Pattern Of Cancer In Adolescent And Young

Adults In INDIA: With A Note On Bone Cancer

Doctor Kalyani MD M.D.(Path), FICP, FIAMS, MNAMS.

Professor of PathologySri Devaraj Urs Medical College

Sri Devaraj Urs Academy Of Higher Education And Research(Deemed to be university)Kolar. Karnataka. India.

Dr.Kalyani R. MD 1

Dr.Kalyani R. MD

The following is the talk presented at an International conference organized by EPS Global Medical Development

form on 18th April 2011 at Yangzhou, China

2

The Present Study is Undertaken at Sri R.L Jalappa Hospital

and Research Institute Kolar INDIA

Dr.Kalyani R. MD 3

The Present Study is Supported with a

Mission… Mission of Sri Devaraj

Urs Medical college shall strive to be an Institution of excellence in the field of Medical Education with continued improvement of systems and process. To serve the poor in and around Kolar India…Dr.Kalyani R. MD 4

Dr.Kalyani R. MD 5

Dr.Kalyani R. MD 6

Cancer pattern in adolescent and young

adults (AYA) is different from those in children & older adults.

The incidence is increasing faster than the increase in either children or older adults.

When diagnosed, AYA suffer from adverse psychosocial effects as most of their potential years of life ahead of them has to be spent with effects of cancer or its treatment.

Introduction

Dr.Kalyani R. MD 7

These cancer are more likely related to

genetic predisposition and specific health behavior & life style among young people exposing themselves to new causative agent before the old do and also the short period of exposure between the beginning of life and cancer diagnosis.

The shift of non-epithelial cancers in children to epithelial cancers in older adults occurs through several years in AYA age group.

Introduction

Dr.Kalyani R. MD 8

Epidemiology helps to track

Hence Epidemiological study helps to know the incidence, age / gender / site distribution & the probable risk factors responsible for cancer.

Dr.Kalyani R. MD 9

A ten year retrospective study from

January 1997 to December 2006 was undertaken at department of Pathology

All histopathology and FNAC cases reported between 15 – 44 years were included in this study.

Multiple Specimens of a patient, where FNAC was done and later followed by histopathology were considered as one case.

Methodology Adopted

Dr.Kalyani R. MD 10

Cases of FNAC …..

FNAC cases which were not followed by biopsy were counted Separately

Dr.Kalyani R. MD 11

The relevant history and clinical findings

of each case were retrieved from department / hospital records.

The diagnosis of each case were critically revised, confirmed and the cumulative data was then categorized and coded accordingly to ICD 10 WHO ISCD 1994 1.

The metastatic cancers of unknown primary were grouped separately.

Methodology

Dr.Kalyani R. MD 12

The Cases were Analyzed.. ….

The cases were analyzed for age / gender / year / site distribution by descriptive analysis and the findings compared with other similar studies.

Dr.Kalyani R. MD 13

Results

Total No. of Cases Reported in 10 Years 19615

Histopathology 15307

FNAC 4308

Total malignancies reported 2744 (13.98%)

Total malignancies in AYA 730 (26.6%)

Males 242 (33.1%)

Females 488 (66.8%)

Male : Female 1 : 2

Malignancies :

With known primary site ; Males (200) + Females (441) = 641.With unknown primary site : Males (42) + Females (47) = 89

Table-1Cases Reported at Dept. of Pathology SDUMC (Jan 1997 to Dec. 2006)

Dr.Kalyani R. MD 14

results

ICD Code Site of Malignancy

Males Females Total

Cases % Cases % Cases %

C06 Mouth 50 20.66 127 26.02 177 24.24

C07/08 Salivary Gland 7 2.89 3 0.61 10 1.36

C15 Esophagus 6 2.47 13 2.66 19 2.60

C16 Stomach 33 13.63 22 4.50 55 7.53

C17 Small Intestine 1 0.41 - - 1 0.13

C18 Colon 9 3.71 2 0.40 11 1.50

C19/20 Rectum 3 1.23 8 1.63 11 1.50

C22 Liver + Hepatobiliary

6 2.47 1 0.20 7 0.95

C26 Other GI - - 1 0.20 1 0.13

C32 Larrgx 6 2.47 1 0.20 7 0.95

C34 Lung 4 1.65 3 0.61 7 0.95

C 38 Pleura, Mediastinum, Heart

- - 1 0.20 1 0.13

C40/41 Bone 13 5.37 20 4.09 33 4.52

C43 Melanoma 4 1.65 2 0.40 6 0.82C44 Other Skin

Cancer2 0.82 6 1.22 8 1.09

C50 Breast 2 - 62 12.70 64 8.76

C51 Vulva - - 1 0.20 1 0.13

C52 Vagina - - 5 1.02 5 0.68

C53 Cervix Uterus - - 90 18.44 90 12.32

C54 Copus Uterus - - 2 0.40 2 0.27

C56 Ovary - - 13 2.66 13 1.78

C57 Other FGO - - 1 0.20 1 0.13

C60 Penis 10 4.13 - - 10 1.36

C61 Prostate 1 0.41 - - 1 0.13

C62 Testis 14 5.78 - - 14 1.91

C64 Kidney 1 0.41 - - 1 0.13

C67 bladder 4 1.65 5 1.02 9 1.23

C73 Thyroid 7 2.89 49 10.04 56 7.67

C81 Hodglain's 8 3.30 6 1.22 14 1.91

C82 Non-Hodgkin layer

9 3.71 5 1.02 14 1.91

C80 Unknown Primary / Metastatis

42 17.35 47 9.63 89 12.19

Total 242 100 488 100 730 100

Table-2 : Site distribution of various cancers (ICD – 10 – WHO ISCD 1994)

Dr.Kalyani R. MD 15

Results

Sl.No. Age Group Males Females M : F

1 15-19 9 10 1:1.1

2 20-24 20 31 1:1.5

3 25-29 32 40 1:1.25

4 30-34 24 73 1:3.04

5 35-39 80 147 1:1.85

6 40-44 77 86 1:2.41

TOTAL 242 488 1:2

Table-3Cancer in various Age Groups in relation to Sex

Dr.Kalyani R. MD 16

Cancer in various Age Groups in relation to Sex

0

20

40

60

80

100

120

140

160

15-19 20-24 25-29 30-34 35-39 40-44

Male

Female

Dr.Kalyani R. MD 17

Results

Sl.No.

Year Males Females

Total

1 1997 12 18 30

2 1998 17 23 40

3 1999 22 32 54

4 2000 24 63 87

5 2001 21 46 67

6 2002 14 19 33

7 2003 21 36 57

8 2004 36 89 125

9 2005 43 84 127

10 2006 32 78 110

Total 242 488 730

Table-4Year wise distribution of Cancer with Sex

1997 1998 1999 2000 2001 2002 2003 2004 2005 20060

10

20

30

40

50

60

70

80

90

100

MalesFemales

Dr.Kalyani R. MD 18

ResultsTable-5

Top Ten Cancers in Males, Females and Combined in present study.

Sl.No.

Males Females Combined

Site % Site % Site %

1 Mouth 20.66 Mouth 26.02 Mouth 24.24

2 Stomach 13.63 Cervix Uterus 18.44 Cervix Uterus 12.32

3 Testis 5.78 Breast 12.70 Breast 8.76

4 Bone 5.37 Thyroid 10.04 Thyroid 7.67

5 Penis 4.13 Stomach 4.50 Stomach 7.53

6 Colon 3.71 Bone 4.09 Bone 4.52

7 NHL 3.71 Esophagus 2.66 Esophagus 2.60

8 Hodgkin’s Lym. 3.30 Ovary 2.66 Testis 1.91

9 Thyroid 2.89 Rectum 1.63 NHL 1.91

10 Salivary gland 2.89 Hodgkin’s lym 1.22 Hodgkin’s lym 1.91Dr.Kalyani R. MD 19

ResultsTable-6

Top five cancer sites in different age groups

15-19 20-24 25-29 30-34 35-39 40-44 45+

Males

Hodgkin’s lymSalivary gland

MouthPenisLung

BoneMouthThyroidColonLiver

StomachTestis

MouthBoneColon

TestisHodgkin’s Lym.

PenisMouthBone

MouthStomach

TestisPenisBone

MouthStomach

NHLColon

Salivary Gland

MouthStomach

EsophagusProstateBladder

Females

ThyroidBone

Hodgkin’s lymRectum

ThyroidMouthBone

StomachBreast

ThyroidCervixMouthBone

Stomach

BreastThyroidMouthCervix

Stomach

MouthCervixBreast

ThyroidBone

MouthCervixBreast

EsophagusStomach

MouthCervixBreast

StomachEsophagus

Dr.Kalyani R. MD 20

Results – Bone cancerTotal malignancies in AYA

730

Total bone malignancies in AYA 33 (4.52%)

Males 13 (39.3%)

Females 20 (60.6%)

Male: Female 1:1.5 Age Males Females M:F Totalgroup

15-19 01 02 1:2 0320-24 04 03 1:0.7 0725-29 02 04 1:2 0630-34 01 02 1:2 0335-39 04 06 1:1.5 1040-44 01 03 1:3 04

Total 13 20 1:1.5 33

Histological type Males Females M:F Total

Synovial sarcoma 05 04 1:0.8 09Osteogenic sarcoma 03 05 1:1.6 08Ewing’s sarcoma 01 04 1:4 05Chondrosarcoma 03 01 1:0.6 04Chondroblastoma 00 01 01Metastatic (Secondary) 1 05 1:5 06

Total 13 20 1:1.5 33 Dr.Kalyani R. MD 21

Discussion – Place of Study

Kolar District shares the borders of Andra Pradesh and Tamil Nadu which has influenced the food habits and lifestyle of the people.

The food is very spicy Rice and Ragi are the staple food There is increase use of Tobacco and alcohol in both

genders with onset of this habit at very young age especially in low socioeconomic group

Our Hospital caters to the local population and also neighboring districts.

Majority of our patients belong to low socioeconomic group with rural background

Dr.Kalyani R. MD 22

Discussion –

Incidence The incidence of AYA cancers reported is 8.7%2.

Each year 500 males & 350 females are diagnosed in California 2.

The incidence increase in males by 0.7% / year and in females 0.5% / year in Bangladesh 3.

Cancer of AYA is 2.7 times more common than cancer of less than 15 years and less common than cancer in older age groups 4.

The incidence in our study is 26.6% of total cancers with a steady rise in number of cases over 10 years.

Dr.Kalyani R. MD 23

Discussion - Age

Mean age of cancer in AYA reported is 34.47 + 6.33 years 3. Non-Hodgkin’s Lymphoma increase and Sarcomas

decrease with age 2. Germ cell tumors peaks between 30-34 years 2. The risk factors responsible in this age group is

infection, adolescent growth spurts, hormones, growth and development factors associated with genetic predisposition 5.

This is the age of crossover from a predominance of non-epithelial cancer in childhood to predominance of epithelial cancers in older adults 6 .

In this study maximum cases were seen between 35-39 years in both gender.

Dr.Kalyani R. MD 24

Discussion- Gender

Majority of the studies show Female preponderance with incidence in males of 38-42% & females 57-62% because of more female cancers of female genital organs, breast and thyroid 2,3,6.

Male : Female ratio reported 0.75 : 1.0 / 1:2 3,5.

Male : Female ratio is reported to decrease linearly from 10-14 years age group to 40-44 years age group 7.

The transition of male predominance in childhood to female predominance in middle years of life occurs during late adolescent & early adulthood with maximum cases in males between 15-29 years 7.

Our study also showed female preponderance (in all age group) with male : female ratio 1:2.Dr.Kalyani R. MD 25

Discussion - GeographyTop ten cancer sites in males in various

studies compared to present study

Sl. England 2010 9 India 2010 9 Present Study1 Testis Leukemia Mouth2 Hodgkin’s lym CNS Stomach3 NHL Bones & Jt Testis

4 Leukemia NHL Bone5 CNS Hodgkin’s lym Penis6 Melanoma Soft tissue Colon7 Bones & Jt Testis NHL8 Soft tissue Colorectal Hodgkin’s lym9 Colorectal Thyroid Thyroid

10 Thyroid Mouth Salivary glandDr.Kalyani R. MD 26

Discussion - GeographyTop ten cancer sites in females in various studies compared to present study

Sl. England 2010 9 India 2010 9 Present Study

1 Melanoma Breast Mouth2 Cervix Leukemia Cervix3 Hodgkin’s lym Ovary Breast4 Breast Thyroid Thyroid

5 Ovary CNS Stomach6 Thyroid Bones & Jt Bone7 Leukemia NHL Esophagus8 CNS Cervix Ovary9 NHL Colorectal Rectum

10 Colorectal Soft tissue Hodgkin’s lymDr.Kalyani R. MD 27

Discussion - GeographyTop ten cancer sites in various studies compared to

present studyEngland 2010 9

Canada 2002 4

California 2005 2

US 2006 7 India 2010 9 Present Study

Testis Breast Breast NHL Leukemia MouthCervix Testis Thyroid Hodgkin's lym Ovary Cervix

Hodgkin’s lym

Melanoma Melanoma Skin Cancer CNS Breast

Melanoma Cervix NHL MGS Bones & Jt ThyroidOvary NHL Hodgkin's

lym.Endocrine NHL Stomach

NHL Thyroid Leukemia FGS Thyroid BoneCNS Colorectal Colorectal CNS Hodgkin’s lym Esophagus

Thyroid Lung Brain Leukemia Cervix TestisBreast Brain Nervous Sys. Breast Testis NHL

Bones & Jt Hodgkin's lym

Testis GIT Soft tissue Hodgkin’s lymDr.Kalyani R. MD 28

Discussion - Cancer type

Epithelial cancers predominate in males > 40 years and in female > 25 years (younger age) 6.

The Predominance of epithelial or non-epithelial cancers give clue to etiology 6 .

Non-Epithelial cancer risk factors: viral infection, radiation, genetic and environmental carcinogens 6.

Epithelial cancer risk factors: Lifestyle factors such as tobacco use, alcohol consumption & dietary factors 6.

Dr.Kalyani R. MD 29

However family history of cancer and

genetic predisposition may shorten latency and increase likelihood of early onset of epithelial cancers 6.

In our study cancers in different age group showed early onset of epithelial cancer especially in females which began in 20-25 years.

The striking feature is oral cancer which predominates in both gender followed by stomach cancer. In females cervical cancer predominates.

Discussion – Cancer type

Dr.Kalyani R. MD 30

Discussion – Bone cancer

The incidence of Primary bone cancer reported is 3% of all cancers in AYA and the incidence between 15-19 years is 8%.2,7

The incidence reported in males is almost double compared to that in females.

Among the histological variants, osteosarcoma is the commonest constituting about 47% followed by Ewing’s sarcoma (27%) and chondrosarcoma (15%). 2,7

The risk factors reported are ionizing radiation, alkylating agents, Paget disease, multiple hereditary exostoses, etc. The role of fluoride in bone cancer is equivocal. 2,7

Dr.Kalyani R. MD 31

The mortality due to bone cancer in AYA

is higher in males than in females. 2,7

In this study primary bone cancer accounted for 4.52% of all cancers in AYA with female preponderance.

Among the histological types, synovial sarcoma was commonest, followed by osteosarcoma, Ewing’s sarcoma and chondrosarcoma.

Kolar district has many pockets of fluorosis, which may have impact on incidence of bone cancer and has to be proved.

Discussion – Bone cancer

Dr.Kalyani R. MD 32

Discussion - Prognosis

Overall prognosis is bad 7. Males have a worse prognosis than females 7. Delay in diagnosis especially of bone & brain cancers in

which professional delay is always longer than patient symptoms delayed

Poor outcome is because of mix of tumor types seen in this age group, having different biology of cancer, high risk prognostic cytogenetic features, more resistant form of cancer, low clinical trial participation and treatment not yet fully adopted to the tumor biology and is not tailored for cancers of AYA 8.

In our study no follow-up of cases was done to comment on prognosis.

Dr.Kalyani R. MD 33

Conclusion

Trends and pattern of cancers in AYA define risk factors. In the present study incidence is high (26.6%) with female

preponderance (in all age groups). Predominance of epithelial cancers than non-epithelial cancers

was seen in both gender at early age compared to other studies which can be correlated to lifestyle & dietary habits of the people.

This study provide leads for further etiological research and identify cancers that have the greatest impact in these age groups.

This epidemiologic study helps to take-up cancer preventive measures and screening programmes in early detection of cancer.

Dr.Kalyani R. MD 34

References

1) Nanda Kumar A, Gupta PC, Gangadhar P, Visweshwara R.N. Development of an atlas of cancer in India : First all India Report : 2001-2002. National Cancer Registery programme (ICMR), Bangalore, India. 2004.

2) Cancer in adolescents & young adults, Department of health sciences, California. 3) Yalukder MH, Jabeen S, Shaheen S, Islam MJ, Haque M. Pattern of cancers in young

adults at National Institute of Cancer research and hospital (NICRH), Bangladesh. Mymensingh Med J, 2007 ; 16 (2) : 528-33.

4) Cancer incidence in young adults special topic from Canadian cancer statistics 2002.

5) More young adults being diagnosed with cancer – First Canadian research in this area Canadian cancer statics 2002 by Canadian cancer society.

6) Xiachengwu Wu, Frank D Groves, Collenc Mclanghlin et al. Cancer incidence patterns among adolescents and young adults in the united states. Cancer causes and control 2005 ; 16 : 309 -320.

7) Archie Blefer, Aaron Viny, Ronald Barr, Cancer in 15 to 29 years olds by primary site. The oncologist 2006 ; 11 (6) : 590 – 601.

8) Conrad V Fernandez, Ronald D Barr. Adolescents and young adults with cancer : An orphane. Paediatric Child Health 2006 ; 11 (2) 103 – 106.

9) Ramandeep s, Robert D Alston, Tim OB Eden, et al. Cancer at ages 15-29 years: The contrasting incidence in India and England. Pediate Blood Cancer @ 2010 Wiley-Liss.Inc.

Dr.Kalyani R. MD 35

ACKNOWLEDGMENT

I thank Honorable Vice-Chancellor Prof. S. Chandrasekhar Shetty, Sri Devaraj Urs Academy Of Higher Education And Research (Deemed to be university) for the constant encouragement.

I thank Dr. M. L. Harendra Kumar, Prof & HOD, Dept. of Pathology, Dr. Subhahish Das, co-author, my colleague staffs and technical staffs for constant support.

I thank Dr. T. V. Rao, Prof of Microbiology for formatting this presentation.

This work is published in Asian Pacific Journal of cancer Prevention 2010;11:655-659.

Dr.Kalyani R. MD 36

Dr.Kalyani R. MD 37