1 MANAGING THE SCOURGE OF CANCERDELIVERED AT KNOWLEDGE PLATFORM ILORIN by Dr BS Alabi Associate professor of Otorhinolaryngology University of Ilorin, Ilorin, Nigeria 230415

2 Neoplasia = new growth Cancer is a form of new growth in the body.It is an abnormal, purposeless, uncoordinated, tissue growth which exceeds normal and persists in the same excessive manner after cessation of the stimulus which evoked the change.

3 BLOOD CANCERS (LEUKAEMIAS)Cancer and tumour TUMOUR: is a broad term for swelling or space-occupying lesion. It may be : Benign tumour or Malignant tumour. Malignant tumour is called CANCER TUMOUR =SWELLING BENIGN MALIGNANT=CANCER SOLID CANCERS BLOOD CANCERS (LEUKAEMIAS)

4 Phenotipic attribute of cancerExcessive growth Local invasiveness Aggression Rapid tumour progresssion High metastatic potential Usually painless in early stage

5 How many types of cancers do we have?The questions are.. How many types of cancers do we have? Is Cancer really a scourge? Answer 1: as many as the number of cells in human body.

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7 No organ is spared! Cancer can start from any organ and spread to any organ(s)

8 No respect for age ! It occurs in all age groups with peak incidence in ages > 50yrs.

9 NIGERIA Nigeria is the most populous country in Africa,the 7th most populous country in the world and Population of 170 million people.

10 NIGERIA Answer 2: The scourge of cancer is real in Nigeria like many other countries of the world. However, It is difficult to appreciate the problem of cancers in Nigeria. This is because most studies available are hospital-based studies. And people continue to succumb to cancer in the community.

11 The great burden The world wide burden of managing CANCER is enormous.More than 10 million persons are diagnosed with cancer Annually. More than half of these persons are in the developing world. The World Health Organization (WHO) estimates that 12.5% of all deaths worldwide are due to cancer. This is greater than HIV/AIDS, malaria and tuberculosis combined The disease is on the increase and the peak incidence involves the active working class. (Jos, Maiduguri – 3rd to 4th decade, Lagos – 4th to 5th decade, Ibadan – 6th decade)

12 The great burden 300,000 cases of various types of cancer are diagnosed in Nigeria every year. Out of which only 10,000 could be managed. The survival rates for cancers in Nigeria were among the lowest in the world. Campbell et al.

13 What is the cause? In most cases, the cause of cancer is not known.However a number of related RISK factors can be identified. Risk factors varies from cancer to cancer and region to region. Knowledge of these risk factors is crucial in planning primary prevention.

14 CONTROL OF CELL CYCLE RB exists in an active hypophosphorylated state in quiescent cells and an inactive hyperphosphorylated state in the G1/S cell-cycle transition © 2005 Elsevier

15 Oncogenesis GROWTH FACTOR Vs TUMOUR SUPRESSOR GENE:Proto-oncogenes (GF- gene)encode proteins that promote cell growth. Tumour suppressor (P53, Rb)genes products apply brake to cell proliferation. Over expression of proto-oncogene or mutation of tumour suppressor gene => CANCER

16 GROWTH FACTOR Vs TUMOUR SUPRESSOR GENEProto-oncogen TUMOUR SUPRESSOR (P53, Rb) GENE Over expression of proto-oncogene or mutation of tumour suppressor gene => CANCER

17 Loss of balance Over expression of proto-oncogene or mutation of tumour suppressor gene => CANCER

18 Carcinogenesis INHERITED GERM LINE. Familial,hereditory,geneticSuch genetic damage [or mutations] may be acquired by the action of environmental agents: CHEMICALS, Petrol/industrial chemicals and hydrocarborns, anticancer drugs;hormones RADIATION, UV rays of sunlight, X rays,γ rays, Particulate-α,ß, proton, neutron VIRUSES, DNA viruses: HPV, EBV,HBV, KSHV. RNA: HCV, HTLV1. OTHER BIOLOGICAL CARCINOGENES: BACTERIA -H. pylori. PARASITES- S. haematobium, Opisthorchis sinensis., FUNGAL MYCOTOXINS e.g. Aflatoxin B1 INHERITED GERM LINE. Familial,hereditory,genetic

19 Aetiological factors. WorldwideCigarette smoking and alcohol cosumption are the two strongest aetiological factors for development of cancer. Both independently and synergistically.

20 contains over 4,800 chemicals, 69 of which are known to cause cancer.Cigarette smoke contains over 4,800 chemicals, 69 of which are known to cause cancer. A 2004 Study by the CDC's National Center for Chronic Disease Prevention and Health Promotion.

21 Challenges of late presentationLate presentation of the advanced disease was a common feature in most reports from different parts of Nigeria. [7,13,19,20,22,23,25,26]. TNM classification of tumour Most cases were already stages III and IV. [7,13,19,20,25,27]. Stage II cancers were few. [7,13,22,27]. Stage I not commonly seen. [13].

22 Why do patient present lateNature of cancer. Distance from health facilities. Ignorance. Stigma. Traditional believes. Poverty. Lack of societal support.

23 Challenges of investigating cancersPhysical Examination. Endoscopy. Examination under anesthesia. Cytology- Pap smear, Fine needle aspiration. Tru-cut biopsy- liver cancer Histology Imaging Biochemicals, Haematological etc. ………..SERVICES EITHER NOT AVAILABLE OR NOT AFFORDABLE!

24 Laboratory facilitiesLimited facilities and Man power. Overburdened health system. Long waiting time. Progression of cancer

25 Imaging Thirty CT scanner machines & fifteen MRI machines are available across the country. Many are refurbished machines and often break down. Power supply is very erratic. (This is roughly 1 scanner to 3.5 million people – in the SGH catchment area there are at least 18 scanners for a population of 2 million people)

26 Imaging 70 % of Nigerian scanners are located in the southern part of the country. To date, considerable distance, sometimes over 500 kilometres, have to be covered to get to a centre that has a functioning CT scan and MRI facilities

27 Challenges of treating cancerAim: Curative for Stage I and II Cancers. Palliative for Stage III and IV. TYPES: SURGERY, CHEMOTHERAPY, RADITHERAPY, IMMUNOTHERAPY. GENE THERAPY. COMBINED TREATMENT OPTIONS ARE NOT WITHOUT RISK AND SIDE EFFECTS

28 Cancer patient Vs treatment….making a choice! Life. Death. Quality of life.

29 Challenges of treating cancerThere are 6 functioning radiotherapy centres in Nigeria today. With a population of over 160 million of which four are located in the south west, one in the middle belt and one in the north. 6 radiotherapy centers in Nigeria – 1:25 million people. Compared with SGH catchment area – 3: 2 million people

30 Outcome PATIENT TREATMENT CHOICE CANCER TYPE Lost to follow up:47.3% of the patient < 2yrs. 16.7% after two years. Alive and disease free: 4 yrs post-treatment = 5.6%. Recurrence: Recurrence rate after 2 yrs = 16.7%. Death: 22.2% = dead after 2yrs of treatment. 5.6% of death were unrelated to the carcinoma. PATIENT TREATMENT CHOICE CANCER TYPE FACILITY/ ENVIRONMT

31 A typical case of late cancer presentation- I

32 A typical case of late cancer presentation- IINeck: Huge multinodular mass Measures 50cm×30cm×20cm) Occupying and overhanging the Lt preauricular, mandibular , submental and anterior neck region.

33 Parliative care only

34 A typical case of rapid cancer progression-III

35 Risk of airway involvement

36 Risk of infection

37 Risk of facial nerve paralysis

38 Traditional therapy

39 Challenges Most patients in our environment present very late at hospitals . Prognosis is poor as only palliative treatment is practicable. Available facilities are over burdened leading to a high chance of cancer up grading within the period of work up. High drop-out rate due to ignorance, poverty, long distances to the health centres and the high cost of drugs.

40 Challenges Researchers face peculiar challenges; mostly fund and inadequate infrastructural support. Poor cancer awareness, dogmatic traditional believes and cultural practices work against preventive efforts. Health policy is not in favour of cancer management, in the face of poverty, food deficit and infection. ORL-HNS Dept., University of Ilorin teaching hospital. Ilorin, Nigeria.

41 What do we do? The only certain way to avoiding cancer is not to be born. To live is to incur the risk of cancer Primary Secondary Tertiary Care provider Community Government /NGOs Patient

42 Multi-disciplinary approach

43 Admit diagnosis and mgt plan.

44 What do we do ? Health educationKnowledge driven Long and short term strategies

45 What do we do? Cancer charity. Community awareness. Family support.Financial, moral and spiritual support. Outreach screening programmmes. Capacity building

46 Screening. Check up endoscopy. Tumour markers. Cytology. Ultrasound.Mamography. Biopsy.

47 Know yourself & family history.

48 Avoid alcohol, Smoking, Drug addiction & indiscriminate sex.

49 More females smoke than we thinkWomen account for 39 percent of all smoking deaths. A 2004 Study by the CDC's National Center for Chronic Disease Prevention and Health Promotion. Adolescent girls who smoke and take oral birth control pills greatly increase their chances of having blood clots and strokes and cancer. More than 90 percent of adult smokers started when they were teens. Peer influence =13 times risk of becoming a smoker

50 Secondhand smoke containsSHS was classified as a carcinogen since 1992. more than 4,000 chemical compounds, including carbon monoxide ( which poisons the human body). 210 are classified by the EPA as known carcinogens—cancer causing agents. The U.S. Environmental Protection Agency (EPA or sometimes USEPA) He]p to quite smoking: Nicotine gum Nicotine Patch. Lozenges. Inhalators. Nasal spays. E-cigarette. Microtab. Zyban. Champix.

51 Screening refers to tests and exams used to find a disease, like cancer, in people who do not have any symptoms. The goal of screening exams, such as mammograms, is to find cancers before they start to cause symptoms. Most cancers are curable if they are caught early enough. That is the justification for screening tests

52 Prostatic cancer

53 Thyroid and throat cancers

54 Risk factors for female cancersAge. Reprouctive history. Age at menarche. Age at first birth. Parity. Breastfeeding. Age at menopause. Oral contraceptives. Breast density. Previous breast diseases. Diet. Body weight. Physical exercise. Shift work/sleep. Alcohol consumption. Smoking. Medical radiation.

55 Cancer of the cervix

56 Breast cancer is the most common cancer in the UK.In 2008, there were 48,034 new cases of breast cancer diagnosed in the UK: 47,693 (over 99%) in women and 341 (less than 1%) in men.

57 Clinical breast exam (CBE)Women yrs old: at least every 3 years. After age 40: every year. Mamography/MRI

58 WAKE UP CALLS TO GOVERNMENT AT ALL LEVELSHEALTH EDUCATION/ CANCER AWARENESS FOR ALL COLLABORATION WITH PRIVATE SECTORS, NGOs AND FOREIGN AGENCIES FOR CAPACITY BUILDING, RESEARCH FUNDING

59 WAKE UP CALLS ESTABLISHMENT OF CANCER DESIGNATED HOSPITALS AND TREATMENT CENTERS PROVISION OF ADEQUATE FACILITIES FOR CANCER SCREEN, INVESTIGATION AND TREATMENT

60 WAKE UP CALLS TRAINING OF MANPOWER FUNDING CANCER RESEARCHPROMOTION OF EARLY CANCER DIAGNOSIS BY SUBSIDISING COST OF CANCER SCREENING AND GENERAL MEDICAL CHECK-UP PROCEDURES .

61 WAKE UP CALLS SUBSIDISING CANCER CARE, DRUGS AND HOSPITAL PROCEDURESCREATION OF MOBILE CANCER CENTER AND OUTREACH FACILITIES TO CATER FOR RURAL AREAS IMPROVING COVERAGE OF NATIONAL HEALTH INSURANCE SCHEME (INFORMAL SECTORS)

62 WAKE UP CALLS LEGISLATION AND POLICIES AGAINST CANCER PROMOTING HABITS MARKETS AND THEIR PROMOTERS (E.G TOBACCO COMPANIES)

63 Government can not do it alone!ROYAL MARSDEN CANCER CENTRE WAS STARTED BY AN INDIVIDUAL BEFORE IT WAS TAKEN OVER BY BRITISH GOVERNMENT. Nelson Mandela was diagnosed in 2001 with early-stage prostate cancer at the age of 83. Mandela was diagnosed and received all his treatment in South Africa, made a full recovery, and lived until the age of 95 years, remaining cancer-free until the end. Queen Elizabeth the Queen Mother developed colon cancer at age 66 and breast cancer at age 83, but made full recovery from both cancers. She died from old age in 2002, aged 101.

64 Mustapha Akanbi Foundation supports cancer care capacity building

65 Conclusion Together we can better Nigeria cancer statistics; if all well meaning Nigerians join the crusade against cancer and stop shopping for healthcare abroad?

66 THANK YOU