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LUNG CANCER EPIDEMIOLOGY AND PREVENTION
Monograph of REZO GAGUA, VASIL TKESHELASHVILI and MEMED DJINCHARADZE
BATUMI, 1999
 The following monography includes the results of joint epidemiological research by the leading specialists of National Cancer Centre (Tbilisi): Dr. Rezo Gagua, PhD, DSc, Professor - Deputy Director of National Cancer Centre, Head of Thorocal Department, Chiet Oncologist of the Republic of Georgia; Dr. Vassil Tkeshelashvili, PhD, DSc, Head of Cancer Epidemiology and Control Department; Dr. Memed Djincharadze, PhD, the Head Doctor of Batumi Oncological Dispancery, Chiet Oncologist of Adjara. This monography represents the analysis of Lung Cancer Incidence in five Continents and its epidemiological features in the Adjara. There are given the modern methods of descriptive and analytical epidemiological research, recommended by the IARC* specified the lung cancer risk factors related to Environment and Life Stile and outlined the prevention of this pathology. The monograph introduces the first steps of telemedicine implemented in Georgia due to 3 grant projects of NCC from OSGF (1995-1996, total amount up to 15 000 US $),consequently to which the e-mail communication was created.This made possible the conduction of first Tele-radiological (1996) and Tele-morphological (1997) conferences. Particularly, at first time in Georgian history, x-ray grams, histograms and cancer incidence data base were transfered from Batumi to Tbilisi National Cancer Centre by E-mail. The necessity of adoption of the legislative bills and amendments is argumented for population protection from the exposition by chemical and radioactive carcinogenic materials and biological agents. The recommendations worked out by the results of research are provided for the oncologists, epidemiologists, pulmonologists, phtisiatrists, family doctors and doctors working at the common health care systems and students. The book includes seven pictures, 65 tables and 160 sources of the used literature.
 
Chapter IV Epidemiological Peculiarities of Lung Cancer Incidence and Its Prevention in Adjarian Autonomic Republic (Conclusion of the Results)
4.1. Lung Cancer Epidemiology and Prevention
According to the literature data lung cancer Incidence is characterized by the distinguished geographical, ethnical-social and sexual characteristics. The epidemiological findings also indicate the important etiological role of the exposure factors related to environment (geographical-ecological factors) and life style in development of lung cancer.
Smoking is considered as the main risk factor, causing lung cancer.
The other carcinogens are ionizing radiation, asbestos, non-ferrous metals (nickel, chrome), arsenic, chemicals (Chlorine-methyl ether, vinyl chloride, beryllium, hydrocarbonates) and toxic gases (coal gas, mustard gas, radon). The contamination of atmosphere in the working places is also considered as the main extrinsic factor causing the lung cancer.
The development of lung cancer depends on the influence of such professional factors as shipbuilding and oil-refining. The genetic factor also has the certain importance in the lung cancer pathogenesis.
It is considered that 90 percent of lung cancer is possible to avoid by means of prevention, especially changing of life style.
Giving up smoking reduces lung cancer risk progress. Those having had smoked about 20 cigarettes per day, 10 years later having given up smoking have the same risk of lung cancer as those who have never smoked.
In order to prevent non-smokers from the influence of carcinogenic agents including the tobacco smoking, necessary is to establish the state control on the nicotine and tar concentrations in tobacco products.
It's recommended increasing fruit and vegetables in the food ration.For the primary prevention of lung cancer incidence it is necessary to adopt the national standards in order to keep fresh air and establish it's State control.For the secondary prevention of lung cancer incidence in high-risk groups (men over 45 smoking 20 and more cigarettes per day) a routine screening (physical examination, X-ray of chest) must be performed.
4.2. The Epidemiological Peculiarities of the Lung Cancer Incidence in AdjaraThe structure of cancer incidence in Adjara was investigated by means of descriptive epidemiological research and cancer incidence of 10 leading sites among men and women was revealed.
To study the peculiarities of cancer incidence in Adjara according to the international standards there were used the indexes of cumulative risk (CR), proportional incidence ratio (PIR), Standardized incidence ratio (SIR), Standardized incidence ratio (SRR) and age-specific rates (ai), except age-standardized incidence rates (ASR).
The levels of 10 leading site cancer incidence was investigated for the first time in each region in Adjara among men and women (by means of ASR): In the cancer incidence structure the relation of each cancer site in each region was proportionally compared with analogous indexes in Adjara for the first time (by means of PIR). For the first time the dynamics of 10 leading site cancer incidence was learned in each region (by means of SIR). The Standardized incidence ratio of lung cancer incidence between men and women in Adjara (by means of SRR), and for the first time it was established cumulative risk of 10 leading site cancer incidences among the men and women for each region in Adjara (by means of CR).
According to the analyses of descriptive epidemiological data the following conclusions may be done:
In the Autonomic Republic of Adjara in 1983-1992 the following 10 leading site cancer incidences were revealed:
In the men lung cancer incidence took the first rank place. According to the age-standardized incidence rates on each 100 000 men 27,1 suffered from lung cancer. The second rank place takes the skin cancer (ASR=14,4), III- stomach cancer (ASR=10,5), IV- larynx cancer (ASR=8,3), V- bladder cancer (ASR=7,5), VI- colorectal cancer (ASR=5,9), VII- prostate cancer (ASR=3,6), VIII- non-Hodgkin's lymphoma (ASR=2,9), IX- leukemia (ASR=2,5) and X- liver cancer (ASR=2,2).
In the women breast cancer took the first rank place (ASR=10,6), II- skin cancer (ASR=10,6), III-cervical cancer (ASR=9,2), IV- stomach cancer (ASR=6,5), V- ovarian cancer (ASR=5,4), VI- colorectal cancer (ASR=4,9), VII- endometrial cancer (ASR=4,3), VIII- lung cancer (ASR=3,1), IX- leukemia (ASR=2,2) and X- non-Hodgkin's lymphoma (ASR=1,3).
In the mixed population according to the structure of 5 leading site cancer incidence lung cancer took the first place. According to the age-standardized incidence rates on each 100 000 resident of Adjara 30,2 suffered from lung cancer. The second - skin cancer (ASR=25,0), III - cancer of breast cancer (ASR=21,0), IV- women's reproductive organs cancer (ASR=19,8), V - stomach cancer.
In the Adjarian mixed population according to the structure of 5 leading site cancer incidence for both sex the lung cancer took the first rank place: According to the age-standardized incidence rates on each 100 000 resident in Adjara 30,2 suffered from lung cancer. Among the men living in Adjara lung cancer risk is high (CR(0-74)=7,4). According to the 10 years findings lung cancer took the first place in the cancer incidence structure in the Adjarian men's population.
The peak of lung cancer incidence in men was revealed in Batumi (ASR=33,6). This Figure is 2.7 times more to the lowest level in Adjara, registered in Khulo region (ASR=12,7). The Highest cumulative risk of lung cancer is in Batumi (CR(0-74)=8,6), also- for men living in Khelvachauri (CR(0-74)=7,3) and Kobuleti (CR(0-74)=6,7) regions. Also the 50 percent increase of lung cancer cases in men in Sthuakhevi Region in 10 year's dynamics is worth to attract attention. Comparing the lung cancer incidence in 50-54 age groups it increases 3 times after 55 and reaches its peak in 65-74 age groups. There was observed the trend of rejuvenation of lung cancer incidence in men of Adjara. This site of cancer incidence has grown 3,5 times in 1988-1992 comparing with 1983-1987 in 35-39 age groups and it was also registered in 30-34 and 25-29 age groups. Probably, this tend is connected with the growing number of young smokers in last years. It was revealed that 64 (!) percent of Batumi residents are active smokers. The majority of lung cancer patients are the working people (37,2 percent) connected with heavy and light industry and being under the high exposition of production ardor and remains. The level of lung cancer incidence in the women's population in Adjara was 8,7 times lower and their incidence risk-10 times lower. In the structure of cancer incidence it took the eighth place. Lung cancer incidence is increasing 1,7 times after 55 comparing the 50-54 age group and reaches its peak in 70-79 age groups.
The level of lung cancer incidence in the women's population of Adjara was 8,7 times and incidence risk-10 times lower. In the structure of cancer incidence it took the eighth rank place. Lung cancer incidence increases 1,7 times after 55 comparing with 50-54 age group and reaches its peak in 70-79 age groups. In Adjara, while screening lung cancer incidence, the prevention examination must be held in 55-79 age group. In order to reveal the earlier stage of professional lung cancer the special attention must be directed to the periodical examinations of persons connected with heavy and light industrial processes.
Unlike Tbilisi, in the mixed population in Adjara the skin cancer took the second place in the cancer incidence structure for both sexes. According to the age-standardized incidence rates on each 100000 resident of Adjara 25,0 inhabitant got the skin cancer. The high cumulative risk of skin cancer of the Black Sea shore regions might be related with high level of population exposure with ultraviolet rays.
In Adjara the dynamics of structural changes of cancer incident levels were observed comparing the 80-90 s (1983-1992) with 50-60 s (1955-1966). After about 30 years' interval the cancer incidences have grown up 1,2 times in men (according to the age-standardized incidence rates on each 100 000 men from 95,6 to 111,9) and 1,04 times in women (on each 100 000 women from 78,0 to 81,4) in Adjara. After the same interval the stomach cancer has sharply decreased (1,8 times) and it's obtained the 3-rd rank place from the 1-st.
In spite of the insignificant increase of skin cancer (from 13,7 to 14,4) it obtained the 2-nd place, as the result of stomach cancer decreasing. In 80-90 s (1983-1992) comparing with 50-60s (1955-1966) in both sex simultaneously the dynamics of structural changes of cancer incidence in 1,5 times (from 20,8 to 30,2) are notified. So, after 30 years' interval in both sex according to the cancer incidence structure stomach cancer incidence passed from its 1-st rank place to the fifth, and the lung cancer incidence- from the fifth -to the first.
In Adjara in 80-90s comparing with 50-60s the factors of environments and life style and the levels of their exposure on population have changed. The exposition of lung cancer etiological factors has extended.
Among the women living in Adjara the breast cancer incidence is very high (CR(0-74)=4,6). According to the 10 years' data (1983-1992) the breast cancer is on the first rank place in the cancer incidence structure is women's population in Adjara. At the same time the cumulative risk of this sites cancer development is particularly high in women living in Batumi (CR(0-74)=6,3), in Khelvachauri (CR(0-74)=3,6) and in Kobuleti (CR(0-74)=3,9).
While cancer control in Adjara (registration, epidemiological research, primary prevention, screening, early detection and so on) the great attention must be paid to the high risk site incidence characterizing each region.
The highest levels of cancer incidence in men and women were revealed in Batumi for the first time.
4.3. The Role of Some Factors of Life Style in the Etiology of Lung Cancer
According to the epidemiological research it was affirmed that tobacco smoking increases lung cancer risk (RR=1,4-3,5). The lung cancer risk is increased while smoking 20 and more cigarettes per day. The role of smoking was established for squamous cell (RR=3,9-4,3) and small-cell (RR=2.0-2.1) carcinoma of lung and the correlative link between smoking and adenocarcinoma of lungs was not revealed.
The risk of development of different chronic pathologic processes is increased 5,5 times by smoking. The reality of correlation was established: tobacco degree-doze (cigarette per day) -duration of smoke- lung pathology.
The chronic lung diseases are more frequent (RR=2,4-31,5 times) in people smoking 20 and more cigarettes per day. At the same time the risk of development of different lung diseases is higher, for those smoking 20 years and more. The tobacco quality has also the great importance for the initiation of lung pathology.
The development of different lung pathology is increased 3,1 times by smoking the foreign filter cigarettes, but it is increased 38,5 times by smoking the non-filter cigarettes of native production. Also there was affirmed the particular significance of passive smoking in the development of different lung chronic pathology. It was established that tobacco smog exposure (passive smoking) increases the risk of chronic lung diseases. The tobacco smog exposure causes the initiation of chronic lung diseases and lung cancer in non-smoker family members and colleagues.
Epidemiological research affirmed the preventive significance of regular citrus diet for chronic lung diseases and cancer. The risk of chronic lung diseases is lower minimum 2 times (RR=0,5) and maximum 11 times (RR=0,09) for persons feeding regularly by citrus, and on the contrary, the risk of chronic lung diseases development is 2,1-10,5 times higher for those not feeding with citrus.
By the additional epidemiological research having held according to the model: exposition-confounding - relative risk the following tends were revealed: In persons not fed with citrus tobacco exposure caused the sharp increase of the risk of chronic lung diseases development; and in spite of tobacco exposure in persons having fed regularly with citrus the risk of the chronic lung diseases progress was law.
According to the epidemiological research data we can conclude that the regular nourishment with citrus is the real mean to prevent the chronic lung diseases and the lung cancer. The role of citrus in lung cancer prevention is related to anti-carcinogenic action of Vitamin C.
The phonic significance of cancer incidences was affirmed in family members and close relatives for the development of chronic lung diseases. The persons whose family members and close relatives have suffered of cancer are under the high risk to get the chronic lung diseases (RR=1,8-12,4); and on the contrary, in those persons whose family members and close relatives have not suffered of cancer the risk of pathologic lung diseases and lung cancer is low minimum 2 times and maximum 100 times.
This correlation affirmed by the epidemiological research points to the importance of the genetic factor for etiologic-pathogenic gearing on the one hand, and doesn't except circumstance that being in the same living conditions family members and close relatives are under the exposition of factors connected with identical environments and life style on the other hand. It is possible that the latter prevails to make the convenient conditions for chronic lung diseases.
Yet in Adjara there are not taught and controlled such important outer factors for the human health as atmosphere and air at the working locality, drinking water, the Black Sea, food etc.
4.4. The Lung Cancer Prevention by the Control of Some Factors of
Environment and Life Style
The primary prevention of lung cancer will be possible after the solving the following tasks:
1. By the protection of environment (atmosphere and Black Sea, plant covering, food) in Adjara from the contamination of chemical and radioactive carcinogenic materials and biological agents (viruses, bacteria).
2. By popularization of Healthy life Stile which must be directed against smoking in Adjara.
3. By preparing and adopting the legislative bills and amendments by Adjarian Supreme Council, that should forbid:
a) Smoking in State and non-state organization and places of public meeting;
b) The advertising of tobacco products (as one of the varieties of health harming narcotics) and alcoholic drinks.
4. By the popularization of citrus in ration for prevention of lung cancer.
For the secondary prevention of lung cancer the formation of risk groups is recommended according to the following factors (5 and more) and/or symptoms:
1. Age 55 and more.
2. Occupation: heavy and light industry, transport.
3. Tobacco smoking.
4. Smoking 20 years and more.
5. Smoking 20 and more cigarette per day.
6. Family member smokers (passive smokers).
7. Smokers at the working localities (passive smokers).
8. Regular alcohol abuse.
9. Not feeding with citrus regularly.
10. Cancer incidences marked within the family members and close relatives.
11. Having been ill with pneumonia 2-3 times.
12. Lung tuberculosis.
13. Chronic bronchitis.
14. Other chronic lung diseases.
15. Having coughed for more than a month.
16. Having had bloody coughing.
A person having any combination of 5 factors from the first 10 ones and/or phonic diseases in the past and/or any symptom must be taken into the lung cancer risk group and needs preventive examination according to the standard scheme.
4.5. The Perspectives in the Distance Early Detection of Lung Cancer
By the introduction of Tele-medicine in Georgia the new stage of progress has begun in health services. This supports the solving of the problems concerning the high skilled specialists (radiologists, morphologies and etc) deficiency and neccessity of considerable improvement of distance early and timely detection of lung (or other localization cancer) in terms of decreasing the clinical detection time and raising its quality. This consequently will increase the efficiency of treatment and patients life-time, reduce the number of death cases caused by this disease, which will be very essential for state economy.
Recommendations
Creation of regional computerized cancer register is recommended to increase the effectiveness of cancer control (registration, epidemiological research, primary prevention, screening, early detection, distance detection by use of Tele-medicine, learning of further results of treating, appreciation program effects and so on) in Adjara. The connection of computerized informational-communicative system Batumi-Kobuleti-Khelvachauri-Shuakhevi-Keda-Khulo with Tbilisi National Cancer Center will support the further progress of Tele-medicine.
Lung cancer primary prevention, which intends the control of factors related to environment and life style and decrease it's influence on population to minimum, will be possible after the solving the following tasks:
Protection of population from chemical, radiological and biological carcinogenic agents exposure.
Popularization of Healthy Life Style directed against smoking and educational activities to increase citrus in diet.
Adoption the law forbidding smoking in state and non state organizations and places of public meetings and the advertising of tobacco products and alcoholic drinks by means of mass media.
For the secondary prevention of lung cancer the formation of risk groups is recommended according to the following factors (5 and more) and/or symptoms:
1. Age 55 and more.
2. Occupation: heavy and light industry, transport.
3. Tobacco smoking.
4. Smoking 20 years and more.
5. Smoking 20 and more cigarette per day.
6. Family member smokers (passive smokers).
7. Smokers at the working localities (passive smokers).
8. Regular alcohol abuse.
9. Not feeding with citrus regularly.
10. Cancer incidences marked within the family members and close relatives.
11. Having been ill with pneumonia 2-3 times.
12. Lung tuberculosis.
13. Chronic bronchitis.
14. Other chronic lung diseases.
15. Having coughed for more than a month.
16. Having had bloody coughing.
A person having any combination of 5 factors from the first 10 ones and/or phonic diseases in the past and/or any symptom must be taken into the lung cancer risk group and needs preventive examination according to the standard scheme.
In difficult and suspicious cases there is recommended to receive the Tele-radiological or Tele-morphological consultation with the participation of National Cancer Center's leading specialists.
CONTENTS
Introduction
Chapter I. Lung Cancer Epidemiology
1.1. Lung Cancer Incidence in Five Continents
1.2. The Methods of Standardization of the Cancer Incidence
1.3. The Structure of Cancer Incidence in Adjara in 1983-1992
1.4. The Peculiarities of 10 Leading Sites Cancer Incidence in Men in Adjara
1.5. The Peculiarities of 10 Leading Sites Cancer Incidence in Women in Adjara
Chapter II. The Risk Factors of Lung Cancer
2.1. Environment and Life Stile Related Risk Factors of Lung Cancer
2.2. Case-Control Study Method of the Epidemiological Research
2.3. Values of Lung Cancer Relative Risks by the Case-Control
Study
2.4. The Significance of Lung Chronic Diseases
Chapter III. Prevention of Lung Cancer
3.1. Lung Cancer Prevention by the Control of Environmental and Life Stiles Related Risk Factors
3.2. The Primary and Secondary Prevention of the Lung Cancer
3.3. The Role of Tele-medicine in the Early Detection of the Lung Cancer on the Modern Stage
3.4. The First Steps of Tele-medicine in the Georgia
Chapter IV. Epidemiological Peculiarities of Lung Cancer Incidence and its Prevention in Adjarian Autonomic Republic (Conclusion of the Results) (in English)
4.1. Lung Cancer Epidemiology and Prevention
4.2. The Epidemiological Peculiarities of the Lung Cancer Incidence in the Adjara
4.3. The Role of some Factors of Life Stile in the Etiology of Lung Cancer
4.4. Lung Cancer Prevention by the Control of some Factors of Environment and Life Stile
4.5. The Perspectives in the Distance Early Detection of the Lung Cancer
Recommendations
Bibliographic Index
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