Published on December 16, 2016
1. CANCERCANCER UNDEFEATEDUNDEFEATED N Engl J Med1997;336:1569-74N Engl J Med1997;336:1569-74 In 1986, we concluded that “some 35 years of intense effort focused largely on improving treatment must be judged a qualified failure.” Now, with 12 more years of data and experience, we see little reason to change that conclusion,.. JOHN C. BAILAR III M.D., PH.D., HEATHER L. G ORNIK M.H.S.
2. True or FalseTrue or False Cancer is a major killerCancer is a major killer disease of “developingdisease of “developing countries”?countries”? Cancer is a “life style”Cancer is a “life style” disease?disease?
3. New Cancer Cases (Incidence) and Deaths (Mortality) in 2002. Parkin DM et al: CA Cancer J Clin 2005;55:74–108 Thousands
4. Parkin DM et al: CA Cancer J Clin 2005;55:74–108 New Cancer Cases (Incidence) and Deaths (Mortality) in 2002. Thousands
5. All Cause Mortality Cancer related mortality 7.6 million Developing countries Developed countries 70% Worldwide Mortality 2005Worldwide Mortality 2005 WHO Cancer Fact sheet number 297
6. Fight Against CancerFight Against Cancer Did you know?Did you know? –Average years of life lostAverage years of life lost Cardiac causesCardiac causes 11 years11 years CancerCancer 15 years15 years
7. IARC Globocan 2002, Figures based on 1998-2002 prevalence Burden of Cancer
8. Magnitude of the Problem New cases in 2020 Future looks GRIM
9. Number of Cancer CasesNumber of Cancer Cases CountryCountry MaleMale FemaleFemale TotalTotal <14 yrs<14 yrs IndiaIndia 386,854386,854 426,741426,741 813,595813,595 33%33% PakistanPakistan 61,62461,624 75,09575,095 136,719136,719 42%42% BangladeshBangladesh 39,98439,984 44,09044,090 84,07484,074 35%35% Sri LankaSri Lanka 8,3658,365 9,7779,777 1814218142 26%26% Nandakumar A et al: UICC Strategies for Cancer Control in South Asia-2006, pp17
10. ATLAS INDIA 2006
11. New Cancer Cases in KashmirNew Cancer Cases in Kashmir Population of KashmirPopulation of Kashmir 10 million10 million Cancer incidenceCancer incidence 111/100,000111/100,000 – Urban estimatesUrban estimates Expected new casesExpected new cases 11000/yr11000/yr New cases per dayNew cases per day App 40App 40 However incidence could be muchHowever incidence could be much higherhigher Expected in 2020Expected in 2020 22000/yr22000/yr (80/day)(80/day)
12. 0.38 0.82 0.46 0.94 0.6 1.2 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2005 2010 2020 Cancer in South AsiaCancer in South Asia Millions Mortality UICC 2006
13. Cancer Related MortalityCancer Related Mortality Higher thanHigher than AIDSAIDS,, TBTB,, MalariaMalaria putput togethertogether Second to cardiovascular diseasesSecond to cardiovascular diseases Years of life lost more than CVYears of life lost more than CV diseasesdiseases IncreasingIncreasing definitelydefinitely
14. Survival related to LiteracySurvival related to Literacy Mumbai-IndiaMumbai-India Yole BB et al: Asia Pacific J Ca Prev 2004; 5:308
15. Literacy in South AsiaLiteracy in South Asia CountryCountry LiteracyLiteracy MaleMale FemaleFemale BangladeshBangladesh 53.953.9 31.831.8 IndiaIndia 68.068.0 44.044.0 NepalNepal 65.165.1 42.542.5 PakistanPakistan 54.854.8 32.032.0 Sri LankaSri Lanka 94.894.8 90.090.0
16. Socioeconomic Status and BreastSocioeconomic Status and Breast Cancer Outcome in PakistanCancer Outcome in Pakistan SocioeconomicSocioeconomic StatusStatus Stage atStage at DiagnosisDiagnosis Treatment OutcomeTreatment Outcome EarlyEarly LateLate AdequateAdequate 10 yr Surv10 yr Surv LowLow 50%50% 50%50% 44%44% 22%22% HighHigh 75%75% 25%25% 89%89% 73%73% Aziz Z. Stigma of Breast Cancer in Developing Countries Costs Lives: ESMO Newsletter. January –March, 2003
17. CountryCountry < 1$/day< 1$/day < 2$/day< 2$/day IndiaIndia 44.2%44.2% 86.2%86.2% BangladeshBangladesh 29.1%29.1% 77.*%77.*% PakistanPakistan 31.0%31.0% 84.7%84.7% South Asia IncomeSouth Asia Income Kurkure AP et al: UICC Strategies for South Asia 2006: 26
18. Poverty Lack of Education •Lack of compliance •Prevention •Early detection •Treatment •Follow up •Late diagnosis
19. Breast Cancer Size vs SurvivalBreast Cancer Size vs Survival 0 10 20 30 40 50 60 70 80 90 <2 2 to 5 >5
20. Cancer Related PainCancer Related Pain At diagnosis 25% Advanced disease 75% During therapy 30% Goudas LC et al: Cancer Invest 2005;23:519
21. Morphine requirement - IndiaMorphine requirement - India Total producedTotal produced 142.32 kg/yr142.32 kg/yr ONLY 0.4% of the required amountONLY 0.4% of the required amount PRODUCEDPRODUCED Rajagopal MR et al: J Pain Control 2007;33:615
22. Palliative Care Problems-Palliative Care Problems- Medical PersonnelMedical Personnel Lack of awarenessLack of awareness prevents deliveryprevents delivery DisseminationDissemination of informationof information OpiophobiaOpiophobia EducationEducation Imitation ofImitation of western models ofwestern models of carecare Develop localDevelop local strategiesstrategies Seamark D et al: J R Soc Med 2000; 93:292
23. Palliative Care Problems-PublicPalliative Care Problems-Public Lack ofLack of awarenessawareness creates delayscreates delays in seekingin seeking palliative carepalliative care PublicPublic educationeducation Seamark D et al: J R Soc Med 2000; 93:292
24. Palliative Care Problems-Palliative Care Problems- Social/SystemSocial/System Silence about cancerSilence about cancer diagnosisdiagnosis Discuss cancer diagnosisDiscuss cancer diagnosis openlyopenly PovertyPoverty Consider financialConsider financial condition of the patientcondition of the patient while prescribingwhile prescribing Coexistence of multipleCoexistence of multiple systems of medicinesystems of medicine Work together asWork together as partners not rivals§partners not rivals§ Transport problemsTransport problems Support private sector toSupport private sector to create rural centerscreate rural centers Involve relativesInvolve relatives Non availability of opioidsNon availability of opioids Public pressurePublic pressure Seamark D et al: J R Soc Med 2000; 93:292
25. is still a cigarette, and still as dangerous! 3 times CO and 5 times Tar compared to a cigarette a cigarette by any other name …
26. Betel leaves Betel nut Lime
27. Nicotine Delivery Device Addicting Nicotine 4000 Chemicals 60 Carcinogens Perfect Killing Machine Hecht SS: Nat Rev Cancer 2003;3:733 Tobacco related cancer (South Asia) Males 50% Females 20% (UICC Data)
28. Trends in prevalence of smoking at ages 3559 in men and women in the United Kingdom, 195098. Trends in mortality from lung cancer in men and women in the United Kingdom BMJ 2000;321;323329
29. Trends in prevalence of smoking at ages >60 in men and women in the United Kingdom, 195098. Trends in mortality from lung cancer in men and women in the United Kingdom, BMJ 2000;321;323329
30. Effect of Screening mammography and adjuvant therapy on breast cancer mortality Berry DA et al: N Engl J Med 2005;353:178492. Data based on multiple models Age adjusted breast cancer mortality rates: 2003 vs 1989 24% less Smith RA. NEJM 2007; 356:1362 Age adjusted breast cancer mortality rates: 2003 vs 1989 24% less Smith RA. NEJM 2007; 356:1362
31. Persistent Non-Hodgkin’s Lymphoma Juweid ME and Cheson BD. N Engl J Med 2006;354:496-507
32. Early Detection of Persistent Hodgkin’s Disease Juweid ME and Cheson BD. N Engl J Med 2006;354:496-507
33. Early Detection of Recurrent Cervical Carcinoma Juweid ME and Cheson BD. N Engl J Med 2006;354:496-507
34. Lymph nodes of Pts from Dutch Trial ASCO Presentation
35. Cell surface HER2 protein (HER2 receptor) Other EGFR/HER family receptor Cell nucleus
36. Activated HER2HER2 dimers Growth signal Cell nucleus
37. Tumor cell growth
38. Herceptin monoclonal antibody
39. Krause DS et al: N Engl J Med 2005; 353:172 Tyrosine kinase as a targetTyrosine kinase as a target Kinase domain
40. Krause DS et al: N Engl J Med 2005; 353:172 Tyrosine kinase as a targetTyrosine kinase as a target
41. Krause DS et al: N Engl J Med 2005; 353:172
42. Binds CD20, which is present on normal andBinds CD20, which is present on normal and malignant pre-B and mature B cells;malignant pre-B and mature B cells; >90% of B-cell NHL express CD20>90% of B-cell NHL express CD20 May induce antibody-dependent cell-mediatedMay induce antibody-dependent cell-mediated cytotoxicity (ADCC) and complement-dependentcytotoxicity (ADCC) and complement-dependent cytotoxicity, based on in vitro datacytotoxicity, based on in vitro data Also triggers apoptosis (programmed cell death)Also triggers apoptosis (programmed cell death) in vitroin vitro No apparent dependence on cell cycle forNo apparent dependence on cell cycle for activityactivity Rituximab
43. Krause DS et al: N Engl J Med 2005; 353:172
44. Rosenberg SA NEJM 2004; 350:1461 Lymphocytes: Sufficient number of recognizing tumor cells Reach the tumor Must be able to destroy the tumor cells
45. National Cancer Institute USANational Cancer Institute USA BudgetBudget Ramsey SD: J Clin Oncol 2007;25:175
46. USA Health Care EconomyUSA Health Care Economy 2006 budget 2.1 trillion dollars2006 budget 2.1 trillion dollars 7000 US$ per person7000 US$ per person NCI budget 4.87 billion dollarsNCI budget 4.87 billion dollars 260 non profit organizations working260 non profit organizations working for cancer in USAfor cancer in USA – More than heart disease, stroke, AIDS,More than heart disease, stroke, AIDS, Alzheimer's disease togetherAlzheimer's disease together Ramsey SD: J Clin Oncol 2007;25:175
47. Metastatic Colorectal Cancer CostMetastatic Colorectal Cancer Cost EffectivenessEffectiveness Wong Y et al: J Clin Oncol2006;24:149
48. Health Expenses vs GDPHealth Expenses vs GDP Meropol NJ et l: J Clin Oncol 2007; 25:180
49. 14 (3) 14 (3) 15 (10)15 (10) 14 (4)14 (4) 180 (147)180 (147) 14 (4)14 (4) 43 (19)43 (19) 31 (5)31 (5) Per capita expenditure on health South Asia- US$ Total (Public) whostat2007_6healthsystems_nha http://www3.who.int/whosis/country Accessed September 2007
50. Radiotherapy Facilities in IndiaRadiotherapy Facilities in India 0 5 10 15 20 25 30 35 40 45 TN Mah Kar UP Ker WB MP Guj Har Ass Ori Pun Bih J&K Cobalt LineacUICC 2006
51. 70% of world’s cancer in developing countries: and these have just 5% of the resources to fight it. Dinshaw KA: Fifty yrs of Cancer Control.. NCCP: MOHFW:2002:6
52. Radiotherapy facilitiesRadiotherapy facilities Developed Developing Stewart BW et al: World Cancer Report IARC: 2003 Population Radiotherapy facilities Needed for 50-60% of pts during the course of illness
53. 2020 Data NR etal: Lancet Oncology 2004;5:696
54. Oncologist’s PerspectiveOncologist’s Perspective Patients should have access toPatients should have access to effective therapy regardless of costeffective therapy regardless of cost Or….continue care till a thresholdOr….continue care till a threshold – 300,000 US$ per quality adjusted life300,000 US$ per quality adjusted life year gainedyear gained Nadler E et al: Oncologist 2006; 11:90
55. “Every man has his price” Bernard Williams: A critique of utilitarianism
The Burden of Cancer in Asia Medical Division ... South Korea. TheburdenofcancerinAsia 10 TaiwanandKoreahavethehighestall-cancerincidencerate(age-standardized)for
Breast cancer in South Asia: a Bangladeshi ... Knowledge of the various aspects of breast cancer in different geographical regions is limited in South Asia.
Basic information about cancer statistics in the U.S. and how they are used to understand the impact of cancer on society and to ... Asia, and Central and South ...
During the last decade, rates of cancer have increased dramatically in Asia. Asia accounts for nearly half of all new cancer cases in the world.
South Asian countries are facing a hidden breast cancer epidemic. A significant proportion of the breast cancer cases occur in premenopausal women. Knowledge of
Abstract. South Asian countries are facing a hidden breast cancer epidemic. A significant proportion of the breast cancer cases occur in premenopausal women.
Global Cancer Facts & Figures 2nd Edition. For more information, contact: ... South-Central Asia 651,100 772,000 1,423,100 496,800 483,200 979,900
Cancer mortality and morbidity Situation and trends. Cancer is a leading cause of death and accounted for 7.6 million deaths (around 13% of all deaths) in 2008.
Researchers find distinctive patterns of cancer in Asian ... But cancer is still a major cause of ... The hepatitis B virus is endemic in Asia, ...