1. NON COMMUNICABLE DISEASES
Epidemology of Cancer

2. What is Cancer?
• Grp of ds characterised by
1. Abn. Growth of cells.
2. Ability to invade adjacent tissues and even distant
organs.
3. Progressed
Major categories of cancer are
1. Carcinomas
2. Sarcomas
3. Lymphomas

5. Time trends
• Cancer is 2nd leading cause of death.
• Reasons:-
1. Longer life expectancy.
2. More accurate dx
3. Cigarette smoking.

6. Causes of Cancer
Environmental factors
• Tabacoo
• Alcohol- oeso& liver Ca
• Dietary factors- smoked
fish,dietary fibres, beef
consumption.
• Occupational exposures
• Viruses- hepb & C
• Parasites – schistosomiasis
• Customs,habits and
lifestyles
• Others
Genetic factors
•Retinoblastoma
•Mongols
HCC
Ca bladder

7. Topic : Diabetes Mellitus

8. DIABETES MELLITUS
• A metabolic disorder of multiple aetiology characterized
by chronic hyperglycaemia with disturbance of
carbohydrate , fat and protein metabolism resulting from
defect in insulin action or both.
• people with DM are also at risk of other diseases
including heart , peripheral arterial and cardiovascular
disease , cataract etc.

9. Epidemiology
• DM is an “iceberg” disease although increase in both the
prevalence and incidence of type 2 DM .
• During year 2014 ,the no. of cases of diabetes worldwide
is estimated to be around 422 million of these >90% are
type 2 DM .
• In 2016 estimated 1.6 million people died from
consequences of high blood sugar.

10. In India
• India is home to 77 million DM , second only to china in
the world.
• In 2019 found 11.8% prevalence of DM in India.
• Male shows prevalence of 12% and female 11.7%.
• The prevalence was higher in urban areas between 10.9 to
14.2%. In rural areas it was 3.0 to 7.8% in population
aged 20 years and above.

11. EPIDEOMIOLOGICAL DETERMINANT
•insulin deficiency
•insulin resistance

12. RISK FACTORS
• age
• gender
• genetic factor
• family history
• physical inactivity
• diet

13. Cardiovascular diseases (CVDs) are a group of
disorders of the heart and blood vessels & they
include:
 Coronary heart disease
 Cerebrovascular disease
 Peripheral arterial disease
 Rheumatic heart disease
 Congenital heart disease

14. Major modifiable factors
 High blood pressure
 Physical inactivity
 Obesity
 Unhealthy diet
 Diabetes mellitus

15. Non-modifiable risk factors
 Age
 Sex
 family history
 Ethnicity

16.  Cardiovascular diseases (CVDs) are the
leading cause of death globally.
 An estimated 17.7 million people died from
CVDs in 2015, representing 31% of all global
deaths.
 In India an estimated 2.59 million People died
of CVD in 2016.
 Incidence of CVD is greater in urban area
then rural areas.

17.  Pain/discomfort in centre of chest
 Difficulty in breathing
 Palpitations
 Cyanosis
 Feeling weak
 Swelling of feet

18. STROKE

19. • The term stroke is applied to acute severe
manifestation of cerebrovascular disease
WHO define stroke as rapidly developed clinical
signs of focal disturbance of cerebral function;
lasting More than 24 hour or leading to death with
no apparent cause other than vascular origin
The disturbance of cerebral function is caused by three
morphological abnormalities, I.e stenosis , occlusion or
rupture of arteries.

20. • Problem: Stroke is the worldwide health problem
Morbidity and Mortality. Cerebrovascular disease remain a
leading cause of death from in NCDS.
In 2016 it was estimated that cerebrovascular disease accounted
for 5.78 million deaths worldwide. Majority of death occurred in
people living in developing countries and 33.72% of subject aged
less than 70 yr
Stroke patients are at highest risk of death in first weeks after the event
and between 20-50% die within first month depending upon severity ,
age , comorbidity
INDIA - prevalance of stroke appear to be less in India than in developed
countries. In India 0.706 million people died at stroke in 2016 of which
0.372 million were men and 0.334 million were women .

21. Risk factors-
Hypertension : main risk factor for cerebral thrombosis
• Other factors contribute to cardiac abnormalities ( i.e left ventricular
hypertrphy , cardiac dilatation ) diabetes, elevated blood lipids ,
obesity, smoking.
• Host factors- Age: It can occur at any age . Globally47% stroke de
• Sex - incidence rates are higher in males than females

22. SCREENING AND
DIAGNOSTICS TOOLS OF
CANCER

23. PRINCIPLES OF SCREENING
• Should be important health problem
• Recognised latent or early asymptomatic stage
• The natural history of the condition including
development from latent to declared disease
should be adequately understood
• Detect disease prior to onset of signs and
symptoms

24. PRINCIPLES OF SCREENING
• Facilities should be available for confirmation of
the diagnosis
• There is evidence that it reduces morbidity and
mortality
• Expected benefit
• Agreed on policy concerning to whom to treat

25. WHY Cancer Screening is POSSIBLE ?
• MALIGNANT DISEASE is preceded by premalignant lesion
removal of which can prevent its development
• High rate of cure as benign lesions are usually localized
METHODS ARE :-
MASS SCREENING : RAPID CLINICAL EXAMINATION
OR OF ONE SITE cervix breast lungs
SELECTIVE SCREENING : People at higher risk such as
age ,chronic smokers,family history

26. Screening of cancers
• Cervix cancer : pap smear and visual inspection based
screening tests using 5% acetic acid with magnification
or lugol’s iodine periodic pelvic examination .
• Management at district hospital treatment based
colposcopy .Information, education and communication
activities are required about vaccine

27. Screening of Cancers
•Breast Cancer: Breast self examination by
patient
• Palpitation by physician
• biopsy gives high false positive
•thermography, mammography most
sensitive and specific .

28. Screening of cancers
LUNG CANCER: Chest Radiograph and Sputum
Cytology . Mass radiography has been used for
early diagnosis at 6 months intervals results are
not convincing so it is not recommended .
•Antismoking campaign for awareness .Initiatives
are smoking cessation ,health warning on packets
taxation

29. Screening of Cancers
•ORAL CANCER : DETECTION AT
PRECANCEROUS STAGE LEUKOPLAKIA
ERYTHROPLAKIA .
•It’s detected by multipurpose workers and
village health guide during home visits .

30. Screening of Cancers
•STOMACH CANCER : ITS incidence are
increasing in HIGH INCOME COUNTRIES .
•Upper GI ENDOSCOPY can be done in
selective population.

31. DIAGNOSIS OF CANCER
PRE DIAGNOSTIC IMAGING
BREAST CA 15-3 CT SCAN BARIUM SWALLOW
LUNG : P53 , RB GENE P63
P40
ORAL CANCER : HPV
MRI
CERVIX : KI 67 , CYCLIN
DEPENDENT KINASE
FNAC BIOPSY
POST DIAGNOSIS FROZEN SECTION
TNM STAGING DETERMING
THE EXTEND
IMMUNOHISTOCHEMISTRY MARKERS
FOLLOW UP
PROGNOSIS

32. Prevention of Cancers
Primordial prevention:
Population strategy: Cancer education, Hygiene education
High-risk strategy: Screening of high risk groups (sex workers, smokers,
alcoholics, older age, occupational groups)

33. Primary prevention:
Health promotion:
Health education: Danger signals of cancer, ill-effects of
smoking/alcohol, Oral/genital/general hygiene maintenance
self-examination in breast cancer
Control of air pollution: Containment, dilution, replacement, legislation
Legislation: Consumption of tobacco/alcohol, control of air pollution,
Protection of industrial workers

34. Specific protection:
1.Avoidance of carcinogens
2.Immunization: Hepatitis B vaccine, HPV vaccines
3.Treatment of pre-cancerous lesions
4.Protective gadgets to industrial workers

35. Secondary prevention:
Early diagnosis:
1.Clinical examination
2..Laboratory investigations
Treatment:
1.Surgery
2.Chemotherapy
3.Radiotherapy
4.Immunotherapy

36. Tertiary prevention:
Disability limitation: Intensive treatment to prevent
disabilities
Rehabilitation: Prosthesis, training, employment, social
rehabilitation.

38.  A fasting plasma glucose test measures your blood glucose after you have gone at
least 8 hours without eating. This test is used to detect diabetes or prediabetes.
 An oral glucose tolerance test measures your blood sugar after you have gone at
least eight hours without eating and two hours after you drink a glucose-containing
beverage. This test can be used to diagnose diabetes or prediabetes.
 In a random plasma glucose test, your doctor checks your blood sugar without
regard to when you ate your last meal. This test, along with an assessment of
symptoms, is used to diagnose diabetes, but not prediabetes.
 A hemoglobin A1c (HbA1c) test can be done without fasting, and can be used to
diagnose or confirm either prediabetes or diabetes.

39. Hba1c Fasting Random 2 hour
post load
venous
glucose
2 hour
post load
capillary
glucose
Normal Below
5.7
99mg/dl
or
below
N/A
Prediabeti
c
5.7 to 6.4 100 to
125 mg/dl
N/A
Diabetic 6.5 or
above
126
mg/dl
Or above
200
mg/dl or
above
200
mg/dl or
above
220
mg/dl or
above

40. A. Population Strategy B. High Risk Strategy
 Primordial Prevention Obesity correction
 Normal body weight Avoid alcohol,
 Healthy nutritional habit diabetogenic drugs
 Regular physical exercise and smoking
Maintain normal B.P.
cholesterol &
triglyceride level
Avoid stress
PRIMARY PREVENTION

41. A. SCREENING
 High risk cases
B. TREATMENT
1- Objectives
 Maintain normal blood glucose levels.
 Maintain the ideal body weight
 Treat the symptoms
 Reduce serum lipids
 Provide adequate nutrition
 Avoid acute complications
2- Modes
 Diet
 Daily exercise
 Drugs
 Health education

42. To limit the disabilities
 By diabetic clinics- To provide diagnostic and
management skill of high order.
 Rehabilitation – i. Psychological
ii. Vocational

43. PREVENTION AND CONTROL OF
ISCHEMIC HEART DISEASE

44. Prevention and
control of Ischemic
Heart disease
PRIMORDIAL
PREVENTION
Preventing the very
emergence of predisposing
conditions.
PRIMARY
PREVENTION
Preventing initiation of
pathological processes or
inhibiting their progress or
disease.
SECONDARY
PREVENTION
Early detection and
pre-hospital care.
TERTIARY
PREVENTION
Adequate treatment and
rehabilitation.
Educating and Motivating large
populations through IEC.
Focusing on groups and individuals
with certain high-risk factors

45. Primordial Prevention
Primordial prevention against Ischemic Heart Disease can be
used by those countries/communities in which lifestyle has not
yet acquired the pattern associated with high CHD incidence and
where the average level of critical risk factors is still favorable
but where economic advancements and changing lifestyles
threaten to undermine this favorable situation.
In these situations, we could act to “prevent the very emergence
of predisposing conditions , in countries and communities in
which they have not yet appeared.”
This essence is primordial prevention. No
Image

46. Primary Prevention
Primary preventive steps can be undertaken through two broad
strategies,
I. The “Population approach or Mass approach”, which focuses on large
population groups , even the entire district , state or country.
II. The “Targeted, high-risk strategy”, which focuses on individuals who
have a high probability of developing IHD, due to the presence of
certain risk factors.
The population approach can be further two types:
a) “Mass strategy”
b) “Targeted strategy”

47. Information , Education, and Communication in
Primary Prevention of Ischemic Heart Disease
1. Eat a diet, in which:
• Calories are as per requirement.
• Total fats provide <30% of calorie need.
• Trans fatty acids are eliminated from diet.
• Most dietary fats are polyunsaturated or monounsaturated .
• Salt consumption is <5 g/day.
• Cholesterol <200mg/day.
• Gravied, fried , creamed and sugared food stuffs are low.
• Plenty of whole grains , cereals , legumes , beans and pulses are present.
Fresh fruits/vegetables 400-500g/day are included.
• Low-fat dairy products.
2. Undertake brisk walk everyday or at least 5 days a week , covering 2 miles
in 30-40 minutes daily.

48. 3. Supplement aerobic exercises (walking, running, cycling,
sports) with light weight training and stretching exercises
such as yoga.
4. Say no to tobacco.
5. Avoid alcohol.
6. Regularly check your body weight and measure your waist and
hip circumferences; BMI should be kept at <25 and waist <90 cm
for males and for females waist <80cm.
7. Control and manage mental stress by the following
• Praying and meditating
• Yoga
• Exercising regularly
8. If you have any symptoms of chest pain, fatigue, palpitation,
or breathlessness, seek medical attention.

49. Secondary Prevention
Early detection of CHD at the incipient stage is important.
The available tools are :
 Resting ECG,a method which has been used in epidemiological surveys.
 Combination of Rose questionnaire(which records symptoms of angina
on effort) and resting ECG can be used.
 Exercise ECG gives better predictive values , either alone or in
conjunction with echocardiography.
All these screening procedures will give better predictive value if used in
high-risk populations , such as middle-aged, obese,those having a family
history , hypertension or dyslipidemia.

50. Immediate First Aid And Pre-Hospital Care
Immediately on suspicion , the person should be put to
complete rest and treated as a stretcher patient.
The essentials of pre-hospital care include six elements :
I. Complete rest
II. Aspirin to be chewed
III. Trinitrin/Sorbitrate and Clopidogrel
IV. Oxygen inhalations (if available)
V. Pain relief by morphine/pethidine
VI. Cardiorespiratory resuscitation

51. Tertiary Prevention
 The patients of IHD need to be adequately treated and
rehabilitated.
 The patient should be reassured and apprehensions allayed.
 Advice should be given regarding long-term drug therapy ,
physical exercise , reduction of risk profile, and gradually
getting back into day-to-day life activities.
 Follow-up, assessment of status at periodic intervals, and
appropriate advice should be ensured.
 Considering the public health importance of IHD , tertiary
prevention should be a teamwork involving the
cardiologist/physician, cardiothoracic surgeon, public health
specialist, dietician , public health nurse , and the family
physician.

52. PREVENTION OF STROKE

53. PRIMARY PREVENTION
Actions toward primary prevention should start
early, during early adulthood itself.
 Avoidance of smoking
 Regular brisk physical exercise
 Adopting healthy dietary methods, with low
consumption of salt, low consumption of
saturated fats and overall fats, reduction in
the overall dietary energy consumption (to
maintain healthy body weight), and
including plenty of fruits, fresh vegetables,
whole grain, and possibly fish in the diet

54.  Maintaining healthy body weight
(BMI <25, preferably <23; waist
circumference <90 cm for men and
<80 cm for women), by a
combination of diet and physical
activity
 Avoiding alcohol consumption (or
atleast adopting moderation)

55. SECONDARY PREVENTION
 This will include early detection and management of
health problems, which have a high potential to cause
stroke. High-risk screening will be more useful, through
screening of those individuals who are middle aged or
elderly (>45 years), have a family history of
cardiovascular disease, are obese, and whose profession
makes them physically inactive.
 Screening for diabetes through blood sugar and
management of those found diabetic/impaired glucose
tolerance (IGT) to obtain tight control on blood sugar
levels

56.  Screening and treatment for hypertension.
 Screening and treatment for lipid abnormalities (rise in total
cholesterol or LDL and lowered HDL) and treatment with
Statins.

57. TERTIARY PREVENTION
It needs a highly specialized neurological team and adequate
facilities.
 Immediate diagnosis as regards the etiology (hemorrhagic
or thrombo-occlusive) and the exact location of lesion and
aggressive management to save life.
 Prevention and management of complications during
hospital stay.

58.  Proper patient and relative education regarding self-care
and prevention before discharge.
 Follow up treatment and frequent reviews along with
dialogs with relatives or caretaker.

59. NPCDCS

60. PROGRAMME BACKGROUND
 India is experiencing a rapid health transition with a rising burden of
(NCD) surpassing the burden of CD
 The NCD are estimated to account for around 60% of all deaths and
loss in potentially productive years of life.
 In order to prevent and control major NCDs, the (NPCDCS) was
launched in 2010 with focus on;-
1. Strengthening infrastructure
2. Human resource development
3. Health promotion
4. Early diagnosis
5. Management and referral.
 .

61. PRAGRAMME BACKGROUND Cont…
 This programme was merged with National Cancer Control Programme
 During 2010-2012, the programme was implemented in 100 districts
across 21 States.
 Review of the initial phase of programme implementation helped to
identify the bottlenecks and accordingly the programme was re-
strategised and scaled-up.
 During 12th Five Year Plan, this
programme has covered all the districts
of the country in phased manner

62. OBJECTIVES
 Health promotion through behavior and lifestyle changes with
involvement of community, civil society, community based
organizations, media etc…
 Outreach Camps for opportunistic screening at all levels in the health
care delivery system from sub centre and above for early detection of
diabetes, hypertension and common cancers.
 Management of chronic NCDs through early diagnosis, treatment and
follow up through setting up of NCD clinics.
.

63. OBJECTIVES
 Build capacity at various levels of health care for prevention, early
diagnosis, treatment, IEC/BCC, operational research and
rehabilitation.
 Provide support for diagnosis and cost effective treatment at primary,
secondary and tertiary levels of health care.
 Provide support for development of database of NCDs through a robust
Surveillance System and to monitor NCD morbidity, mortality and risk
factors.

64. STRATIGIES
1. Health promotion
2 .Awareness generation
3. promotion of healthy lifestyle
4.Screening and early detection
5.Timely, affordable and accurate diagnosis
6. Access to affordable treatment
7. Rehabilitation

65. STRATIGIES
Health Promotion
Health promotion is the process of enabling people to increase control over, and
to improve, their health.
.
Importance ;-healthy behaviours of community.
;- motivates people to make behavioural and lifestyle changes
that reduce the risk of developing chronic diseases, and
other morbidities, thus reducing premature deaths.
;-to prevent disease complications

66. STRATIGIES
.
Health Promotion specifically related to:
1. Healthy Diet
2. Overweight/Obesity
3. Physical Activity
4. Tobacco
5. Alcohol
6. Stress

67. STRATIGIES
Approaches to Health Promotion
T – TELL About healthy life style
A – ADVISE community on what to do to reduce risk factors
L – LEAD Collective community action for reducing risk factors by working with
community based organizations, Village Health Sanitation and Nutrition
Committees/ Mahila Arogya Samities/Self-help groups .
K – KNOW more about health promotion and healthy life style, self-help
approaches to reduce risk and community resources for treatment and support

68. STRATIGIES
Promotion of healthy lifestyle
 Salt reduction
 Increased physical activity/regular exercise
 Avoidance of tobacco and alcohol
 Reduction of obesity
 Stress management
 Awareness about warning signs of cancer etc.
 Regular health check-up
 Increased intake of healthy foods

69. STRATIGIES
Screening and early detection

70. Facilities at different levels of health care

71. Facilities at different levels of health care

73. GUIDELINES FOR REFERRAL AND TREATMENTBy GOI
IN 2016
 1. Those with SBP >140 and DBP >90mmhg, RBS 140/>140 would be
referred to a MO at the nearest health facility for confirmation, conducting lab
investigation and initiation of treatment.
 2 .Those who are found positive for pre cancerous/ cancer lesion will be
referred by ANM/ Staff nurse in specified screening site to the appropriate
PHC/CHC/District Hospitals for confirmation and treatment by trained
specialists for Cancer screening and management.
 3. Once the diagnosis of HTN / diabetes is established, the patient must receive
at least a month's supply of drugs from the PHC.
 4.Once the condition is stable, the state could also decide to provide the patient
with a three-month supply, with the ANM/ASHA visiting the patient each
month for ensuring compliance, checking on diet and life style modification,
and measuring the blood pressure/blood Glucose

74. Guidelines and referral cont…
 4. The patient will need to go the PHC for the first follow up at the end of the
first three months after diagnosis, and sooner if required.
 5. For those individuals who are already on treatment under the care of a
private practitioner, they could be offered the choice of taking drugs from the
public health system, after appropriate confirmation
 6 Community Follow up of these individuals would be by the ASHA making
visits to enable positive behaviour modifications, treatment compliance, and
encouraging patients to go the sub-centre for regular check-up of BP blood
glucose.

75. RECENT INITIATIVES
 Population-based screening (PBS) for NCDs has been expanded under
NHM to >400 districts.
 Launch of NCD Mobile App (such as m-Diabetes) for capturing patient-
wise data, follow up from PBS districts and for adherence of treatment
and promotion of healthy lifestyle.
 Under Ayushman Bharat, NCDs are included in the spectrum of
services being offered at Health and Wellness Centers.

76. RECENT INITIATIVES cont…
 National Multi-sectoral Action Plan for prevention and control of NCDs
has been developed with several stakeholders including other
Ministries/Departments.
 Issues pertaining to prevention and management of (COPD) and (CKD)
have been included in the program.
 Pradhan Mantri National Dialysis Program (PM-NDP)is being
implemented in 496 districts in 35 States/Union Territories .
 Prevention, early detection, and treatment of rheumatic fever and
rheumatic heart diseases, in conjunction with Rashtriya Bal Swasthya
Karyakram.

77. RECENT INITIATIVES Cont
 "National Framework for Joint Tuberculosis-Diabetes collaborative
activities" has been developed to formulate a national strategy for "bi-
directional screening," early detection and better management of
tuberculosis and diabetes co-morbidities.
 Indian Hypertension Management Initiative, with support from ICMR.
 Opportunistic and sample screening of NCDs has been started at India
International Trade Fair (IITF) at Pragati Maidan, New Delhi during
November, every year.
 • "Integration of AYUSH (including Yoga) with NPCDCS" project has
been started.

78. PROGRESS
 Till March 2020, 665 District NCD Cells, 637 District NCD Clinics, 4472 CHC
NCD Clinics, 181 Cardiac Care Units (CCU) for emergency cardiac care and 218
Day Care Units for cancer chemotherapy were functional in all 36 States/UTS
in the country.
 Free diagnostic facilities and free drugs for NCD patients.
 Pattern of assistance: Funds are provided to States under NCD :State share in
ratio of 60:40 (except for North-Eastern and Hilly States, where the share is
90:10).
 Tertiary Care Cancer Centers (TCCCs) Scheme focuses on establishing and
strengthening 20 State Cancer Institutes (SCIs) and 50 TCCCs for
comprehensive cancer care throughout India. This scheme has provision for a
"one time grant" of 120 crore for every SCI and 45 crore for every TCCC.