1. Introduction to Cancer basics?
Candy Cooley, Manager National Genetics Education and Development Centre
cancernursing.org online lecture March 2009

2. 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

3. The Global Burden of Cancer 2000
Men
Women
5.3 million cases
3.5 million deaths
4.7 million cases
2.7 million deaths
Lung
Breast
Colon/Rectum
Stomach
Liver
Prostate
Cervix uteri
Oesophagus
Bladder
Non-Hodgkin Lymphoma
Leukaemia
Oral cavity
Pancreas
Kidney
Ovary
902
337
810
293
1050
370
499
446
255
234
558
318
405
241
398
166
384
165
543
204
471
233
279
133
227
111
260 76 99 33
167
121 93 68
144
113
109 86
170 97 81 47
Incidence
Mortality
116
101
112
101
119 71 57 34
192
114
(Thousands)
From: D.M. Parkin The Lancet Oncology 2: (2001)

4. WHO Statistics 2020 15 million people will die from cancer Causes
Ageing population
Obesity
Smoking

8. 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
the effects on the economy go far beyond this to include substantial financial burdens upon families and carers resulting from the disabilities and deaths of people during their productive middle years.

9. 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)

10. 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

11. Division – uncontrolled cell division
Oncogenes
Tumour suppressor genes – p53
Suicide genes – apoptosis
DNA repair genes
There are four main types of gene involved in cell division. Most tumours have faulty copies of more than one of these genes:
Oncogenes
Oncogenes are genes that, under normal circumstances, play a role in telling cells to start dividing. We can think of them as being a bit like the accelerator pedal in a car. When oncogenes are activated, they speed up a cell's growth rate. When one of them becomes damaged, causing cancer, it is like the accelerator becoming stuck down - the cell, and all its daughter cells, are permanently instructed to divide.
Tumour suppressor genes
These genes make proteins whose normal function is the opposite of oncogenes. They tell the cell NOT to divide, and must be switched off by other proteins before a cell can grow. They are like a car's handbrake - it is supposed to be on when the car is at rest. One of the most important tumour suppressor genes is called p53. This gene was co-discovered in 1979 by Cancer Research UK scientist Professor Sir David Lane.
Suicide genes
Apoptosis, or cell suicide, is a highly complex and hugely important process. Cells are usually able to commit suicide whenever something goes wrong, to prevent damage to their neighbours. There are many different genes (and therefore proteins) involved. If these 'suicide genes' become damaged, then a faulty cell can keep dividing and become cancerous.
DNA-repair genes
The DNA in every cell in your body is under constant assault from a variety of directions. But cells contain many different proteins whose job is to repair damaged DNA. Thanks to these, scientists think that the vast majority of DNA damage is repaired immediately, with no ill effects.
But if the DNA damage occurs to a gene that makes a DNA repair protein, a cell's ability to repair itself will be reduced, and this can allow errors to accumulate in other genes over time. This can cause cancer.

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

13. Mutation and Spread Invasion Angiogenesis
To do this, it must acquire more mutations that allow it to survive in other parts of the body. For a cancer cell to spread, it must be able to do two things that the normal cell it grew from could not:
it must be able to leave its usual environment and travel through the blood or lymph system, a process called invasion.
when it arrives at its new location, it must be able to make new blood vessels grow around it and supply it with oxygen and nutrients, a process known as angiogenesis.

14. Types of Cancer Carcinomas Sarcomas Lymphomas Leukaemias Adenomas
Often prefixed by the specific cell
From one point of view, there are as many types of cancer as there are different people, because everyone's genes are different and so no two cancers are exactly alike.
From another point of view, there are as many different types of cancer as there are different types of human cell - just over 200.
However, cancers can be broadly grouped into different types, depending on which tissues they come from.
Carcinomas, the most common types of cancer, arise from the cells that cover external and internal body surfaces. Lung, breast, and colon are the most frequent cancers of this type.
Sarcomas are cancers arising from cells found in the supporting tissues of the body such as bone, cartilage, fat, connective tissue and muscle.
Lymphomas are cancers that arise in the lymph nodes and tissues of the body's immune system.
Leukaemias are cancers of the immature blood cells that grow in the bone marrow and tend to accumulate in large numbers in the bloodstream.
Adenomas are tumours that come from glandular tissue like the thyroid, the pituitary gland the adrenal gland. They are often benign.

16. What are the differences in the features of normal and cancer cells?

17. Malignant versus benign tumours

18. Normal and abnormal cell growth

19. Normal cell growth

20. Cancerous growth

21. Metastatic cancer
Explain the issue of smallest capillary network

22. What causes cancer?

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

24. Heredity 5-10% of Cancers ?15% of all cancers
Molecular biology and Human Genome Project

25. 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)

26. Immunity
HIV / AIDS
Immunosuppression

27. Virus’s Hepatitis B Human T-cell Leukaemia virus Epstein Barr Virus
Human Papilloma Virus (HPV)

28. Bacterial H. pylori Other Parasites: Schistosoma spp
Clonorchis sinensis

29. Estimated Burden of Cancer from Infection Worldwide in 2000
No. of cases Agent % World
cancer
Liver 509,000 HBV, HCV, flukes 5.1
Cervix 471,000 HPV
Stomach 442,000 H. pylori 4.4
Kaposi’s (HIV related) 134,000 HHV
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 ,000 EBV, HIV
Bladder , Schistosoma 0.1
Leukaemia 3,000 HTLV1 0.03
Total 1,801,

30. Chemical Alcohol Asbestos Wood dust Rubber, plastics, dyes
Tar / bitumen
Aflatoxin
Alkylating agents
Tobacco

31. 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 is the single biggest cause of cancer in the world
Experts agree that smoking is the single biggest cause of cancer in the world Smoking causes over a quarter of cancer deaths in developed countries.4
Around half of current smokers will be killed by their habit if they continue to smoke. And 25-40% of smokers will die in middle age 5 6
Smoking causes even more deaths from other respiratory diseases and heart conditions than from cancer.2 If current trends continue, scientists estimate that tobacco will kill about one billion people in the twenty-first century.2
Back to top
Smoking greatly increases the risk of lung cancer
Studies from Europe, Japan and North America have shown that 9 in 10 lung cancers are caused by smoking.2 7 In 2002, lung cancer killed around 33,600 people – about one person every 15 minutes.8
Tobacco smoke was first shown to cause lung cancer in This study found that people who smoked cigarettes a day had 26 times the lung cancer risk of non-smokers. And people who smoked less than 15 cigarettes a day still had 8 times the lung cancer risk of non-smokers.
After these first results came out, UK scientists began a large study of smoking in British doctors, which Cancer Research UK has helped to fund.10 This British Doctors’ Study has provided much of our current knowledge about the dangers of smoking.

32. Smoking and alcohol

33. Industrial pollution

34. Physical causes Ultraviolet radiation Radiation Sunlight
Certain industrial sources
Radiation
Radon
Cancer treatment

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

37. Lifestyle
Age
Occupation
Ethnicity
Deprivation

38. 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)

39. Diagnosis and staging Clinical History Normal diagnostic procedures
Scans, xrays
Blood tests
Biopsy
Pathological staging

40. Staging
Size
Invasion
Lymph nodes
Metastasises

41. 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)

42. 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

43. 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.

44. 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
The Rai stages can be separated into low, intermediate, and high-risk categories. Stage 0 is considered low-risk, 1 and 2 are considered intermediate-risk, and 3 and 4 are considered high-risk. The Rai classification recognizes 5 stages:
Rai Stage 0:Lymphocytosis (blood lymphocyte count is too high, defined as over 15,000 lymphocytes per cubic millimeter).
Rai Stage I: Lymphocytosis plus lymphadenopathy (enlarged lymph nodes).
Rai Stage II: Lymphocytosis plus hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen). Lymphadenopathy may be absent or present.
Rai Stage III: Lymphocytosis and anemia (too few red blood cells). Lymphadenopathy, hepatomegaly, or splenomegaly may be absent or present.
Rai Stage IV: Lymphocytosis and thrombocytopenia (too few blood platelets).
In the Binet staging system, CLL is classified according to the number of affected lymphoid tissue groups (the lymphoid tissue groups are neck lymph nodes, groin lymph nodes, underarm lymph nodes, and the spleen) and the presence of anemia (too few blood cells) or thrombocytopenia (too few blood platelets).
Binet Stage A: Fewer than three areas of lymphoid tissue enlargement.
Binet Stage B: More than three areas of palpable lymphoid tissue enlargement.
Binet Stage C: Anemia and thrombocytopenia .

45. 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.

46. 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".
The principal stage is determined by location of the tumor:
Stage I indicates that the cancer is located in a single region, usually one lymph node and the surrounding area. Stage I often will not have outward symptoms.
Stage II indicates that the cancer is located in two separate regions, an affected lymph node or organ within the lymphatic system and a second affected area, and that both affected areas are confined to one side of the diaphragm - that is, both are above the diaphragm, or both are below the diaphragm.
Stage III indicates that the cancer has spread to both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen.
Stage IV indicates diffuse or disseminated involvement of one or more extralymphatic organs, including any involvement of the liver, bone marrow, or nodular involvement of the lungs.
or B: the absence of constitutional (B-type) symptoms is denoted by adding an "A" to the stage; the presence is denoted by adding a "B" to the stage.
E: is used if the disease is "extranodal" (not in the lymph nodes) or has spread from lymph nodes to adjacent tissue.
X: is used if the largest deposit is >10 cm large ("bulky disease"), or whether the mediastinum is wider than 1/3 of the chest on a chest X-ray.
S: is used if the disease has spread to the spleen.

47. 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).

48. 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

49. 6. Eat fresh fruit and vegetables several times a day.
10 Rules to Avoid Cancer
1. Don’t smoke
2. Don’t smoke.
3. Don’t smoke.
4. Avoid exposure to other known carcinogens, including aflatoxin, asbestos and UV light.
5. Enjoy a healthy diet, moderate in calories,
salt and fat, and low in alcohol.
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 !

50. Thank You!