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TUMOURS ASSOCIATED WITH HIV/AIDS Approximately 30-40% of patients with HIV infection are likely to develop malignancies. Kaposi sarcoma is the most common malignancy in patients with HIV infection. Since no current therapies have proven curative, both delivery of effective treatment and maintenance of adequate control of HIV and other infections remain the goals of current treatment. Several studies have shown benefits of highly active anti-retroviral treatment (HAART) on Kaposi sarcoma lesions. HAART might be a useful alternative both to immune response modifiers during less aggressive stages of this disease and to systemic cytotoxic drugs in the long term maintenance therapy of advanced Kaposi sarcoma (Tavio M et al., Ann Oncol, 9: 923, 1998; Tirelli U and Bernardi D, Eur J Cancer, 37: 1320-24, 2001). Liposomal anthracyclines are considered the standard treatment for patients with advanced stages of AIDS-related Kaposi sarcoma. Concomitant use of both HAART and haematological growth factors is needed, with the aim of reducing opportunistic infections and myelotoxicity. Non-Hodgkin lymphoma in patients with HIV infection is about two hundred-fold more frequent than expected. One feature of AIDS-non-Hodgkin lymphoma is the widespread extent of the disease at initial presentation and the frequency of systemic B-symptoms (general symptoms such as night sweats, weight loss, temperature change). Whether intensive or conservative chemotherapy regimens are appropriate is still a matter of controver- alter gastric acid secretion, elevating gastric pH, changing the gastric flora and allowing anaerobic bacteria to colonize the stomach. These bacteria produce 60 The causes of cancer sy. In fact, the poor bone marrow reserve and underlying HIV immunodeficiency make the management of systemic non- Hodgkin lymphoma very difficult. Intensive chemotherapy regimens may be given to low or intermediate risk category patients and conservative chemotherapy regimens to high or poor risk patients (Spina M et al., Ann Oncol, 10: 1271-1286, 1999). The prognosis of AIDS-non-Hodgkin lymphoma is very poor. Hodgkin disease in patients with AIDS carries a relative risk much lower than that for non-Hodgkin lymphoma but the histological subtypes tend to be those with unfavourable prognosis and the response rate remains poorer than that of the general population. Outcome may be improved by an optimal combination of anti-neoplastic and HAART to improve control of the underlying HIV infection. The inclusion of growth factors may allow the use of higher doses of the drugs (Vaccher E et al., Eur J Cancer, 37: 1306-15, 2001) Cervical intraepithelial neoplasia (CIN) has been increasingly diagnosed in HIV-infected women; invasive cervical cancer is currently an AIDS-defining condition. CIN in HIV-infected women is associated with high grade histology, more extensive and/or multifocal disease and disseminated lower genital tract HPV-related lesions (Mandelblatt JS et al., AIDS, 6: 173-178, 1992; Robinson W 3 rd, Semin Oncol, 27: 463-470, 2000). Therapeutic recommendations are the same as for non-HIV-infected women, because most HIV-infected women will die from cervical cancer rather than other AIDS-related diseases. Testicular cancer appears to be more frequent in HIV-seropositive homosexual men but the risk is not directly related to the active reductase enzymes that transform food nitrate into nitrite, an active molecule capable of reacting with amines, amides and ureas to produce carcinogenic Fig. 2.51 Kaposi sarcoma of the skin in a patient with AIDS. The biopsy (below) reveals the presence of human herpes virus 8 (HHV-8) in tumour cell nuclei, demonstrated by immunohistochemistry (brown colour). Affected individuals are uniformly co-infected with HIV and HHV-8. level of immune deficiency. Patients with HIV infection are offered the standard chemotherapy, since the majority can be cured of their tumour and have a good quality of life (Bernardi D et al., J Clin Oncol, 13, 2705-2711, 1995). The spectrum of cancers in patients with HIV infection may further increase as these patients survive longer. Based on advances in current understanding of HIV viral dynamics and the availability of newer anti-retroviral therapies, continuation of HAART with prophylaxis against opportunistic infections in patients receiving chemotherapy may significantly improve treatment outcome. N-nitroso compounds. H. pylori acts as a gastric pathogen and thereby mediates a carcinogenic outcome involving soluble bacterial products and the inflammatory
REFERENCES H. pylori infection Normal gastric mucosa Chronic active gastritis Gastric atrophy Intestinal metaplasia Dysplasia Adenocarcinoma Fig. 2.50 The proposed natural history of the development of stomach cancer as a progressive process associated with atrophy and intestinal metaplasia with reduced acidity. 1. Rous P (1911) Transmission of malignant new growth by means of a cell-free filtrate. J Am Med Assoc, 56: 198. 2. Pisani P, Parkin DM, Muñoz N, Ferlay J (1997) Cancer and infection: estimates of the attributable fraction in 1990. Cancer Epidemiol Biomarkers Prev, 6: 387-400. 3. IARC (1994) Hepatitis Viruses (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 59), Lyon, IARCPress. 4. IARC (1994) Schistosomes, Liver Flukes and Helicobacter Pylori (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 61), Lyon, IARC 5. IARC (1995) Human Papillomaviruses (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 64), Lyon, IARCPress. 6. IARC (1996) Human Immunodeficiency Viruses and Human T-Cell Lymphotropic Viruses (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 67), Lyon, IARCPress . 7. IARC (1997) Epstein-Barr Virus and Kaposi's Sarcoma Herpesvirus/Human Herpesvirus 8 (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 70), Lyon, IARCPress. response generated by the infection (Fig. 2.50). Infection by the liver fluke O. viverrini causes oedema, desquamation and acute inflammatory responses in the bile ducts in the early stages. Bile ducts of chronic carriers may exhibit metaplasia and adenomatous hyperplasia, which progress in some cases to cholangiocarcinoma [4]. Alternatively, such indirect agents may cause immunosuppression and the reactivation of latent oncogenic viruses. In fact, several virus-induced cancers occur almost exclusively under severe immunosuppression (Immunosuppression, p68) [6]. Global burden of cancer attributed to infectious agents Recent estimates are that at least 1.6 million cases (18%) of the approximately 9 million new cases of cancer that occurred in the world in 1995 can be attributed to the infectious agents discussed (Table 8. Muñoz N, Bosch FX, de Sanjose S, Tafur L, Izarzugaza I, Gili M, Viladiu P, Navarro C, Martos C, Ascunce N (1992) The causal link between human papillomavirus and invasive cervical cancer: a population-based case-control study in Colombia and Spain. Int J Cancer, 52: 743-749. 9. Rolon PA, Smith JS, Muñoz N, Klug SJ, Herrero R, Bosch X, Llamosas F, Meijer CJ, Walboomers JM (2000) Human papillomavirus infection and invasive cervical cancer in Paraguay. Int J Cancer, 85: 486-491. 10. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, Snijders PJ, Peto J, Meijer CJ, Muñoz N (1999) Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol, 189: 12-19. 11. Piot P, Bartos M, Ghys PD, Walker N, Schwartlander B (2001) The global impact of HIV/AIDS. Nature, 410: 968- 973. 12. Chey WD (1999) Helicobacter pylori. Curr Treat Options Gastroenterol, 2: 171-182. 13. zur Hausen H (1999) Viruses in human cancers. Eur J Cancer, 35: 1174-1181. 2.18) [2]. The proportion of cancers attributed to infectious agents is higher in developing countries (23%) than in developed countries (9%). This proportion is greatest among women in Western, Eastern and Central Africa, where 40% of all cancers are associated with chronic infections, followed by South-American and Asian women in whom this proportion is around 25% (Fig. 2.47). A similar picture is seen among males but with lower attributable proportions (Fig. 2.48). The realization that approximately onequarter of all cancers occurring in the developing world can be attributed to infectious agents opens great hopes for prevention and treatment. This is particularly true for cancers of the cervix, stomach and liver (Chapter 4), which are very common in developing countries, where they represent 91% of the cancers associated with infectious agents. WEBSITES National Center for Infectious Diseases (USA CDC): http://www.cdc.gov/ncidod/index.htm WHO infectious disease information resources: http://www.who.int/health_topics/infectious_diseases/en Infectious agents 61
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WORLD HEALTH ORGANIZATION WHO OMS I
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WORLD CANCER REPORT Editors Bernard
Page 6 and 7: CONTENTS Foreword 9 1 The global bu
Page 8 and 9: The global burden of cancer Cancer
Page 10 and 11: Fig. 1.2 Incidence and mortality of
Page 12 and 13: Central and Southern Europe differ
Page 14 and 15: Incidence of cancer in South Centra
Page 16 and 17: from documentation of disease to a
Page 18 and 19: TOBACCO SUMMARY >In addition to lun
Page 20 and 21: Fig. 2.3 Smoking by children is inc
Page 22 and 23: Cancers positively Sex Standardized
Page 24 and 25: PHARMACOLOGICAL APPROACHES TO SMOKI
Page 26 and 27: level the dose—response relations
Page 28 and 29: lipoprotein-associated cholesterol,
Page 30 and 31: Agent Cancer site/cancer Main indus
Page 32 and 33: Industry, occupation Cancer site/ca
Page 34 and 35: to occupational exposures in develo
Page 36 and 37: Air pollutant WHO Air Quality Guide
Page 38 and 39: der cancer of the order of 50% is p
Page 40 and 41: AFLATOXIN B 1 HEPATITIS VIRUS (chro
Page 42 and 43: Fig. 2.30 Correlation between regio
Page 44 and 45: MEDICINAL DRUGS SUMMARY > Certain d
Page 46 and 47: Drug or drug combination Cancer IAR
Page 48 and 49: Agent or substance Cancer site/canc
Page 50 and 51: sources of electromagnetic fields [
Page 52 and 53: CHRONIC INFECTIONS SUMMARY > Infect
Page 54 and 55: Infection Subclinical Mutagenic fac
Page 58 and 59: DIET AND NUTRITION SUMMARY > Up to
Page 60 and 61: Fig. 2.54 The age-adjusted mortalit
Page 62 and 63: OVERWEIGHT, OBESITY AND PHYSICAL AC
Page 64 and 65: IMMUNOSUPPRESSION SUMMARY >Persiste
Page 66 and 67: Fig. 2.64 Cancer following immunosu
Page 68 and 69: Syndrome Gene Location Cancer site/
Page 70 and 71: viduals, confirmation of a gene def
Page 72 and 73: REPRODUCTIVE FACTORS AND HORMONES S
Page 74 and 75: PHYTO-ESTROGENS AND CANCER PEVENTIO
Page 76 and 77: Indicator Number of oral contracept
Page 79 and 80: Mechanisms of tumour development Th
Page 81 and 82: The stages in tumorigenesis have be
Page 83 and 84: PRECURSOR LESIONS IN CHEMOPREVENTIO
Page 85 and 86: CARCINOGEN ACTIVATION AND DNA REPAI
Page 87 and 88: adducts, a few weeks or months for
Page 89 and 90: I Reactive oxygen species Methylati
Page 91 and 92: which remove the mismatched bases,
Page 93 and 94: Common human oncogenes Many common
Page 95 and 96: product of the RB1 gene (pRb) and a
Page 97 and 98: ates a molecular bridge between p53
Page 99 and 100: potential cancer genes altered thro
Page 101 and 102: One of the earliest genes to be ide
Page 103 and 104: Regulation of the cell cycle and co
Page 105 and 106: CELL-CELL COMMUNICATION SUMMARY > C
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Connexin genes and tumour suppressi
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APOPTOSIS SUMMARY > The term apopto
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Caspase-8 Caspase-3 c-FLIP Procaspa
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ways. Several options are under inv
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INVASION AND METASTASIS SUMMARY > T
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laminin, entactin and also heparan
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Target Example of agent Comments Ad
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organs, and to respond to local gro
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TOBACCO CONTROL SUMMARY > Tobacco-i
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Region Deaths due to % of total dea
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ipated, is primarily attributable t
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smoke. This may be achieved in part
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there is no evidence for the effica
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industries, processes and occupatio
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stoves arises in rural areas of dev
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Climbing plants on trellis at end r
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HEPATITIS B VACCINATION SUMMARY > P
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Fig. 4.17 Chronic active HBV-associ
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HUMAN PAPILLOMAVIRUS VACCINATION SU
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Vaccine Site of trial Number of pat
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prolonged use. Similar drugs, that
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aspirin and other non-steroidal ant
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SCREENING FOR BREAST CANCER SUMMARY
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Fig. 4.35 Cumulative mortality from
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SCREENING FOR PROSTATE CANCER SUMMA
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Fig. 4.39 Poster designed for an an
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is around 10% for cancer (out of ev
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45 with one positive rehydrated FOB
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eing based on (i) time trends in th
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Fig. 4.48 Women at a clinic in Indi
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SCREENING FOR ORAL CANCER SUMMARY >
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India will provide useful informati
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cer incidence following cure of inf
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100 50 25 10 5 2.5 1 Japan Males Fe
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Human cancers by organ site Maligna
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tobacco smoking: age at start, aver
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diagnosis is usually confirmed by h
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is frequent and survival rates are
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Fig. 5.14 Physician reading digital
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Markers of prognosis in breast canc
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cer in the contralateral breast (Ch
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100 50 25 10 5 2.5 1 Japan Chile Po
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depends on staging. Small intramuco
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Fig. 5.30 A diet rich in fresh frui
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ane protein involved in cell adhesi
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LIVER CANCER SUMMARY > About 560,00
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Fig. 5.39 A woman in the Gambia pre
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REFERENCES 1. Ferlay J, Bray F, Par
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Certain Possible Uncertain Age Andr
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Management The dramatic division be
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TUMOUR NORMAL Gastrula PGC 2n Impri
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CANCERS OF THE FEMALE REPRODUCTIVE
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Fig. 5.62 Five-year relative surviv
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Inheritance of high-penetrance gene
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invasive malignant. Malignant germ
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OESOPHAGEAL CANCER SUMMARY >Cancer
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Fig. 5.76 A radiographic view of an
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with a stent; laser recannulation,
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Fig. 5.82 Risk of bladder cancer am
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Partial cystectomy is appropriate f
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poorly known since hypopharyngeal c
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Fig. 5.92 Oral leukoplakia with mil
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LYMPHOMA SUMMARY > Malignant lympho
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T Fig. 5.101 Nuclear magnetic reson
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Fig. 5.106 Five-year relative survi
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Fig. 5.109 The immediate aftermath
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A B Fig. 5.113 Acute myeloid leukae
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Fig. 5.118 Five-year relative survi
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Fig. 5.120 Age-specific incidence a
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Hereditary condition Mode of inheri
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MELANOMA SUMMARY > Approximately 13
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Fig. 5.131 Primary melanoma with a
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THYROID CANCER SUMMARY > Cancer of
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Papillary carcinoma RET/PTC TRK BRA
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KIDNEY CANCER SUMMARY > Cancer of t
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Stage Clear cell carcinoma Papillar
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TUMOURS OF THE NERVOUS SYSTEM SUMMA
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ing the optic tract, brain stem and
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mut = mutant p53 wt = wildtype p53
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SURGICAL ONCOLOGY SUMMARY > Surgica
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Year Radical mastectomy (%) Modifie
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TELEMEDICINE The prospects for tele
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Equipment Energy 50% depth dose App
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CANCER EDUCATION IN MEDICAL COURSES
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Fig. 6.10 Crystals of cisplatin: mo
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Responsiveness Cancer (in decreasin
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Most of the world’s most common c
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treatment of cancer. The problems l
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duction. It is clear that tumour ce
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REHABILITATION SUMMARY > Rehabilita
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cer and its associated disability.
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REFERENCES 1. Garden FH, Gillis TA
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Cancer pain relief varies and in so
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EMERGING ISSUES IN PALLIATIVE CARE
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Cancer control The negative impact
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priority to cancer control activiti
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Prevention of cancer Every country
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- Assessing the magnitude of the ca
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high-risk women. Further details on
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ecords departments are either rudim
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THE INTERNATIONAL AGENCY FOR RESEAR
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in the capitals/urban areas of four
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in the overall cancer strategy. WHO
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68% 1955 1975 1995 2025 32% 40% by
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Fig. 7.15 A grandfather at work in
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Fig. 7.17 Main causes of death in d
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Contributors and Reviewers Sources
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Dr Vera Luiz da Costa e Silva Tobac
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Georgia Moore Centers for Disease C
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REVIEWERS Dr Sandra E. Brooks 405 W
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2.53 T. Norat and E. Riboli, IARC 2
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Gastroenterology, 118(2 Suppl 1): S
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5.106 & 5.107 IARC/SEER/Osaka Cance
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4.17 R. Lambert, IARC/Adapted from
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Brain cancer, see nervous system tu
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Fibroblast growth factor (FGF), 117
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Microarray, 240 Micronutrients, 65,
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S Saccharin, 64, 85 Salicin, 153 Sa
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