Cancer in the Arab World: Magnitude of the Problem

Inas Elattar, DrPH

Professor of BiostatisticsDepartment of Biostatistics & Epidemiology

NCI, Egypt

APHANovember, 2004

Introduction

Cancer incidence in Arab countries is increasing. This is due partly to:

Reduction in the incidence of infectious diseases

Increase in the population average age

Westernization of social and dietary habits

Increase smoking

Increase of the incidence of hepatitis B and C

Wrong use of plastic materials, pesticides and insecticides

Low socioeconomic status

YemenYemen

Regional Cancer Registry

National Cancer Registry

No Registry

Cancer Databases in Arab World

Source of Data National Population-based Cancer Registries:

Gulf Center for Cancer Registration, 2000 Qatar, Oman, Bahrain, and UAE

Saudi Arabia, 1999-2000

Kuwait, 2001

Jordan, 1999

Regional Population-based Cancer Registries:

Egypt: Gharbiah 1999

Algeria: Algiers, Constantine, Oran, &Setif, Globocan 2002

Tunisia: Tunis, Sousse, Sfax, Globocan 2002

All others Globocan 2002, IARC

Age-Adjusted Incidence Rates in Arab World, Males

96

88

114

99 154

102

180180

123

123

60

180166

121

72

99

123

178

178

178178

81

Rates/100,000

Age-Adjusted Incidence Rates in Arab World, Females

87

90

78

85 137

84

167167

118

127

61

216159

120

77

89

118

176

176

176176

94

Rates/100,000

Male to Female Ratio, All Cancer Sites

0.0 0.5 1.0 1.5 2.0

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

M/F ratio

Ratio <1 Ratio >1

ASR of Stomach Cancer in Arab World

3.3

4.1

2.9

1.5

5.2

6.5

5.6

3.8

3.1

3.0

2.9

7.2

6.7

4.3

2.7

8.1

11.2

13.2

5.2

5.9

5.3

3.8

0 5 10 15

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

Males

Females

ASR of Colorectal Cancer in Arab World

33.1

13.2

14.8

4.5

7.6

9.0

4.4

15.8

5.0

6.9

5.5

44.6

11.5

14.0

4.7

7.5

12.5

4.1

13.5

5.5

6.3

5.8

0 10 20 30 40 50

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

Males

Females

ASR of Liver Cancer in Arab World

2

1.1

3.6

2.7

0.7

7.3

3.1

8.7

1

1.2

6

5.5

2

10.3

6.1

4.1

7.4

5.9

14

0.8

2.5

21.4

0 5 10 15 20 25

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

Males

Females

Relative Frequency of Liver Cancer, NCI - Egypt 1975-2002

1975-85 1990 1995 2000

Year

0

2

4

6

81975-97 2001-02

Egypt Mortality Statistics, 2001 Most common sites (The Cancer Database, 2001)

425

550

797

834

1662

1869

2006

2023

2497

3197

0 1000 2000 3000 4000

Prostate (2%)

Pancreas (2.5%)

Stomach (3.7%)

Colorectal (3.9)

Lung&Bronchus (7.7%)

Bladder (8.7%)

Breast (9.3%)

Brain (9.4%)

Lymph&Leuk (11.6%)

Liver (14.8%)

Number of cases

Trend of HCC Mortality in Egypt, 1981-1996

1.0

1.2

1.5

2.0

2.3

2.5

2.3

2.5

1.4

2.1

2.4

3.23.3

3.0

4.2

4.6

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

80 82 84 86 88 90 92 94 96

Rate/1

00

,0

00

Females

Males

ASR of Lung Cancer in Arab World

36.1

1.2

2.0

4.1

3.5

4.1

5.8

12.3

2.0

1.9

3.6

61.9

6.1

8.8

9.4

16.3

11.3

36.6

33.5

16.9

27.8

14.0

0 10 20 30 40 50 60 70

USA

Saudi Arabia

Oman

UAE

Jordan

Kuwait

Qatar

Bahrain

Algeria

Tunisia

Egypt

Rates/100,000

Males

Females

Prevalence of Smoking in Arab World

8%

2%

1%

10%

2%

1%

3%

7%

8%

18%

19%

16%

18%

48%

30%

37%

17%

44%

62%

40%

0% 20% 40% 60% 80%

Saudi Arabia (1996-2001)

Oman (1995)

UAE (1996)

Jordan (1999)

Kuwait (1996)

Qatar (1999)

Bahrain (2001)

Algeria (1997-98)

Tunisia (1997)

Egypt (2000)

Percent

Males

Females

ASR of Prostate Cancer in Arab World

124.8

10.6

12.6

3.6

8

19.3

8.7

11.8

5.6

8.7

6.6

0 25 50 75 100 125

USA

Jordan

Kuwait (5th)

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

ASR of Bladder Cancer in Arab World

6.5

1.5

3.9

1

3.9

3.7

1.5

1.1

1.1

5.3

24.5

13.3

8.1

3.7

4.7

14.5

3.6

21.2

8.1

13.5

26.3

0 5 10 15 20 25 30

USA

Jordan

Kuwait (5th)

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

Males

Females

Histological Type of Bladder Cancer

The first differential pattern which characterizes bilharzial

bladder cancer is the histological type of the tumor

SCC type is the most frequent type of cancer in countries

with a high prevalence of schistosomiasis

SCC type is rare in industrialized countries

TCC type is considered typical for chemically induced

bladder cancer

TCC type is low in areas with schistosomiasis

Changing Pattern of Bladder Cancer Type, NCI 1975-2002

*

*

*

** * * *

**

** *

** *

* *

**

* ** *

+

+

+

++

+

+

+

++++

+ +++

+++

+++

+

+

1975 1980 1985 1990 1995 2000

Year

0

10

20

30

40

50

60

70

80

SCC

TCC

ASR of Lymphomas in Arab World

13.5

6

7.1

5

5.7

6.9

7.3

19.6

4.2

4.6

11.9

20.3

10.7

13.3

7.2

6.9

9.1

10.4

12.0

6.5

7.4

17.7

0 5 10 15 20 25

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

Males

Females

Age Specific Incidence Rates (ASIR) of Lymphoma in Selected Arab Countries (Males)

0

20

40

60

80

100

120

140

Age groups (years)

ASI

R

EgyptSaudi ArabiaKuwaitJordan

ASR of Leukemias in Arab World

7.4

6

2.8

3

3.8

2.6

4.1

4.5

2.1

3.8

5.8

11.2

7.0

4.8

3.4

1.8

6.3

5.9

12.9

3.2

4.6

7.0

0 5 10 15

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

Males

Females

ASR of Breast Cancer in Arab World (Females)

101.1

42.6

36.0

13.9

12.9

56.0

14.9

50.7

23.5

19.6

49.6

0 20 40 60 80 100 120

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

Age Specific Incidence Rates (ASIR) of Breast in Selected Arab Countries (Females)

0

50

100

150

200

250

300

<5 5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

44-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

475

+

Age groups (years)

ASI

R

EgyptBahrainKuwaitJordan

ASR of Cervical Cancer in Arab World

6.8

1.5

6.8

2.1

6.5

4.4

7.0

10.5

15.6

7.7

2.8

0 5 10 15 20

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

ASR of Cancer of Uterus in Arab World

22.8

5.5

5.8

2.4

3.6

5.5

1.3

12.0

1.5

2.1

3.1

0 5 10 15 20 25

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

ASR of Cancer of Ovary in Arab World

10.6

6.2

4.0

2.2

1.4

8.2

6.0

7.2

3.7

2.7

5.0

0 5 10 15

USA

Jordan

Kuwait

Saudi Arabia

UAE

Bahrain

Oman

Qatar

Alegria

Tunisia

Egypt

Rates/100,000

Cancer in Arab WorldMain conclusions

Lung High prevalence of smoking

Liver Endemicity of hepatitis B & C

Bladder Smoking, Schistosoma

NHL Low SES, malnutrition, parasitic & viral infections (Epstein-Barr)

Prostate Increasing with aging population

Breast Leading cancer similar to developed countries, present at younger age

Cervix High in Algeria, 50% of cases are diagnosed in late stage

Most Common Cancer Sites among Males

Egypt Tunisia Algeria Jordan Kuwait

Bladder Lung Lung Lung Colorectal

Liver Bladder Bladder Bladder NHL

NHL Prostate Stomach Prostate Prostate

Lung Larynx Prostate NHL Lung

Leukemia Colorectal Colorectal Skin Liver

Colorectal NHL Nasopharynx Brain&CNS Brain&CNS

Most Common Cancer Sites among Males

KSA UAE Bahrain Oman Qatar

NHL Lung Lung Stomach Lung

Liver Stomach Prostate NHL Bladder

Leukemia Prostate Bladder Prostate Liver

Colorectal Colorectal Colorectal Lung Colorectal

Lung NHL Stomach Leukemia Prostate

Prostate Bladder Liver Colorectal Leukemia

Most Common Cancer Sites among Females

Egypt Tunisia Algeria Jordan Kuwait

Breast Breast Breast Breast Breast

NHL Colorectal Cervix Colorectal Colorectal

Leukemia Cervix Colorectal Ovary Thyroid

Liver Leukemia Ovary Thyroid NHL

Colorectal NHL NHL Skin Cervix

Ovary Stomach Thyroid Uterus Uterus

Most Common Cancer Sites among Females

KSA UAE Bahrain Oman Qatar

Breast Breast Breast Breast Breast

Thyroid Cervix Lung Cervix NHL

Leukemia Leukemia Ovary NHL Skin

Colorectal Thyroid Thyroid Leukemia Thyroid

NHL NHL Liver Ovary Colorectal

Ovary Stomach Kidney/NHL Stomach Hodgkins Disease

National Cancer InstituteNational Cancer Institute , ,Cairo, EgyptCairo, Egypt

National Cancer Institute, Cairo, Egypt

The National Cancer Institute (NCI) is the largest comprehensive

cancer center in Egypt

The present hospital with its 550 beds is overloaded by patients

referred from allover the country

During the years 2001-2002: 38,400 new patients visited the NCI

19,568 (51%) were malignant cases

Half of the cases were males

11% were children, less than or equal to 18 years

About 54% of the cases were between the ages 41 through 65 years

19,568 New Cancer Cases by Systems, NCI 2001-2002

1590

1211

1718

376

513

2357

909

305

3729

509

845

515

1242

3056

693

0 1000 2000 3000 4000

Others

Leukemia

Lymphoma

Thyroid &other endocrine

Eye & brain

Urinary system

Female genital

Male genital

Breast

Skin

Soft tissue

Bones & joints

Respiratory system

Digestive system

Lip, oral cavity &pharynx

Number of cases