Epidemiology Of Breast Cancer In Saudi Arabia - Article Example

Abstract Data regarding cancer in Saudi Arabia are clearer than it used to be. This has been made possible through the National Cancer Registry of Saudi Arabia (NCR). In fact, has become easier to make comparison with trends in other countries. It is a population-based registry tracing back from 1992 established through Ministry of Health. Since then, NCR has been providing the needed reports on the development of cancer in the country with its primary objective being the definition of the population-based incidence of the disease. This article thus builds on these reports to critically gather all information from Saudi Cancer Registry with an aim of ascertaining epidemiology of the pandemic in Saudi Arabia. This will be done through the analysis of methodologies and results as presented. Introduction Larger bodies of well supported evidence now explain the cause and widespread of the disease in the country and even compare such with other countries (Annual report of the Tumor Registry, 2010; Boffetta, 2004 Cancer prevention and control, Alexandria, 2006). Furthermore, scholars such as Rabadi (2007) have given comprehensive data on the spread on breast cancer per region in Saudi Arabia. This in many aspects is similar to the same information published by W.H.O report on the global tobacco epidemic (2008). Cornerstone of the information regarding the disease is now well elaborated through the registration of cancer in the Saudi Arabia which has been regarded as approach that has effectively controlled cancer on a rational basis (Semaan, 2003). Since its inception, cancer registry has been significant tool as the data generated has been handy in understanding epidemiology, evaluation of necessary preventative measures, quality control and enhancement of further research regarding cancer. As explained by Directory of Radiotherapy Centres (2008), these reports represent basics on the ground as the methods adopted are scientific and work with population estimations as presented by ministry of planning. While doing comparative analysis on the spread of cancer in Saudi Arabia and other Arabian countries, Bin Yousef et al. (2004) admit that data from King Faysal Specialist Hospital and Research Center Saudi as represented in National Cancer Registry Report (2000) shows scientific approach to the study of cancer and thus concur with its accuracy and reliability. One notable aspect about these reports is that it is an evolving process which gives information regarding the rise in the disease. In as much, the reports have been grappling with many challenges among them unavailability of medical records in some hospitals. a. Methods Generally, these reports adopt some similarities and difference based on the formats, data management and notifications presented. i. Formats Beginning with 2001, it can be agreed that if someone had read previous reports then the format presented in 2001 bears some resemblance. However, in terms of its format, 2001 gives evolution of a new dimension whereby there is a map representation of cancer distribution. This helps in understanding regions with high cases of the disease. It can also be argued that relying on a map representation of cancer distribution enables accuracy in terms of understanding age gaps that are worst hit owing to a report published by Gulf Cooperation Council Countries (2000) as cited in Akhtar et al. (2008). However, this method changes in 2002 whereby cancer distribution has been done through age standardised rate (ASR) as opposed to Geographic Information System (GIS) mapping used in 2001. Cancer Incidence and Survival Report, (2007) argues that adoption of ASR enables comparison of cancer cases among Saudis and other populations from other selected countries. This is exactly what has been represented in 2003 and 2004. However, there are some slight changes in 2006, 2007 and 2008 whereby there is an exception of regional distribution of age standardised rate for a given cancer across the country. This has been represented in bar graphs. ii. Data management It is important to note that data that NCR has used are from ministry of health and designated hospitals within the country. Their management has been diverse since the first report was published. Another important aspect to mention is that these data as represented in the reports are abstracted from medical reports. In 2001 report, management of the data abstracted involved a change for coding of cancer behaviors and types. Also included during this year is the staging. However, reading through reports from 2001 to 2008 some sites are coded different guidelines and indeed some difference in the timing rules for determining stage thus hard for NCR to make a comparison of staging data from 1994-2000. It can also be noted that in 2001 and 2002 reports, there are no remarkable changes in the primary site codes since that has adopted coding which was done by International Classification of Diseases for Oncology 3rd Edition (ICD-O-3) (Directory of Radiotherapy Centres, 2008). Also introduced in 2001 report to hasten data management is the CanReg 4.27 software which facilitates outputs as well as data entries. This program was upgraded to CanReg 4.30 in the 2002, CanReg 4.31in 2003, 2004 and 2005. Whereas ICD-0-3 has been used since 2001 for the purposes of coding and identification, a new trend emerged in 2003 report where ICD-0-3 codes are converted to ICD-10 to facilitate analysis. But in 2001 across to 2005 reports, World Health Organisation did not convert the ICD-10 hematopoietic disease behavior changes therefore CanReg 4.27software did not reflect such cases. In 2006 to 2008, CanReg software was updated and the analysis was done using CanReg 4.33 which can now facilitate data analysis for international statistics regarding specified cancer cases and the ranking worldwide. The use of CanReg 4.33 was also adopted during the research conducted by Annual report of the Tumor Registry (2010) which indicates that accuracy in terms of age-specific incidence rates. iii. Notifications This section notifies consumers of the reports on the period the data used cover. For instance, data reported by 2001 was abstracted up to 2004 meaning the information contained in this report covers data and information from the last report up to 2004. Similarly, the 2002 report covers information up to 2005 and cases or incidences not captured but took place in 2002 has been considered as late reporting and such will should appear in 2003 report. The 2003 report covers data up to June 2005 with late incidences covered in preceding report. The 2005 report reflects data up to June 2006. This trend is observed in 2006 and 2007 reports. However, the 2008 report covers almost two years incidence with the last data to be captured being that of June 2010. Discussion Looking at the reports, it is alarming that total number of female with breast cancer cases has been on the steady increase from 2001 to 2008. Comparing number of cases of breast cancer vis-à-vis their percentages, the rate seem to be on the increase. For example, in figure 1 below, 2001, the country had 545 cases standing at 19.9% (according to figure 2 below). This was even higher compared to data from previous reports. This figure rose to 614 by 2002 representing an increase of 1.2%. By 2007, there were 1239 cases reported with a percentage increment of 6.1. This was the highest figure to be reported and according to Cancer Incidence and Survival Report (2007) such figures were due to changes in living standards. Interestingly, the figure dropped to 1152 in the 2008 report. Ravichandran et al. (2005) attribute these changes to the fact that breast malignancy which was having highest relative frequency in regions of eastern parts was coming down. Figure 1: Number of Female Breast Cancer Cases from 2001 to 2008 Figure 2: Total % of Female Breast Cancer Cases from 2001-2008 The next aspect that has been captured by the reports is the average number of female breast cancer reported between 2001 and 2008. According to figure 3 shown below, the age groups reflected by the reports are 16-29, 30-44, 45-59, 60-74 and female above the age of 70 years. Such numbers have also been replicated in percentages according to figure 4. By numbers and percentages, these reports agree that the least affected age group and female with ages above 70 years followed by those within the bracket of 15-29. This finding conforms to that of World Health Organisation on Global Tobacco Epidemic (2008). It is suggested that the reason why the rate at this age brackets is low is due lack of menstrual circles which is one of the risk factors. On the other hand, the report also suggests that women within the age bracket of 31 to 55 years stand higher chance of contracting breast cancer since they have a longer lifetime exposure to progesterone and estrogen hormones which are equally risk factors. Figure 3: Average Number of Female Breast Cancer Cases from 2001 to 2008 Figure 4: Average percentage of Female Breast Cancer Case from 2001-2008 Average female breast cancer cases from 2001-2008 adjusted by regions indicate that there are regions that are worst hit than others. According to figure 5, the reports show that by average, Eastern region shows the highest cases followed by Makkah. Figure 5: Average Percentage of Breast Cancer Case from 2001 to 2008 Adjusted by Regions Researchers have shown that these regions have massive petroleum resources therefore people living around here have different lifestyles compared to regions around Asir and Baha (Akhtar, 2008). Cancer Incidence and Survival Report (2007) points out that lifestyle may not be the factor with Makkah but its huge population which makes it record highest number of cases at a given time. Crude incidence rate of female breast cancer from 2001 to 2008 per every 100,000 females indicate steady increase in the number of women with the disease between 2001 and 2007. According to the figure 6 below, the number stood at 6.8 crude incidence rate per every 100,000 and at 14.3 per every 100,000 in 2007 going above linear the set crude incidence rate. However, this figure dropped by 1.4 in 2008. Figure 6: Crude Incidence Rate of Female Breast Cancer from 2001-2008 This was a similar trend with total number of female with breast cancer as earlier discussed. Therefore, suggestion by Cancer Incidence and Survival Report (2007) could be applicable. The same trend is replicated in terms of crude incidence rate mean with Eastern region leading with a mean of 15.36 and the lowest in this case being Jazan at the mean of 3.14. Figure 7 further indicates Riyadh mean to be growing significantly at 11.95. Figure 7: Average of Crude Incidence Rate from 2001-2008 Adjusted by Regions Report by Cancer Incidence and Survival Report suggests elaborated health services especially at Jeddah which necessitates early detection and treatment as the reason behind the decline. Age standardised incidence rate of female breast cancer from these reports suggest a similar trend as witnessed in Crude incidence rate of female breast cancer from 2001 to 2008. That is, there has been increase in the cases of female breast cancer diagnosed between 2001 and 2008 with 2007 recording 21.6 as the highest. Figure 8: Age Standardised Incidence Rate of Female Breast Cancer (2001-2008) This is followed by a slight decrease in the number according to reports released in 2008 (19.2) Percentage representation of the same shows the same trend found with percentage distribution of average of crude incidence ratings. This can be compared with average of age standardised incidence rate (2001-2008) as represented in figure 9. In a similar trend, Eastern still leads with a mean value of 26.58 and the lowest being Jazan with 4.80. Figure 9 An interesting analysis regards the percentage rates for incidence rate and age standardised rate in Saudi Arabia between 2001 and 2008 reports (figure 10a). As at 2001 report, Riyadh stood at about 19%, Makkah at about 24% and Eastern region at 26%. These findings conforms to research by Ibrahim (1998) explaining that by average between 1999-2003 Eastern regions of Saudi Arabia has been recorded highest cases of breast cancer. According to the result, it can be seen that cases diagnosed in Riyadh dropped significantly between 2001 and 2003 and remained steadily at around 20 percent up to 2008. On the other hand, Makkah also followed the same pattern but there was sudden decline in 2006 that rose in 2007 and dropped significantly in 2008. Figure 10a: The highest %, incidence rate and age standardised rate in Saudi Arabia This pattern has been different with Eastern region with case rising from 2001 to 2004 then fluctuations from 2004 to 2008. Rastogi (2004) explains these fluctuations to be as a result of population redistribution. Comparing crude incidence rate of female breast cancer of the three regions, different patterns are realised (Figure 10b). Riyadh and Makkah begins slightly at less than 10% and rises to the highest of 12% and 20% respectively before dropping at 13%. Eastern region begins at about 14.8% with the lowest being 12% and the highest at 21%. Figure 10b: Crude Incidence Rate of Female Breast Cancer Age standardised incidence rate of female breast cancer for the three regions even varies significantly with crude incidence rate of female breast cancer of the same regions. For instance, Riyadh and Makkah do not begin at the same point; starting at 17% and 13% respectively (Figure 10c). Figure 10c: Age Standardised Incidence Rate of Female Breast Cancer At the same time (2001) cases recorded in Eastern region were 24%. These three regions indicate rise and fall in the cases diagnosed but was on a rising trend between 2006 and 2007. In 2008 Riyadh and Makkah registered a drop while Eastern region continued rising. Lastly, results for confidence interval on overall percentage crude incidence rate and ASIR adjusted by regions and year of diagnosis show increase or decreases depending on the region. Interpreting the tables (see figure 11a and 11b), regions such as Baha and Jazan continue to register fewer cases as compared with Eastern region recording higher figures. Figure 11a: Confidence Interval for Overall %, Crude Incidence rate and ASIR adjusted by Regions and Year of diagnosis Percentage Crude Incidence Rate Per 100,000 Age Standardized Incidence Rate Per 100,000 Year % 95% CI Lower 95% CI Upper CIR 95% CI Lower 95% CI Upper ASIR 95% CI Lower 95% CI Upper 2001 19.9 15.1 24.7 6.8 4.61 8.99 11.8 7.9 15.7 2002 21.1 17.8 24.4 7.9 6.3 9.5 12.6 9.2 16 2003 20.8 16.9 24.7 8.4 6.3 10.5 13.9 9.9 17.9 2004 22.4 18.4 26.4 9.5 7.3 11.7 15.4 11.8 19 2005 24.3 18.7 29.9 11 7.9 14.1 18 12.7 23.3 2006 23.6 19.6 27.6 11.4 8.6 14.2 18.1 13.9 22.3 2007 26 22.6 29.4 14.3 11.1 17.5 21.6 16.8 26.4 2008 25 21.2 28.8 12.9 10.2 15.6 19.2 14.8 23.6 Overall 22.9 18.8 27.0 10.3 7.8 12.8 16.3 12.1 20.5 Figure 11b: Overall Percentage Overall CIR Overall ASIR Regions % 95% CI Lower 95% CI Upper CIR 95% CI Lower 95% CI Upper ASIR 95% CI Lower 95% CI Upper Asir 13.45 11.7 15.2 4.7 3.6 5.8 7.3 6.0 8.7 Baha 14.67 10.2 19.1 4.4 2.0 6.8 6.1 2.7 9.5 Jazan 14.08 9.0 19.1 3.1 1.9 4.4 4.8 2.8 6.8 Madinah 19.31 16.4 22.2 7.2 4.8 9.5 11.8 9.2 14.3 Hail 19.95 14.3 25.6 6.5 3.8 9.2 9.3 6.0 12.7 Qassim 25.18 21.8 28.5 8.8 7.1 10.5 13.4 11.7 15.1 Riyadh 21.53 19.4 23.7 12.0 9.7 14.2 20.5 17.7 23.3 Makkah 26.08 23.9 28.3 12.7 9.4 16.1 19.4 15.4 23.4 Najran 14.93 9.6 20.2 4.5 2.5 6.5 8.1 4.5 11.7 Jouf 22.04 15.8 28.2 7.4 4.4 10.4 12.4 7.5 17.2 Tabuk 19.73 16.6 22.9 7.4 5.2 9.6 15.1 12.1 18.2 Eastern Region 28.98 26.8 31.1 15.4 12.8 17.9 26.6 23.2 30.0 Northern Region 13.53 6.4 20.7 4.8 2.6 6.9 9.4 5.2 13.5 Conclusion It is clear from the analysis of the reports that Saudi Arabia experiences increase in female breast cancer annually. This is increase is even worrying in some regions such as Eastern, Makkah, Riyadh and Qassim. As earlier pointed, it could be due to different life styles but averagely the rate of increase is even across the board. However, the report fails to give total population screened so that it can be used to estimate the population coming out for cancer screening. Furthermore, fails to recognize one important aspect, existing associations between different exposures of breast cancer among women of different age brackets. References Akhtar, S., Abdelsalam, M., El Weshi, A., Al Husseini, H., Janabi, I., M Rahal, and Maghfoor, I. (2008). Autologous stem cell transplantation for Hodgkin's lymphoma in the kingdom of Saudi Arabia: King Faisal specialist hospital and research centre experience. Annual report of the Tumor Registry (2010), Riyadh, Saudi Arabia, King Faisal Specialist Hospital and Research Centre. Bin, Y., Malik, O., Kandil, A., Chaudhary, M.A. and Sorbris, R. (2004), Surgical Management of breast cancer in Saudi Arabia. Boffetta, P. (2004), Epidemiology of environmental and occupational cancer. Oncogene. 23:6392–403, Review. Cancer Incidence and Survival Report (2007), Kingdom of Saudi Arabia: Ministry of Health Saudi Cancer Registry. Semaan, S. (2003), Breast cancer in Syria. Pan Arab Cancer Congress Proceedings, Damascus, Syria. Cancer prevention and control, Alexandria (2006), W.H.O. Regional Office for the Eastern Mediterranean; (EMRO Technical Paper Series 2). Directory of Radiotherapy Centres (2008), Radiotherapy risk profile. Technical manual Geneva, World Health Organization. Ibrahim, E.M., al-Mulhim, F.A., al-Amri, A., al-Muhanna, F.A., Ezzat, A.A., Stuart, RK., and Ajarim D. (1998), Breast cancer in the eastern province of Saudi Arabia. Med Oncol., vol. 15, no. 4, pp. 241-7. National Cancer Registry (2000), Cancer incidence report 1999–2000. Riyadh, Ministry of Health. Rabadi, S.J. (2007), Cancer at Dhahran health center, Saudi Arabia. Annals of Saudi medicine. Rastogi, T. (2004), Opportunities for cancer epidemiology in developing countries. Nature Reviews Cancer. 4:909–17, Review. Ravichandran, K., Hamdan, N.A., and Dyab, A.R. (2005), Population based survival of female breast cancer cases in Riyadh Region, Saudi Arabia. Asian Pac J Cancer Prev., vol. 6, no. 1, pp. 72-6. W.H.O report on the global tobacco epidemic (2008), The MPOWER package. Geneva, W.H.O. Read More