Bladder cancer April 2016 Bladder cancer Introduction Bladder
![Bladder cancer April 2016 Bladder cancer April 2016](https://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-1.jpg)
Bladder cancer April 2016
![Bladder cancer: Introduction • Bladder cancer (BC): Heterogeneous disease • Although disease may occur Bladder cancer: Introduction • Bladder cancer (BC): Heterogeneous disease • Although disease may occur](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-2.jpg)
Bladder cancer: Introduction • Bladder cancer (BC): Heterogeneous disease • Although disease may occur in young persons >90% of new cases occur in persons ≥ 55 yr of age • 70% of patients presenting with superficial tumours, which tend to recur but are generally not life threatening • 30% presenting as muscle-invasive disease associated with high risk of death from distant metastases Kaufman DS, et al. Lancet 2009; 374: 239– 49/ Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.
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![Rawal S. Indian J Urol. 2008; 24(1): 60. Rawal S. Indian J Urol. 2008; 24(1): 60.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-4.jpg)
Rawal S. Indian J Urol. 2008; 24(1): 60.
![Epidemiology • 2 nd most common genitourinary malignancy after prostate cancer (PC) • 9 Epidemiology • 2 nd most common genitourinary malignancy after prostate cancer (PC) • 9](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-5.jpg)
Epidemiology • 2 nd most common genitourinary malignancy after prostate cancer (PC) • 9 th most common cancer in the world • Globally, incidence of bladder cancer varies significantly, with Egypt, Western Europe and North America having highest incidence rates & Asian countries the lowest rates • 430, 000 new cases diagnosed worldwide, male to female ratio: 3: 1 (2012) • Men: 7 th most common cancer • Women: 17 th most common cancer Kaufman DS, et al. Lancet 2009; 374: 239– 49/ Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.
![Males Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626. Males Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-6.jpg)
Males Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.
![Females Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626. Females Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-7.jpg)
Females Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.
![A high fluid intake is associated with decreased risk of BC in men Michaud A high fluid intake is associated with decreased risk of BC in men Michaud](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-8.jpg)
A high fluid intake is associated with decreased risk of BC in men Michaud DS, et al. NEJM. 1999; 340: 1390 -7.
![Divergent molecular pathways of oncogenesis in superficial & muscle invasive urothelial carcinoma of urinary Divergent molecular pathways of oncogenesis in superficial & muscle invasive urothelial carcinoma of urinary](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-9.jpg)
Divergent molecular pathways of oncogenesis in superficial & muscle invasive urothelial carcinoma of urinary bladder Zhao M, et al. Chin J Cancer Res 2016; 28(1): 92 -98.
![Bladder cancer: Clinical Presentation • Main presenting symptom of all bladder cancers: Painless haematuria Bladder cancer: Clinical Presentation • Main presenting symptom of all bladder cancers: Painless haematuria](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-10.jpg)
Bladder cancer: Clinical Presentation • Main presenting symptom of all bladder cancers: Painless haematuria • Diagnosis established by: Urinary cytology & transurethral tumour resection Kaufman DS, et al. Lancet 2009; 374: 239– 49.
![Guidelines: Primary assessment of NMIBC Babjuk M, et al. EAU 2015. Guidelines: Primary assessment of NMIBC Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-11.jpg)
Guidelines: Primary assessment of NMIBC Babjuk M, et al. EAU 2015.
![Guidelines on non-invasive bladder cancer (Ta, T 1 and CIS) Guidelines for TURB and/or Guidelines on non-invasive bladder cancer (Ta, T 1 and CIS) Guidelines for TURB and/or](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-12.jpg)
Guidelines on non-invasive bladder cancer (Ta, T 1 and CIS) Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. EAU 2015.
![Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-13.jpg)
Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. EAU 2015.
![Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-14.jpg)
Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. EAU 2015.
![Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-15.jpg)
Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. EAU 2015.
![Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-16.jpg)
Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. EAU 2015.
![Bladder diagram Babjuk M, et al. EAU 2015. Bladder diagram Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-17.jpg)
Bladder diagram Babjuk M, et al. EAU 2015.
![Structure of urinary bladder wall & urothelium Zacche MM, et al. Research and Reports Structure of urinary bladder wall & urothelium Zacche MM, et al. Research and Reports](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-18.jpg)
Structure of urinary bladder wall & urothelium Zacche MM, et al. Research and Reports in Urology 2015: 7 169– 178.
![2009 TNM classification of urinary bladder cancer Babjuk M, et al. EAU 2015. 2009 TNM classification of urinary bladder cancer Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-19.jpg)
2009 TNM classification of urinary bladder cancer Babjuk M, et al. EAU 2015.
![WHO grading: 1973 & 2004 Babjuk M, et al. EAU 2015. WHO grading: 1973 & 2004 Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-20.jpg)
WHO grading: 1973 & 2004 Babjuk M, et al. EAU 2015.
![WHO grading: 2004 Babjuk M, et al. EAU 2015. WHO grading: 2004 Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-21.jpg)
WHO grading: 2004 Babjuk M, et al. EAU 2015.
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![Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626. Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-23.jpg)
Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.
![Summary of main urinary markers Babjuk M, et al. EAU 2015. Summary of main urinary markers Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-24.jpg)
Summary of main urinary markers Babjuk M, et al. EAU 2015.
![Photosensitizing agent 5 -aminolevulinic acid (5 -ALA) is used to induce red fluorescence under Photosensitizing agent 5 -aminolevulinic acid (5 -ALA) is used to induce red fluorescence under](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-25.jpg)
Photosensitizing agent 5 -aminolevulinic acid (5 -ALA) is used to induce red fluorescence under exposure to blue light using cystoscopy to identify cancerous and precancerous lesions Lerner SP, et al. Cancer. 2015; 121: 169 -78.
![Optical coherence tomography (OCT) can resolve layers of bladder & distinguish benign from malignant Optical coherence tomography (OCT) can resolve layers of bladder & distinguish benign from malignant](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-26.jpg)
Optical coherence tomography (OCT) can resolve layers of bladder & distinguish benign from malignant characteristics Lerner SP, et al. Cancer. 2015; 121: 169 -78.
![Weighting used to calculate disease recurrence & progression scores Babjuk M, et al. EAU Weighting used to calculate disease recurrence & progression scores Babjuk M, et al. EAU](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-27.jpg)
Weighting used to calculate disease recurrence & progression scores Babjuk M, et al. EAU 2015.
![Probability of recurrence & disease progression according to total score Babjuk M, et al. Probability of recurrence & disease progression according to total score Babjuk M, et al.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-28.jpg)
Probability of recurrence & disease progression according to total score Babjuk M, et al. EAU 2015.
![Probability of recurrence & disease progression according to total score Babjuk M, et al. Probability of recurrence & disease progression according to total score Babjuk M, et al.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-29.jpg)
Probability of recurrence & disease progression according to total score Babjuk M, et al. EAU 2015.
![Risk group stratification Babjuk M, et al. EAU 2015. Risk group stratification Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-30.jpg)
Risk group stratification Babjuk M, et al. EAU 2015.
![Algorithm for selection of treatment method Smith ZL, et al. BJUI. 2013; 112: 13 Algorithm for selection of treatment method Smith ZL, et al. BJUI. 2013; 112: 13](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-31.jpg)
Algorithm for selection of treatment method Smith ZL, et al. BJUI. 2013; 112: 13 -25.
![Smith ZL, et al. BJUI. 2013; 112: 13 -25. Smith ZL, et al. BJUI. 2013; 112: 13 -25.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-32.jpg)
Smith ZL, et al. BJUI. 2013; 112: 13 -25.
![Recommendations for adjuvant therapy in Ta, T 1 tumours and for therapy of CIS Recommendations for adjuvant therapy in Ta, T 1 tumours and for therapy of CIS](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-33.jpg)
Recommendations for adjuvant therapy in Ta, T 1 tumours and for therapy of CIS Babjuk M, et al. EAU 2015.
![Summary of key steps & mediators in mechanism of action of BCG immunotherapy Fuge Summary of key steps & mediators in mechanism of action of BCG immunotherapy Fuge](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-34.jpg)
Summary of key steps & mediators in mechanism of action of BCG immunotherapy Fuge O, et al. Research and Reports in Urology 2015: 7 65– 79.
![Guidelines on non-invasive bladder cancer (Ta, T 1 and CIS) Guidelines for follow-up in Guidelines on non-invasive bladder cancer (Ta, T 1 and CIS) Guidelines for follow-up in](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-35.jpg)
Guidelines on non-invasive bladder cancer (Ta, T 1 and CIS) Guidelines for follow-up in patients after TURB of NMIBC Babjuk M, et al. EAU 2015.
![Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-36.jpg)
Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU 2015.
![Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-37.jpg)
Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU 2015.
![Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-38.jpg)
Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU 2015.
![Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-39.jpg)
Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU 2015.
![Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015. Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-40.jpg)
Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015.
![Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015. Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-41.jpg)
Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015.
![Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015. Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-42.jpg)
Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015.
![TURBT TURBT](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-43.jpg)
TURBT
![TURBT TURBT](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-44.jpg)
TURBT
![TURBT TURBT](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-45.jpg)
TURBT
![Categories of unsuccessful treatment with intravesical BCG Babjuk M, et al. EAU 2015. Categories of unsuccessful treatment with intravesical BCG Babjuk M, et al. EAU 2015.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-46.jpg)
Categories of unsuccessful treatment with intravesical BCG Babjuk M, et al. EAU 2015.
![Treatment strategy in recurrence during or after intravesical BCG* Babjuk M, et al. EAU Treatment strategy in recurrence during or after intravesical BCG* Babjuk M, et al. EAU](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-47.jpg)
Treatment strategy in recurrence during or after intravesical BCG* Babjuk M, et al. EAU 2015.
![Treatment strategy in recurrence during or after intravesical BCG* Babjuk M, et al. EAU Treatment strategy in recurrence during or after intravesical BCG* Babjuk M, et al. EAU](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-48.jpg)
Treatment strategy in recurrence during or after intravesical BCG* Babjuk M, et al. EAU 2015.
![Invasive Bladder Cancer • For muscle-invasive tumours, radical cystectomy with pelvic lymphadenectomy has been Invasive Bladder Cancer • For muscle-invasive tumours, radical cystectomy with pelvic lymphadenectomy has been](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-49.jpg)
Invasive Bladder Cancer • For muscle-invasive tumours, radical cystectomy with pelvic lymphadenectomy has been the gold standard for the past several decades • Complication & perioperative mortality rates have been declining, with reported rates as low as 17% to 32% and 2% to 3%, respectively Yafi FA, et al. Can Urol Assoc J. 2009; 3(5): 409– 412.
![Radical cystectomy Radical cystectomy](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-50.jpg)
Radical cystectomy
![Results of radical cystectomy Results of radical cystectomy](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-51.jpg)
Results of radical cystectomy
![Results of radical cystectomy Stage Recurrence-Free 5 y. 10 y. Overall Survival 5 y. Results of radical cystectomy Stage Recurrence-Free 5 y. 10 y. Overall Survival 5 y.](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-52.jpg)
Results of radical cystectomy Stage Recurrence-Free 5 y. 10 y. Overall Survival 5 y. 10 y. T 2 N 50 78 41 62 29 50 33 77 52 64 40 49 24 44 26 T 3 a T 3 b T 4 a N+ NN+ NN+ Stein JP, et al. J Clin Oncol. 2001; 19(3): 666 -75. 89 50 76 37 61 29 45 33 87 57 52 44 26 29 12 23 20
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![Treatment recommendations in Ta, T 1 tumours and CIS according to risk stratification Babjuk Treatment recommendations in Ta, T 1 tumours and CIS according to risk stratification Babjuk](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-60.jpg)
Treatment recommendations in Ta, T 1 tumours and CIS according to risk stratification Babjuk M, et al. EAU 2015.
![Treatment recommendations in Ta, T 1 tumours and CIS according to risk stratification Babjuk Treatment recommendations in Ta, T 1 tumours and CIS according to risk stratification Babjuk](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-61.jpg)
Treatment recommendations in Ta, T 1 tumours and CIS according to risk stratification Babjuk M, et al. EAU 2015.
![Treatment recommendations for BCG failure & recurrences after BCG Babjuk M, et al. EAU Treatment recommendations for BCG failure & recurrences after BCG Babjuk M, et al. EAU](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-62.jpg)
Treatment recommendations for BCG failure & recurrences after BCG Babjuk M, et al. EAU 2015.
![Intravesical chemotherapy in non-muscle invasive BC Porten SP, et al. Indian J Urol. 2015; Intravesical chemotherapy in non-muscle invasive BC Porten SP, et al. Indian J Urol. 2015;](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-63.jpg)
Intravesical chemotherapy in non-muscle invasive BC Porten SP, et al. Indian J Urol. 2015; 31(4): 297– 303.
![Instillation regimes for intermediate-risk tumors Jokisch JF, et al. Indian J Urol. 2015; 31(4): Instillation regimes for intermediate-risk tumors Jokisch JF, et al. Indian J Urol. 2015; 31(4):](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-64.jpg)
Instillation regimes for intermediate-risk tumors Jokisch JF, et al. Indian J Urol. 2015; 31(4): 304– 311.
![High-risk tumors and its treatment Jokisch JF, et al. Indian J Urol. 2015; 31(4): High-risk tumors and its treatment Jokisch JF, et al. Indian J Urol. 2015; 31(4):](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-65.jpg)
High-risk tumors and its treatment Jokisch JF, et al. Indian J Urol. 2015; 31(4): 304– 311.
![Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-66.jpg)
Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman H, et al. Ther Adv Urol. 2015; 7(6): 312 -330.
![Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-67.jpg)
Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman H, et al. Ther Adv Urol. 2015; 7(6): 312 -330.
![Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-68.jpg)
Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman H, et al. Ther Adv Urol. 2015; 7(6): 312 -330.
![Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-69.jpg)
Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman H, et al. Ther Adv Urol. 2015; 7(6): 312 -330.
![Key molecular pathways, therapeutic targets & drugs under investigation in urothelial carcinoma Knollman H, Key molecular pathways, therapeutic targets & drugs under investigation in urothelial carcinoma Knollman H,](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-70.jpg)
Key molecular pathways, therapeutic targets & drugs under investigation in urothelial carcinoma Knollman H, et al. Ther Adv Urol. 2015; 7(6): 312 -330.
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![PUTTING CANCER IN CHECK PUTTING CANCER IN CHECK](http://slidetodoc.com/presentation_image_h2/718224c56735c42983838adad6527944/image-72.jpg)
PUTTING CANCER IN CHECK
- Slides: 72