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PowerPoint Slides Cancer Prevention: Part I English Text Cancer Prevention: Part 1 VideoTranscript 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