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Cancer Prevention: Part I
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Cancer Prevention: Part 1
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Professional Oncology Education
Cancer Prevention: Part 1
Time: 26:20?
Sally Scroggs, MS, RD, LD
Manager, Health Education
Cancer Prevention Center
The University of Texas, MD Anderson Cancer Center
Hello, I am Sally Scroggs and I am the Health Educator
for the Cancer Prevention Center at University of Texas
MD Anderson Cancer Center.
Spanish Translation
Prevención del cáncer: Parte 1
Transcripción del video
Educación Oncológica Profesional
Prevención del cáncer: Parte 1
Duración: 26:20?
M.C. Sally Scroggs, Dietista Autorizada y Registrada
Gerente de Educación para la Salud
Centro de Prevención del Cáncer
Universidad de Texas, MD Anderson Cancer Center
Hola. Soy Sally Scroggs y soy Educadora de Salud del
Centro de Prevención del Cáncer en el MD Anderson
Cancer Center de la Universidad de Texas.
Cancer Prevention: Part I
Sally Scroggs, MS, RD, LD
Manager, Health Education
Cancer Prevention Center
1
Cancer Prevention: Part I
Objectives
• Upon completion of this lesson, participants will
be able to:
Today, I am going to talk to you about cancer prevention.
This is Part I. The objectives that we are going to be
covering are discussing: lifestyle modification strategies
for risk reduction. Life. The other two objectives will be
covered in Part II.
Hoy hablaremos de la prevención del cáncer. Esta es la
Parte I de la presentación, donde cubriremos y
analizaremos las estrategias para cambiar el estilo de vida
a fin de reducir el riesgo. Los otros dos objetivos se
tratarán en la Parte II.
I am going to start out with cancer mortality rates and
good news is that fewer Americans are dying of cancer.
And, yes, this is due to better treatment modalities, but
also to cancer prevention activities. The even better news
is, or more exciting news, is that we are now seeing fewer
Americans being diagnosed with cancer, and, again, this
is due to aggressive cancer prevention activities, for
example, there are fewer people smoking now. There are
less people starting to smoke. So, this can have an
impact on decreasing the cancer diagnosis, but also we
now have screening activities, for example, removing --being able to remove precancerous polyps during a
colonoscopy, which further has a result of decreasing
risk.
Voy a comenzar con las tasas de mortalidad del cáncer.
La buena noticia es que menos estadounidenses mueren
por cáncer. Esto se debe a las mejores modalidades de
tratamiento, así como a las actividades de prevención del
cáncer. Otra noticia alentadora y a la vez interesante es
que ahora hay cada vez menos estadounidenses con
diagnóstico de cáncer. También en este caso, ello se debe
a las intensas actividades de prevención del cáncer. Por
ejemplo, ahora hay menos personas que fuman y menos
que se inician en el hábito. Esto ha tenido un impacto en
la disminución de diagnósticos de cáncer, pero ahora
también utilizamos métodos preventivos, como la
extirpación de pólipos precancerosos por medio de
colonoscopia, lo que reduce aún más el riesgo.
– Discuss lifestyle modification strategies for risk
reduction.
– List types of prophylactic surgical interventions used
to prevent malignancies.
– Identify chemoprevention strategies for several
common cancers.
Cancer Prevention: Part I
Cancer Mortality Rate
Fewer Americans dying of cancer
• Better treatment
• Cancer prevention activities
Fewer Americans being diagnosed with cancer
• Related to cancer prevention activities
- Tobacco cessation
- Colorectal cancer prevention through removal
of precancerous polyps
2
Cancer Prevention: Part I
Cancer Control
• Cancer Treatment
• Cancer Prevention
Cancer control certainly encompasses cancer treatment,
but also a part of cancer control is cancer prevention. And
we can divide it into three different areas: primary
prevention, secondary prevention, and tertiary prevention.
And we will be covering these in detail.
El control del cáncer sin duda abarca el tratamiento del
cáncer, pero otro elemento es su prevención, que puede
dividirse en tres áreas diferentes: prevención primaria,
prevención secundaria y prevención terciaria. Más
adelante las describiremos en detalle.
The first that I am going to discuss is risk assessment.
So, this is the starting point of cancer prevention. And
what we do is come up with target recommendations on
an --- for an individual for their level of risk for each
specific cancer type.
Lo primero que analizaremos es la evaluación de riesgos,
que es el punto de partida de la prevención del cáncer.
Para ello, preparamos recomendaciones a seguir para
cada persona según su nivel de riesgo y para cada tipo
específico de cáncer.
– Primary Prevention
• Reducing the incidence of cancer through health promotion
and cancer risk reduction
– Secondary Prevention
• Cancer screening and early detection to identify cancer
cases early before signs or symptoms develop
– Tertiary Prevention
• Survivorship activities to monitor for and prevent recurrence
and late effects of treatment
Cancer Prevention: Part I
Risk Assessment
3
Cancer Prevention: Part I
Risk Assessment
• Qualitative Risk Assessment
- Identifying risk factors
• e.g. smoking
• Quantitative Risk Assessment
We can do this qualitatively and quantitatively. Mostly,
it is qualitative. So, for example, we know that, if a
person is smoking, that they are going to be at higher risk
for lung cancer and head and neck cancers. But, also
quantitatively, in a few cases now, we have computerized
risk assessment models that can estimate an individual’s
risk of developing cancer. An example would be the risk
assessment tool that can estimate a woman’s risk of
developing breast cancer. A couple of these are
computerized.
Estas pueden ser cualitativas o cuantitativas, pero en su
mayoría son cualitativas. Por ejemplo, sabemos que si
una persona fuma, tiene un mayor riesgo de cáncer de
pulmón, cabeza y cuello. Cuantitativamente, en algunos
casos contamos con modelos computarizados de
evaluación de riesgos para estimar el riesgo individual de
desarrollar cáncer, tal como una herramienta de
evaluación que estima el riesgo de una mujer de
desarrollar cáncer de mama. Tenemos varias
herramientas computarizadas.
This is an example of the Gail model. It is also called the
Breast Cancer Risk Assessment Tool. In this assessment
you can --- you can find this on the National Cancer
Institute’s web page, but it is also on the
breastcancerprevention.com web page. And, this model
estimates a woman’s risk of developing breast cancer
based on some identifiable factors, and these factors
include age. They include the age of the first menstrual
cycle. It also includes the age of the first live birth of a
child, family history of breast cancer in first-degree
relatives, and also the individual’s breast biopsy history
[excuse me] including any biopsy identified as atypical
hyperplasia. So, the model estimates a woman’s breast
cancer risk for over the next five years and over her
lifetime. Increased risk is defined as a five-year risk of
1.7 or greater.
Este es un ejemplo del modelo de Gail, o Herramienta de
Evaluación del Riesgo de Cáncer de Mama. Esta
herramienta se encuentra en la página Web del Instituto
Nacional del Cáncer, así como en la página Web “breast
cancer prevention punto com”. Este modelo estima el
riesgo de una mujer de desarrollar cáncer de mama
basándose en algunos factores identificables. Uno de tales
riesgos es la edad: la edad al primer ciclo menstrual y la
edad al primer nacimiento con vida. Asimismo, considera
antecedentes familiares de cáncer de mama en parientes
de primer grado, y el historial de biopsias de mama,
incluida cualquier biopsia identificada como hiperplasia
atípica. El modelo estima el riesgo de cáncer de mama
para los próximos cinco años y para toda la vida.
El riesgo aumentado se define como un riesgo a cinco
años de 1.7 o mayor.
- Use of computerized models to estimate cancer risk
• e.g. breast (Claus, Gail, BRCAPRO)
Cancer Prevention: Part I
Breast Cancer Risk Assessment Tool
4
Cancer Prevention: Part I
Risk Reduction Strategies
Once we have identified an individual’s risk, then we can
provide them with strategies to reduce the risk of
developing cancer.
Una vez que hemos identificado el riesgo de una persona
podemos proporcionarle estrategias para reducir el riesgo
de desarrollar cáncer.
I am going to start out with what you can do to make
lifestyle changes and I am going to be using the
American Institute for Cancer Research information.
Where they --- it is the most comprehensive research we
have to date where they looked at over 7,000 studies. And
they came up with about eight guidelines, two special
recommendations. And then they --- this slide is a
grouping of the main message from those guidelines,
which includes choosing mostly plant-based foods and
limiting red meat, avoiding processed meat, being
physically active every day for 30 minutes or more, and
aim for a healthy weight throughout life. And I am going
to go into more detail.
Comenzaremos por lo que podemos hacer para introducir
cambios de estilo de vida, según la información del
Instituto Americano para la Investigación del Cáncer.
Es la investigación más completa disponible hasta la
fecha, pues recopila más de 7,000 estudios, con los que se
prepararon alrededor de ocho pautas y dos
recomendaciones especiales. Esta diapositiva muestra sus
mensajes más importantes: comer alimentos
principalmente de origen vegetal, limitar las carnes rojas
y procesadas, ejercitarse físicamente todos los días
durante 30 minutos o más, y mantener un peso saludable
durante toda la vida. Veamos ahora los detalles.
• Health Promotion
- Diet
- Lifestyle modification
• Prophylactic surgical interventions
• Chemoprevention
Cancer Prevention: Part I
American Institute of Cancer Research Guidelines
1. Choosing mostly plant foods, limit red meat
and avoid processed meat.
2. Be physically active everyday in any way for
30 minutes or more.
3. Aim to be a healthy weight throughout life.
2007 World Cancer Research Fund/ American Institute for
Cancer Research Expert Report: Food, Nutrition, Physical
Activity and the Prevention of Cancer: a Global Perspective
5
Cancer Prevention: Part I
Summary of “Convincing” and “Probable”
Judgements
First of all, I would like to show you a summary of the
research. And, this is a very good patient education tool.
It has the cancer sites across the top. And then, on this
left side, it has different elements, for example, in food
and also physical activity, body weight. As you can see,
colorectal cancer --- it is convincing that body fatness and
abdominal fatness increases risk. And yet physical
activity convincingly decreases risk. So, there are both
things that we can do that can protect, but there also
maybe things that can increase the risk of cancer. So,
again, you can look at what an individual’s specific
cancer risks are, maybe from family history, or their
individual history, and give them specific guidelines on
what they can do to be proactive and make some changes
for reducing their risk of cancer.
En primer lugar, mostraré un resumen de la investigación.
Esta es una excelente herramienta para educar al paciente
que muestra en la parte superior los órganos donde puede
ocurrir el cáncer. A la izquierda, diversos factores, como
alimentos, actividad física y peso corporal. Para el cáncer
colorrectal, hay evidencias convincentes de que la grasa
corporal y abdominal aumenta el riesgo, y que la
actividad física lo disminuye. Son factores que ayudan a
brindar protección, pero también hay otros que aumentan
el riesgo de cáncer. Podemos entonces analizar los
riesgos específicos de cáncer de un paciente, según sus
antecedentes familiares o su historial individual, y darle
pautas específicas sobre cómo ser proactivo e introducir
cambios para reducir su riesgo de cáncer.
The first guideline --- and this is the first for both the
American Institute for Cancer Research and for the
American Cancer Society, putting emphasis on the risk
factor with cancer and obesity. So, the first one is
maintaining a healthy weight throughout life. And one
way to assess this with your patients is using body mass
index. And typically the body mass index healthy range is
8.5 to 24.9. The American Institute for Cancer Research
narrowed that to 21 to 23; and this is a reflection of if
individuals, even ethnic populations, who are at higher
risk of heart disease or diabetes with excess weight would
also be at higher risk for the cancer sites that are
associated with obesity. So, there are other ways to
measure abdominal fatness, which we just saw was
related to colorectal cancer. It is also related to increased
risk with post --- with breast cancer for postmenopausal
females. So weight gain, increase in waist circumference,
and even hip-to-weight --- waist-to-hip ratio can also be
used to assess body fatness and risk.
La primera pauta, tanto para el Instituto Americano para
la Investigación del Cáncer como para la Sociedad
Americana del Cáncer, es destacar la relación entre el
cáncer y la obesidad como factor de riesgo. Entonces, lo
primero es mantener un peso saludable durante toda la
vida. Una manera de evaluarlo en un paciente es con el
índice de masa corporal. Por lo general, el rango de
valores saludables es de 8.5 a 24.9. El Instituto redujo
estos valores a 21 y 23. Esto indica que si una persona o
incluso un grupo étnico tienen mayor riesgo de
enfermedad cardíaca o diabetes por exceso de peso,
también tendrá mayor riesgo de cáncer en los órganos
asociados con la obesidad. Hay otras maneras de medir la
grasa abdominal, que como vimos está relacionada con el
cáncer colorrectal. También se asocia con un mayor
riesgo de cáncer de mama en mujeres posmenopáusicas.
El aumento de peso, una mayor circunferencia abdominal
e incluso la relación entre la cadera y el peso, permiten
evaluar la grasa corporal y el riesgo.
World Cancer Research Fund/American Institute for Cancer Research.
Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington, DC: AICR, 2007
Cancer Prevention: Part I
American Institute for Cancer Research
Guidelines Include:
• Maintain a healthy weight throughout life
• BMI 21-23
• Avoid weight gain and increases in waist circumference,
especially post-menopausal for females
6
Cancer Prevention: Part I
Obesity and Cancer
Convincing Increased Risk
Probable Increased Risk
• Breast (among
postmenopausal women)
• Colon
• Endometrium
• Esophagus
• Kidney
• Pancreas
• Gallbladder
Limited-suggestive
Increased Risk
The American Institute for Cancer Research uses
convincing, probable, and limited suggestive risks to
determine severity. And for obesity right now, there are
eight different cancer sites that are associated with
obesity. And, you can see that there --- it is convincing
that it increases the risk, again, breast (postmenopausal
women), colon, endometrial cancer, esophageal cancer,
kidney, and pancreatic cancer.
Para determinar la gravedad de los riesgos, el Instituto
utiliza los términos “convincente”, “probable” y
“limitado”. En este momento hay ocho tipos de cáncer
asociados con la obesidad. Vemos que se considera
convincente y que aumenta el riesgo de cáncer de mama
en mujeres posmenopáusicas, colon, endometrio,
esófago, riñón y páncreas.
The next guideline, again both for the American Institute
for Cancer Research and the American Cancer Society, is
being physically active. The guideline is be moderately
physically active for at least 30 minutes every day and
then, as fitness improves, aim for at least 60 minutes of
moderate activity or 30 minutes of vigorous activity
every day. There is --- there are some studies that are
identified through the American Cancer Society that
indicate 45 minutes of activity most days of the week can
reduce the risk of both colon cancer and breast cancer.
La pauta siguiente, tanto del Instituto Americano para la
Investigación del Cáncer como de la Sociedad Americana
del Cáncer, es ser físicamente activo. Se recomienda una
actividad física moderada de al menos 30 minutos todos
los días y, a medida que el estado físico mejore, no
menos de 60 minutos de actividad moderada o 30
minutos de actividad vigorosa. Algunos estudios citados
por la Sociedad Americana del Cáncer indican que
45 minutos diarios de actividad varias veces por semana
pueden reducir el riesgo de cáncer de colon y mama.
• Liver
Cancer Prevention: Part I
Adopt a Physically Active Lifestyle
• Be moderately physically active for at least 30
minutes every day
• As fitness improves, aim for at least 60 minutes of
moderate activity or 30 minutes of vigorous activity
every day
7
Cancer Prevention: Part I
Consume a Healthy Diet with an Emphasis
on Plant Sources and Limit Red Meats
• Eat 5 or more servings of vegetables and
fruits per day
• Choose whole grains instead of processed
grains and sugar
Cancer Prevention: Part I
Limit Intake of Red Meat and Avoid Processed Meat
Public Health Goal
• Population average consumption of red meat* to be no
more than 300 g (11 oz) a week, very little if any of which
to be processed
Personal Recommendation
• People who eat red meat to consume less than 500 g
(18 oz) a week, very little if any to be processed
* “Red meat refers to beef, pork, lamb, and goat…”
USDA 2006 Average Per Capita Weekly Consumption: Red meat - 36 oz., Beef – 20 oz.
The next guideline focuses on dietary intake. And I think
most of us have heard the Eat 5 a Day, which actually
behaviorally that is the minimum amount of fruits and
vegetables one would want to eat in a day. And it is split
up: three vegetables and two fruits. And that is because
typically most Americans have between three to four
servings a day. So, the 5 a day is meeting the minimum
amount. Sometimes you will hear seven. Sometimes you
will hear nine. So, it is typically five to nine servings of
fruits and vegetables a day --- is something you can do to
be proactive in reducing your cancer risk. It is estimated
that you can reduce your risk as much as 20% by just
having the five fruits and vegetables per day. It is also
important to choose whole grains instead of processed
grains and sugars including avoiding sugary drinks.
La siguiente pauta se refiere a la ingesta alimentaria. Creo
que la mayoría de nosotros conoce la pauta de “Comer 5
al día”, que corresponde a la cantidad mínima de frutas y
verduras que debemos ingerir a diario. Se divide en tres
porciones de verduras y dos de frutas. Normalmente, la
mayor parte de los estadounidenses come de tres a cuatro
porciones al día. La pauta de “5 al día” se refiere a la
cantidad mínima. A veces se mencionan siete; otras,
nueve. En general, abarca de cinco a nueve porciones de
frutas y verduras al día, y es una medida para ser
proactivos en la reducción del riesgo de cáncer. Se estima
que el riesgo se reduce hasta en un 20% con sólo comer
cinco frutas y verduras por día. También es importante
elegir granos enteros en lugar de azúcares y granos
procesados, y evitar las bebidas azucaradas.
I wanted to give you one example of the --- how specific
the guidelines are for the American Institute for Cancer
Research. So, I chose to use the red meat as this
example. They give a public health goal and then they
give a personal recommendation. I am going to focus on
the personal recommendation in the presentation, which
indicates that people, who eat red meat --- and let us
clarify what red meat is. It is beef. It is pork, lamb, and
goat, for example. People should have just over or not
more than just over a pound, 18 ounces a week and the
very little of any of it to be processed. So, is this
something that you should discuss with your patients?
Well, I looked at the per capita consumption of red meat
in the United States and actually just the beef alone is
over what is recommended to take in weekly. Beef alone
in the United States is estimated to be 20 ounces a week.
Red meat total is 36 ounces a week. So, obviously, this is
something you can address with your patients and could
make a difference in reducing cancer risk.
Las pautas del Instituto Americano para la Investigación
del Cáncer son sumamente específicas. Consideremos,
por ejemplo, las carnes rojas. El Instituto establece un
objetivo de salud pública y una recomendación personal.
En esta presentación, me centraré en esta recomendación
específica para las personas que comen carnes rojas.
Aclaremos primero qué son las carnes rojas. Es carne
vacuna, o de cerdo, cordero y cabra, por ejemplo. Se
recomienda comer alrededor de una libra o 18 onzas a la
semana, lo cual incluye muy poca cantidad de carne
procesada. ¿Debe conversar esto con sus pacientes? Si
consideramos el consumo de carnes rojas por habitante en
los Estados Unidos, el consumo de carne vacuna ya es
superior a la cantidad semanal recomendada. Se estima
que en este país su consumo es de 20 onzas por semana.
El total de carnes rojas es de 36 onzas semanales.
Obviamente, esto es un tema a tratar con sus pacientes y
podría marcar una diferencia para reducir el riesgo de
cáncer.
8
Cancer Prevention: Part I
Meat and Cancer Risk
Red Meat
Processed Meat
•
•
•
•
•
•
•
•
•
•
•
Colorectum *
Endometrium ♦
Esophagus ♦
Lung ♦
Pancreas ♦
Colorectum *
Endometrium ♦
Esophagus ♦
Lung ♦
Prostate ♦
Stomach ♦
* Convincing increased risk
♦ Limited–suggestive increased risk
Cancer Prevention: Part I
If you Drink Alcoholic Beverages,
Limit Consumption
• Women - 1 drink/day
• Men- 2 drinks/day
• 1 Drink means:
– 12 ounces of regular beer
– 5 ounces of wine
– 1.5 ounces of liquor
• Convincing increased risk for: mouth, pharynx, larynx,
esophagus, breast, colorectum (men)
• Probable increased risk for: liver, colorectum (women)
If you look at the risk factors --- or if you look at the
convincing increased risk for red meat, colorectal cancer
is convincing and also for processed meat, colorectal is -- it is convincing. The others are limited suggested
increased risks, but still the evidence is there that they
play a role with cancer at a number of sites. They could
not even come up with a limited amount of processed
meats, which is why it says limit or avoid processed
meats altogether. And this has to do with the heme iron
that is in red meats that is associated with increasing the
known carcinogen of N-nitroso compounds production.
So, even if there are nitrates or nitrites in the food that is
processed with the iron, you can still produce more of
those in the gut, which increases risk. Also, red meat
increases bile acids, which can irritate the colon and set
the stage for cancer there.
Si consideramos los factores de riesgo, o el mayor riesgo
convincente para las carnes rojas, esto está asociado al
cáncer colorrectal, al igual que para las carnes
procesadas. Los demás riesgos sugeridos son mayores,
pero limitados, aunque la evidencia indica una relación
con el cáncer de diversos órganos. Podrían no tener
incidencia con una cantidad limitada de carnes
procesadas, por lo que se recomienda limitar o evitar
consumirlas. Esto se debe al hierro de los hemos,
presente en las carnes rojas y asociado al aumento de la
producción de compuestos cancerígenos de N-nitroso.
Por lo tanto, aun si los alimentos procesados junto con el
hierro contienen nitratos o nitritos, el intestino puede
producir más, lo que aumenta el riesgo. Además, las
carnes rojas aumentan los ácidos biliares, que pueden
irritar el colon y sentar las bases para el cáncer.
Alcohol is --- also needs to be discussed. And typically
the guidelines for cancer risk reduction mesh very well
with the recommendations for heart disease and diabetes,
but this is one place where they deviate. So, you would
need to look at your patient’s individual risk factors. If
cancer is more of a risk factor, then you would want to
talk specifically about limiting consumption of alcohol if
they drink at all. The recommendations are not more
than one drink per day for women and not more than two
drinks per day for men. And then it is also important to
discuss portion sizes. The convincing risk is associated
with head and neck cancers, breast cancer. It is
convincing that alcohol increases the risk for colorectal
cancer in men, and then probable increased risk for liver
cancer with alcohol, and then probable increased risk
with colorectal cancer with women.
También debemos mencionar el alcohol. Las pautas de
reducción del riesgo de cáncer se combinan muy bien con
las recomendaciones para la enfermedad cardíaca y la
diabetes, excepto en un punto. Por eso, deben evaluarse
los factores de riesgo individuales del paciente. Si el
cáncer tiene un mayor factor de riesgo, recomiende
específicamente limitar el consumo de alcohol, o
abstenerse de tomarlo. Las recomendaciones indican no
más que una porción diaria para las mujeres y no más de
dos para los hombres. Es importante especificar los
tamaños de las porciones. El riesgo convincente se asocia
al cáncer de cabeza y cuello, y al de mama. Es un riesgo
convincente que el alcohol aumenta el riesgo de cáncer
colorrectal en los hombres, pero es un riesgo probable
para el cáncer de hígado, así como para el cáncer
colorrectal en las mujeres.
9
Cancer Prevention: Part I
Tobacco Cessation
Health Care Professionals Role in Smoking Cessation:
•
•
•
•
•
Ask patients if they smoke
Assess patients attitude towards smoking and quitting
Advise cessation clearly and unequivocally
Assist with a cessation plan
Arrange follow up to support choice of cessation
Cancer Prevention: Part I
Tobacco Cessation
The quit plan involves:
• Identifying daily triggering behaviors
• Uncovering motivation for the behaviors
• Adopting alternative coping strategies
• Tobacco cessation medications
• Social Support
I am now going to talk to --- address another lifestyle
behavior that you --- your patients have control over and
this is tobacco cessation. Health care professionals often
don’t realize the important role. We take it for granted
that patients know that they shouldn’t smoke, but you
really need to ask the patients. A lot of my patients have
said. “Well, no one has ever told me that I needed to stop
before.” So, first of all, asking. These are actually the 5
A’s. Asking and then discussing with the patient what
their attitude is towards smoking at this time. Giving
advice to the patient on how you can quit, helping them
develop a plan, and then finally arranging support. This
can be from you or your staff or a follow-up phone call.
Ahora trataré otro comportamiento de estilo de vida que
los pacientes pueden controlar, y es interrumpir el
consumo de tabaco. A menudo, los profesionales de la
salud no reconocen su importancia. Damos por sentado
que el paciente sabe que no debe fumar, pero en realidad
es necesario averiguar si lo sabe. Muchos de mis
pacientes han afirmado “Hasta ahora, nadie me había
dicho que dejara de fumar”. Lo primero es averiguar, que
es la primera de “Las 5 A”. Averiguar y luego aconsejar
al paciente acerca de su punto de vista sobre el tabaco.
Asesorar al paciente sobre cómo dejar de fumar, ayudarlo
a desarrollar un plan y, por último, apoyarlo. Esto puede
hacerlo usted o su personal, incluso con una llamada
telefónica de seguimiento.
Quitting involves a plan of, you know, starting out with
identifying daily triggers. These are habits that they have
formed with smoking. An example may be having a
cigarette with the first cup of coffee in the morning and
talking to them about how they can start working on
breaking that habit, for example, using a different mug or
having tea instead of coffee, as they work on changing
that behavior. Uncovering motivation for the behaviors;
are they using nicotine for stress? Are they using it for
depression? Giving them alternative coping strategies.
And we also have tobacco cessation medications that can
ease the withdrawal symptoms. Also, discussing social
support: what can help them? What can hurt them? And
how to ask for social support from family members and
people that they work with and from you as the
healthcare provider.
Dejar de fumar comienza por identificar los
desencadenantes diarios. Estos son hábitos que se han
desarrollado con el tabaquismo. Por ejemplo, fumar un
cigarrillo con la primera taza de café por la mañana.
Después, hablar de cómo interrumpir ese hábito, quizás
usando una taza diferente o tomar té en vez de café, a
medida que procuran modificar ese comportamiento.
Deben descubrir la motivación de sus comportamientos.
¿Consumen nicotina para el estrés o la depresión? Darles
alternativas para enfrentarlos. Existen medicamentos para
dejar de fumar que pueden aliviar los síntomas de
abstinencia. Hablar también del apoyo social: ¿qué puede
ayudarlos y qué puede perjudicarlos? Y cómo pedir el
apoyo social de familiares y personas en el trabajo, así
como el suyo propio como proveedor de cuidado de la
salud.
10
Cancer Prevention: Part I
Cessation Counseling
• Assess readiness to change
• Provides problem-solving guidance to develop
a plan to quit and overcome common barriers
• Provides social support
• Motivational interviewing
• The 5 R's (relevance, risks, rewards,
roadblocks, repetition)
Cancer Prevention: Part I
Medications
• Nicotine replacement therapy
– Nicotine substitutes (gum, patches, lozenges, inhalers)
– Reduce nicotine levels gradually
• Antidepressants
– Bupropion reduces withdrawal symptoms
• Nicotine blocking drugs – Varenicline
– Activates nicotine receptors in the brain to reduce severity
of cravings and withdrawal symptoms
– If patients smoke while taking Varenicline, reduces the
sense of satisfaction from smoking
Cessation counseling can come from a trained counselor
where they can address the readiness to change. What all
is going on with this individual in their life right now? Is
this a good time to have them quit or are we just going to
be setting them up for yet another failure? So helping
provide problem-solving guidance to develop a plan to
quit, to overcome some of the common barriers; looking
at where their social support is; and then helping with
motivational interviewing; looking at the 5 R’s. Is this
relevant? What are the risks? Coming up with rewards,
identifying roadblocks, and then repeating the positive
behaviors, so that they replace the other habits for
smoking.
El asesoramiento sobre cesación puede brindarlo un
profesional capacitado que aborde su disposición al
cambio. ¿Cuál es la situación actual en la vida de esta
persona? ¿Es este un buen momento para que deje de
fumar o sólo cabría esperar un nuevo fracaso? Deben
incluirse pautas para resolver problemas, desarrollar un
plan para dejar de fumar y superar los obstáculos más
comunes, evaluar si cuenta con apoyo social, y ayudarlo
con una entrevista motivacional. Por último, tenemos
“Las 5 R”. ¿Es esto relevante? ¿Cuáles son los riesgos?
Identificar las recompensas y las resistencias, y luego la
repetición de comportamientos positivos a fin de
reemplazar un hábito por otro.
The medications now to --- first of all to gradually
decrease nicotine, would be nicotine replacement therapy.
And you work with the patient individually. You may
have to try a number of these before you find out what
works. They may try the patch and then have an allergy
reaction to it. The lozenges may work better. There
actually is some research identifying different types of
the --- of characteristics in a person’s personality that
may make the inhaler more successful for them. Again,
this is where cessation counselors can help you. They
can actually lessen the severity of the withdrawals by
reducing nicotine levels gradually. Also, there is research
with Zyban that helps --- shows that this antidepressant
can reduce withdrawal symptoms associated with
smoking cessation. And a newer drug on the market is
ChantixTM. This drug actually works in two ways. It
activates the nicotine receptors in the brain to reduce the
severity of cravings with withdrawal symptoms. And
then, if the patient smokes while they are taking
ChantixTM, they do not get the fix that they are used to
because the nicotine receptors in the brain have already
Veamos los medicamentos. Primero, para reducir
gradualmente la nicotina, tenemos la terapia de
reemplazo. Se trabaja individualmente con el paciente.
Puede ser necesario probar varias para saber cuál es la
que funciona. Podría comenzar con los parches y tener
una reacción alérgica. Las pastillas pueden funcionar
mejor. Se han realizado investigaciones que identifican
los rasgos de la personalidad que suelen dar mejor
resultado con los inhaladores. También en este caso, los
asesores de cesación pueden ayudar. La intensidad de la
abstinencia puede reducirse disminuyendo gradualmente
los niveles de nicotina. Otras investigaciones indican que
el antidepresivo Zyban® ayuda a reducir los síntomas de
abstinencia asociados con dejar de fumar. Hay un nuevo
medicamento en el mercado llamado Chantix™ que
funciona de dos maneras. Primero activa los receptores
de nicotina en el cerebro para reducir la intensidad de la
ansiedad causada por la abstinencia. Luego, si el paciente
fuma mientras está tomando Chantix™, no recibe la
misma estimulación que antes porque los receptores
cerebrales de nicotina ya están activados por el fármaco,
11
Cancer Prevention: Part I
When Smokers Quit…
Quit….
• 20 minutes after quitting: heart rate and blood pressure drop
• 12 hours after quitting: CO level in blood drops to normal
• 2 weeks to 3 months after quitting: circulation improves
• 1 to 9 months after quitting: coughing and shortness of
breath decrease
been activated by the drug, so they don’t get that reward.
So it is looking at these different medications and in
combination individually to help the patient with
cessation.
When smokers quit, it is important for them to know that
they immediately start the healing process. Twenty
minutes after quitting, their heart rate and blood pressure
drops, but you can see this continues on out 5, 10, 15
years from stopping smoking. A lot of the people that I
have worked with will keep this type of information in
their pocket or in their purse. And when they are having
a craving they can pull this out to remind them why they
are going through this difficult activity.
y no obtienen ninguna recompensa. Estos medicamentos
deben evaluarse individualmente y en combinación para
ayudar al paciente a dejar el hábito.
So, next, on to another lifestyle behavior that you can
change is reducing your risk of skin cancer. Skin cancer
is the number one cancer among Americans and there are
some simple behaviors that you can practice that can
reduce your risk. One of them is avoiding the sun
between 10 a.m. and 4 p.m. That is particularly when the
sunrays are the most intense in the Southern climate as
well. Covering up with protective clothing is a difficult
one to sell to patients often. But with the new synthetics
that are breathable, these --- this clothing can actually be
more comfortable then having the sun hit their skin
directly. Baseball caps are still very popular for both
males and females, but you need to remind them that this
does not cover their ears or their necks, and a wide brim
hat would be more appropriate. One way to tell how
intense the rays are is looking at your shadow and, if your
shadow --- the more shorter it is, the more damaging the
Otro comportamiento de estilo de vida que se puede
cambiar es reducir el riesgo de cáncer de piel. El cáncer
de piel es el más común entre los estadounidenses, pero
hay ciertos comportamientos sencillos que permiten
reducir el riesgo. Uno de ellos es evitar el sol de 10 a.m. a
4 p.m., cuando los rayos son más intensos, y protegerse
en lugares más cercanos al ecuador. Cubrirse con ropa
protectora es una recomendación que pocos pacientes
aceptan. Las nuevas telas sintéticas permiten que la piel
respire, y esta ropa puede ser mucho más cómoda que el
contacto directo del sol. Las gorras deportivas son muy
populares entre hombres y mujeres, pero hay que
recordarles que no cubren las orejas o el cuello.
Un sombrero de ala ancha sería más apropiado. Una
forma de estimar la intensidad de los rayos solares es con
la sombra: cuanto más corta sea, tanto más perjudiciales
serán. Recomendamos usar pantallas solares con un
Cuando un fumador deja de fumar, es importante
informarle que de inmediato comienza un proceso de
curación. Veinte minutos después de dejar de fumar, el
ritmo cardíaco y la presión arterial disminuyen, y esto
continúa durante 5, 10 o 15 años. Muchas personas con
quienes he trabajado guardan esta información en el
bolsillo o en el bolso, y cuando sienten ansiedad, vuelven
a leerla para recordar el motivo por el que han hecho
tanto esfuerzo.
• 1 year after quitting: risk of CHD is half that of a smoker's
• 5 years after quitting: stroke risk is reduced to that of
a non-smoker
• 10 years after quitting: lung cancer death rate is half that
of a smoker
• 15 years after quitting: risk of CHD is that of a non-smoker's
Cancer Prevention: Part I
Preventing Skin Cancer
• Avoid the sun between 10 a.m. and 4 p.m.
• Cover up with protective clothing
• Cover head with wide-brimmed hat, shading face,
ears, neck
• The shorter your shadow, the more damaging the
sun rays
• Use sunscreen, at least SPF 30
12
Cancer Prevention: Part I
Sun Protection Factor (SPF)
• Measures the effectiveness of a sunscreen in
filtering out UV rays
• SPF 30 means that if you are exposed to noonday
summer sun, the sunscreen protected skin
would take 30 times longer to burn than the
unprotected skin
• Choose a sunscreen with UVA and UVB protection
• Generously apply sunscreen 20 to 30 minutes before
going outside
• Reapply as indicated
Cancer Prevention: Part I
UV Exposure
UVA rays
•
•
•
•
Contribute to skin cancer formation (tanning beds)
Penetrate skin layers more deeply
Remain intense throughout the year
Contribute to premature aging, harmful to eyes and
immune system
UVB rays
•
•
•
•
Cause damage to DNA of skin cells, increasing risk
Most likely to cause sunburns
Primary contributor to premature aging and wrinkling
Vary in intensity throughout the seasons
rays are. We recommend that you use a minimum of
sunscreen of 30.
So this sunscreen, the SPF, is the sun protective factor,
and this measures the effectiveness of a sunscreen in
filtering out ultraviolet rays. So, for example, a SPF of
30 would mean that, if you are exposed to noonday
summer sun, the sunscreen-protected skin would take 30
minutes longer to burn than the unprotected skin. So,
what ideally you would want to choose the sunscreen that
protects both UVA now and UVB. So generously apply,
which is actually about an ounce or two tablespoons, if
you are covering your entire body with sunscreen. And
to help get it absorbed to the skin, you need to apply it at
least 30 minutes before going out and then repeat as
indicated. And the type that you are using will let you
know if it is water-resistant, water-repellent, and how
often it needs to be reapplied.
factor de protección de al menos 30.
There are different ultraviolet rays. We now know that
UVA rays also contribute to skin cancer formation. This
is the ray that is most common in tanning beds, which is
why you want to tell your patients to avoid tanning beds.
It penetrates skin layers more deeply. It remains intense
throughout the year and it contributes to premature aging,
which mentioning this is actually a motivation factor for
a lot of people. It is also harmful to eyes and the immune
system. The UVB rays, we have known for a long time,
cause damage to DNA of skin cells, increasing the risk of
skin cancer. It is the one that is most likely to cause
sunburns. It is the primary contributor to premature
aging and wrinkling, and this is the one that varies with
intensity being more intense during the summer seasons.
Hay dos tipos de rayos ultravioletas. Sabemos que los
rayos UVA contribuyen al desarrollo del cáncer de piel.
Este tipo de rayos es el más común en las camas de
bronceado, y por eso sus pacientes deben evitarlas, pues
penetran profundamente las capas de la piel. Son intensos
durante todo el año y contribuyen al envejecimiento
prematuro, lo cual es un poderoso factor de motivación
para muchas personas. Son perjudiciales para los ojos y el
sistema inmunológico. Los rayos UVB se conocen desde
hace tiempo y dañan el ADN de las células dérmicas, lo
que aumenta el riesgo de cáncer de piel. Son los más
propensos a causar quemaduras de sol y el principal
contribuyente al envejecimiento prematuro y las arrugas
precoces. Su intensidad varía y es más intensa en la
temporada de verano.
Este factor, también llamado FPS, indica la eficacia de la
pantalla solar para filtrar los rayos ultravioletas. Así, por
ejemplo, un FPS de 30 significa que al exponerse al sol
del mediodía de verano, la piel protegida demora 30
minutos más en quemarse que la piel sin protección.
Lo ideal son las pantallas solares que protegen contra los
rayos UVA y UVB. Aplíquela abundantemente,
aproximadamente 1 onza o dos cucharadas, para cubrir
todo el cuerpo con protección solar. Para ayudar a que
sea absorbida por la piel, debe aplicarse al menos media
hora antes de salir y luego repetir según se indique.
El envase especifica si la loción es resistente o repelente
del agua y con qué frecuencia debe volver a aplicarse.
13
Cancer Prevention: Part I
UVA and UVB Protectors
• UVA and UVB – titanium dioxide, zinc oxide,
Photoplex with avobenzone, benzophenones
(oxybenzone)
• UVA – ecamsule
• UVB – PABA, salicylates (ocytl salicylate)
Cancer Prevention: Part I
ABCDEF’s
ABCDEF s for Skin Self Exam
•
Asymmetry
– One half unlike the other half
•
Border
– Irregular or poorly defined border
•
Color
– Varied from one area to another
– Shades of tan, brown, black, red
•
Diameter
– The mole is larger than 6 mm across
– (about 1/4 inch the size of a pencil eraser)
•
Elevation
– The mole is raised
•
Feeling
– The sensation around the mole has changed, itchy, painful
So, looking at the physical and chemical ingredients in
your sunscreen is important. Telling your patients, if
they only have the PABA or the MexorylTM, they are
getting protection for only UVB or UVA. So what they
want to look for is one that provides titanium dioxide,
zinc oxide, and they have changed these physical
components. They don’t leave --- they are not just white
now. So, they’re --- they are --- more people will use
them now than just the lifeguards with the zinc oxide on
their nose. The Photoplex with Parsol protects for UVA
and UVB, as does oxybenzone. So, what is most
important is that you get a sunscreen that has both UVA
and UVB protectors.
Es importante considerar los componentes físicos y
químicos de la pantalla solar. Si la loción sólo contiene
PABA o Mexoryl™, estarán protegidos únicamente
contra los rayos UVA o UVB. Deben utilizar pantallas
que contengan dióxido de titanio u óxido de zinc, dado
que la composición varía. Ahora, las lociones no sólo son
de color blanco. Por este motivo, es más probable que la
gente las utilice, y no sólo los guardavidas que se aplican
óxido de zinc en la nariz. El Photoplex con Parsol®
protege de los rayos UVA y UVB, tal como la
oxibenzona. Lo más importante es utilizar una pantalla
solar con protectores de rayos UVA y UVB.
We commonly hear about the ABCs for skin self-exam.
Now they have been expanded to the ABCDEF and I
would like to go over these. The A is asymmetry. It
means there is not a mirror image; one half of the mole
does not look like the other half of the mole. The B is
border: irregular or poorly defined border. Color: the
color is not the same; it varies. It goes from shades of tan
to brown to black to red. Diameter: if the diameter of the
mole becomes larger than the size of a pencil eraser. Or
elevation: if the mole is flat and it raises. Or if, all of a
sudden, there is feeling in the mole and there has not been
before, such as itching or it becomes painful. These
would be of concern and these are things that you can
teach your clients about. And they can --- the patient can
be taught these and look for these between clinical exams
and then schedule an appointment or bring them to the
provider’s attention at their follow-up visit.
Comúnmente se habla del ABC para el autoexamen de la
piel. Ahora se ha ampliado y es ABCDEF. Veamos de
qué se trata. A es la asimetría: significa que no hay una
imagen en espejo; una mitad del lunar no se parece a la
otra. B es el borde: un borde irregular o mal definido.
C es el color: no es uniforme y varía; cambia entre tonos
canela, marrones, negros y rojos. D es el diámetro: si el
tamaño del lunar aumenta y se hace mayor que el
borrador de un lápiz. E es la elevación: si el lunar es
plano o sobresale. F es el factor de sensibilidad: un
cambio de sensación repentino, si la zona comienza a
picar o se vuelve dolorosa. Todo esto es motivo de
preocupación y debe mencionarse a sus pacientes.
El paciente puede aprender estas cosas y estar atento a
ellas entre un examen clínico y otro, para luego
programar una cita, o llevarlas a la atención del
proveedor en su visita de seguimiento.
14
Cancer Prevention: Part I
Risk Reduction: Reduce Risk of HPV Infection
• Reduce risk of human papilloma virus infection
- Delay onset of sexual activity
- Maintain a monogamous relationship
- Use barrier contraception
Cancer Prevention: Part I
Risk Reduction:
Hormone Therapy (HT)
HT)
• Prior to starting HT, women should be
counseled regarding risk vs. benefits of therapy
and non-hormonal alternatives
• If HT is initiated, use minimum dose needed to
control menopausal symptoms
• Consider occasional trials off of HT to reassess
benefits derived
Next, I am going to switch to what you can do to reduce
the risk of cervical cancer and cervical dysplasia. This
can be done by delaying the onset of sexual activity, as
the cervix is more susceptible to HPV at younger ages.
Maintaining a monogamous relationship; well, that would
reduce exposure. And barrier contraception may also
reduce the transmission of HPV infections.
Ahora veremos qué puede hacerse para reducir el riesgo
de cáncer de cuello uterino y displasia cervical. Se
recomienda retrasar el inicio de la actividad sexual
porque el cuello uterino es más susceptible al VPH a
edades más tempranas. Mantener una relación monógama
reduce la exposición. Los anticonceptivos de barrera
también reducen la transmisión del virus.
For individuals who are considering hormone therapy, we
want them to fully understand the risks and benefits of
therapy and also understand that there are non-hormonal
alternatives. What we recommend is, particularly for
people who are at high risk for breast cancer, that they
consider these other options. And, if they are going to
start hormone --- hormone therapy, that it be initiated
with minimum doses needed to control menopausal
symptoms. And then, from time-to-time challenge the
hormone therapy. So, take a --- what is considered a trial
off of the hormone therapy to re-assess if the individual is
getting the benefits that they are hoping to get from the
medication.
Las personas que estén considerando la terapia hormonal
deben comprender plenamente sus riesgos y beneficios, y
saber que existen alternativas no hormonales. Siempre
recomendamos —sobre todo a las personas con alto
riesgo de cáncer de mama— que consideren otras
opciones. En caso de elegir este tratamiento, la terapia
hormonal debe comenzar con las dosis mínimas para
controlar los síntomas menopáusicos. De allí en adelante,
se deben evaluar periódicamente sus resultados. Por
ejemplo, iniciar un tratamiento de prueba y analizar si el
paciente está recibiendo los beneficios que debería
obtener de la medicación.
15
Cancer Prevention: Part I
Risk Reduction Strategies
•
This concludes my presentation. This is Part I of Cancer
Prevention. I have addressed health promotion, diet,
lifestyle modifications.
Esto concluye la Parte I de la presentación sobre la
prevención del cáncer. Hemos visto cómo promover la
salud y los cambios en la dieta y en el estilo de vida.
And, in summary, there are things that you can do to be
proactive about health choices. You can significantly
reduce the incidence of cancer through diet and lifestyle
modification. Thanks for your attention. I hope this gave
you new information. Please let us know how we are
doing with this part of the program. And please contact
us if you have any questions. Thanks.
En síntesis, es posible ser proactivo en las opciones de
salud. Podemos reducir considerablemente la incidencia
de cáncer modificando la dieta y el estilo de vida. Gracias
por su atención. Espero haberle dado nueva información.
Háganos saber su opinión sobre esta parte del programa.
Si tiene preguntas, no dude en comunicarse con nosotros.
Gracias.
Health Promotion
-
Diet
Lifestyle modification
•
Prophylactic surgical interventions
•
Chemoprevention
Cancer Prevention: Part I
Summary
Being proactive about health choices can
significantly reduce the incidence of cancer
through diet and lifestyle modifications!
16