MBBS V WCS 14 – The War against Cancer

The War against Cancer

Epidemiology
 Global burden:
o Incidence: 18.1 million
o Mortality: 9 million deaths
 Future trends
o Incidence: 29 million by 2040
 WHO
o SDG:
 Decreased 1/3 premature deaths from non-communicable disease
through prevention and treatment by 2030
o Comprehensive Cancer Control Strategy and Action Plan
1. Prevention
2. Early detection
3. Diagnosis and treatment
4. Palliative care and survivorship treatment
 Hong Kong
o Incidence: 34028 in 2018
 Colorectal: most common
 Nasopharyngeal CA: decreased most past 2009
o Mortality: lung CA most common
o Men: age standardized rates of common cancers is 0 (total number of cases
increase due to ageing population, but age standardized rate is stable)
o Women: age standardized rates are still increasing
o Age standardized mortality has decreased (reflects success of current tx)
 HK Cancer Strategy 2019
1. Reduce incidence and mortality of cancer
2. Adopt a holistic approach
3. Improve QoL of patients through better access to evidence based prevention,
screening, early detection and diagnosis
4. Transform concept of care for survivors and perceive cancer as chronic illness
5. Capitalise on innovation, technology, surveillance system and research
 Principles
o Prevent preventable
o Treat the treatable
o Palliate the palliable

Cancer prevention
 Risk factors: 1/3 to ½ are preventable if reduce risk factors
1. Tobacco (20% of all cancer deaths, associated with 17 different cancers)
 WHO Framework Convention on Tobacco Control: MPOWER
 Decrease public area smoking
 Advertising control
 Tax increase
2. Infection
 H. pylori  stomach cancer
 Hepatitis B and C  liver cancer
 Vaccination
 HPV  cervix, oropharyngeal CA
 Vaccination
MBBS V WCS 14 – The War against Cancer

3. Obesity (increase risk for 13 cancer types)

 Unhealthy diet: processed meat (increase risk of colorectal CA)
 Physical inactivity
4. Alcohol (4% of all cancers deaths)
5. Hormonal factors (breast cancer)
 Increasing breastfeeding duration from 12 months to 2 years can reduce
22,000 breast cancer deaths per year
6. Ultraviolet radiation (>90% skin cancer UV light prevented)
 Sunlight
 Tanning
7. Occupational carcinogens and environmental pollutants
8. Human carcinogens
 Nitrosamines  nasopharyngeal cancer
 General recommendation: healthy lifestyle
1. No smoking
2. Regular physical activity (150 min moderate activity, 75 min vigorous activity)
3. Limit alcoholic drinks (<2 drinks for men; 1 drinks for women per day)
4. Healthy diet (3 portions fresh veg + 2 portion fruit, <500g of red meat, no
processed meat)
5. Avoid exposure to UV rays
6. Breastfeeding
7. Maintain healthy body weight

Early detection
 Principles
o Alertness to presenting features
 Reduce delay in seeking medical treatment
o Screening of asymptomatic people  detect cases earlier
 Well recognized natural history of condition (development from latent
to confirmed malignancy)
 Effective treatment for detected cancer
 Suitable test/examination with a high level of accuracy

*Should be fully informed and associated with counselling

 Methods
o Education for public and health professionals (e.g. HK cancer society)
o Population screening (government sponsored)
 Cancer should be a common health problem
 Cost effective analysis performed
 Cost of screening (include diagnosis and treatment)
 vs Expenditure on medical care as a whole
MBBS V WCS 14 – The War against Cancer

i. Colorectal cancer (most common in HK)

 Prevention
1. Healthy diet
2. Increase physical activities
3. Maintain healthy body weight
4. Avoid smoking
5. Limit alcohol consumption
 Screening: strongly recommended for 50-75 years (strong evidence – incidence and
mortality are both reduced) via following 3 methods
o Fecal occult blood test or fecal immunochemical test (preferred) annually
 Positive test then followup with colonic evaluation (colonoscopy)
 Immunochemical test: fewer false +ve and more specific for colon
 Problem: sensitivity limited due to intermittent bleeding only
o Flexible sigmoidoscopy (FS) every 5 years
 Simple without need of sedation
 Problem: only detecting cancer in sigmoid and rectum
o Colonoscopy every 10 years
 Benefit: significant impact shown by case control and cohort study
 Sensitivity and specificity >90% and 99%
 Polypectomy (reduce 50% incidence of CRC)
 Problem: sedation is needed
o *Sponsored by government in HK
 HK Colorectal cancer screening
o 3 year pilot programme in 2016 for aged 50-61-75 years
o Fecal occult blood +ve sponsored
o If +ve  colonoscopy sponsored ($7800 – 8500/case)

ii. Cervical cancer

 Pathophysiology
o Orderly sequence, with long latency before progression
 1. HPV infection
 2. High grade lesion
 3. Invasive cancer
o HPV types: 13 associated with cervical intraepithelial neoplasia (most HPV
infections never progress beyond low grade disease CIN1 and 80-90% of low
grade disease regress spontaneously)
 Prevention
1. Preventive vaccine before sexually active
2. Practice safe sex
3. Avoid smoking
4. Healthy diet: rich in fresh fruit and vegetables
 Screening: strongly recommended for 25-64 years
o Vaccination does NOT substitute screening
o Hong Kong screening programme (low compliance rate though)
 Aged 25-64
 Cervical smear (liquid based pap) at 3 yearly intervals after 2
consecutive normal annual smears
 Presentation: 60% are diagnosed at stage I (32%) and II (30%)
MBBS V WCS 14 – The War against Cancer

o Another option: HPV DNA test

 Advantages
 Self-testing (from vaginal sample herself)
 High sensitivity for detecting CIN
 HPV precede cytology changes (persistent HPV infection 
LSIL  HSIL)
 Potential benefit of spacing screening period from 3 to 5 years
 Challenge: good triage method to for colposcopy when +ve test
 Globally: WHO Call to eliminate cervical cancer (have tools to do it)
o By 2030: aim to reduce incidence to <4 per 100,000 (rare than rare dx) and
reduce 30% mortality from cervical cancer
 90% girls fully vaccinated with HPV vaccine by 15 years
 70% of women screened with HPV test at 35-45 years
 90% women identified with cervical disease with effective treatment
iii. Breast cancer
 Prevention
1. Healthy body weight
2. Increase physical activity
3. Limit alcohol consumption
4. Healthy diet
5. Consider breastfeeding
6. Consider earlier childbirth
7. Cautious about post-menopausal hormonal replacement pills (combined pill)
 Screening: different ways
o Breast self examination
 Insufficient evidence to reduce incidence or mortality
 However, encouraged to do so to be more familiar with breast texture
and report any obvious changes promptly
o Clinical breast examination (annually)
 Insufficient evidence: sensitivity is 54% (though specificity is 94%)
o Mammography (MMG)
 Sensitivity: 83-95% (false positive 0.9-6.9)
 Reduce mortality by 20% via routine screening
 Limited evidence in Cochrane review
 Adequate randomized trials did not show significant benefit
 Concerns about over-diagnosis
o Different countries have different policies
 Hong Kong: no population screening
 Positive predictive value with MMG is only 5%
 No randomized control trial for Chinese women
 Incidence of breast cancer in HK is lower than the West
 Cost effectiveness may be questioned
 However, HK anti-cancer society
 Consider screening for high risk cohorts:
1. BRCA gene mutation
2. Family of breast and ovarian cancer
 If screen, consider starting at age 40 years
o 18% of invasive cancer and 19% carcinoma in situ
patients are >45 years
 Re-evaluated cost effectiveness for general population
 Other countries: start at diff. age groups and frequencies
MBBS V WCS 14 – The War against Cancer

iv. Liver cancer

 Prevention
1. Preventive vaccine against Hep B at birth
2. Limit alcohol
3. Avoid fermented peanut (aflatoxin)
4. Avoid smoking
5. Safety measure against Hep C transmission via blood transfusion
 Screening
o High risk cohort:
1. Chronic carrier of Hep B
2. Liver cirrhosis
o Recommendation
 Half yearly ultrasound with serum AFP  reduce HCC mortality 37%

v. Lung cancer
 Prevention
1. Avoid or quit smoking (most important)
2. Healthy diet
 Screening
o Consider low dose CT for heavy smokers (more sensitivity than CXR)  reduce
mortality
 Currently in the USA: 55 to 80 years with 30 pack year smoking hx,
currently smoke, or quitted within the past 15 years
 Some concerns about cost effectiveness (hence not applied in all
countries)

v. Prostate cancer
 Prevention
o Healthy diet: low meat and other low fatty foods reduce incidence by 10-20%
 Screening: controversy
o Generally NOT recommended population screening tool
 False positive: elevated PSA (2/3 of men elevated PSA do not have
prostate cancer at biopsy)
 Prostatic hypertrophy
 Prostatitis
 Urinary tract infection
o US Preventive services task force
 2012: Grade D (more harm than benefit)
 2018: Grade C for aged 55-69 years (small benefit); Grade D >70 years
MBBS V WCS 14 – The War against Cancer

Treatment
 Principles: timely and appropriate treatment for all
 Multidisciplinary

 Marked inequity in accessibility to treatment  survival

o Manpower
o Equipment
o Essential drugs
MBBS V WCS 14 – The War against Cancer

 Hong Kong (90% cancer patients go to public hospitals for treatment)

o Delay in treatment from first diagnosis to first treatment at 90th percentile:
 80 days for colorectal cancer
 66 days for breast cancer
 54 days for nasopharyngeal cancer
o Recommendation for improvement
1. Setting targets
 Reduce waiting time (90th percentile) to <30 days
o From 1st suggestive symptom to definitive diagnosis
o From diagnosis to 1st definitive treatment
2. Advanced planning
 Manpower, hospital infrastructure, equipment
3. Public private partnership
 Expansion of subsidy to cover essential investigations and tx
4. Affordability (many still self financed items – esp. middle class)
 To steadily increase scope of coverage for expensive tx
 To enforce health insurance coverage for cancer tx
 To consider tax deductions for cancer treatment

Palliative care
 Principles: palliative care and holistic care for cancer survivors and carers
o With effective treatment, more survivors >60% cancer patients survive more
than 5 years (>30% patients survive more than 10 years)
o However, increasing medical (due to cancer itself and treatment), emotional
(recurrence), social challenges
 7.8 million disability years worldwide
 Pain control (marked inequity in accessibility to pain control)
o Principle
 More than 80% incurable cancer patients suffer from pain
 More than 80% cancer pain can be controlled
 Palliative care
o Enhance psychosocial support
 Morbidities due to cancer or treatment (rising prevalence of survivors)
 Emotional fear of recurrence
 Essential drugs for pain and symptom relief
 Hospice care and spiritual support
o Multidisciplinary programs to regain capability
o Analyze unmet needs of cancer patients/survivors and carers

Nasopharyngeal cancer (success story: decrease incidence and mortality)

 Found out carcinogen ingested rather than inhaled (Ho, 1978)
o Salted fish contains nitrosamines
 Prevention recommendation effective  significant decrease in incidence of NPC
1. Avoid consumption salted fish and preserved foods (esp. young children)
2. Decrease smoking
3. Increase fresh vegetable
 Screening: insufficient evidence  shift in stage distribution and survival
o Recommended for high risk cohorts: EBV serology/DNA + endoscopy
 Family members of NPC patients (1st degree relatives)
o Highly curable if stage I (>95% curable by radiotherapy + chemo) but only 19%
stage I and stage II at diagnosis (many present late)
MBBS V WCS 14 – The War against Cancer

Advancing radiotherapy techniques: 2D to 3D to IMRT Era (accuracy)

 Deliver high dose whilst protecting normal tissues (with chemo too)
o Increase survival
o Decrease toxicity
 New trends
o New developments in radiotherapy techniques
o Adjuvant chemotherapy
o Changing sequence of chemotherapy (induction AND concurrent chemo)