Lecture 19: Cancer

Question 1

What is cancer?

Answer 1

The normal cell growth and death process breaks down and growing cells become abnormal. They divide and can form tumours. malignant tumours can spread into other parts of the body. Parts of the tumour can break off and travel through the blood or lymph to other parts of the body

Question 2

how is cancer described?

Answer 2

By its grade - how abnormal the cells looks
and its stage - extent of its spread

Question 3

why does cancer develop?

Answer 3

• genetics
• lifestyle: diet, smoking, exercise, alcohol, nutrition
• environment exposure: carcinogens, asbestos, occupational chemical exposure

Question 4

what is cancer epidemiology for Maori and non-Maori?

Answer 4

• cancer and CVD are the two leading causes of death in NZ for Maori and non-Maori
• for Maori males lung cancer is 2nd leading cause of death
• for non-maori males lung cancer is 3rd leading cause of death
• lung cancer is leading cause of death for maori women
• for non-maori women 3 of the top 5 causes of death are breast, lung and colorectal cancer

Question 5

what are the leading causes of death for maori females?

Answer 5

• ischemic heart disease
• lung cancer
• chronic lower respiratory disease
• cerebrovascular disease
• diabetes

Question 6

what are the leading causes of death for non-maori females?

Answer 6

• ischemic heart disease
• cerebrovascular disease
• breast cancer
• lung cancer
• chronic lower respiratory disease

Question 7

what are the leading causes of death in maori males?

Answer 7

• ischemic heart disease
• lung cancer
• chronic lower respiratory disease
• diabetes
• cerebrovascular disease

Question 8

what are the leading causes of death in non-maori males?

Answer 8

• ischemic heart disease
• lung cancer
• cerebrovascular disease
• chronic lower respiratory disease
• bowel cancer

Question 9

what can be done about cancer?

Answer 9

• prevention
• diagnosis
• treatment (curative intent, extending quality and quantity of life without curative intent, palliative care
• living well post-treatment/good survivorship

Question 10

what are the goals of primordial prevention?

Answer 10

target population: general population

goals: reduce risk

underlying clinical disease: absent

example: reduce uptake of smoking, healthy diet and physical activity promotion, HPV vaccination

Question 11

what are the goals of primary prevention?

Answer 11

target population: susceptible population

goals: reduce disease incidence

underlying clinical disease: at risk

example: smoking cessation, cervical smears, surveillance, high risk family colorectal cancer

Question 12

what are the goals of secondary prevention?

Answer 12

target population: people with disease

goals: reduce prevalence or consequences

underlying clinical disease: first defect of lesion

example: mammography, bowel cancer screening, lung cancer screening

Question 13

what are the goals of tertiary prevention?

Answer 13

target population: people with disease

goals: reduce complications or disability

underlying clinical disease: first symptom

example: surgery, chemotherapy, radiation therapy

Question 14

how can cancer be diagnosed?

Answer 14

• through screening
• symptomatic
• incidental

Question 15

what are the types of cancer recovery?

Answer 15

• palliative care
• survivorship - adjusting to life post-Rx and thriving

Question 16

explain a framework for disease, illness or condition?

Answer 16

What is the disease, illness, condition:
- definition, description
- epidemiology by ethnicity, equity, inequities
- aetiology

Why is it important
- impacts on patients, whanau, community, society
- by ethnicity, equity, inequities

What is known about outcomes by ethnicity, equity, inequities in prevention, screening and treatment

(next cards are using this framework for bowel cancer)

Question 17

what is colorectal cancer? aka bowel cancer

Answer 17

malignant tumour starting in large bowel of rectum

Question 18

what is the epidemiology of bowel cancer?

Answer 18

• 2nd most common cause of cancer death in total population
• 1214 deaths in 2017
• NZ has one of the highest rates of bowel cancer in the world
• Maori incidence is similar to non-maori (used to be lower)
• Maori mortality is similar/higher to non-maori

Question 19

what is the issue with Maori representation of bowel cancer?

Answer 19

WHO chooses age standardised data instead of age specific date. this creates inequity as it looks like Maori rates are similar to non-maori rates but because the maori population is younger, and cancer is an age related disease, Maori cancer rates are not accurately presented.

Question 20

what are the changes in bowel cancer mortality?

Answer 20

12.9 per 100,000 - Maori
14 per 100,000 - non-Maori

• this will be changing with the roll out of bowel screening programme

Question 21

why is bowel cancer important?

Answer 21

Costs to society
- health related costs
- costs associated with morbidity and premature mortality

Much of colorectal cancer is preventable/curable is diagnosis is early enough

Costs to whanau due to stress, morbidity, mortality

Question 22

what are the determinants of colorectal cancer?

Answer 22

• age
• sex
• history of polyps in colon
• History of inflammatory bowel disease
• family history of bowel cancer - genetic mutations
• hereditary conditions
• geographical differences
• smoking
• diet - red meat, animal fats, low in fruit and vegetable fibre
• insufficient physical activity/exercise
• alcohol

Question 23

what are the causes of inequities in bowel cancer mortality?

Answer 23

• maori are 20% more likely to die than non-Maori
• differences in incidence
• difference in tumour characteristics at diagnosis
• differences in patient characteristics that may affect outcome
• inequities in access to screening, surveillance, primary care
• differences in investigation and/or treatment

Question 24

what is known about colon cancer management?

Answer 24

• there is a very clear, evidence based treatment pathway from colon cancer management

Question 25

what did the hill et all articles do?

Answer 25

- had a cohort of Maori and non-Maori with a first diagnosis of colon cancer - only includes colon cancer (not appendix, rectum, anal) - mean age of first diagnosis was 60.3 in Maori and 70.6 in non-Maori - they found differences in cancer treatment that contribute to inequities

Question 26

what differences did the Hill et al article find in colon cancer between maori and non-maori?

Answer 26

- no differences in stage - tumour grade in maori was well differentiated (good thing) - maori were more likely to have a bowel obstruction - maori were more likely to have comorbidities e.g diabetes, respiratory disease, renal disease, heart failure - maori were more likely to be treated in a public hospital or non-cancer centre - maori were less likely to be treated in a private hospital ^important for explaining inequitable mortality through patient/tumour characteristics

Question 27

what significant treatment differences did the Hill et all article find?

Answer 27

- maori less likely to have primary tumour removed - maori more likely to have emergency surgery - maori more likely to have palliative bypass - maori more likely to have bowel obstruction - maori less likely to have glands removed - maori most likely to die after surgery - in those with stage 3, maori less likely to be offered or receive adjuvant chemotherapy - maori wait longer for surgery and chemotherapy - in those with stage 4, maori less likely to be offered or receive palliative chemotherapy

Question 28

what does the hazard ratio findings of the hill et al article show about equity?

Answer 28

Inequities is a combination of several small inequities along the pathway. It is not a simple solution. a lot of things need to be addressed to reach equity.

Question 29

what is a primordial prevention for colorectal cancer?

Answer 29

- reducing risk of bowel cancer in the population - improve diet - exercise - weight management - don't smoke - limit alcohol

Question 30

what are primary preventions of colorectal cancer?

Answer 30

surveillance people at high risk - past history or known hereditary condition - have regular colonoscopy screening - remove polyps people who have previously had cancer - intensive clinical follow up, regular colonoscopy

Question 31

what are secondary preventions for colorectal cancer?

Answer 31

- identifying a cancer before it causes symptoms - bowel cancer screening programme

Question 32

what is the bowel cancer screening programme?

Answer 32

- occurs age 60-74 - self administered - but maori bowel cancer is already diagnosed at age 50-59 - bowel cancer needs to start at 50 for Maori in order for equity to be reached. - non-maori 30% diagnosed before aged 60, if Maori screening started at 50, 30% will be diagnosed in Maori too.