Published on December 16, 2016
1. Hakim Sanaullah Cancer Centre Rafiabad Kashmir
2. Hakim Sanaullah Cancer Centre the fight against CANCER
3. CancerCancer UndefeatedUndefeated Prof. Shad Salim AkhtarProf. Shad Salim Akhtar MBBS, MD, MRCP(UK), FRCP(Edin), FACP(USA)MBBS, MD, MRCP(UK), FRCP(Edin), FACP(USA) MemberMember AUICC Fellows, ASCO, ESMOAUICC Fellows, ASCO, ESMO Global Community Against CancerGlobal Community Against Cancer Consultant Medical OncologistConsultant Medical Oncologist Chairman Board of DirectorsChairman Board of Directors Hakim Sanaullah Specialist Hospital & Cancer Centre,Hakim Sanaullah Specialist Hospital & Cancer Centre, Sopore, Kashmir, J & K, IndiaSopore, Kashmir, J & K, India Overseas Advisor Royal College of Physicians UKOverseas Advisor Royal College of Physicians UK Scientific Advisor Al-Qassim Screening Mammography ProgramScientific Advisor Al-Qassim Screening Mammography Program
4. Health Expenses vs GDPHealth Expenses vs GDP Meropol NJ et l: J Clin Oncol 2007; 25:180
5. National Cancer Institute USANational Cancer Institute USA BudgetBudget Ramsey SD: J Clin Oncol 2007;25:175
6. 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
7. Early Detection of Persistent Hodgkin’s Disease Juweid ME and Cheson BD. N Engl J Med 2006;354:496-507
8. Early Detection of Recurrent Cervical Carcinoma Juweid ME and Cheson BD. N Engl J Med 2006;354:496-507
9. Lymph nodes of Pts from Dutch Trial ASCO Presentation
10. Cell surface HER2 protein (HER2 receptor) Other EGFR/HER family receptor Cell nucleus
11. Activated HER2-HER2 dimers Growth signal Cell nucleus
12. Tumor cell growth
13. Herceptin monoclonal antibody
14. Krause DS et al: N Engl J Med 2005; 353:172
15. 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
16. Rosenberg SA NEJM 2004; 350:1461 Lymphocytes: Sufficient number of recognizing tumor cells Reach the tumor Must be able to destroy the tumor cells
17. A Defeated Soldier Being Apprehended By The Victorious (A monument in Albania) That Is Defeat
18. Mortality from All Malignant Neoplasms, 1970 through 1994, in the Total U.S. Population and According to Race and Sex. The rates have been age-adjusted to the U.S. resident population of 1990. Bailar JC et al: NEJM 1997; 336; 1569.
19. 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.
20. What Now
21. New Cancer Cases (Incidence) and Deaths (Mortality) in 2002. Parkin DM et al: CA Cancer J Clin 2005;55:74–108 Thousands
22. Parkin DM et al: CA Cancer J Clin 2005;55:74–108 New Cancer Cases (Incidence) and Deaths (Mortality) in 2002. Thousands
23. What is this?
24. 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
25. 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
26. 70% of world’s cancer occurs 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
27. 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
28. 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 Incidence could be much higherIncidence could be much higher Expected in 2020Expected in 2020 22000/yr22000/yr (80/day)(80/day)
29. 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
30. 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
31. Radiotherapy Facilities in South AsiaRadiotherapy Facilities in South Asia 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
32. 2020 Data NR etal: Lancet Oncology 2004;5:696
33. 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
34. “Every man has his price” Bernard Williams: A critique of utilitarianism
35. One of The Lost Wars
36. Metastatic Colorectal Cancer CostMetastatic Colorectal Cancer Cost EffectivenessEffectiveness Wong Y et al: J Clin Oncol2006;24:149
37. Average age adjusted mortality US Males 1930-2000. Ahmedin J et al. CA Cancer J Clin 2004;54:8–29
38. Ahmedin J et al. CA Cancer J Clin 2004;54:8–29 Average age adjusted mortality US females 1930-2000.
39. Trends in prevalence of smoking at ages 35-59 in men and women in the United Kingdom, 1950-98. Trends in mortality from lung cancer in men and women in the United Kingdom BMJ 2000;321;323-329
40. Effect of Screening mammography and adjuvant therapy on breast cancer mortality Berry DA et al: N Engl J Med 2005;353:1784-92. 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
41. Anderson LD et al: The Oncologist 2002; 7:200 Smoking cessation Early detection Screening Dietary changes Cancer Mortality 1990 vs 2000 USA
42. 0-9 10 to 19 20-29 30+ African Asian European 0 0.2 0.4 0.6 0.8 1 1.2 1.4 African Asian European Risk of Breast CarcinomaRisk of Breast Carcinoma Origin vs Duration of Stay in IsraelOrigin vs Duration of Stay in Israel Duration of Stay in Years Steinitz R etal: IARC 1989
43. Risk of Malignant MelanomaRisk of Malignant Melanoma Origin vs Duration of Stay in IsraelOrigin vs Duration of Stay in Israel 0-9 10 to 19 20-29 30+ African Asian European 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 African Asian European Duration of Stay in Years Steinitz R etal: IARC 1989
44. Cancer Among Female Iranian Migrants to British Columbia, Canada Yavari P et al: Asian Pac J Cancer Prev 2006;7:86-90.
45. Incidence of colorectal cancer in AsianIncidence of colorectal cancer in Asian migrants to USA and their descendantsmigrants to USA and their descendants Flood DM et al: Cancer Causes Control 2000;11:403-11
46. Nature Nurture Fate c a n c e r
47. Nature, Nurture and CancerNature, Nurture and Cancer
48. YESYES Cancer Is A Life Style Disease?Cancer Is A Life Style Disease? IARC 2000
49. Modifiable Causes of CancerModifiable Causes of Cancer SmokingSmoking AlcoholAlcohol Overweight & obesity (high incomeOverweight & obesity (high income countries)countries) Low intake of vegetables and fruitLow intake of vegetables and fruit Infections (HPV) (middle & low incomeInfections (HPV) (middle & low income countries)countries) (others air pollution, fuels,(others air pollution, fuels, contaminated injections, physicalcontaminated injections, physical inactivity)inactivity) Goodarz D et al: Lancet 2005; 366: 1784
50. Common Cause of CancerCommon Cause of Cancer Sub Saharan Africa Europe IARC 2000
51. Beautifully packed carcinogen
52. 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)
53. 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 …
54. Betel leaves Betel nut Lime
55. Survival related to LiteracySurvival related to Literacy Mumbai-IndiaMumbai-India Yole BB et al: Asia Pacific J Ca Prev 2004; 5:308
56. 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
57. 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
58. 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
59. Poverty Lack of Education •Lack of compliance •Prevention •Early detection •Treatment •Follow up •Late diagnosis
60. Breast Cancer Size vs SurvivalBreast Cancer Size vs Survival 0 10 20 30 40 50 60 70 80 90 <2 2 to 5 >5
61. Cancer Related PainCancer Related Pain At diagnosis 25% Advanced disease 75% During therapy 30% Goudas LC et al: Cancer Invest 2005;23:519
62. 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
63. 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
64. 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 We are working at understandingWe are working at understanding and knowledge is powerand knowledge is power Nadler E et al: Oncologist 2006; 11:90
65. Second Report 2007
66. Esophageal Cancer & DietEsophageal Cancer & Diet Decreased riskDecreased risk Increased riskIncreased risk ConvincingConvincing Alcohol drinks, bodyAlcohol drinks, body fatnessfatness ProbableProbable Non-starchy vegetablesNon-starchy vegetables FruitsFruits Foods containingFoods containing beta carotenebeta carotene Vitamin CVitamin C Mate (hot South AmericanMate (hot South American drink)drink) Limited-Limited- suggestivesuggestive Foods containingFoods containing dietary fibredietary fibre FolateFolate PyridoxinePyridoxine Vitamin EVitamin E Red meat, processed meat,Red meat, processed meat, high temperature drinkshigh temperature drinks Gastric reflux, achalasia, Barret’s esophagus, SMOKING, HPV?
67. Gastric Cancer & DietGastric Cancer & Diet Decreased riskDecreased risk Increased riskIncreased risk ConvincingConvincing ProbableProbable Non-starchy vegetablesNon-starchy vegetables Allium vegetablesAllium vegetables FruitsFruits SaltSalt Salted and salty foodsSalted and salty foods Limited-Limited- suggestivesuggestive Foods containingFoods containing seleniumselenium PulsesPulses ChilliChilli Processed meatProcessed meat Smoked foodsSmoked foods Grilled or barbecued animalGrilled or barbecued animal foodsfoods H pylori, EB virus, industrial chemicals
68. Breast Cancer PremenopausalBreast Cancer Premenopausal Decreased riskDecreased risk Increased riskIncreased risk ConvincingConvincing LactationLactation AlcoholAlcohol ProbableProbable Body fatnessBody fatness Adult attained heightAdult attained height Greater birth weightGreater birth weight Limited-Limited- suggestivesuggestive Physical activityPhysical activity
69. Breast Cancer PostmenopausalBreast Cancer Postmenopausal Decreased riskDecreased risk Increased riskIncreased risk ConvincingConvincing LactationLactation AlcoholAlcohol Body fatnessBody fatness Adult attained heightAdult attained height ProbableProbable Physical activityPhysical activity Abdominal fatnessAbdominal fatness Adult weight gainAdult weight gain Limited-Limited- suggestivesuggestive Total fatTotal fat
70. Vaccines for PreventionVaccines for Prevention HP Virus (almost all cervical cancers)HP Virus (almost all cervical cancers) – Bivalent L1 vaccine (HPV16 & 18)Bivalent L1 vaccine (HPV16 & 18) PreventedPrevented – 96% incident infection96% incident infection – 100% of persistent infections100% of persistent infections – Quadrivalent HPV vaccine (HPV 6, 11, 16, 18)Quadrivalent HPV vaccine (HPV 6, 11, 16, 18) 90% lower rate of infection in immuized90% lower rate of infection in immuized 100% prevention of pre and noninvasive cancers100% prevention of pre and noninvasive cancers – Versus 21 detected in non immunized (12,000 women,Versus 21 detected in non immunized (12,000 women, 17 months follow up)17 months follow up) Harper DM etal: Lancet 2004; 364:1757 Villa LL et al: Lancet Oncolo 2005;6:271 Herbst RS et al: J Clin Oncol 2006; 24:190
71. Craxi A et al: Clin Liver Dis 2005; 9:329 Education Vigorous blood product screening
72. Vaccination-Taiwan ExperienceVaccination-Taiwan Experience Nation wide HBV vaccination programNation wide HBV vaccination program – Initiated 1984Initiated 1984 HBsAg carrier state in childrenHBsAg carrier state in children – Pre vaccinationPre vaccination 10%10% – Post vaccination 10 yrsPost vaccination 10 yrs <1%<1% Annual incidence of HCC (perAnnual incidence of HCC (per 100,000) in children 6-14 yrs100,000) in children 6-14 yrs – 1981-861981-86 0.700.70 – 1986-901986-90 0.570.57 – 1990-941990-94 0.360.36 Chang MH et al: NEJM 1997; 336:1855
73. Cereals etc and Risk of CancerCereals etc and Risk of Cancer Decreased riskDecreased risk Increased riskIncreased risk ExposureExposure CancerCancer sitesite ExposureExposure CancerCancer sitesite ConvincingConvincing AflatoxinsAflatoxins LiverLiver ProbableProbable FoodFood containingcontaining dietary fiberdietary fiber ColorectalColorectal Limited-Limited- suggestivesuggestive FoodFood containingcontaining dietary fiberdietary fiber EsophagusEsophagus
74. Vegetables and CancerVegetables and Cancer Decreased riskDecreased risk ExposureExposure Cancer siteCancer site ProbableProbable Non-starchy vegetablesNon-starchy vegetables Allium vegetablesAllium vegetables GarlicGarlic FruitsFruits Folate containing foodsFolate containing foods Foods containing carotenoidesFoods containing carotenoides Foods containing betaFoods containing beta carotene, vit Ccarotene, vit C Foods containing lycopene &Foods containing lycopene & seleniumselenium Mouth, pharynx, larynx,Mouth, pharynx, larynx, esophagus, stomachesophagus, stomach StomachStomach ColorectalColorectal Mouth, pharynx, larynx,Mouth, pharynx, larynx, esophagus, lung, stomachesophagus, lung, stomach PancreasPancreas Mouth, pharynx, larynx, lungMouth, pharynx, larynx, lung EsophagusEsophagus ProstateProstate
75. Cancer Risk & DietCancer Risk & Diet Decreased riskDecreased risk ExposureExposure Cancer siteCancer site Limited-Limited- suggestivesuggestive Non-starchy vegetablesNon-starchy vegetables CarrotsCarrots FruitsFruits PulsesPulses Foods containing folateFoods containing folate Foods containing Vit EFoods containing Vit E Foods containing pyridoxineFoods containing pyridoxine Foods containing seleniumFoods containing selenium Foods containing quercetinFoods containing quercetin Nasopharynx, lung, colorectum,Nasopharynx, lung, colorectum, ovary, endometriumovary, endometrium CervixCervix Nasopharynx, pancreas, liver,Nasopharynx, pancreas, liver, colorectumcolorectum Stomach, prostateStomach, prostate Esophagus, colorectalEsophagus, colorectal Esophagus, prostateEsophagus, prostate EsopahgusEsopahgus Stomach, lung, colorectalStomach, lung, colorectal LungLung Increased risk of gastric cancer with chillies
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