Community Medicine — Cancer
CANCER
Community Medicine — Exam Notes
Non-Communicable Diseases
Definition of Cancer
Group of diseases characterised by three features:
1. Abnormal growth of cells
2. Ability to invade adjacent tissues and even distant organs (metastasis)
3. Eventual death of the patient if the tumour has progressed beyond the stage at which it can be
successfully removed
Cancer can occur at any site/tissue of the body and may involve any type of cell.
Major Categories of Cancer
• Carcinomas — arise from epithelial cells lining internal organs (mouth, oesophagus, intestines, uterus) and
skin epithelium
• Sarcomas — arise from mesodermal cells of connective tissues (fibrous tissue, fat, bone)
• Lymphomas, myeloma and leukaemias — arise from cells of bone marrow and immune system
Problem Statement
World (2022)
• Global burden: 19,976,499 (≈19.98 million) new cases; 9,743,832 (≈9.74 million) deaths
• Top cancers by cases/deaths globally: lung, breast, prostate, colorectum
• Asia: ~56.1% of global cancer cases and a still-higher share of deaths (higher case-fatality + larger
population)
• Europe: ~22.4% of global cases despite smaller population share (better detection/reporting + ageing
population)
• Both-sex age-standardized incidence rate (World): ~196.9 per 100,000
Males Females Both sexes
Population 3,972,735,747 3,912,335,034 7,885,070,781
New cancer cases 10,311,610 9,664,889 19,976,499
Age-std. incidence rate 212.6 186.3 196.9
Cancer deaths 5,430,284 4,313,548 9,743,832
Rates are per 100,000 population. Source: WHO Global Cancer Observatory, 2024.
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India (2022)
• National Cancer Registry Programme (NCRP) under ICMR — data from 28 population-based and 5
hospital-based cancer registries
• New cancer cases: 1,413,316; deaths: 916,827; 5-year prevalent cases: 3,258,518
• Top 3 cancers in men (by cases): lip/oral cavity, lung, stomach
• Top 3 cancers in women (by cases): breast, cervix uteri, ovary
• Cancer burden is unequally distributed between developed/developing countries, with differing patterns
of distribution
Males Females Both sexes
Population 730,746,615 675,885,166 1,406,631,781
New cancer cases 691,178 722,138 1,413,316
Age-std. incidence rate 97.1 100.8 98.5
Cancer deaths 470,055 446,772 916,827
Age-std. mortality rate 66.5 62.6 64.4
“Westernization” Trends
As low-Human Development Index (HDI) countries become more developed (“westernized”), rapid societal and
economic change alters cancer incidence/mortality patterns — similar to trends already seen in high-HDI
settings.
• Lung cancer is essentially a fatal condition — incidence ≈ mortality, so it dominates cancer deaths
worldwide (1.81 million deaths/year)
• Breast cancer ranks 2nd in incidence worldwide but is NOT among the top 3 causes of cancer death —
reflects effective early diagnosis and treatment
• Incidence : mortality ratio is an indicator of prognosis — a particular cancer with good outcome will show
high incidence but lower rank in mortality
• Westernization is associated with increase in breast, prostate and colorectal cancers (linked to
reproductive, dietary and hormonal risk factors) and decline in infection-related cancers (e.g. stomach,
cervix uteri, liver) as hygiene and infection control improve
Cancer Patterns
Wide variation in distribution of cancer worldwide, e.g.:
• Stomach cancer — common in Japan, low incidence in USA
• Cervical cancer — high in Colombia, low in Japan
• WHO South-East Asia Region — majority are cancers of oral cavity and uterine cervix
International variations attributed to: environmental factors, food habits, lifestyle, genetic factors, or
inadequacy of detection/reporting.
Hospital data: two organ sites most commonly involved are (i) uterine cervix in women and (ii) oropharynx in
both sexes — together ≈ 50% of all cancer cases.
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• Both are predominantly environment-related with a strong socio-cultural relationship
• Both are easily accessible for physical examination and amenable to early diagnosis (clinical exam +
exfoliative cytology)
• Cure rate is very high if treated surgically at Stages I and II
• Problem: most patients present only when disease is far advanced and not amenable to treatment — the
crux of the problem
Causes of Cancer
As with other chronic diseases, cancer has a multifactorial aetiology.
1. Environmental Factors
Responsible for 80–90% of all human cancers.
• (a) Tobacco — major cause of cancers of lung, larynx, mouth, pharynx, oesophagus, bladder, pancreas,
probably kidney; smoking responsible for >1 million premature deaths/year worldwide
• (b) Alcohol — associated with oesophageal and liver cancer; beer consumption possibly linked to rectal
cancer; contributes ≈3% of all cancer deaths
• (c) Dietary factors — smoked fish → stomach cancer; low dietary fibre → intestinal cancer; high beef
consumption → bowel cancer; high-fat diet → breast cancer; also food additives/contaminants under
suspicion
• (d) Occupational exposures — benzene, arsenic, cadmium, chromium, vinyl chloride, asbestos, polycyclic
hydrocarbons; risk considerably increased if individual also smokes; occupational exposure accounts for 1–
5% of human cancers
• (e) Viruses —
◦ Hepatitis B & C → hepatocellular carcinoma
◦ HIV → high relative risk of Kaposi's sarcoma (first recognized manifestation of AIDS); Non-Hodgkin's
lymphoma is a late complication of AIDS
◦ Epstein-Barr virus (EBV) → Burkitt's lymphoma and nasopharyngeal carcinoma; Hodgkin's disease also
believed to be of viral origin
◦ Cytomegalovirus (CMV) — suspected oncogenic agent, linked with Kaposi's sarcoma
◦ Human papilloma virus (HPV) — chief suspect in cancer cervix
◦ Human T-cell leukaemia virus → adult T-cell leukaemia/lymphoma (USA, southern Japan)
• (f) Parasites — e.g. schistosomiasis (Middle East) → carcinoma of the bladder
• (g) Customs, habits and lifestyles — smoking–lung cancer; tobacco and betel chewing–oral cancer, etc.
• (h) Others — sunlight, radiation, air and water pollution, medications (e.g. oestrogen), pesticides
2. Genetic Factors
• Retinoblastoma occurs in children of the same parent (hereditary pattern)
• Mongols (Down syndrome) more likely to develop leukaemia than normal children
• Genetic factors are less conspicuous and more difficult to identify than environmental ones
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• Probably a complex interrelationship between hereditary susceptibility and environmental carcinogenic
stimuli
Cancer Control
A series of measures based on present medical knowledge in the fields of prevention, detection, diagnosis,
treatment, after-care and rehabilitation, aimed at:
• Reducing significantly the number of new cases
• Increasing the number of cures
• Reducing the invalidism due to cancer
Basic approach is through primary and secondary prevention. At least one-third of all cancers are considered
preventable.
1. Primary Prevention
• (a) Control of tobacco & alcohol consumption — offers the greatest hope; control of smoking alone could
reduce cancer burden by over a million cancers/year
• (b) Personal hygiene — improvements may reduce incidence of certain cancers, e.g. cancer cervix
• (c) Radiation — reduce amount of radiation (incl. medical) received by individuals to a minimum, without
reducing benefits
• (d) Occupational exposures — protect workers from industrial carcinogens; enforce in industries
• (e) Immunization — Hepatitis B vaccine (primary liver cancer); HPV vaccine (cancer cervix)
• (f) Foods, drugs and cosmetics — should be tested for carcinogens
• (g) Air pollution — control is another preventive measure
• (h) Treatment of precancerous lesions — cervical tears, intestinal polyposis, chronic gastritis, chronic
cervicitis, adenomata — one of the cornerstones of prevention
• (i) Legislation — to control known environmental carcinogens (tobacco, alcohol, air pollution)
• (j) Cancer education — directed at “high-risk” groups; aims to motivate early diagnosis and treatment
“Danger Signals” of Cancer (early warning signs)
4. A lump or hard area in the breast
5. A change in a wart or mole
6. A persistent change in digestive and bowel habits
7. A persistent cough or hoarseness
8. Excessive loss of blood at periods, or loss outside usual dates
9. Blood loss from any natural orifice
10. A swelling or sore that does not get better
11. Unexplained loss of weight
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2. Secondary Prevention
i) Cancer Registration
A sine qua non for any cancer control programme — provides a base for assessing magnitude of the problem
and planning services. Two types:
• Hospital-based registries — includes all patients (in/out) treated by a particular institution; valuable for
evaluating diagnostic/treatment programmes, but limited for epidemiological use (selected population)
• Population-based registries — extends coverage to a defined geographic area (optimum base population:
2–7 million); provides true incidence rates; useful for aetiological research, surveillance of time trends,
planning and evaluation
ii) Early Detection of Cases
Cancer screening is the main weapon for early detection at a pre-invasive (in situ) or pre-malignant stage.
Effective programmes exist for cervical, breast and oral cancer.
• No point detecting cancer early unless treatment & after-care facilities are available
• Requires mobilization of resources and a cancer infrastructure from primary health care up to complex
cancer centres at state/national level
iii) Treatment
• Should be available to all patients; surgery, radiation, chemotherapy, or combination (multi-modality
approach is now standard practice)
• In developed countries, treatment is geared to high technology
• For patients beyond the curable stage, the goal must be pain relief — “Freedom from cancer pain” is now
considered a right of cancer patients (WHO guidelines)
Cancer Screening
Definition: “Search for unrecognized malignancy by means of rapidly applied tests.”
Screening is possible because:
• (a) Malignant disease is, in many instances, preceded for months/years by a premalignant lesion —
removal prevents subsequent cancer
• (b) Most cancers begin as localized lesions, and if found at this stage a high rate of cure is obtainable
• (c) As much as 75% of all cancers occur in body sites that are accessible
Methods of Cancer Screening
• Mass screening — comprehensive cancer detection exam: rapid clinical exam and examination of one or
more body sites by the physician
• Mass screening at single sites — examination of single sites such as uterine cervix, breast or lung
• Selective screening — examination of people thought to be at special risk, e.g. parous women of lower
socio-economic strata above 30 years for cancer cervix, chronic smokers for lung cancer
1. Screening for Cancer Cervix
• Pap smear (cervical smear) detects the prolonged early phase of cancer in situ
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• Current policy: Pap test at age 30, then every 3 years thereafter; periodic pelvic examination also
recommended
• Organized population-based screening has reduced incidence and mortality from cervical cancer in many
developed countries
• Pap smear requires excessive resources (labs, equipment, trained personnel) → search for cost-effective
alternatives:
◦ VIA — Visual Inspection with 5% Acetic Acid
◦ VIAM — VIA with Magnification
◦ VILI — Visual Inspection post-application of Lugol's Iodine
• Sensitivity of VIA is similar to cytology-based screening; easy to perform and to train health workers
• VIA technique: apply freshly prepared 5% acetic acid (5 ml glacial acetic acid + 95 ml distilled water); a
well-defined opaque acetowhite lesion near the squamo-columnar junction = positive test; single-visit
approach for further management (colposcopy-based treatment) at district hospital
• WHO now recommends HPV testing (HPV-DNA / HPV-mRNA) for cervical screening — an objective test,
simpler, prevents more pre-cancers, and more cost-effective than visual inspection or cytology
• Screening schedule: from age 30 in general population (HPV test every 5–10 years); from age 25 for
women living with HIV (screened every 3–5 years, more frequently)
• HPV-positive women may be treated without diagnostic verification in limited-resource settings; a triage
test (e.g. VIA) is essential before treating HIV-positive HPV-positive women
2. Screening for Breast Cancer
Screening has a favourable effect on mortality from breast cancer. Basic techniques:
• (a) Breast self-examination (BSE) — useful adjuvant though effectiveness not fully quantified; most
cancers are found by women themselves rather than by a physician; likely to remain the only feasible
approach for wide population coverage in many countries
• (b) Palpation by a physician — unreliable for large fatty breasts
• (c) Thermography — advantage of no radiation exposure, but not a sensitive tool
• (d) Mammography — most sensitive and specific for detecting small tumours sometimes missed on
palpation. Three drawbacks:
◦ (i) radiation exposure — ≈500 milliroentgen vs 30–40 milliroentgen for a chest X-ray
◦ (ii) requires high-standard technical equipment and very experienced radiologists, limiting
widespread use for mass screening
◦ (iii) biopsy from a suspicious lesion may be false-positive in as many as 5–10 cases for each true case
detected
• Medical opinion is against routine mammography in the very young — women under 35 should not have
X-rays unless symptomatic or with a family history of early-onset breast cancer
3. Screening for Lung Cancer
• Only two techniques available: chest radiograph and sputum cytology
• Mass radiography at six-monthly intervals has been suggested but evidence in support is not convincing
• Mass screening for lung cancer is NOT recommended as a routine public health policy
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Epidemiology of Selected Cancers
1. Oral Cancer
• One of the ten most common cancers in the world; high frequency in Central & South-East Asian countries
(India, Bangladesh, Sri Lanka, Thailand, Indonesia, Pakistan)
• 2022: ≈3,89,896 persons had oral cancer worldwide; ≈1,88,438 died of it (1.8% of all cancer deaths)
• India 2022: caused 8.7 deaths/100,000 population (total 79,979 deaths); age-std. incidence rate
14.7/100,000 (men), 5.0/100,000 (women)
Epidemiological Features
• (a) Tobacco — ≈90% of oral cancers in South-East Asia are linked to tobacco chewing and smoking; the 10-
year follow-up study (1966–77) of 30,000 individuals in Ernakulam (Kerala), Srikakulam (Andhra) and
Bhavnagar (Gujarat) showed: oral cancer/precancerous lesions occurred almost solely among tobacco
users; cancer almost always occurred on the side of the mouth where the tobacco quid was kept; risk was
36 times higher than non-chewers if the quid was kept in the mouth during sleep
• (b) Alcohol — has a synergistic effect with tobacco in causing oral cancer
• (c) Pre-cancerous stage — leukoplakia and erythroplakia can be detected up to 15 years prior to change
into invasive carcinoma; intervention at this stage may cause regression
• (d) High-risk groups — tobacco chewers/smokers, bidi smokers, betel-quid users, people who sleep with
the quid in the mouth
• (e) Cultural patterns — indigenous smoking forms: bidi, chutta (cigar), chilum, hookah; betel quid = betel
leaf + arecanut + lime + tobacco; khaini = rubbed tobacco flakes + slaked lime; nass/nasswar (Central Asian
USSR) = tobacco + ash + lime + cottonseed oil
• Epidermoid carcinoma of the hard palate is common in the eastern coastal districts of Andhra Pradesh,
associated with reverse smoking of chutta (burning end inside the mouth)
Prevention
• Primary — amenable to primary prevention; eliminating tobacco habits achieves great reduction in
incidence; requires intensive public education and legislative measures (banning/restricting tobacco sale)
• Secondary — oral cancers are easily accessible for inspection, allowing early detection; leukoplakia can be
cured by stopping tobacco use; main treatment modalities are surgery and radiotherapy; in developing
countries, over 50% of oral cancers are detected only after reaching an advanced stage; primary health
care workers (village health guides, multi-purpose workers) play a key role in early detection during home
visits
2. Cancer of the Cervix
• 4th most frequent cancer in women — 6,60,000 new cases in 2022 (7.1% of all female cancers); ≈3,50,000
deaths (3.6% of all cancer deaths in women)
• ≈94% of cervical cancer deaths occur in low- and middle-income countries; rates have declined markedly
(40 years) in industrialized countries, mainly due to extensive screening programmes
• India: cancer cervix = 9.0% of all cancer incidence among women; age-std. incidence rate ≈17.7/100,000;
estimated deaths 79,979 (2022)
Natural History
Normal epithelium ↔ Dysplasia ↔ Cancer in situ → Invasive cancer (Fig. 5 — hypothetical model)
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• Carcinoma in situ persists for a long time — more than 8 years on average
• Progression from pre-invasive to invasive stage may average 15–20 years or longer (not precisely known)
• Some in situ cases will spontaneously regress without treatment
• Once invasive, disease spreads by direct extension into lymph nodes and pelvic organs
Symptoms
• Early stage: irregular spotting/light bleeding between periods, postmenopausal bleeding/spotting,
bleeding after intercourse, increased (sometimes foul-smelling) vaginal discharge
• Advanced stage: persistent back/leg/pelvic pain, weight loss, fatigue, loss of appetite, foul-smelling
discharge and vaginal discomfort, swelling of one or both legs
Causative Agent
Human papilloma virus (HPV) — sexually transmitted; found in >95% of cervical cancers; current evidence shows
HPV is a necessary cause. >90% of infected persons eventually clear the infection. Takes 15–20 years to develop
cervical cancer in women with normal immunity, but only 5–10 years in immunocompromised women (e.g.
untreated HIV infection).
Risk Factors
• (a) Age — incidence rises rapidly from 25 to 45 years, then levels off, and finally falls again
• (b) Genital warts — past/present clinical genital warts is an important risk factor
• (c) Marital status — cases more likely to be widowed, divorced, separated, or have multiple sexual
partners; rare in virgins, common in those with multiple partners
• (d) Early marriage — early coitus, early childbearing, repeated childbirth associated with increasing risk
• (e) Oral contraceptive pills — increased risk with increased duration of use, and with use of high-
oestrogen pills
• (f) Socio-economic class — more common in lower socio-economic groups (reflects poorer genital
hygiene)
• (g) HIV — women living with HIV are 6 times more likely to develop cancer cervix
Prevention and Control (WHO Global Strategy, 2020)
Primary prevention Secondary prevention Tertiary prevention
Screening from age 30 (general
HPV vaccination (girls 9–14 yrs);
population) / age 25 (women with Treatment of invasive cancer at
health info & warnings on tobacco;
HIV) with a high-performance test any age — surgery, radiotherapy,
sex education; condom promotion;
≥ HPV test, followed by immediate chemotherapy, palliative care
male circumcision
treatment
Prevention should be multidisciplinary: community education, social mobilization, vaccination, stopping smoking, condom
use, voluntary male circumcision, screening, treatment, palliative care.
HPV Vaccination
• Works best if administered prior to exposure to HPV
• WHO recommends vaccinating girls aged 9–14 years (before most have started sexual activity); some
countries also vaccinate boys (prevents HPV-related cancers in males)
• HPV vaccination does NOT replace cervical cancer screening — population-based screening programmes
are still needed even after vaccine introduction
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3. Breast Cancer
• 2nd leading cause of global cancer incidence (2022): 2.29 million new cases (11.5% of all cancer cases); 5th
leading cause of cancer mortality — 6,70,000 deaths
• Among women: breast cancer accounts for 1 in 4 cancer cases and 1 in 6 cancer deaths; ranks 1st for
incidence in the vast majority of countries
• HDI inequity: very high-HDI countries — 1 in 12 women diagnosed in lifetime, 1 in 71 die of it; low-HDI
countries — 1 in 27 diagnosed, but 1 in 48 die (poorer survival despite lower incidence)
• India 2022: TOP cancer overall — 192,020 new cases (13.6%); incidence rate ≈26.6/100,000; mortality
13.7/100,000; survival decreases 2.7× when detected at Stage IV vs Stage I
The Disease
• Most commonly presents as a painless lump or thickening in the breast; women should consult a doctor
within 1–2 months of finding an abnormal lump, even without pain
• Symptoms: lump/thickening; alteration in size, shape or appearance; dimpling, redness, pitting or other
skin changes; change in nipple appearance; abnormal nipple discharge
• ≈90% of breast masses are NOT cancerous — benign causes include fibroadenomas, cysts and infections
• Most common first detectable site of spread: lymph nodes under the arm; later spread to lungs, liver,
brain, bones
Risk Factors
• (a) Age — uncommon below 35; incidence rises rapidly between 35–50 years; slight bimodal dip at
menopause; secondary rise after age 65
• In Indian women, breast cancer occurs about a decade earlier (mean age ≈42) than in Western/white
women (mean age ≈53)
• (b) Family history — risk is high with a positive family history, especially if a mother or sister had breast
cancer while premenopausal
• (c) Parity — risk directly related to age at first full-term pregnancy: early first pregnancy is protective;
pregnancy delayed to late 30s = higher risk than multiparous women; unmarried women have more breast
tumours than married women
• (d) Age at menarche/menopause — early menarche and late menopause are established risk factors;
surgically induced menopause reduces risk; 40+ years of menstruation doubles the risk compared with 30
years
• (e) Hormonal factors — elevated oestrogen and progesterone are important risk factors
• (f) Prior breast biopsy — for benign disease is associated with increased risk
• (g) Diet — high-fat diet and obesity are linked to breast cancer
• (h) Socio-economic status — more common in higher socio-economic groups (explained by later age at
first birth)
• (i) Others — radiation exposure increases risk; prolonged use of oral contraceptives before first pregnancy
or before age 25 may increase risk in younger women
Prevention
Behavioural choices that reduce risk:
• Prolonged breastfeeding
• Regular physical activity
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• Weight control
• Avoidance of harmful use of alcohol
• Avoidance of exposure to tobacco smoke
• Avoidance of prolonged use of hormones
• Avoidance of excessive radiation exposure
Even controlling all modifiable risk factors would reduce risk of developing breast cancer by at most 30%. Female gender is
the strongest risk factor; ≈0.5–1% of breast cancers occur in men.
Treatment
• Surgery — historically mastectomy (complete removal); today majority can be treated with
lumpectomy/partial mastectomy + radiation
• Lymph node surgery — sentinel node biopsy now preferred over complete axillary dissection (fewer
complications)
• Systemic therapy by biological subtype: ER/PR-positive → endocrine therapy (tamoxifen, aromatase
inhibitors) for 5–10 years; ER/PR-negative → chemotherapy; HER2-positive → targeted therapy (e.g.
trastuzumab) combined with chemotherapy
• Radiotherapy — can allow avoidance of mastectomy in early-stage disease; reduces recurrence even after
mastectomy in later-stage disease
• Effectiveness of therapy depends on completing the full course — partial treatment is less likely to give a
positive outcome
WHO Global Breast Cancer Initiative (GBCI)
• Objective: reduce global breast cancer mortality by 2.5% per year (2020–2040), averting 2.5 million deaths
• This would avert 25% of breast cancer deaths by 2030 and 40% by 2040, among women under 70 years
• Three pillars: (1) health promotion for early detection; (2) timely diagnosis; (3) comprehensive breast
cancer management
4. Lung Cancer
• Known in industrial workers from the late 19th century; became a public health problem in the Western
world in the 1930s (men), followed in the 1960s by women — following the adoption of cigarette smoking
• WHO: death rate due to lung cancer increased 76% in men and 135% in women between 1960–1980
• 2022: 2.48 million new cases, 1.81 million deaths — the top most commonly diagnosed cancer and the
leading cause of cancer death worldwide (12.4% of all cases, 18.7% of all deaths)
• In men: leading cause of both incidence and mortality; in women: 2nd for incidence (after breast) and 2nd
for mortality (after breast)
• Incidence/mortality rates ≈2× higher in men than women; male-to-female ratio ranges from 1.2 (North
America) to 5.6 (Northern Africa)
• Rates 3–4× higher in transitioned vs transitioning countries; pattern may shift as 80% of smokers (≥15 yrs)
now reside in low/middle-income countries
• India 2022: age-std. incidence rate — total 5.8/100,000 (men 8.5, women 3.2); estimated deaths 75,031;
mortality rate 5.3/100,000
Epidemiological Features
• a. Age and sex — about 1/3 of all lung cancer deaths occur below age 65; in many industrialized countries
incidence is currently rising faster in females than males
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• b. Risk factors:
◦ (i) Smoking — first suggested as a cause in the 1920s; causal relationship with cigarette smoking now
well established
◦ Indian studies: lung cancer risk for cigarette smokers is 8.6× that of non-smokers
◦ Risk is strongly related to: number of cigarettes smoked, age of starting, inhalation/smoking habits,
nicotine and tar content, and length of cigarette smoked
◦ “Passive smoking” (exposure to others' smoke) also increases risk
◦ In countries with widespread smoking, it is responsible for 90% of lung cancer deaths; incidence falls
after cessation of smoking (shown in a 20-year prospective study of British doctors)
◦ Most noxious components of tobacco smoke: tar (carcinogenic), carbon monoxide and nicotine
(cardiovascular risk via blood coagulation and reduced threshold for ventricular fibrillation)
◦ A study in India found no difference in tar/nicotine delivery between filter and non-filter cigarettes —
filters give no protection to Indian smokers
◦ Bidi smoking carries a higher lung cancer risk than cigarette smoking, owing to higher concentration
of carcinogenic hydrocarbons in the smoke
◦ (ii) Other factors — air pollution, radioactivity, occupational exposure to asbestos, arsenic and its
compounds, chromates, polycyclic aromatic hydrocarbons, certain nickel-bearing dusts; interaction
demonstrated between smoking and asbestos exposure
Prevention
1. Primary Prevention — of greatest importance, since 80–90% of lung cancer cases in developed countries are
due to cigarette smoking. Broad methods:
• a. Public information and education — mass media campaigns; target entire population, with emphasis
on young people and school children; national anti-smoking campaign needed
• b. Legislative and restrictive measures — control of sales promotion; health warnings on
packets/advertisements; product description of harmful substance yield; upper limits for harmful
substances; taxation; sales restrictions; restriction on smoking in public places/workplaces
◦ In India: the Cigarettes (Regulation of Production, Supply and Distribution) Act, 1975 mandates the
statutory warning “Cigarette Smoking is Injurious to Health” on all cigarette packets
◦ Cigarettes and Other Tobacco Products Act (COTPA), 2003 — comprehensive tobacco control
legislation (advertisement, trade, commerce, production, supply, distribution)
• c. Smoking cessation activities — over 90% of those who quit do so of their own volition; treatments aim
to relieve “abstinence symptoms” (sleeplessness, craving, dizziness, constipation); methods include
smoking cessation clinics, nicotine substitutes, hypnosis
• d. National and international coordination — required since smoking is a worldwide epidemic
2. Secondary Prevention
• Only two procedures available for early detection: chest X-ray and sputum cytology
• Screening for early-stage lung cancer is less attractive: more expensive and less potential for reducing
mortality than primary prevention
• Mass screening for lung cancer is NOT recommended as a routine public health policy
• Untreated patients: median survival 2–3 months; with combined chemotherapy: 10–14 months — given
these limitations, primary prevention deserves greater attention; pain relief is an important part of
treatment
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5. Stomach Cancer
• 2022: over 0.968 million new cases; 6,60,175 deaths — 6.8% of all cancer deaths; 5th most frequently
diagnosed cancer and 5th leading cause of cancer death
• Rates are 2-fold higher in men than women
• Two topographical categories:
◦ Noncardia gastric cancer (arising from distal regions) — rates have steadily declined over the last 50
years in most populations
◦ Cardia cancer (arising near the oesophageal-gastric junction) — epidemiologically similar to
oesophageal adenocarcinoma; key risk factors are obesity and gastro-oesophageal reflux disease
(GERD); incidence is increasing, particularly in high-income countries
• India 2022: age-std. incidence rate 6.1/100,000 (men), 3.0/100,000 (women); crude mortality rate
4.1/100,000; total 57,727 deaths
• Decline in industrialized countries linked to: improved food preservation practices; better nutrition richer
in vitamins from fresh vegetables/fruits; less consumption of preserved, cured and salted foods
• Helicobacter pylori infection contributes to risk, probably by interacting with other factors
• Symptoms are non-specific (weight loss, fatigue, gastric discomfort) → most cases diagnosed at an
advanced stage
• Diagnosis: barium X-rays and biopsy
• Treatment: surgical removal of the tumour, with or without adjuvant chemotherapy
• Prognosis: generally poor — overall ≈20% 5-year survival; if tumour is localized to the stomach, ≈60% 5-
year survival, but only ≈18% of all cases are diagnosed at this early stage
• Screening by photofluoroscopy has been widespread in Japan since the late 1960s, with declining
mortality (unclear whether attributable to screening alone)
Time Trends
• A few decades ago, cancer was the sixth leading cause of death in industrialized countries; today it is the
second leading cause of death
• There are a number of reasons for the screening control and self/assisted detection strategies being
developed about advanced and incurable cancer patients
• Three main reasons for the overall increase:
12. Longer life expectancy
13. More accurate diagnosis
14. Rise in cigarette smoking, especially among males
• Overall rates do NOT reflect different trends according to type of cancer:
◦ Large increase in lung cancer incidence
◦ Stomach cancer has shown a declining trend in most developed countries, for reasons not fully
understood
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Quick Revision — Key Numbers (India, 2022)
Cancer Top by Key fact
Top cancer overall in India; 192,020 cases;
Breast Incidence (women)
26.6/100,000
Oral cavity Incidence (men) ASR 14.7/100,000 (men); ~90% linked to tobacco
Lung Mortality (overall) ASR 5.8/100,000; leading global cause of cancer death
Cervix uteri Incidence (women) 9.0% of female cancers; ASR 17.7/100,000
Stomach — ASR 6.1/100,000 (men); H. pylori-linked
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