Oral Cancers

Student : Dr. Bhuwan

Dr. Shamal

Teacher : Dr. Yasmeen Kazi

Cancer

• It may be regarded as a group of disease characterized by : (a) abnormal cell growth, (b) ability to invade adjacent tissue & even distant organs, and (c) eventual death of the affected patients if tumor progressed beyond a critical stage.

• At the beginning of the century, cancer was the sixth most common cause of death worldwide, but now it’s the 2nd leading cause.

• There are wide variations in distribution of cancers around the globe, eg. Stomach cancer in Japan, cervical cancer in Columbia, and cancers of oral cavity in SEARs.

Mortality due to cancer : Worldwide vs. India

Cancer Site Deaths

Lung (1st ) 1.4 million

Stomach 740,000

Liver 700,000

Colorectal (3rd ) 610,000

Breast (2nd ) 460,000

Cancer Site Deaths (/ 100,000)

Liver 13.49

Lung (2nd ) 6.49

Oral (1st ) 4.82

• India accounts 86% of the world's oral cancer cases 18 cases/100,000 (IIPH, feb.2011).

What is Oral cancer..?

Cancer that starts in the mouth is oral cavity cancer– Includes lips– Inside lining of cheeks (buccal mucosa)– Gingiva (gums)– Floor of the mouth– Anterior 2/3rds of the tongue– Hard palate

Major Risk Factors for Oral Cancer are:

Tobacco use - 90%

Alcohol use - 75-80%

Age over 40

UV – exposure – 30% association with lip cancer.

HPV – 20 – 30% association HSV Nutritional deficiencies (Vit.A) Oral lichen planus Immuno- Supression Syphilis Marijuana use Chronic irritation (ill-fitted dentures, broken

tooth) Chronic candidiasis P53 gene mutation (under study)

Additional Risk Factors Linked To Oral Cancer Include:

Tobacco

• Approx. 90% of oral cancers in SEARs are linked to tobacco smoking or chewing.

• The risk of oral cancer increases with the : amount and duration both.

• Smokers have 6 times greater risk of developing oral cancer than nonsmokers.

• Tobacco users who regularly use alcohol are at greatest risk.

• All tobacco types are associated with oral cancer, for example: cigarettes / cigars / pipes / snuff / chew / quid.

• Indigenous forms of smoking are : bidi, chutta (epidermoid Ca of hard palate - Andhra Pradesh), chilam, hookah. It can also be inhaled as snuff.

• Most common form of tobacco chewing in India is betal quid : betal leaf, arecanut, lime & tobacco (36 times higher in non chewers).

• It is common for the poor people to rub with thumb – flakes of sun dried tobacco and slaked lime to form a mixture (khaini), which is then put in mouth at frequent intervals during the day.

• The areca nut contains three main alkaloids: Arecoline, Arecaidine and Guvacine which has vasoconstricting properties.

• The betel leaf chewed with it contains eugenol, also vasoconstrictor.

Symptoms

• The most common symptom is a sore in themouth that bleeds easily and does not heal.

• Other symptoms include:– Pain in the mouth that does not go away– A lump or thickening in the cheek– A white or red patch on the gums, tongue,

tonsil, or lining of the mouth– A sore throat or a feeling that something is

caught in the throat– Difficulties in chewing, swallowing, or moving

the tongue or jaw (late symptoms)

Oral cancer often precedes by a pre cancerous stage (leuko/erythoplakia), which can be detected upto 15 yrs .

• 5- 20 % of oral leukoplakia will turn malignant• 10 -20% of submucous fibrosis will turn

malignant

Relationship Between Cell Events

Prevention

Primary prevention : -• Tobacco Control – if tobacco habits are

eliminated from the community, a great deal of reduction in oral cancer incidence can be achieved.

a) behavior modification

b) counseling

c) health education

d) legislative measures

Tobacco Ban – Implications

• India 3rd largest producer of tobacco• 900,000 employed in growing and curing

industry and 3.4 million in manufacturing• 97.7 million dollar trade surplus• Smokeless tobacco $ 1 billion annually = 0.2 %

of the gross national product

“Only industry that has had a constant growth for last few decades”

Conclusion

• Banning tobacco- difficult but useful• Behavioural modifications

- do have an impact

- however, time consuming

- sustained effort required• Nonetheless tobacco counseling must

be pursued (national & individual)

Other methods of primary prevention

• Limiting Alcohol consumption• Improve diet : fruits and vegetables• Maintaining good oral hygiene• Control of STDs• Prompt treatment of conditions like Lichen

planus, candidiasis.• Correcting ill - fitted dentures and other

conditions causing chronic irritation.• Protection from excessive UV – exposure.

Secondary prevention

• Oral cancers are easily accessible for inspection allowing early detection.

• If detected early (pre – cancerous lesions), can be easily treated or cured.

• The pre – cancerous lesions can be detected upto 15 years, prior to becoming invasive carcinoma.

• Regular annual oral cancer examinations after age 40.

• The primary health care workers are in a strategic position to detect oral cancers at an early stage during home visits. They can prove to be a vital link & key instrument in control of oral cancer in countries like India.

• Leukoplakias can be cured by cessation of tobacco smoking.

• Radiation therapy and surgery are the main methods of treatment for oral cancer.

Surgery : An operation to remove cancer cells.

Radiotherapy : Uses high-energy rays to shrink or kill cancer cells.

• In advanced cancer, chemotherapy may be used in combination with either treatment.– Chemotherapy - Uses anticancer drugs

that attack cancer cells and normal cells. The drugs are usually given by injection or by mouth.

5-year localized survival rate is 82% 5-year overall survival rate is 59%

NATIONAL CANCER CONTROL PROGRAMME:

• National Cancer Control Programme was started in 1975-76. Its Goals & Objectives are: -

1. Primary prevention of cancers by health education regarding hazards of tobacco consumption and necessity of genital hygiene for prevention of cervical cancer.

2. Secondary prevention by early detection and diagnosis of cancers, for example, cancer of cervix, breast cancer and the oro-pharyngeal cancer by screening methods and patients‘ education on self examination methods.

3. Strengthening of existing cancer treatment facilities, which were inadequate.

4. Palliative care in terminal stage cancer.

Strategies

• Prevention and early detection of cancers through district cancer control activities and strengthened IEC campaign.

• To promote ‘centre of excellence’ in the field of cancer management with support to existing RCC of proven track record by providing financial assistance.

• To augment comprehensive cancer facilities across the country through institutional capacity building in new and existing regional cancer centers and through new & existing oncology wings.

• Development of early diagnostic facilities in district hospitals.

• Encouraging PPP.• Increase capacity for palliative care.• Promote cancer research relevant to India.• Capacity building & training of all personnel in

cancer prevention & early detection to be done for all categories in phased manner.

• Health education to general public through various audio- visual means regarding early detection of cancer.

• Promote innovation in cancer care and indigenization of cancer treatment equipments.

Organizational structure

• It is a two level committee : Central govt. & state govt. with linkage through the central council of health.

• The full time officer in charge of cancer control is an oncologist who heads the cancer control cell at the DGHS.

Schemes under the program

1. Financial Assistance to Voluntary Organisations:

• This scheme is meant for IEC activities and early detection of cancer.

• Under the scheme financial assistance upto Rs.5 lakh is provided to the registered voluntary organisations recommended by the State government for undertaking health education and early detection activities in cancer.

• A linkage with the Regional Cancer Centre (or Medical is now mandatory by the NGO concerned.

2. District cancer control scheme :

• It is known that a large number of cancer cases can be prevented with suitable health education and early case detection.

• Accordingly the scheme for district projects regarding prevention, health education, early detection and pain relief measures was started in 1990-91.

• Under this scheme one time financial assistance of Rs.15.00 lakh is provided to the concerned State Government for each district project selected under the scheme with a provision of Rs.10.00 lakh every year for the remaining four years of the project period.

• The project is linked with a Regional Cancer Centre or an institution having good facilities for treatment of cancer patients. The patients are provided treatment at the concerned Regional Cancer Centre or the nodal institution.

3 ) Financial assistance for Cobalt unit installation:

• To strengthen the cancer treatment facilities, the financial assistance of Rs. 1 crore for charitable organisations and 1.5 crore for government institutions is provided for procurement of teletherapy, brachytherapy equipments etc. This is one time grant at present.

4. Development of Oncology Wings in Govt. Medical College Hospitals:

• This scheme has been initiated to fill up the geographical gaps in the availability of cancer treatment facilities in the country.

• Central assistance is provided for purchase of equipments, which include a cobalt unit beside other equipments. The civil works and manpower are to be provided by the concerned State Government/ Institution.

• The quantum of central assistance is Rs.2 crore per institution under the scheme. The scheme provides one time grant only.

5. Assistance for Regional Research and Treatment Centres:

• There are 19 Regional Cancer Research and Treatment Centres recognised by Government of India.

• A recurring grant of Rs.75 lakhs is being given to 15 of these RCCs.

• In addition CNCI, Kolkatta and IRCH, AIIMS are also funded under NCCP.

New Initiatives

• Outreach activities by medical colleges for increasing awareness and early detection of cancer.

• Training of personnel in early detection and awareness of cancer.

• Supply of Morphine• Telemedicine and supply of computer hardware

and software.• IEC activities.• Modified District Cancer Control Programme• National Cancer Awareness Day (7th november)

• Training of cytopathologists and cytotechnicians in the quality assurance in Pap Smear technology.

• Participation in Health Melas and distribution of health education material.

• Postage stamp depicting 'Breast Self Examination' was brough out by Department of Posts on National Cancer Awareness Day

• Telecast of a health magazine 'Kalyani' in the current year with cancer and anti tobacco items under the agreement with Prasar Bharti & MOHFW.

National Cancer Registry Program

• Objectives :

To generate authentic data on magnitude of cancer problem in India.

To undertake epidemiological investigations and advice control measures.

Promote human resource development in cancer epidemiology.

• Population based registers :

There are six in numbers ; 5 in urban area (Delhi, Bhopal, Mumbai, Bangalore, Chennai) and one in rural area (Barshi in Maharashtra)

• Hospital based registers :

At Chandigarh, Banglore, Mumbai, Chennai, and Thiruvananthpuram, six hospital based registers are maintained.

A total of 3.3 % population is covered by these registers (12.85 urban and 0.06% in rural)

These registers generate annual report which indicate the annual incidence of particular cancer in population, which helps in planning and evaluation of cancer control.

National Tobacco control program

• MOHFW has recommended that a comprehensive Anti – tobacco program should be implemented as part of NCCP with following strategies :

Education of the public. Practice of tobacco control. Advocacy of tobacco control.

Major efforts for tobacco control in India

• Warnings on cigarette packages/ advertisements.

• Warning on smokeless tobacco products.• Cabinet guidelines for smoking in public places.• Comprehensive legislation on tobacco control.• Multi - Sectoral approach for tobacco control.• Community education on tobacco.• Expert committee on health hazards of pan

masala containing tobacco.

TOBACCO CONTROL ACT, 2003

• Scope of Act : -

The Act is applicable to all products containing tobacco in any form i.e. Cigarettes, Cigars, Cheroots, bidis, gutka, pan masala (containing tobacco) khaini, mawa, mishri, snuff etc. as detailed in the schedule to the Act.

The Act extends to whole of India.

MAIN PROVISIONS OF THE ACT

• Prohibition of smoking in public places. Implement from 2, Oct, 2008.in the hole of India.

• Prohibition of advertisement, sponsorship and promotion of tobacco products.

• Prohibition of sale of tobacco products near educational institutions.

• Regulation of health warning in tobacco products packs.

• Regulation of tar and nicotine contents of tobacco products.