Head Neck Cancer Dr P.K

8/8/2019 Head Neck Cancer Dr P.K

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Epidemiology and scope ofEpidemiology and scope of

preventive oncology in Head andpreventive oncology in Head and

Neck CancerNeck Cancer

Prof. Prabir Kr. SurProf. Prabir Kr. Sur

DirectorDirector, IPGME&R, KOLKATA, IPGME&R, KOLKATA&&

ChairmanChairman, ICRO, ICRO


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BackdropBackdrop

There are approximately 2 to 2.5 millionThere are approximately 2 to 2.5 millioncases of cancer in India at any given pointcases of cancer in India at any given pointof timeof time

There are 7,00,000 new cancer patientsThere are 7,00,000 new cancer patientsdiagnosed every year in India.diagnosed every year in India.

Commonest cancers in India are:Commonest cancers in India are:

## Tobacco related cancersTobacco related cancers -- around 3,00,000 cases / yeararound 3,00,000 cases / year# Cancer of the Cervix Uteri# Cancer of the Cervix Uteri -- around 1,00,000 cases / yeararound 1,00,000 cases / year

# Breast cancer# Breast cancer -- around 80,000 cases / yeararound 80,000 cases / year..


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Head & Neck CancerHead & Neck Cancer

Usually refers to neoplasms arising fromUsually refers to neoplasms arising frombelow the skull base to the region of thoracicbelow the skull base to the region of thoracicinletinlet

Diverse group of diseases each with distinctDiverse group of diseases each with distinct

epidemiologic, anatomic and pathologicepidemiologic, anatomic and pathologicfeaturesfeatures

Wide variation in natural history, prognosisWide variation in natural history, prognosisand treatment considerationsand treatment considerations

An area of great importance to theAn area of great importance to theresearchers and oncologists because of theresearchers and oncologists because of thephysical and psychological morbidity itphysical and psychological morbidity it

producesproduces


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World scenario in Head & Neck CancerWorld scenario in Head & Neck Cancer

Constitute 5% of all cancers worldwideConstitute 5% of all cancers worldwide Wide variation in incidence across theWide variation in incidence across the

globeglobe

Incidence relatively low in WesternIncidence relatively low in WesternEurope and the USA, although highEurope and the USA, although highincidence of oral cancer found in Franceincidence of oral cancer found in France

Higher incidence in countries of southHigher incidence in countries of south--

east Asia, parts of Africa and Southeast Asia, parts of Africa and SouthAmericaAmerica

In USA, incidence in black males isIn USA, incidence in black males isalmost double than that of white males.almost double than that of white males.


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Incidence of Oral CancerIncidence of Oral Cancer


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Indian ScenarioIndian Scenario

India is one of the high incidence zones inIndia is one of the high incidence zones inhead & neck cancerhead & neck cancer

In India,the most common H&N cancers areIn India,the most common H&N cancers are

those of oral cavity and pharynxthose of oral cavity and pharynx Age adjusted incidence for these sites inAge adjusted incidence for these sites in

Indian males range from 10.8 to 38.8 andIndian males range from 10.8 to 38.8 andamong females, 6 to 15 per 1 lakh populationamong females, 6 to 15 per 1 lakh population

In fact, mouth and pharynx cancers are 3In fact, mouth and pharynx cancers are 3rdrd

most common cancer in males and 4most common cancer in males and 4thth mostmostcommon in females in the developingcommon in females in the developingcountriescountries


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Indian ScenarioIndian Scenario (contd)(contd)

In our hospital practice, H&N CancersIn our hospital practice, H&N Cancersrepresent almost 25% of all new casesrepresent almost 25% of all new casesannuallyannually

Relative proportion of individual cancer sitesRelative proportion of individual cancer sitesvary in different regions of India e.g Bhopalvary in different regions of India e.g Bhopal

has the highest incidence of Tongue cancerhas the highest incidence of Tongue cancerin the world (8.8 /1 lakh), compared toin the world (8.8 /1 lakh), compared toBangalore (with a rate of 3.5/ 1 lakhBangalore (with a rate of 3.5/ 1 lakhpopulation)population)

Laryngeal and hypopharyngeal cancers areLaryngeal and hypopharyngeal cancers aremore common in Eastern India whereas themore common in Eastern India whereas theNorthNorth--eastern states (Mizoram, Arunachaleastern states (Mizoram, ArunachalPradesh) have higher predominance ofPradesh) have higher predominance ofnasopharyngeal cancersnasopharyngeal cancers


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Etiologic Factors in H & N CancerEtiologic Factors in H & N Cancer

AgeAge: Risk increases with age, most: Risk increases with age, mostpatients are above 50 except for salivarypatients are above 50 except for salivarygland and nasopharyngeal tumoursgland and nasopharyngeal tumourswhich occur in younger age groups.which occur in younger age groups.

Overall male to femaleOverall male to female ratioratio is nearlyis nearly 4:14:1 Commonest knownCommonest known etiological factoretiological factor isis

tobaccotobacco smokingsmoking which increases risk ofwhich increases risk ofdeveloping cancer by 5developing cancer by 5--25 folds.25 folds.

AlcoholAlcohol has an additive effecthas an additive effect

Tobacco chewingTobacco chewing is also another highis also another highrisk factor, which increases incidence ofrisk factor, which increases incidence of

oral cancer among womenoral cancer among women


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Etiologic FactorsEtiologic Factors

Local customsLocal customs:: incidence of hard palateincidence of hard palatecancer due to Reverse smoking of chuttacancer due to Reverse smoking of chuttain Andhrapradeshin Andhrapradesh

Pipe and cigarPipe and cigar smokerssmokers: High incidence: High incidence

of lip and oral cavity cancersof lip and oral cavity cancers

Tobacco chewingTobacco chewing: High buccal and: High buccal and

oropharyngeal canceroropharyngeal cancer

Low nutritional statusLow nutritional status and poor vitaminand poor vitaminintakeintake

Poor oroPoor oro--dental hygienedental hygiene and ill fittingand ill fitting

denturesdentures


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Etiologic FactorsEtiologic Factors (contd)(contd)

Occupational exposureOccupational exposure:: Wood dust,Wood dust,textile fibre, nickel,radium etctextile fibre, nickel,radium etc

Exposure to dust and chemicalExposure to dust and chemical

constituents:constituents: High incidence of cancerHigh incidence of cancerof nasal and paranasal sinusesof nasal and paranasal sinuses

Viral infectionsViral infections:: EB VirusEB Virus caustive factorcaustive factor

for incidence of nasopharyngeal cancerfor incidence of nasopharyngeal cancer HPV 16HPV 16:: in >50% of oropharyngealin >50% of oropharyngeal

cancer Better clinical outcome incancer Better clinical outcome in

tumours positive to HPV DNA(E6 &E7)tumours positive to HPV DNA(E6 &E7)


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Field CancerizationField Cancerization

Typically found in Cancer of head and neckTypically found in Cancer of head and neck(especially oral and pharyngeal cancers) and(especially oral and pharyngeal cancers) andurinary bladderurinary bladder

Multiple cancers throughout upper aeroMultiple cancers throughout upper aero--

digestive tractsdigestive tracts Occurs in patients with heavy tobacco andOccurs in patients with heavy tobacco and

alcohol exposuresalcohol exposures

Molecular studies point towards a commonMolecular studies point towards a common

clonal progenitor cell with an early molecularclonal progenitor cell with an early molecularalterationalteration

Treated patients have High risk (3Treated patients have High risk (3--4%/yr) of4%/yr) ofdeveloping metachronous tumoursdeveloping metachronous tumours

ChemopreventionChemoprevention can reduce this riskcan reduce this risk


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Studies done in IndiaStudies done in India

Studies by Sankaranarayan,Nair et alStudies by Sankaranarayan,Nair et al::

i) established causative role of bidi andi) established causative role of bidi andcigarette smoking and alcohol drinking incigarette smoking and alcohol drinking inIndian population of oral,pharyngeal &Indian population of oral,pharyngeal &laryngeal cancerslaryngeal cancers

ii) Quantitative estimation of risk done alsoii) Quantitative estimation of risk done also

Studies by P.C.Gupta et alStudies by P.C.Gupta et al:: showed reverseshowed reverseeffects of stopping tobacco in interventioneffects of stopping tobacco in interventiontrialstrials

Recent study by Gangadharan fromRecent study by Gangadharan fromKeralaKerala:: showed trends of decreasingshowed trends of decreasingincidence of H&N Cancer (possibly due to lessincidence of H&N Cancer (possibly due to lesstobacco use)tobacco use)


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Development of Multimodal Therapy

for Head & Neck Cancer

Development of Multimodal Therapy

for Head & Neck Cancer

19001900 19501950 19601960 19801980 20002000

Surgery

Radiotherapy

Chemotherapy

GeneTher.

1990199019701970


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Ca cer llCa cer ll

Pain and miseryPain and misery

Over 70% of cases are detected late andOver 70% of cases are detected late and

report for treatment in very advancedreport for treatment in very advancedstages.stages.

Economic impact of this disease isEconomic impact of this disease iscatastrophic. For example, it costs Indiancatastrophic. For example, it costs Indian

Rupees 3,50,000 (Rs. 3.5 lakhs) [ICMRRupees 3,50,000 (Rs. 3.5 lakhs) [ICMRTask Force Study, 1999], to treat oneTask Force Study, 1999], to treat onetobaccotobacco--related cancer.related cancer.


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Opposite Trend in DevelopedOpposite Trend in Developed

RegionsRegions

Mortality from cervical cancer isMortality from cervical cancer isuncommon in developed countries.uncommon in developed countries. In 1989In 1989inin the United States, mortality from cervical cancer wasthe United States, mortality from cervical cancer was

only 3.1 per 100,000 women per year.only 3.1 per 100,000 women per year. This lowThis lowmortality from cervical cancer can bemortality from cervical cancer can beattributed to early detection of andattributed to early detection of andelimination of precancers, by periodicelimination of precancers, by periodiccytologic screening with Papanicolaoucytologic screening with Papanicolaou

smears.smears.Theoretically, periodic cytologic screeningTheoretically, periodic cytologic screeningcan prevent 90% of invasive squamouscan prevent 90% of invasive squamouscancers of the cervix.cancers of the cervix.


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Two TermsTwo Terms

Two terms that are commonly usedTwo terms that are commonly used

in the context of cancer preventionin the context of cancer prevention

are:are:

Predictive OncologyPredictive Oncology

Preventive OncologyPreventive Oncology


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PredictivePredictive Onc lOnc l

Predictive oncology encompassesPredictive oncology encompasses primaryprimarycancer prevention by assessment andcancer prevention by assessment andcontrol of the basic mechanisms that maycontrol of the basic mechanisms that maylead to the development of neoplasticlead to the development of neoplasticdiseases.diseases.


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Primary prevention activities are importantPrimary prevention activities are importantbecause many cancers are preventable.because many cancers are preventable.

Tobacco and dietTobacco and diet--related risk factors alonerelated risk factors aloneaccount for about half of fatal cancers inaccount for about half of fatal cancers inOntario.Ontario.

Tobacco, diet and physical activity are theTobacco, diet and physical activity are the

most important targets for cancermost important targets for cancerprevention.prevention.


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Predictive oncology for primaryPredictive oncology for primaryprevention of cancer, involves:prevention of cancer, involves:

role of multistage cofactorial exposures identification of avoidable risk factors

molecular biology of cancer susceptibility

genetic predisposition to cancer

prognostic assessment of occult, incipient andadvanced neoplasms

prediction of response to anticancer therapies

genetic markers

assessment of exposure to carcinogens


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Successful primary prevention strategies forSuccessful primary prevention strategies forcancer reduce the likelihood that cancer willcancer reduce the likelihood that cancer will

develop in the first placedevelop in the first place

by modifying risk factors related toby modifying risk factors related tolifestyle, the environmentlifestyle, the environment and occupation,and occupation,andand

by working towards healthy public policiesby working towards healthy public policiesto create the conditions in a variety ofto create the conditions in a variety ofsettings where making the healthiestsettings where making the healthiestlifestyle choices are easier to do.lifestyle choices are easier to do.


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Lifestyle choices play a major role in theLifestyle choices play a major role in thedevelopment and progression of a numberdevelopment and progression of a numberof chronic diseases, in particular cancer.of chronic diseases, in particular cancer.Research has found that plantResearch has found that plant--based diets,based diets,regular physical activity, and the use ofregular physical activity, and the use ofstress reduction techniques can preventstress reduction techniques can preventcancer, increase diseasecancer, increase disease--free survival, andfree survival, andimprove quality of life in cancer patients.improve quality of life in cancer patients.


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PreventivePreventive Onc lOnc l

Preventive oncology forPreventive oncology forsecondarysecondaryprevention focuses on routine clinical andprevention focuses on routine clinical andlaboratory procedures for early detectionlaboratory procedures for early detectionand treatment of cancer, patientand treatment of cancer, patientmanagement and education, managementmanagement and education, managementof curable lesions, education and lifestyleof curable lesions, education and lifestylemodification.modification.


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PreventivePreventive Onc lOnc l

Preventive oncology for secondaryPreventive oncology for secondaryprevention of cancer, involves:prevention of cancer, involves:

screening modalities and their cost effectiveness

methodological issues of cancer detection

public awareness and professional education

screening guidelines for cancer detection

management of patients with preneoplastic alterations

management of early curable neoplasms

novel therapeutic approaches


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ScreeningScreening

Screening appears to be the sheetScreening appears to be the sheetanchor for prevention of cancer.anchor for prevention of cancer.

The process ofScreening implies aThe process ofScreening implies asearch for unrecognized disease in ansearch for unrecognized disease in anapparently well individual.apparently well individual.


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ScreeningScreening

Two means are available for screeningTwo means are available for screeningof the people:of the people:

1.1. The cancer care providers can go toThe cancer care providers can go tothe peoplethe people

2.2. Utilize the peoples usual visits to theUtilize the peoples usual visits to thehealth serviceshealth services


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Cancer care providers go to the peopleCancer care providers go to the people

This isThis is notnot a practical proposition because:a practical proposition because:

1.1. Ours is a country with a billion peopleOurs is a country with a billion people2.2. Cancer is not the only pressing healthCancer is not the only pressing health

problem; the individual is going to haveproblem; the individual is going to haveto be contacted by the Preventiveto be contacted by the PreventiveCardiologist, the PreventiveCardiologist, the PreventiveNephrologist, the Preventive GastroNephrologist, the Preventive Gastro--enterologist and so on and soenterologist and so on and so forth;forth; thisthisis plainly ridiculous.is plainly ridiculous.


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Utilize peoples visits to health servicesUtilize peoples visits to health services

This is a more practical proposition because:This is a more practical proposition because:

1.1. This recognizes the logic ofThis recognizes the logic of bottombottom--up approachup approach

2.2.A generalist need to be involved to provide firstA generalist need to be involved to provide firstcontact care, and he needs to be oriented wellcontact care, and he needs to be oriented wellabout preventive oncology.about preventive oncology.

3.3. Specialists in curative cancer care need enter theSpecialists in curative cancer care need enter thepicture at the referral level for providing his uniquepicture at the referral level for providing his uniqueexpertise in specialized care, and, what is muchexpertise in specialized care, and, what is muchmore important and need be emphasizedmore important and need be emphasizedparticularly, also for imparting periodic trainingparticularly, also for imparting periodic traininginputs to the generalist.inputs to the generalist.


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Utilize peoples visits to health servicesUtilize peoples visits to health services

The bottomThe bottom--up approach:up approach:


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Preventive Oncology ResearchPreventive Oncology Research

Multidisciplinary endeavor involvingMultidisciplinary endeavor involvingthese disciplines:these disciplines:

nutritional science,nutritional science, behavioral science,behavioral science,

epidemiology,epidemiology,

biostatistics,biostatistics, health education and health psychology,health education and health psychology,

clinical medicine,clinical medicine,

nursing etc.nursing etc.


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Challenges ofPreventive OncologyChallenges ofPreventive Oncology

The challenges are for:The challenges are for:

traditional health care structure, process, equity and access,traditional health care structure, process, equity and access,

nonnon--traditional health care such as complimentary and alternativetraditional health care such as complimentary and alternativemedicine,medicine,

individual and societal ethics,individual and societal ethics,

resource allocation,resource allocation,

organizational and community planning and action, andorganizational and community planning and action, and governmental health policy.governmental health policy.

To achieve success in cancer prevention, we mustTo achieve success in cancer prevention, we must

take the initiative, personally and collectively.take the initiative, personally and collectively.


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Challenges ofPreventive OncologyChallenges ofPreventive Oncology

To achieve success in cancerTo achieve success in cancerprevention, we must take theprevention, we must take theinitiative, personally and collectively.initiative, personally and collectively.


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ThankThank

Head Neck Cancer Dr P.K

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