1. CHAPTER SIXTEEN: CANCER MAY 18, 2012 Albert J. Farias, MPH PhD ‘14

2. Today’s talk:  Normal cell growth  What is cancer  Disparities in cancer outcomes  Risk factors (modifiable and non-modifiable)  Screening recommendations  Common cancers

3. Healthy Cell Growth Divide when needed to replace cells that have died or been sloughed off (different rates, different cell types) Divide when needed to replace cells that have died or been sloughed off (different rates, different cell types) ~10 14 cells in adults ~10 14 cells in adults ~10 16 divisions in a lifetime ~10 16 divisions in a lifetime Complicated system of checks and balances that control cell growth and division. Complicated system of checks and balances that control cell growth and division. Send and receive messages from other cells Send and receive messages from other cells Healthy cells (except blood cells) require presence of neighboring cells for growth - stick together Healthy cells (except blood cells) require presence of neighboring cells for growth - stick together

4. Healthy Cell Growth – safety checks Repair mechanisms Repair mechanisms Each time a cell divides, there is a possibility of mutation or an error in DNA replication. Each time a cell divides, there is a possibility of mutation or an error in DNA replication. Enzymes in nucleus scan DNA for errors- repair or destroy Enzymes in nucleus scan DNA for errors- repair or destroy Pre-programmed number of cell divisions Pre-programmed number of cell divisions Immune system monitors Immune system monitors

6. Overview: Normal versus Cancer cells http://www.youtube.com/watch?v=Q9cuEYSt0GE&fe ature=youtu.be

7. What Is Cancer?  Condition characterized by the uncontrolled growth of cells  Develops from a single cell that goes awry, but a combination of events must occur before the cell turns into a tumor  Clonal growth: replication of a single cell that produces thousands of copies of itself in an uncontrolled manner  Cancer is categorized based on the function/location of the cells from which they originate

8. Cancer Cell Characteristics  Cancer- Carcinoma (Gr. Crab) Hippocrates, 460-370 BCE. Cytoskeletal changes (affects interactions with neighbor cells). Cell adhesion/motility. Nuclear changes (shape and organization). Enzyme production (evade neighboring tissue)

9. Cancer Cell Growth  Starts from a single cell that is undergoes a critical mutation caused by:  an error in duplication  in response to a carcinogen, a cancer causing substance  Radiation  Initiating event: allows a cell to evade one of the protective restraints  For cell to become cancer- must evade other constraints- usually series of 5-10 mutations required  Oncogene: a gene that drives a cell to grow and divide regardless of signals from surrounding cells

10. © 2009 McGraw-Hill Higher Education. All rights reserved. Cancer Cell Growth  Tumor: mass of extra tissue  Benign - slow growth and unlikely to spread; can be dangerous or fatal in certain locations  Malignant - capable of spreading to surrounding tissues (don’t stick together)  Metastasis: secondary tumor that appears when cancerous cells spread to other parts of the body

11. © 2009 McGraw-Hill Higher Education. All rights reserved. Stem Cells Embryonic or adult – important to distinguish Embryonic or adult – important to distinguish Stem cells pose a greater risk for cancer (omnipotent) but have special protective mechanisms. Stem cells pose a greater risk for cancer (omnipotent) but have special protective mechanisms. Located deep within tissues and are protected from factors that increases the risk of genetic mutation (exposure to the sun, chemicals, and irritation). Located deep within tissues and are protected from factors that increases the risk of genetic mutation (exposure to the sun, chemicals, and irritation).

13. Types of Cancer Four broad types of cancer are distinguished: Carcinomas : arise from epithelial tissue, (skin, lining of the intestines and body cavities, surface of body organs, outer portion of glands) and represents about 80% of all cancer cases Carcinomas : arise from epithelial tissue, (skin, lining of the intestines and body cavities, surface of body organs, outer portion of glands) and represents about 80% of all cancer cases Sarcomas : arise from connective tissue (bone, tendon, cartilage, muscle, fat tissues) Sarcomas : arise from connective tissue (bone, tendon, cartilage, muscle, fat tissues) Leukemias: cancers of the blood originate in the bone marrow or the lymphatic system Leukemias: cancers of the blood originate in the bone marrow or the lymphatic system Lymphomas : cancers that originate in lymph nodes and glands Lymphomas : cancers that originate in lymph nodes and glands Myeloma: cancer involving the white blood cells responsible for production of antibodies (B lymphocytes or B-cells) Myeloma: cancer involving the white blood cells responsible for production of antibodies (B lymphocytes or B-cells)

15. Death rates For men Death rates For women U.S. Mortality Data 1960-2004.National Center for Health Statistics Centers for Disease Control and Prevention, 2006

16. Cancer Disparities: Diagnosis and Outcomes  The National Cancer Institute (NCI) defines "cancer health disparities" as adverse differences in cancer incidence (new cases), cancer prevalence (all existing cases), cancer death (mortality), cancer survivorship, and burden of cancer or related health conditions that exist among specific population groups in the United States. These population groups may be characterized Age GenderIncomeLocation DisabilityEducation

17. Cancer Disparities: Diagnosis and Outcomes

18. Discussion: What are things that could account for the differences in cancer outcomes among groups of people? Think about what we’ve talked about in class (where you live, health behaviors).

19. Cancer Disparities  Lack of medical coverage  barriers to early detection and screening  unequal access to improvements in cancer treatment  Aggressive breast tumors are more common in younger African American/Black and Hispanic/Latino women living in low SES areas.  Less responsive to standard cancer treatments and is associated with poorer survival

20. Risk Factors for cancer  Modifiable versus non-modifiable risk factors  Think about duration, frequency, and timing of exposures  Cancer Prevention  Primary  Secondary  Tertiary

21. Risk factors for cancer  Family History (genetics)  BRCA1 and BRCA2 (60% increased risk versus 12% risk in general population)

22. Risk Factors for Cancer Environmental Factors Environmental Factors – Ultraviolet radiation – Other forms of radiation – Chemical and physical carcinogens – Infectious agents – Asbestos – Magnetic field exposure

23. Risk factors for cancer Lifestyle factors Lifestyle factors – Tobacco use – Dietary patterns – Overweight and obesity – Physical inactivity – Alcohol consumption – Reproductive factors (pregnancy, abortion, menstruation)  Infections  HPV  H. pylori infection  Chronic Inflammation (hepatitis)  Other possible factors  Antiperspirants  Artificial Sweeteners  Acrylamide  Pesticides  Cell phone use  Chronic stress

24. Screening Recommendations

25. Screening recommendations (women)  Breast cancer: Mammograms biennial starting age 50 Self breast exam? Clinical breast exam? High risk: earlier, MRI, ultrasound?  Cervical Cancer: Pap screen- age 21 HPV vaccine  Endometrial cancer: report unexpected bleeding (esp after menopause) endometrial biopsy

26. Screening recommendations (men)  Testicular cancer: controversy over self exam  Prostate cancer: PSA blood test - offered age 50  Digital rectal exam  High risk: offer starting age 40

27. Screening recommendations (men and women)  Colon cancer: flexible sigmoidoscopy or colonoscopy or barium enema  starting at age 50  annual stool fecal occult blood test  Lung cancer: controversial

28. Common cancers  Testicular  Prostate  Breast  Cervical  Ovarian  Lung  Colorectal  Skin  Oral  Leukemia  Lymphoma

29. Most common cancers 15-39 year olds Typemenwomen All sites51.2 (vs 1202 >40)81.6 (vs 873.8 >40) Lymphoma8.56.8 Leukemia3.52.5 Germ cell10.51.0 Soft tissue sarcomas3.42.4 Melanoma and skin CA5.69.6 Thyroid cancer13.72.7 Gastrointestinal5.74.9 CNS3.12.5 Per 100,000

30. Cancer Treatment  Surgery  Radiation therapy  Chemotherapy  Immunotherapy  Targeted therapy  Hormonal therapy

31. Common Cancers – all age groups Lung Cancer Lung Cancer Leading cause of cancer death in the US Leading cause of cancer death in the US Second most commonly diagnosed cancer Second most commonly diagnosed cancer Colon and Rectal Cancer Colon and Rectal Cancer 3 rd leading cause of death 3 rd leading cause of death 3 rd most commonly diagnosed cancer 3 rd most commonly diagnosed cancer Breast Cancer Breast Cancer Second leading cause of cancer death in women Second leading cause of cancer death in women Prostate Cancer Prostate Cancer Second most common cause of cancer death in men Second most common cause of cancer death in men Most commonly diagnosed cancer for men Most commonly diagnosed cancer for men

32. Lung Cancer Risk Factors Risk Factors – Smoking – Exposure to carcinogenic chemicals, arsenic, radon, asbestos, radiation, air pollution, and environmental tobacco smoke Symptoms Symptoms – Coughing – Blood-streaked sputum – Chest pain – Difficulty breathing – Recurrent lung infections

33. Lung Cancer Prevention Prevention – Remove smoke element Early detection? Early detection? Treatment Treatment – Surgery – Radiation – Chemotherapy – Radiation and Chemotherapy combination

34. Colon and Rectal Cancer Risk factors Risk factors – Age – Genetic and dietary habits – Personal or family history of colon polyps, inflammatory bowel disease, colorectal cancer – Smoking, obesity, physical inactivity, diet high in fat or red or processed meat, diet inadequate in fruit and vegetables Warning signs Warning signs – Change in bowel movements – Change in stool size or shape – Pain in the abdomen – blood in the stool

35. Colon and Rectal Cancer Early Detection Early Detection – Rectal exams, stool test, sigmoidoscopy, colonoscopy, double-contrast barium enema, CT colonography Treatment Treatment – Surgery, radiation and/or chemotherapy

36. Breast Cancer Risk factors – Early first menstruation – Late onset of menopause – Family history – Older age – Higher socioeconomic class – Women with no children or having children after 30 – Obesity after menopause – Hormone replacement therapy use – Drinking more than two alcoholic beverages a day

37. Breast Cancer Prevention Prevention – Diet – Exercise – Maintaining healthy body weight – Pregnancy and breastfeeding decisions Screening/detection Screening/detection – Breast self-exam – Mammography Treatment Treatment – Lumpectomy – Mastectomy – Radiation and/or chemotherapy treatments © Royalty-Free/Corbis

38. Prostate Cancer Risk factors Risk factors – Age – Family history – Being Black – High-fat diet Symptoms during the advanced stage Symptoms during the advanced stage – Difficulty urinating – Pain in the pelvic region – Pain with urination – Blood in the urine

39. Prostate Cancer Early Detection Early Detection – Digital rectal exam – Prostrate-specific antigen (PSA) screenings Treatment Treatment – Surgery – Radiation, sometimes in combination with chemotherapy – Hormonal medications – Vaccine

40. Cancers of the Female Reproductive System Cancer can develop throughout the female reproductive system but occurs more frequently in the following areas: Cervix Cervix Uterus Uterus Ovaries Ovaries

41. Cervical Cancer Risk factors Risk factors – HPV infection (cervical dysplasia), tobacco use, immuno-suppression, multiple births, early sexual activity, multiple sex partners, socioeconomic status, and nutritional status Early detection through PAP test has significantly reduced the rates of cervical cancer and mortality – HPV detection Early detection through PAP test has significantly reduced the rates of cervical cancer and mortality – HPV detection HPV Vaccine HPV Vaccine Treatment Treatment – Electrocoagulation – Cryotherapy – Surgery – Radiation/chemotherapy

42. Ovarian Cancer The leading gynecological cause of cancer death and the fifth overall cause of cancer in women The leading gynecological cause of cancer death and the fifth overall cause of cancer in women – Risk factors Family history Family history Personal history of breast, colon, or endometrial cancer Personal history of breast, colon, or endometrial cancer – Prevention Using oral contraception Using oral contraception Pregnancy Pregnancy Breastfeeding Breastfeeding Avoiding postmenopausal hormone replacement therapy Avoiding postmenopausal hormone replacement therapy – Early detection?? – Treatment Surgery, chemotherapy, drug therapy Surgery, chemotherapy, drug therapy

43. Skin Cancer 3 forms of skin cancer: 3 forms of skin cancer: Basal cell cancer (lesions and sores) Basal cell cancer (lesions and sores) Squamous cell cancer (raised bumps and sores) Squamous cell cancer (raised bumps and sores) Melanoma (spreads quickly ) Melanoma (spreads quickly ) Risk factors Risk factors – Severe sunburn during childhood, chronic sun exposure during young adulthood, cumulative sun exposure – Large number of moles – Family history Prevention Prevention – Reduce exposure to sun’s rays, use sunscreen Early detection: skin exams Early detection: skin exams Treatment Treatment – Surgery, local removal, chemotherapy, immunotherapy

44. ABCD Evaluation of Moles for Melanoma

45. Testicular Cancer Most common cancer for men aged 20-35  Risk factors Family history, personal history of testicular cancer in other testicle, abnormal development of the testes, history of undescended testicle, infertility or abnormal sperm  Detection - controversial Self exams Medical exams  Treatment Surgery, chemotherapy, radiation

46. Oral Cancer  Cancers that develop in the mouth or the pharynx  Risk factors include: Cigarettes, cigars, pipes, smokeless tobacco High levels of alcohol consumption  Early signs include: Persistent sore in the mouth Lump or bump that won’t heal Patch of white or red along the gums or cheeks  Treatment Surgery Chemotherapy Radiation © MedioImages/PictureQuest

47. Leukemia Group of cancers - originate in the bone marrow or other parts of the body where white blood cells form Group of cancers - originate in the bone marrow or other parts of the body where white blood cells form Overproduction of one type of white blood cell and can lead to increased risk of infection, anemia, and bleeding Overproduction of one type of white blood cell and can lead to increased risk of infection, anemia, and bleeding Risk factors are: Risk factors are: Cigarette smoking and exposure to chemicals Cigarette smoking and exposure to chemicals Ionizing radiation exposure Ionizing radiation exposure Infection with a virus Infection with a virus Treatment Treatment Chemotherapy Chemotherapy Possible bone marrow transplant Possible bone marrow transplant

48. Lymphoma Cancers that originate in the lymph system, part of the body’s immune system Cancers that originate in the lymph system, part of the body’s immune system – Hodgkin’s lymphoma – Non-Hodgkin’s lymphoma Risk factors are: Risk factors are: Infections, medications, or genetic change that weaken the immune system Infections, medications, or genetic change that weaken the immune system Radiation, herbicides, insecticides, and some chemical exposures Radiation, herbicides, insecticides, and some chemical exposures Treatment Treatment Often includes a combination of surgery, chemotherapy, and radiation Often includes a combination of surgery, chemotherapy, and radiation Can sometimes involve immunotherapy or bone marrow transplant Can sometimes involve immunotherapy or bone marrow transplant

49. Questions?