Introduction to Cancer

basics?
Candy Cooley, Manager National Genetics Education and
Development Centre
cancernursing.org online lecture March 2009
Statistics
>9.7 million cases are detected
each year
6.7 million people will die from
cancer
Every day, around 1700
Americans die of the disease
20.4 million people living with
cancer in the world today
1 in 3 people will be diagnosed
with cancer in the UK and 1 in 4
will die from their disease
Lung
Breast
Colon/Rectum
Stomach
Liver
Prostate
Cervix uteri
Oesophagus
Bladder
Non-Hodgkin
Lymphoma
Leukaemia
Oral cavity
Pancreas
Kidney
Ovary
1000 800 600 400 200 0 200 400 600 800 100
0
Men Women
From: D.M. Parkin The Lancet Oncology 2: 533-543 (2001)
(Thousands)
Incidence
Mortality
337
293
105
0
370
241
318
446
234
165
166
471
233
133
111
76
33
121
68
113
86
47
97
101
101
34
71
192
114
810
902
558
405
255
499
398
384
204
543
279
260
227
99
93
167
144
109
81
170
116
112
57
119
5.3 million cases
3.5 million deaths
4.7 million cases
2.7 million deaths
The Global Burden of Cancer 2000
WHO Statistics
2020 15 million people will die from cancer

Causes
Ageing population
Obesity
Smoking
The burden of cancer
6% of NHS hospital expenditure
$// etc millions spent on research
Substantial financial burdens upon families
and carers
Physical and emotional burden





Personal views of cancer
in the popular
imagination cancer
equals death



(Susan Sontag,1977)


Cancer forces us to
confront our lack of
control over our own
or others death

Kleinman (1988)
What is Cancer?
Division uncontrolled cell division

Growth formation of a lump (tumour) or large
numbers of abnormal white cells in the blood

Mutation changes to how the cell is viewed by
the immune system

Spread ability to move within the body and
survive in another part
Division uncontrolled cell division
Oncogenes

Tumour suppressor genes p53

Suicide genes apoptosis

DNA repair genes



Growth
Tumour
Pressure on nerves
Blocking organs
Stopping normal function
Altering nerve signals
Fungating

Mutation and Spread
Invasion

Angiogenesis
Types of Cancer
Carcinomas
Sarcomas
Lymphomas
Leukaemias
Adenomas

Often prefixed by the specific cell





What are the differences in the
features of normal and cancer cells?
Malignant versus benign
tumours
Normal and abnormal cell
growth
Normal cell growth
Cancerous growth
Metastatic cancer
What causes cancer?

Carcinogenesis.
Some factors to consider
Heredity
Immunity
Chemical
Physical
Viral
Bacterial
Lifestyle



Heredity
5-10% of Cancers

?15% of all
cancers

Molecular biology
and Human
Genome Project
Heredity
Genes isolated for
several classic familial
cancer syndromes:
RB1 (retinoblastoma)
APC (familial polyposis)
Human Non Polyposis
Colon Cancer (HNPCC)
BRCA 1&2 (breast
cancer)
p53 (many cancers)

Immunity


HIV / AIDS

Immunosuppression
Viruss
Hepatitis B
Human T-cell
Leukaemia virus
Epstein Barr Virus
Human Papilloma
Virus (HPV)

Bacterial
H. pylori

Other Parasites:
Schistosoma spp
Clonorchis sinensis
Estimated Burden of Cancer from Infection Worldwide in 2000
Liver 509,000 HBV, HCV, flukes 5.1
Cervix 471,000 HPV 4.7
Stomach 442,000 H. pylori 4.4
Kaposis (HIV related) 134,000 HHV-8 1.3
Non Hodgkin lymphoma 72,000 H. pylori, EBV, HIV 0.7
Ano-genital 65,000 HPV 0.6
Nasopharyngeal 63,000 EBV 0.6
Hodgkin disease 33,000 EBV, HIV 0.3
Bladder 10,000 Schistosoma 0.1
Leukaemia 3,000 HTLV1 0.03
Total 1,801,000 17.9
No. of cases Agent % World
cancer
Chemical
Alcohol
Asbestos
Wood dust
Rubber, plastics, dyes
Tar / bitumen
Aflatoxin
Alkylating agents

Tobacco
Smoking
Single biggest cause
of cancer
25-40% smokers die
in middle age
9 in 10 lung cancers
Know to cause cancer
in 1950


Smoking and alcohol
Industrial pollution
Physical causes

Ultraviolet radiation
Sunlight
Certain industrial sources

Radiation
Radon
Cancer treatment




Obesity
Lifestyle:
- Highly caloric diet, rich in
fat, refined carbohydrates
and animal protein
- Low physical activity
Consequences:
- Cancer
- Diabetes
- Cardiovascular
disease
- Hypertension

Lifestyle
Age

Occupation

Ethnicity

Deprivation


Survival variations
CONCORD Study (1.9 million survivors)
demonstrated a clear relationship to
income not only between countries but
also between the ethnic groups in those
countries
(Coleman et al Lancet Oncology 2008)
Diagnosis and staging
Clinical History

Normal diagnostic procedures
Scans, xrays
Blood tests
Biopsy

Pathological staging
Staging
Size

Invasion

Lymph nodes

Metastasises
TNM Staging
T (a,is,(0),1-4): size or direct extent of the primary tumor
N (0-3): degree of spread to regional lymph nodes
N0: tumor cells absent from regional lymph nodes
N1: tumor cells spread to closest or small number of regional
lymph nodes
N2: tumor cells spread to an extent between N1 and N3.
N3: tumor cells spread to most distant or numerous regional
lymph nodes
M (0/1): presence of metastasis
M0: no distant metastasis
M1: metastasis to distant organs (beyond regional lymph nodes)

Other parameters
G (1-4): the grade of the cancer cells (i.e. they are "low
grade" if they appear similar to normal cells, and "high
grade" if they appear poorly differentiated)
R (0/1/2): the completeness of the operation (surgery-
boundaries free of cancer cells or not)
L (0/1): invasion into lymphatics
V (0/1): invasion into vein
C (1-4): a modifier of the certainty (quality) of the last
mentioned parameter

Examples
Small, low grade cancer, no metastasis, no spread to
regional lymph nodes, cancer completely removed,
resection material seen by pathologist - pT1 pN0 M0 R0
G1; this would be considered Stage I.

Large, high grade cancer, with spread to regional lymph
nodes and other organs, not completely removed, seen
by pathologist - pT4 pN2 M1 R1 G3; this would be
considered Stage IV.

Most Stage I tumors are curable; most Stage IV tumors
are not.

Staging for Chronic Lymphocytic
Leukemia (CLL)

There are two different systems for staging
chronic lymphocytic leukemia. The Rai
classification is used more often in the United
States, whereas the Binet system is used more
widely in Europe
Stages of Leukemia: Acute
Lymphocytic Leukemia (ALL)

For adults, ALL is classified as untreated, in remission,
or recurrent. For childhood ALL, risk groups are used
instead of stages to describe cases of the disease. Risk
groups for childhood ALL include:

Standard (low) risk
High risk
Recurrent.

Other staging
Lymphoma: uses Ann Arbor staging

Hodgkin's Disease: follows a scale from I-IV and
can be indicated further by an A or B, depending
on whether a patient is non-symptomatic or has
symptoms such as fevers. It is known as the
"Cotswold System" or "Modified Ann Arbor
Staging System".

Duke Staging System

Modified Duke A The tumor penetrates into the mucosa of the
bowel wall but no further.
Modified Duke B B1: tumor penetrates into, but not through the
muscularis propria (the muscular layer) of the bowel wall. B2: tumor
penetrates into and through the muscularis propria of the bowel wall.
Modified Duke C C1: tumor penetrates into, but not through the
muscularis propria of the bowel wall; there is pathologic evidence of
colon cancer in the lymph nodes. C2: tumor penetrates into and
through the muscularis propria of the bowel wall; there is pathologic
evidence of colon cancer in the lymph nodes.
Modified Duke D The tumor, which has spread beyond the
confines of the lymph nodes (to organs such as the liver, lung or
bone).
Summary
Cancer is a disease of
Division, growth and
spread

It has a number of causes
many of them
preventable

The survival of the patient
is determined by the
stage of the disease, the
earlier the detection or
the smaller the tumour
the better the survival


10 Rules to Avoid Cancer
2. Dont smoke.
3. Dont smoke.
4. Avoid exposure to other known carcinogens,
including aflatoxin, asbestos and UV light.
6. Eat fresh fruit and vegetables several times a day.
7. Be physically active and avoid obesity.
8. Have vaccination against, or early detection/treatment
of, cancer causing chronic infections.
9. Have the right genes.
10. Have good luck !
5. Enjoy a healthy diet, moderate in calories,
salt and fat, and low in alcohol.
1. Dont smoke