodular goiter

TREATMENT 90% are well-differentiated and highly curable with surgical resection Radioactive iodine is the main treatment for metastasis to other organs Advanced cancer: PALLIATION (ganito din sa advanced cases ng lahat ng ibang cancer) ORAL CAVITY CANCER INCIDENCE, MORTALITY AND SURVIVAL In 2010 Cancer of the mouth will be the 15th most common site in both sexes (2%) NHL will be 11th among the men (2%) NHL will be 15th among the women (1%) Estimated 1,427 new cases in both sexes, 833 cases in men and 594 in women Cancer can occur in any part of the oral cavity There will be 912 deaths in both sexes, 509 among males and 403 in females Incidence Rate Rise steeply starting at age 55 in males and 60 among females Declining incidence rates have been observed in both sexes from 1998-2002, with an annual decline of -3.3% in males and 4.1% in females In 2008: Estimated age-standardized national incidence rate were 2.1 per 100,000 in both sexes, 2.6 among males and 1.7 among females. Less than one (0.3) out of 100 men and less than one (0.2) out of 100 women would have a likelihood of getting oral cavity before age 75 Less than one (0.2) out of 100 men and less than one (0.1) out of 100 women would have died from NHL before age 75 Estimated national mortality rates were 1.4 per 100,000 in both sexes, 1.7 among males and 1.2 among females In Philippines, median survival was reported to be 19 months, survival rate was 27% at 5 years and 17% at 10 years.

Surgery most accessible curative treatment Small lesion: radiotherapy Advanced cases can benefit from judicious and cost-effective palliative care

NASOPHARYNGEAL CANCER INCIDENCE AND MORTALITY Year 2008 estimated agestandardized national incidence rates estimated standardized rates national mortality in both sexes 1.2 per 100,000 0.9 per 100,000 among males 1.7per 100,000 1.2 per 100,000 < 0.2 out of 100 among females 0.7 per 100,000 0.5 per 100,000 < 0.1 out of 100

would have had a likelihood of getting pancreas cancer before the age 75 would have died from pancreas cancer before the age 75 Year 2010 rank as leading site for cancer estimated new cases deaths

< 0.1 out of 100

< 0.1 out of 100

in both sexes 18th (1%) 919 612

among males 13th (2%) 638 428

among females 18th (0.7%) 281 184

RISK FACTORS AND PREVENTION Highly preventable Cigarette smoking Betel buyo nut chewing Chewing tobacco Excessive alcohol consumption Inverted cigarette smoking Diet lack of fruits and vegetables WARNING SIGNALS Sore that does not heal or bleeds easily Lump or thickening Reddish or whitish patch that persists Difficulty in chewing, swallowing or moving tongue and jaw late manifestations EARLY DETECTION Annual oral examination starting at age 50 TREATMENT Early cancer of oral cavity is curable

* Incidence rate starts rising steeply at age 45 among males and age 50 among females. RISK FACTORS Heredity Unique ethnic lifestyles Highest incidence observed in residents from South China Cause still unclear Previous infection with EBV has also been implicated WARNING SIGNALS Bloody nasal or postnasal discharge Nasal obstruction Ear pain Fullness of the ear Unilateral recurrent otitis media First presentation: enlarged lymph nodes at the upper part of the neck below the ear More advanced: neurological or ocular manifestations (headache, bulging of one eye, double vision, hoarseness or difficulty of swallowing)

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EARLY DETECTION: No efficient screening method Earlier diagnosis and appropriate treatment of symptomatic cases must be the goal Middle-aged persons with the aforementioned complains should undergo nasopharyngoscopy and biopsy of suspicious areas TREATMENT Principal treatment radiotherapy Advanced stage - judicious and cost-effective palliative care LARYNGEAL CANCER INCIDENCE, MORTALITY AND SURVIVAL Year 2008 estimated agestandardized national incidence rates estimated standardized rates national mortality in both sexes 1.2 per 100,000 0.8 per 100,000 among males 1.9 per 100,000 1.3 per 100,000 < 0.2 out of 100 among females 0.6 per 100,000 0.4 per 100,000 < 0.1 out of 100

Early stage curable small lesions: radiotherapy, voice can be preserved large lesions: surgery, voice is lost Advanced stage - judicious and cost-effective palliative care

would have had a likelihood of getting pancreas cancer before the age 75 would have died from pancreas cancer before the age 75

BREAST CANCER INCIDENCE, MORTALITY AND SURVIVAL Leading cancer site Number one cause for morbidity and mortality among Filipino women (30% of all Filipino malignancies) 3 of 100 Filipinas will develop breast cancer in their lifetime 1 of 100 Filipinas will die of breast cancer before age 75 Survival rate in the Philippines 40% (vs in developed countries 8090%) Projected increase smoking, unhealthy lifestyle, decreased fertility DOH and PCSI aim to promote early breast cancer screening particularly among poor women by providing assurance to medicines, as well as other forms of support Advocacy Breast cancer is a curable disease when detected, treated and managed early Patient Navigation Program for breast cancer shall be implemented in four government hospitals covering the catchment areas of the Metro Manila Cancer Registry and the Rizal Cancer Center (Main sources of data) Government Hospital Partners East Avenue Medical Center (EAMC) Jose Reyes Memorial Medical Center (JRMMC) Philippine General Hospital (PGH) Rizal Medical Center (RMC) RISK FACTORS Most risk factors are associated with increased exposure to estrogen Alcohol Benign proliferative breast disease BRCA genes Cigarette smoking Contraceptive steroids Early menarche Female sex High socio-economic group Higher education Hormone-replacement therapy Increasing age Induced abortion Childbirth over 30 y/o Late menopause Nulliparity Premature birth before 32 weeks Postmenopausal obesity Radiation Second trimester miscarriage Factors that decrease risk include: Breast feeding Cruciferous vegetables (i.e. broccoli) Early menopause Exercise Having kids Late menarche

< 0.2 out of 100

< 0.04 out of 100

Year 2010 rank as leading site for cancer estimated new cases deaths

in both sexes 21st (1%) 786 504

among males 14th (1%) 577 385

among females 21st (0.5%) 209 119

*Incidence rate starts rising steeply at age 50 among males and age 70 among females. RISK FACTOR Cigarette smoking WARNING SIGNALS hoarseness initial presentation: enlarged lymph nodes in the lower part of the neck advanced stage: difficulty in swallowing or even breathing problems EARLY DETECTION direct laryngoscopy and biopsy of suspicious areas TREATMENT

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Omega-3 fatty acids Oophorectomy Soy isoflavones

WARNING SIGNALS Lump or thickening in the breast (esp if 30 y/o) Change in size/shape of breasts Discharge from or inversion of nipple Change in color/texture of skin in the breast/nipple area Depression on breast surface EARLY DETECTION Monthly breast self-exam (BSE) and annual health worker breast exam should be habitual by age 30 All suspicious masses biopsied (FNAB) Core needle biopsy when hormone receptor assay is available Mammography Major reason for late diagnosis of many breast cancers in the Philippines is not lack of awareness, but inability of patients to afford direct and indirect costs of diagnosis and treatment Efforts should be directed at the local level (community-based monitoring) PREVENTION Breast Cancer Control Program (BCCP) Implementation of a nationwide anti-breast cancer scheme Public information and health education Case-finding and treatment incorporated into community health structure and equipped to control breast cancer in a systematic sustained manner TREATMENT Early breast cancer primary lesion is in the breast; spread in axillary LNs can be completely removed by surgery; no indication of spread in other areas Usual curative operation modified radical mastectomy Small lesions removal of lesion and affected axillary LNs, with breast radiotherapy Community-based programs on early detection and treatment should be primarily concerned with getting women with breast cancer to undergo mastectomy as early as possible Program planning should have mastectomy as the primary endpoint Spread to axillary LNs is the most important prognostic factor Tumors hormone receptor status (via estrogen receptor assay or progesterone receptor assay) is the most important information to consider in deciding what kind of adjuvant treatment is most appropriate HR (+) adjuvant hormonal therapy HR (-) adjuvant chemotherapy Mammography for women at least 50 y/o Annual clinical breast examination Monthly BSE Reduction of breast cancer mortality to 1/3 attributable to screening, mainly MAMMOGRAPHY LUNG CANCER INCIDENCE, MORTALITY AND SURVIVAL Number one cause of cancer deaths in the Philippines Almost 100% of all lung cancer cases are caused by CIGARETTE SMOKING Smokers reach cancer age 15 years younger than non-smokers

Smoking Facts Non-smokers exposed continuously to tobacco smoke in enclosed areas also run the risk of getting lung cancer Tobacco smoking reduces life expectancy Tobacco smoking before and during pregnancy may cause birth defects CAUSES Cigarette smoking (75-90%) Involuntary smoking (2nd hand or 3rd hand) Pollution SYMPTOMS Worsening persistent dry cough Constant chest pain Blood-tinged sputum Extreme shortness of breath, wheezing, or hoarseness Repeated pneumonia or bronchitis Swelling of neck/face Weight loss Fatigue Difficulty in swallowing PREVENTION Lung Cancer Control Program (LCCP) primary prevention at the community level, tertiary prevention at special medical centers and rehab centers at both community and hospital levels Trimedia Yosi Kadir and No sa Yo campaigns of the DOH, in collaboration with the DepEd Bureau of Secondary Education Inclusion in the school curriculum of smoking as a health problem Social mobilization Establishment of a national information and counseling center 28 January 1993 DOH Administrative Order prohibiting smoking within DOH premises March 1993 DOH Administrative Order laid out rules and regulations on the labeling and advertising of cigarettes DOH is the implementing agency of Chapter IV (Labeling and fair packaging) of RA 7394 with respect to hazardous substances Article 94 of the same chapter All cigarettes for sale or distribution shall bear the following statement or its equivalent in Filipino: Warning: Cigarette Smoking is Dangerous to Your Health. Some cities have issued a No Smoking in Public Places ordinance 23 October 2001 All members of the senate co-authored Senate Bill 1859 to severely restrict cigarette promotion and trade and smoking in public places STOMACH CANCER INCIDENCE, MORTALITY, SURVIVAL 7th leading site for both sexes (4%), 5th among males (5%) and 10th among females (3%) 2008 about 1 (0.7) in 100 men and less than 1 (0.4) in 100 women had a likelihood of getting stomach cancer before 75 y/o Highest incidence rates in males in Manila and Pasig, females in QC and Manila (1998-2002) RISK FACTORS Pernicious anemia Atrophic gastritis Diet of salty food, smoked fish, pickled vegetables

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WARNING SIGNS Early Symptoms Indigestion Dyspepsia Loss of appetite Anemia Advanced Symptoms Weight loss Difficulty swallowing Vomiting Abdominal mass EARLY DETECTION No effectiveprimary prevention or method of detection To increase survival, earlier diagnosis of symptomatic patients must be the goal TREATMENT Surgery remains the most effective treatment for gastric cancer LIVER CANCER INCIDENCE, MORTALITY, SURVIVAL Third leading site for both sexes, 2nd in males, 6th in females Incidence increases at age 35 for males, 50 for females Slight decrease in incidence from 1980-2002 1.2%among males 0.8% among females RISK FACTORS HepB and HepC virus Heavy alcohol intake Prolonged heavy intake of foodstuffs containing large amts of aflatoxin and other carcinogens PREVENTION Hep B vaccination Improve sanitation nationwide Adequate screening of blood and blood products Avoidance of multiple syringe use Education versus drug abuse Strict implementation of health check-ups among commercial sex workers WARNING SYMPTOMS Abdominal pain Constitutional symptoms, particularly in a person with cirrhosis or who is a known HBV carrier EARLY DETECTION No effective early detection method TREATMENT Early stage (occasional) surgery Majority are seen in incurable stage = judicious and cost-effective palliative care

PANCREATIC CANCER INCIDENCE, MORTALITY, SURVIVAL Year 2008 estimated agestandardized national incidence rates estimated national standardized mortality rates would have had a likelihood of getting pancreas cancer before the age 75 would have died from pancreas cancer before the age 75 Year 2010 rank as leading site for cancer estimated new cases deaths in both sexes 2 per 100,000 1.8 per 100,000 among males 2.3 per 100,000 2 per 100,000 < 0.3 out of 100 among females 1.8 per 100,000 1.6 per 100,000 < 0.2 out of 100

< 0.2 out of 100

< 0.2 out of 100

in both sexes 16th (2%) 1,334 1,144

among males 12th (2%) 716 609

among females 14th (1%) 618 535

* Incidence rate starts rising steeply at age 55 and continues to rise with increasing age. RISK FACTORS Exposure to certain chemicals Cigarettes smoking History of DM Excessive alcohol intake Exact cause still unclear

WARNING SIGNALS **no specific signs and symptoms, but the ff should elicit suspicion: Upper abdominal pain Painless jaundice Unexplained weight loss in middle aged or older persons EARLY DETECTION No efficient mass screening method. The above mentioned warning signals should be taken into consideration. TREATMENT Early stage - surgery Advanced stage - judicious and cost-effective palliative care

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CORPUS UTERI CANCER INCIDENCE, MORTALITY, SURVIVAL In 2010: The Cancer of the body of the Uterus will be the 7th leading site among women (4%) There will be 1,760 new cases There will be 796 deaths Incidence rate: Rise steeply starting at 40 years old In 2008: Estimated age-standardized national incidence rate was 4.6 per 100,000 One (0.5) out of 100 women would have a likelihood of getting corpus uteri cancer before age 75 Estimated national standardized mortality rate was 2.2 per 100,000 Less than one (0.2) out of 100 women would have died from corpus uteri cancer before age 75 RISK FACTORS ESTROGEN Increase risk with: nulliparity, infertility, long-term estrogen use, obesity, hypertension, history of breast cancer, DM Healthy lifestyle and healthy diet and normal weight decrease risk WARNING SIGNALS Postmenopausal bleeding Intermenstrual bleeding Excessive menstrual bleeding TREATMENT Early cancer curable by surgery Advanced cancer judicious and cost-effective palliation CERVIX UTERI CANCER INCIDENCE, MORTALITY, SURVIVAL 5th leading cancer for both sexes (6%), 2nd among women (11%) in 2010 Incidence rate rises steeply at age 30 Slight decrease in incidence from 1998-2002 by -0.3% annually Highest rates Manila, Makati, Taguig, Pasig, Pasay Lowest in Rizal Province Estimated age-standardized national incidence rate in 2008 = 11.7 per 100,000 1.1 out of 100 women have likelihood of getting cervical cancer before age 75 In 2008, estimated national standardized mortality rate was 5.3 per 100,000 predicting 1.984 deaths in 2010 RISK FACTORS HPV 16 and 18, sexual transmission PREVENTION

Condom use HPV Vaccines Regular Pap tests for all women who have been sexually active and who have a cervix Regular testing can be discontinued after age 65 in women who have had regular previous screening with consistently normal results Policy shift from Pap smear to visual acetic acid as a nationwide screening modality

WARNING SIGNALS Intermenstrual, postcoital, post-douching or postmenopausal bleeding Unusual vaginal discharge EARLY DETECTION Pap Smear every 5 years after an initial negative test at age 30 for average-risk individuals, more frequently in high-risk females Proposed screening activities and programs should address socioeconomic factors that have been barriers to early detection TREATMENT Surgery and radiotherapy for early cervical cancer Radical hysterectomy usually employed Ideal cervical cancer control program: Widespread practice of sex Peri-adolescent HPV vaccination Screening and earlier detection with appropriate treatment Choice of screening modality to use requires Ability to do high-quality screening Provision of reliable follow-up for women with abnormal results Prompt and adequate treatment Acceptable coverage in women 30 years and older Judicious and cost-effective palliation in advanced cancer OVARIAN CANCER INCIDENCE, MORTALITY, SURVIVAL 10th most common cancer overall (3%) in 2010; 5th in women (5%) Incidence starts to rise at age 40 Estimated age-standardized national incidence was 5.7 per 100,000 In 2008, 0.6 out of 100 women would likely have ovarian cancer before age 75 Estimated national standardized mortality rate in 2008 was 2.8 per 100,000 Less than one (0.3) out of 100 women would have died from ovarian cancer before age 75. 1,016 deaths in 2010 RISK FACTORS Nulliparity Menstrual irregularities History of breast or endometrial cancer Genetic Pregnancy and OCPs may be protective WARNING SIGNALS

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Usually asymptomatic Many are detected late Usually detected as an abdominal mass or enlargement

EARLY DETECTION Annual pelvic exam starting at age 40 TREATMENT Surgery for early ca Surgery + chemo for clear cell ca Palliation for advanced PROSTATE CANCER INCIDENCE, MORTALITY, SURVIVAL 8th most common cancer overall (3%) in 2010; 4th in men (7%) Incidence starts to rise at age 55 Estimated age-standardized national incidence was 10.1 per 100,000 Highest incidence rates in 1998-2002 in QC, Paraaque and Manila (27-29) Lowest in Rizal Province (12.4) In 2008, 1.1 of 100 males would most likely have prostate ca before age 75 Estimated national standardized mortality rate in 2008 was 5.3 per 100,000 and 0.5 out of 100 males would have died from prostate cancer before age 75. 1,410 deaths in 2010 Median survival of 52 months, 43% 5-year survival rate and 31% 10year survival rate RISK FACTORS Increasing age Correlation with healthy lifestyle not as clear as with other ca Healthy lifestyle may lower risk WARNING SIGNALS Early cancer asymptomatic Dysuria Frequency, nocturia May have initial presentation of bone pain (for prostate cancer metastatic to bone) EARLY DETECTION Prostate specific antigen Biopsy, guided by digital rectal exam and/or transrectal UTZ Annual DRE of men 50 y/o TREATMENT Surgery for early ca Hormonal manipulation, orchiectomy for ca with capsular invasion and distant spread Radiation Palliation if advanced

COLORECTAL CANCER INCIDENCE, MORTALITY AND SURVIVAL 4th most common cancer overall (7%) in 2010; 3rd in men (8%), 4th in women (6%) Incidence starts to rise steeply at age 50 for both sexes In 2010, about 5,787 new cases of colorectal cancer is estimated, 3,208 in males and 2,579 in females. Estimated age-standardized national incidence rates for colon and rectum cancers were 8.6 per 100,000 in both sexes in 2008 and that 10.0 were males and 7.3 are females. One out of 100 men and one out of 100 females would have a likelihood of getting colorectal cancer before age 75 in 2008. In 2010, 3,060 deaths in both sexes, 1,690 for males and 1,370 for females are predicted. Cities with the highest incidence rates on 1998-2002 Colon cancer Rectal cancer Male Mandaluyong, Manila, Quezon, Paranaque, Manila, Quezon Quezon City Female Paranaque, Quezon, Manila, Pasig, Manila Quezon RISK FACTORS Family history Lifestyle = diet, alcohol consumption, high fat intake, low whole grains, fruit and vegetables SCREENING Annual FOBT Sigmoidoscopy every 3-5 years DOH Iwas Sakit Diet, Tia Kulit Digital Rectal Exam WARNING SIGNALS Change in bowel habits Abdominal discomfort Weight loss Unexplained anemia Blood in stool EARLY DETECTION Difficult to develop d/t asymptomatic early stages Aim: earlier diagnosis of symptomatic patients, esp among those 50 y/o and older, via DRE, proctoscopy, proctosigmoidoscopoy, barium enema, and colonoscopy TREATMENT Surgery for early ca Surgery + chemotherapy Palliation if advanced LEUKEMIA INCIDENCE, MORTALITY, SURVIVAL

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6th most common cancer overall (4%) in 2010; 6th in men (4%), 8th in women (3%) Incidence of myeloid leukemia slighty higher than lymphoid leukemia Age-incidence rate of LL are highest among children and people aged 70 years and older. Age-incidence rate of rise from age 50 years. Estimated age-standardized national incidence rates for colon and rectum cancers were 3.8 per 100,000 in both sexes in 2008 and that 4.1 were males and 3.6 are females. Less than one out of 100 men and less than one out of 100 females would have a likelihood of getting colorectal cancer before age 75 in 2008. In 2010, 2,609 deaths in both sexes, 1,381 for males and 1,228 for females are predicted.

In Metro Manila Children (0-14yo) NHL comprised of 50% lymphomas, and 40% of childhood lymphomas occurred at age 10-14 years. The 5-year relative survival rate of Metro Manila children with NHL was lower compared to Asian American (85%) and Caucasian children (81%) in the US. RISK FACTORS Causes are unclear Viruses may be involved WARNING SIGNALS Painless, enlarged lymph nodes Associated with fever, night sweats, itching or weight loss EARLY DETECTION Lymph node enlargement that cannot be explained by prevalent causes, their persistence and progressive enlargement should elicit concern Biopsy of suspicious lymph nodes TREATMENT Chemotherapy is primary curative Adjuvant radiotherapy Advanced cases can benefit from judicious palliative care

RISK FACTORS Acute exposure to radiation Chronic exposure to certain chemicals WARNING SIGNALS Easy fatigability Weight loss Pallor Easy bruising Frequent nosebleed Repeated infections, esp. in children EARLY DETECTION Goal is to detect early symtpomatic patients, especially children. No practical screening method Lab results (i.e. bone marrow exam) can confirm the diagnosis TREATMENT Highly curable by chemotherapy Budget allocation for chemo of poor/indigent children

Activity Corner ni Perry! Kulayan!!!

NON-HODKINS LYMPHOMA INCIDENCE AND MORTALITY 14th most common cancer overall (2%) in 2010; 9th in men (3%), 13th in women (2%) Estimated 1,664 cases new cases in 2010, 982 in men, 682 in women Estimated 967 deaths in both sexes, 598 in men, 369 in women Incidence rate rises steeply at age 50 in males, 55 in females In 2008 Estimated age-standardized national incidence rate were 2.3 per 100,000 in both sexes, 2.7 among males and 1.8 among females. Less than one (0.3) out of 100 men and less than one (0.2) out of 100 women would have a likelihood of getting NHL before age 75 Less than one (0.2) out of 100 men and less than one (0.1) out of 100 women would have died from NHL before age 75 Estimated national mortality rates were 1.3 per 100,000 in both sexes, 1.7 among males and 1.0 among females 1 Corinthians 13:1-3 If I speak in the tongues of men and of angels, but have not love, I am only a resounding gong or a clanging cymbal. If I have the gift of prophecy and can fathom all mysteries and all knowledge, and if I have a faith that can move mountains, but have not love, I am nothing. If I give all I possess to the poor and surrender my body to the flames, but have not love, I am nothing. Treat everyone with love.

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