Can you all see my screen? Yes. All right. Okay, perfect. All right, so I'm gonna be talking about some basics about cancer prevention. So full disclosure, I am not an epidemiologist. So this is definitely from the lens of a clinician as far as cancer prevention goes. So just to review kind of some basics, which this was great for me to put the talk together because I haven't thought about some of this stuff since either studying for my GYN oncology boards or even earlier before that. So, and this kind of spans across all, not just cancer prevention, but prevention of any clinical scenarios, whether it's infectious. These are all kind of different types of clinical prevention that we think of that hold true. So immunization is one broad category. There's four categories. Screening, such as, as we know, cervical cancer screening or colonoscopy is a very common one. Lifestyle changes are also known as behavioral counseling. So the easy ones to think about are smoking cessation, exercise, and then eating a healthy diet. So especially in the world of hypertension, diabetes, cardiac disease, obesity, this is a huge clinical prevention strategy. And then lastly, chemo prevention. So using medications in some, we'll talk about in some arena to help treat or prevent disease. And we'll talk more about that. So the different levels of clinical prevention. So there's essentially three. I'm not even gonna talk about the one before primary, but if you read in the text, there's actually a primordial, which is before primary. And that is essentially trying to make everyone on an equitable playing field. So thinking about this also, again, this is broad clinical strokes. So talking about like safe housing, not being abused or neglected, safe water. So this a huge umbrella. But as we talk about kind of cancer prevention, we'll talk more about these three. So primary, secondary, and tertiary prevention. Primary essentially is when there is no disease present and you're trying to prevent the disease by modifying or taking out risk factors. Then if you have the onset of the risk factor or the onset of the cause of said disease, then that kind of falls into the secondary prevention category where they have been exposed, but they have no symptoms. And so this has multiple layers to it, which we'll talk about, including early detection, but also treatment of early asymptomatic disease. And then once they have a diagnosis of, in our case, cancer, then that turns into a tertiary prevention strategy. And that has also multiple layers, which I'll talk about here in a second. So just to review primary prevention. So the idea of primary prevention is to remove the cause of the disease. So as you'll see here, multiple of those four different types of clinical prevention can be used in any of these. So as primary prevention examples, just for cancer, not even including all of the infectious categories. So immunization against hepatitis B for liver cancer and HPV for cervical cancer. Behavioral counselings like smoking cessation for a lot of cancers, but namely lung, which I'll give us some more data about here shortly. And then weight loss, which we're learning more and more about impacts numerous and increases risk of numerous types of cancers. And then one that I hadn't really thought, to be honest, this hard about as far as what category this fell into, but this also includes risk-reducing surgeries. So even a surgical intervention can be technically considered a primary prevention strategy, which I thought was really interesting to think about. So secondary prevention, this is a two-step process. So somebody has already been exposed, but the idea is to catch something earlier before people have symptoms. So this often includes early detection, typically using a screening test, but then also treatment of earlier asymptomatic disease. So for us, that would be treatment of pre-invasive disease as well as early disease. So some easy examples that obviously are very pertinent to why we're all here today in the asymptomatics, HIV testing, and then pap smear and HPV testing. And obviously, depending on where you're at in the world, here for us in the U.S., this also includes colon cancer screening in asymptomatic patients, breast cancer screening in asymptomatic patients, and then tertiary prevention. So this is somebody has a disease, and then your goal at that point is just to decrease complications and reduce the morbidity of them living with the disease, or after you treat them for the disease, and while they're still living and hopefully surviving after a diagnosis of cancer. So these are some very broad categories that all would fall under tertiary prevention. That could be adjuvant treatment, surgery, palliative care, as well as surveillance follow-up. So like the case that Kenneth presented in this scenario, how are we gonna follow this patient after we hopefully cure her of her cancer would be included in a tertiary prevention strategy. So when thinking about, especially from a political global impact on where to stress resources and advocate, obviously all of them, of course, but if you're gonna pick what's gonna have the biggest impact on the population as a whole, primary prevention is seven times more effective than secondary. So I think that number speaks for itself that it's really important. So I just wanted to bring a couple cancer-specific examples up when I was researching for this talk. So for lung cancer, so again, primary prevention, trying to take away risk factors for them getting lung cancer. They found that the behavioral counseling or intervention of smoking cessation decreased the risk of developing lung cancer by 50 to 80%. And I've got a whole lot of references on every slide. And so these were some that I found that were the most helpful. And I thought also were very specific about showing that the reduction was from the primary prevention standpoint, that it was from the counseling or behavioral modification, and that the studies that they did and the references I have listed there were able to demonstrate that, yes, that was in fact the piece that decreased the risk of lung cancer. And then in patients with genetic mutations, again, a surgery being a primary prevention strategy. So in patients with BRCA mutations, when you perform a risk-reducing removal of both tubes and ovaries, there's a 96% reduction in ovarian cancer and a 50% reduction in breast cancer. So again, using this surgical procedure as a primary prevention strategy in this very targeted specific population. And then for secondary prevention, again, they've had the exposure, and now this is kind of the combo of early detection and treatment of earlier pre-invasive disease. So in the example of colon cancer, so colonoscopy basically can be used as both. It is used for the screening component, but also can be used as the treatment component for pre-invasive or early disease like a polyp. So colonoscopy itself reduced early stage cancers by 12% and reduced late stage cancers by 37%. And I suspect because of the combination of both detection and treatment for this specific test. And then in the example of breast cancer, mammography, and this is, there's a lot, you can get into the weeds pretty quick about risk, benefit, target ages. When is the right time to start? When is it too much in causing harm? But between women 40 to 69, in general, the biggest systematic reviews of randomized control trials for mammography said that there was a 15 to 20% decrease risk in breast cancer mortality when using screening mammography. So I just wanted to take just a minute to talk about and just kind of review when you're thinking about the secondary prevention and the screening test in the perfect world, what does an ideal screening test have and what are the components that are important? And so you want it to be sensitive, meaning if people have the disease, it's gonna be picked up and that there's so low false negatives. So that if it's positive, people really do have it. And so again, thinking about low false positives. Ideally, it's simple, both for the patient and for the clinician, that it's safe. And this, when I was reading a lot of the springs up when you're weighing risk and balance of risk and benefit, colonoscopy is not super safe. There's plenty of bowel perfs and depending on what age, it was interesting. There's a higher risk of bowel perforation than finding a cancer. So trying to weigh again, what age and what's the target range for patients. Ideally, it's acceptable to the patient. And I think for this group, bringing up the self-collection of HPV, I think is a perfect example of this. And then ideally that it's cheap and doesn't cost much. Financially, it's not taxing on the system or infrastructure. So in an ideal world, a perfect screening test is all of these things. And to determine what the true benefit of a screening test, when you look at a whole population, you want to see a decrease in deaths from the cancer that you're studying because of the screening. So obviously that takes many decades to study and demonstrate kind of over time, the screening test did in fact do this. And I'm not nearly well-versed enough in epidemiology to tell you exactly what tests to do to determine how that happens. But you just want to make sure that you're saying the screening test is the thing that's changing the outcome and not that you have less cancer or better treatment to actually say that the screening test is what's making the difference. So how do you choose a screening method? There's not one right answer. Just like there's not one right answer of how often you do a screening test or when do you start a screening test? It's very specific based on where you're at, what the incidence and prevalence of the cancer or disease that you're looking at. And so these are just some of the things, especially for us that we think about when trying to decide what's the best option, thinking about what's the patient access, do they have transportation, the infrastructure of the system in the country, technology that's available or not available, and then of course training. And ideally that the results are immediate, which we all can appreciate how that important that is. So quickly, just some screening methods that we all know about, but that pertain to us. We have pap smears or cervical cytology, HPV testing, the combo or co-testing, and then visual inspection with acetic acid or Lugol's iodine. And then secondary prevention, just some examples. So again, secondary prevention is that two-step process. You have the diagnosis or screening some type of early detection, and then also treatment of pre-invasive or early disease. So again, colonoscopy kind of fits both. And then obviously one that we all know and love, the thermal ablation, LEAP or LETS for pre-invasive disease. The whole and the importance for this step is that treatment of this early disease has to be superior and patients have to do better than if you just waited and they were treated at the time that they became symptomatic. So there's a big, a lot of data on lung cancer, specific lung cancer when they were looking at trying to decide what the best screening population, frequency, timing, test, and finding out that in the past, the things that they were using for screening actually didn't impact people's outcome or survival. They didn't do better than if you just waited until they became symptomatic. So again, just something, another component that we need to be thinking about. And then a couple of examples of tertiary prevention. So in colon cancer, I thought this was really interesting. So this first column here is an effect on risk. So that would be more primary prevention. So smoking, alcohol, obesity, vitamin D, physical activity, aspirin. So it's kind of a combination of chemo prevention with the aspirin, behavioral and lifestyle modifications, also screening with the vitamin D deficiency and how those impact primary prevention, impact the risk of getting the disease. But those same things you can look at from a tertiary prevention and how do they impact somebody who has a disease and their outcome. And then for breast cancer, I'm gonna keep going fast since I only have a couple minutes. For breast cancer, I just thought this was very telling. So tertiary prevention is not only how do we make people do better with the disease, but the things we need to be thinking about after we treat patients. So this is literally just the one list that if you search on up-to-date for breast cancer complications, it's the first thing that pops up on basically the impact we have on people long-term in their survival after breast cancer. So I thought that that was just a very visually impressive list and things that are important even after we cure people of their cancer. So other things that would be considered in tertiary prevention, like I said, adjuvant treatments, chemo-radiation, maintenance strategies, and also palliative care, the surveillance follow-up. So imaging, lab work, office exams, transportation, psychosocial support, all of those are considered in this avenue. And then specific to this group, I just wanted to throw in a couple of slides just about what we're all here for. So this is the most updated map from WHO that was just published about data from 2022. So still, this has not changed. Cervical cancer is still the fourth most common female cancer worldwide. Majority of cases are in low and middle-income countries. So in 2022, there were 660,000 new cases, 350,000 new cases, and in 2022, there were 660,000 new cases, 350,000 deaths, and 94% of the deaths were in low and middle-income countries. And then here, I just wanted to highlight the seven countries that we have represented in our pre-invasive echo, just based on 2022 data from WHO, the most common female cancer. So four out of the seven are cervix, and the other three being breast. So primary prevention for us specifically, obviously the HPV vaccine, quickly, does it work? There's some great graphs and data from England who started their national campaign to vaccinate girls in school in 1990. And so cohort zero is people who weren't vaccinated. Cohort one, you can see on that bottom left table, ages 16 to 18. Cohort two, 14 to 16. Cohort three, 12 to 13. And you can see on the graphs significant changes in the rates of invasive cervical cancer and CIN3. And then basically this graph down here at the bottom left under vaccine efficacy, those numbers, so for example, the very bottom right number, essentially that's an 87% risk reduction of cervical cancer in that group that was vaccinated at ages 12 to 13. And then other things just for cervical cancer prevention, not to forget about, but is, so the counseling behavioral modification piece, smoking cessation, condom use. And then for secondary prevention, obviously testing, HIV testing, HPV testing, whatever screening is appropriate in your setting and available. And then treatment for pre-invasive disease, LETs, thermal ablation, and then having local GYN oncologists to be able to treat early cancers when you find them. This is the GYN group from Rwanda when we were there in January. And then the tertiary prevention strategies for us. So cancer strategies, again, I'm just gonna say importance of including brachytherapy in the radiation for cervical cancer, that that needs to be a component we think about. And then all the other components that are important for us when treating cervical cancer. Thank you very much. Appreciate your attention. Thank you, Lindsay.

cancer prevention

immunization

screening

lifestyle changes

chemo prevention