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Burden of Cancer in the Arab World

  • Ammar Ahmed SiddiquiEmail author
  • Junaid Amin
  • Freah Alshammary
  • Eman Afroze
  • Sameer Shaikh
  • Hassaan Anwer Rathore
  • Rabia Khan
Living reference work entry
  • 98 Downloads

Abstract

Cancer is a major health burden globally, and the burden of cancer will be aggrandized mostly by an increasing elderly population as the world population expands due to greater engagement in cancer-causing habits such as various forms of smoking and alcoholism. These habits poise cancer to become a leading cause of morbidity and mortality in almost every region of the globe.

The Arab world is a region of 22 Arabic speaking countries with a population of 620 million and straddles the continents of Asia and Africa. This chapter reviews the incidence, patterns, economic, and health burden of various types of cancers in the Arab world. Cancer registries in the Arab region are excellent resource of various aspects of cancer. In this chapter, a substantial amount of authentic population-based data on cancer in the Arab world is narrated.

Progress and achievements in screening, prevention, and management can reduce cancer incidence and/or mortality rates within the Arab world. This can be achieved through better coordination of the research and healthcare communities and such collaborative efforts within the Arab world could bring significant improvements in cancer control and prevention in the region.

Keywords

Cancer control Cancer prevention Epidemiology Eastern Mediterranean Region Arab world 

Introduction

The majority of deaths in the world are from noncommunicable diseases (NCDs), which include deaths from various types of cancers (Ilbawi and Velazquez-Berumen 2018). The most important threat associated with cancer is that its incidence and mortality are rapidly rising worldwide. According to the World Health Organization (WHO), the burden of cancer is estimated to have risen to 18.1 million cases, with 9.6 million deaths in 2018. Approximately every 1 out of 5 men and 1 out of 6 women develop cancer in their lifetimes, and 1 out of 8 men and 1 out of 11 women die because of it (World Health Organization 2018a, b). Cancer has become the leading cause of death in those aged less than 70 years in almost 91 countries (Fig. 1) (Bray et al. 2018).
Fig. 1

Global map representing ranking of cancer as a cause of death below the age of 70 years in 2015 (WHO 2016)

There can be many probable reasons for the rapid increase of cancer prevalence around the world. However, these reasons can be attributed to aging and rapid increase in world population as well as ever increasing range of cancer-causing risk factors; some of which are dependent on socioeconomic development (Gersten and Wilmoth 2002). This impact and burden of cancer on socioeconomic growth cannot be neglected in emerging economies such as those in the Arab world which are disproportionately affected by cancer where many people are diagnosed with cancer, leading to a loss of economic development (Maule and Merletti 2012).

According to the WHO, the Eastern Mediterranean Region (EMR) consists of 22 countries located in North Africa and the Middle East, with an approximate population of 620 million people in low-, middle-, and high-income countries. This leads to substantial differences in health outcomes, infrastructure of healthcare and the level and quality of health expenditure in individual populations of these countries. In addition, political instability and cultural practices prevalent in these countries pose a tremendous challenge to the development of cancer prevention and control programs. Hence, a strategic approach is needed to uplift cancer control programs in the EMR as the burden of cancer is projected to double by 2030 (Lyons et al. 2018). The focus should largely be on early detection and screening methods, and healthcare facilities should be within the reach of everyone. Likewise, awareness should be created in the population so that there is greater utilization of these healthcare facilities. Only half of the countries in the EMR currently have strategies for cancer control through easier access for cancer treatment. The hurdles for an effective cancer control strategy include lack of practitioners from various specialties such as oncologists, radiologists, chemotherapists, surgeons, medical staff, and assistants (Lyons et al. 2018). It is also believed that adopting Western lifestyle has increased the prevalence and incidence of cancer in various countries of the Arab world, although changing population dynamics and the presence of local risk factors cannot be neglected (Maule and Merletti 2012). The countries in the Arab world should adopt a common risk factor approach to combat obesity and smoking, and by doing so, help in preventing cancer in addition to reducing other common chronic diseases such as diabetes mellitus, cardiovascular diseases, and even dental caries. These chronic diseases are an enormous financial burden to the economy of any country, which also comes with personal experiences in chronic pain, physiological stress, and a lower health-related quality of life (Agarwal and Lee 2019).

Global Cancers

A study by Bray et al. (2018) reviewed global cancer statistics and estimated the mortality and incidence of various cancers throughout the globe. They estimated that there were more than 18 million new cases of cancer [17.0 million cancer cases excluding nonmelanoma skin cancer (NMSC)] and 9.6 million cancer deaths (9.5 million excluding NMSC) worldwide in 2018. The results further indicated that in 2018, nearly half of the cases and over one-half of the cancer deaths in the world occurred in Asia, because close to 60% of the global population resides there. Asia includes countries from the Eastern Mediterranean region (EMR), prominently Arab speaking countries and the number of new cancer cases in the EMR increased from 495,000 in 2005 to 723,000 cases in 2015 (46.1% increase) (Bray et al. 2018).

Global Patterns for Cancers According to Human Evolution

The overall incidence of most cancers is 2–3 times more in countries with large or very large human development as compared to those with low or medium human development. Nevertheless, the variations in death rates between these two groups are small, likely because some have higher prevalence of certain cancers that are associated with poor survival and also because timely access to diagnosis and effective treatments is less common (Bray et al. 2018; IARC and WHO GLOBOCAN 2018).

An Overview of Cancer in the Eastern Mediterranean Region (EMR) and Arab World

Cancer is the second leading cause (after cardiovascular related deaths) of mortality in many countries, contributing to one in eight deaths in the world (Ervik et al. 2016; Townsend et al. 2015). In the Eastern Mediterranean Region, cancer is the fourth leading cause of mortality with ~419, 000 deaths due to cancer in 2018 (Kulhánová et al. 2017; IARC and WHO GLOBOCAN 2018). The incidence of most cancers in the EMR is predicted to double by 2030 where the most prevalent cancers are breast, colorectal, lung, liver, and bladder cancers (IARC and WHO GLOBOCAN 2018). The predominant cancers in males are lung (10.4%), liver (8.4%), and prostate cancer (8%), whereas major cancers among females are breast (34.7%), colorectal (5.7%), and cervical cancer (4.6%) (Ferlay et al. 2019). The growing population, aging, urbanization, industrialization, changing lifestyles, and more frequent exposure to potential causative agents are likely contributors to a higher incidence of these cancers in the future (Pourghazian et al. 2019).

Regional Age and Sex Variation in Cancer Burden

The age-standardized incidence of cancer in EMR was higher in females than in males (199.6 in females and 163.3 in males) in 2015. On the other hand, the age-standardized mortality rate was higher in males (113.8) compared to females (95.8). Breast cancer, leukemia, and cervical cancer had the highest rates of occurrence in females with 177,000, 21,000, and 20,000 cases, respectively. Cancers with highest mortality rates in females were breast cancer (38,000), colon cancer (13,000), rectal cancer (13,000), and stomach cancer (12,000). Cancers which caused the most disability in females were breast cancers (1.3 million Disability-Adjusted Life Years or DALYs), leukemias (498,000 DALYs), and other tumors (459,000 DALYs).

There were 38,000 newly diagnosed tracheal, bronchial, and lung cancers in males in the Arab world in 2015, which was more than prostate (28,000) and stomach (27,000) cancers. Cancers which caused the greatest disabilities in males (in DALYs) were lung cancers (1 million) and leukemias (637,000), while other tumors were associated with (494,000).

Leukemia, cancers of brain, and nervous system were the most commonly occurring cancers in children between the ages of 0 and 14. The mortality rates for these cancers were also high in children. Breast cancers and leukemias were the most common cancers in adolescents and young adults between the ages of 15 and 39, which also led to high mortality rates.

Distribution of Cancer According to Income

There is a considerable diversity in the population size, economy, risk factors profile, healthcare infrastructure, political stability, health expenditures, and access to health care facilities in the EMR countries (Lyons et al. 2018). Six countries of the EMR (Qatar, Bahrain, Kuwait, Oman, United, Arab Emirates, and Saudi Arabia) have a high per capita gross national income, while 12 countries (Lebanon, Iran, Jordan, Tunisia, Egypt, Libya, Morocco, Sudan, Syria, Pakistan, Iraq, and Palestine) are considered middle-income countries, whereas the remaining four countries (Afghanistan, Yemen, Somalia, Djibouti) are low-income countries (Lyons et al. 2018). The diversity in economy and the incidence of the top five cancers of various countries in the EMR is summarized in Table 1.
Table 1

Incidence of top five cancers according to income of countries in the Eastern Mediterranean Region in 2018 (GLOBOCAN 2018)

 

First

Second

Third

Fourth

Fifth

High-income Countries (GCC) (Qatar, Bahrain, Kuwait, Oman, United, Arab Emirates, Saudi Arabia)

Incidence (Both sexes)

Breast

Colorectal

Corpus Uteri

Prostate

Thyroid

Mortality (Both sexes)

Breast

Colorectal

Lung

Liver

Corpus Uteri

Incidence (Male)

Colorectal

Prostate

Lung

Liver

Leukemia

Incidence (Female)

Breast

Uterus

Thyroid

Colorectal

Leukemia

Middle-income countries (Lebanon, Iran, Jordan, Tunisia, Egypt, Libya, Morocco, Sudan, Syria, Pakistan, Iraq, Palestine)

Incidence (Both sexes)

Breast

Prostate

Lung

Liver

Colorectal

Mortality (Both sexes)

Breast

Lung

Liver

Prostate

Colorectal

Incidence (Male)

Lung

Prostate

Liver

Bladder

Colorectal

Incidence (Female)

Breast

Colorectal

Uterus

Ovary

Liver

Low-income countries (Afghanistan, Yemen, Somalia, Djibouti)

Incidence (Both sexes)

Breast

Uterus

Esophagus

Stomach

Prostate

Mortality (Both sexes)

Breast

Uterus

Esophagus

Stomach

Prostate

Incidence (Male)

Stomach

Esophagus

Lung

Prostate

Lips, oral Cavity

Incidence (Female)

Breast

Uterus

Esophagus

Stomach

Uterus

Key Findings of Cancers in the Eastern Mediterranean Region (EMR)

The statistics shown in Figs. 2, 3, 4, and 5 compare the EMR with other WHO regions, where it is observed that the incidence of breast cancer is ranked first and cervical cancer is ranked second in females in the EMR and other WHO regions. Moreover, the incidence and mortality of cervical cancer is higher in the African and South East Asian regions (Figs. 2, 3, 4, and 5).
Fig. 2

Comparison of incidence and mortality rate of East Mediterranean Region with the African region in 2018 (GLOBOCAN 2018)

Fig. 3

Comparison of incidence and mortality rate of East Mediterranean Region with the American region in 2018 (GLOBOCAN 2018)

Fig. 4

Comparison of incidence and mortality rate of East Mediterranean Region with the European region in 2018 (GLOBOCAN 2018)

Fig. 5

Comparison of incidence and mortality rate of East Mediterranean region with South-East Asia region in 2018 (GLOBOCAN 2018)

Cancers with high incidence in males are prostate and lung cancers, with the incidence rate of prostate cancer being higher in the African, American, and European regions as compared to the EMR. On the other hand, the incidence and mortality of lung cancer is higher in the European and American regions compared to the other WHO regions, including the EMR (Figs. 2, 3, 4, and 5).

Leading Cancers in the Eastern Mediterranean Region (EMR) and Arab World

The age-standardized incidence (per 100,000 population) of the five most common cancers in EMR are breast, prostate, lung, colorectal, and liver. In 2018, the highest incidence of cancers in males were of lung, prostate, liver, bladder, and colorectal cancers, whereas breast, colorectal, cervix uteri, ovary, and liver cancers were more common in females as shown in Table 2. The overall age-standardized mortality rate was high for lung, liver, stomach, prostate, and colorectal cancers (GLOBOCAN 2018).
Table 2

Estimated age-standardized incidence rates of cancers in 2018 in the Eastern Mediterranean Region. Data are for both sexes of all ages (GLOBOCAN 2018)

Country/Region

First

Second

Third

Fourth

Fifth

Afghanistan

Breast

Uterus

Colorectal

Prostate

Lung

Bahrain

Breast

Stomach

Esophagus

Uterus

Lips, oral cavity

Djibouti

Breast

Prostate

Lung

Colorectal

Uterus

Egypt

Breast

Liver

Bladder

Non-Hodgkin lymphoma

Prostate

Iran

Breast

Prostate

Stomach

Colorectal

Lung

Iraq

Breast

Lung

Bladder

Prostate

Colorectal

Jordan

Breast

Lung

Colorectal

Prostate

Bladder

Kuwait

Breast

Prostate

Colorectal

Uterus

Lung

Lebanon

Breast

Prostate

Bladder

Lung

Colorectal

Libya

Breast

Prostate

Lung

Colorectal

Uterus

Morocco

Breast

Lung

Colorectal

Prostate

Uterus

Oman

Breast

Prostate

Colorectal

Stomach

Non-Hodgkin lymphoma

Pakistan

Breast

Lips, oral Cavity

Uterus

Lung

Prostate

Palestine (Gaza Strip and West Bank)

Breast

Colorectal

Prostate

Lung

Non-Hodgkin lymphoma

Qatar

Breast

Lung

Colorectal

Prostate

Bladder

Saudi Arabia

Breast

Colorectal

Uterus

Thyroid

Prostate

Somalia

Breast

Uterus

Prostate

Colorectal

Ovary

Sudan

Breast

Prostate

Corpus Uteri

Ovary

Leukemia

Syria

Breast

Prostate

Lung

Colorectal

Bladder

Tunisia

Breast

Lung

Prostate

Colorectal

Bladder

United Arabs Emirates

Breast

Uterus

Prostate

Colorectal

Ovary

Yemen

Breast

Prostate

Lung

Colorectal

Uterus

Overall in EMR

Breast

Prostate

Lung

Colorectal

Liver

EMR (Male)

Lung

Prostate

Liver

Bladder

Colorectal

EMR (Female)

Breast

Colorectal

Uterus

Ovary

Liver

Lung Cancer

The most common cancer is the lung cancer in both sexes accounts for 11.6% of all global burden of cancers (Bray et al. 2018). It is also the most frequent cancer and leading cause of mortalities among males in EMR (Table 2) and has a higher frequency in males of Bahrain, Qatar, and UAE. Tobacco smoking is the most common risk factor in the development of lung cancer but the Arab countries are experiencing a large shift to water pipe smoking which can also increase lung cancer (Lyons et al. 2018). However, in Saudi Arabia, the lower incidence of lung cancer has been linked to decreased tobacco smoking (Al Hamdan et al. 2009).

High rates of consuming tobacco in the Middle East are of a great concern. The consumption of tobacco has been reported to be higher in Lebanon, with rates of use being 50–60% in males. More alarming is that consumption of tobacco products has also increased in Lebanese women with a prevalence of 34.1%. These high rates of tobacco consumption will increase the incidence of lung cancer in Lebanon within the next 30–40 years (Middle East Medical Portal 2018).

Survival rate of lung cancer in the EMR region is only 8% despite significant advancements in their health care system (Jazieh et al. 2019). Other than limited resources, some of the challenges faced by the countries in EMR related to cancer diagnosis and management are also reflected by a failure in strategic development in the primary prevention of lung cancer.

Breast Cancer

Breast cancer is the most common cancer in females of the Gulf Cooperation Council (GCC) countries (Table 1). It constituted 22.7% in Kuwait, 22.4% in UAE, and 21.7% in Bahrain to the new cases of all cancers of both sexes during 2018, while the lowest incidence in the GCC was reported in Oman (13.7%) followed by Saudi Arabia (14.8%) and Qatar (15.1%) (IARC and WHO GLOBOCAN 2018). Breast cancer has been associated with frequency of pregnancy and breast feeding because of the high levels of oxytocin and estrogen during lactation and reduced ovulation lowering the possibility of breast cancer.

The incidence and mortality of breast cancer can be significantly reduced if it is diagnosed and treated before progression to a malignant state. Early detection of breast cancer varies from self- examination to screening and mammography at least once a year, and awareness of early detection can reduce the chances of metastasis. Unfortunately, most women in Arab countries have little self-awareness of breast cancer and the disease is diagnosed at late stages. A study of Saudi females (200 females aged 20 and over) in Jeddah on knowledge of the warning signs of breast cancer, its risk factors, screening methods, and self- examination reported that 50.5% undertook self-examination of breast lumps as a cautionary sign, 57.5% believed that cancer was related to inheritance, and 20.5% underwent breast screening. About 79% of these females were aware of the concept of breast self-examination; however, only 47.5% women knew how to perform it (Radi 2013).

Tumors which are diagnosed at an early stage are easier to treat and have better prognosis. Diagnosis at later stages often means that the tumors may have already spread to other parts of the body. A study conducted in Riyadh (from 1994–1996) investigated breast tumors with a favorable prognosis. A broad-brush biopsy obtained at 1, 3, and 5 years of the study indicated survival rates of 93.9%, 79.2%, and 59.6%, respectively. The 5-year survival rates of middle- and older-aged women were between 60% and 69%. Furthermore, localized tumors had better prognosis (67.5%) as compared to metastasized tumors (57.6%) (Ravichandran et al. 2005).

A poor rate of survival is also associated with late presentation of the cancer and seeking for help at last stages has been reported in the Middle East. Nearly, 75% of patients in the UAE seek medical help when they experience a symptom related to cancer. The key reasons were mostly related with an inability to recognize the symptoms, social stigma, and abandonment from spouse (Elobaid et al. 2016). Women in the UAE do not divulge their cancer history in fear of stigmatization, and as a consequence, such women present at advanced stages of the disease; usually when it has metastasized. According to the “Cancer Registry Report 2012,” late presentation of breast cancer is the second most common cause of death in women (38 per 100,000) (Elobaid et al. 2016).

Another important reason for the late presentation for breast cancer diagnosis or management in Arab women is their strong belief in religion and spirituality. These women attain peace through prayers and isolation after they have been diagnosed with breast cancer. Awareness campaigns should be conducted to encourage these women to seek medical treatment without the fear of social stigmatization (Assaf et al. 2017).

Prostate Cancer

Prostate cancer is the second most common cancer worldwide after the lung cancer among men (Bray et al. 2018). It is also the second most frequent cancer leading to mortalities among males in EMR (Table 2). Prostate cancer occurs most commonly in world among men between 60 and 70 years old and almost half a million new cases are diagnosed each year. Prostate cancer has an incidence of only 4% in developing countries and 15% in developed countries (Quinn and Babb 2002). According to the latest estimates by IARC and WHO GLOBOCAN (2018), prostate cancer is the most frequently occurring tumor in men after lung-cancer, with an incidence of about 1,276,106 and 358,989 deaths worldwide in 2018. The mortality and incidence rate of prostate cancer increases with an increase in age. The worldwide average age for diagnosis of prostate cancer in men is 66 years (Rawla 2019). The incidence and mortality rate of prostate cancer in Saudi Arabia is 2.5% and 1.4%, respectively, ranking 13th in incidence of all cancers and 21st in terms of mortality (IARC and WHO GLOBOCAN 2018).

There are no early preventive methods that men can take to prevent this disease to the more advance stage. Some studies reported that consuming alcohol is associated with prostate cancer while other studies suggested that it is directly related to number of female sexual partners the subject had (Quinn and Babb 2002). It is a highly unpredictable tumor and difficult to diagnose at early stage because it remains dormant until it reaches a size of 1 mm or larger. Thus, the risk for metastasis is quite higher than other cancers (McNeal et al. 1986).

Colorectal Cancer

Colorectal cancer is the third most common cancer in men (after lung and prostate cancers) and second most common cancer in females (after breast cancer) in the world. Colorectal cancer constitutes more than 10% of the global cancer burden (Bray et al. 2018). The incidence and mortality rate of colorectal cancer in the EMR is ranked fourth in the six WHO regions (Fig. 1). The GLOBOCAN 2018 survey estimates reported that 1,026,215 new cases of colorectal cancers were diagnosed in men, and 823,303 in women worldwide in 2018, with 24,031 new cases in men and 19,762 in women in the EMR. The global age-standardized incidence rate for colorectal cancer in 2018 was 23.1 per 100,000 in men and 15.7 per 100,000 in women, while in the EMR, these rates were 9.1 per 100,000 in men and 7.6 per 100,000 in women. The global age-standardized mortality rate was 10.6 per 100,000 in men and 7.0 per 100,000 in women, the rates in the EMR were 5.5 per 100,000 in men and 4.4 per 100,000 in women (IARC and WHO GLOBOCAN 2018).

Incidence and Mortality Rate of Colorectal Cancer in EMR

The highest incidence of colorectal cancer was reported in Lebanon followed by Palestine, Jordan, Syria, and UAE, while morality was highest in Palestine followed by Lebanon, Syria, Jordan, and Qatar. The lowest incidence has been seen in Afghanistan followed by Pakistan, Sudan, Djibouti, and Iraq, whereas the lowest mortality rate was reported in Pakistan followed by Afghanistan, Egypt, Iraq, and Sudan Syria (IARC and WHO GLOBOCAN 2018).

The incidence of colorectal cancer in males was highest in Palestine, followed by Lebanon, Saudi Arabia, Jordan, and UAE, while the mortality rate due to colorectal cancer in males was highest in Palestine, followed by Lebanon, Syria, Qatar, and Bahrain. The incidence of colorectal cancer in females was highest in Jordan followed by Lebanon, Palestine, Syria, and Kuwait. The mortality rate in females was highest in Palestine followed by Lebanon, Jordan, Qatar, and Syria (Figs. 6 and 7) (IARC and WHO GLOBOCAN 2018).
Fig. 6

Worldwide incidence rates of colorectal cancer in 2018 (GLOBOCAN 2018)

Fig. 7

Worldwide mortality rates of colorectal cancer in 2018 (GLOBOCAN 2018)

Colorectal cancer incidence rates are related to socioeconomic development and the highest rates occur in nations with very high ranges of the Human Development Index (HDI) (Arnold et al. 2017).

Colorectal Cancer in the GCC

Colorectal cancer is the second most common cancer in the Gulf countries (Table 1) with a spike in incidence and mortality rates noted during the last decade. The role of improved access to testing or improved testing methods in the Gulf countries in the greater incidence rates of colorectal cancer is unknown (Al-Sharbatti et al. 2017). The highest incidence of colorectal cancer was reported in the UAE followed by Kuwait, Saudi Arabia, and Qatar while morality was highest in Qatar, followed by Bahrain, Kuwait, and the UAE. The incidence of colorectal cancer in males was highest in Saudi Arabia followed by the UAE, Bahrain, Qatar, Kuwait, and Oman, while the mortality was highest in Qatar followed by Bahrain, UAE, Kuwait, Saudi Arabia, and Oman. The incidence of colorectal cancer in females was highest in Kuwait followed by Qatar, UAE, Bahrain, Saudi Arabia, and Oman, whereas the mortality among females was the highest in Qatar, followed by Kuwait, Bahrain, UAE, Oman, and Saudi Arabia (IARC and WHO GLOBOCAN 2018).

Cancer Registries

Population-based cancer registries contain the records of each patient diagnosed with cancer and are used to obtain reliable data on the prevalence, incidence, trends, and survival of various cancers. Population-based cancer registries are available in 17 of the 22 countries of the region and half of the countries in the region have adopted strategies to control and prevent the cancer. In most of the countries (e.g., Oman, Saudi Arabia, Kuwait, and Pakistan) national level cancer registries are available while for other countries, specific regional registries are used (e.g., Gulf Cancer Centre for Cancer Registration). However, Afghanistan, Djibouti, Sudan, Palestine, and Somalia have not established cancer registries (Table 3).
Table 3

Cancer registries in the Eastern Mediterranean Region

Country

Registry name

Population covered

Status

Afghanistan

Not established yet

Djibouti

Not established yet

Bahrain

Bahrain cancer registry

National: 742 562

Last data produced in 2006

Uses CANREG4

Egypt

Tanta population-based registry

Sub-National: Gharbiah district

Last data published 2007

Uses CANREG4

Iran, Islamic Republic of

National cancer registry of Iran

National:

Last data published 2007

66.7 million

Uses (PARS)

Iraq

Iraqi cancer registry

Sub-National (Duhok, Erbil and Sulaimaniya provinces excluded):

Last data published 2009

23.5 million

Uses CANREG3

Jordan

Jordan cancer registry

National:

Last data conducted 2010, published 2012

 

Uses CANREG4

Kuwait

Kuwait cancer registry

Kuwaitis and non-Kuwaitis:

Last data published 2006

2.48 million

Uses CANREG4

Lebanon

Lebanese cancer registry

National

Last data published 2008

Uses Epidata+ SPSS

Libyan Arab Jamahiriya

Lybian cancer registry- African Cancer Oncology Centre

Sub-National

Last data published 2007

Uses CANREG

Morocco

Registre du grand Casablanca

Grand Casablanca district (4 million)

Last data published 2004

Uses an Italian software

Registre du Rabat

la population de Rabatest de 628000 habitants

Last published in English_2005

Uses EPI-INFO+ SPSS

Oman

National Cancer Registry

National

Last data published 2011

Uses CANREG4

Pakistan

National Cancer Registry

Sub-National

Last dated 2008

Uses CANREG4

Palestine

In plan

Qatar

Qatar cancer registry

National

Last data published 2008

Uses CANREG4

Saudi Arabia

National cancer registry

National

Last data published 2004

Uses CANREG4

Somalia

Not established yet

Sudan

In planning stages

South Sudan

In planning stages

Syrian Arab Republic

Syrian cancer registry

National: 18.2 million

Last published data 2006

Uses SPSS

Tunisia

Register of North Tunisia

North Tunisia (10 governorates): 4.4 million

Last data published 1995–1998

Uses CANREG

Register of South Tunisia

South Tunisia

Uses locally produced software

(7 governorates): 2.2 million

United Arab Emirates

2 central cancer registries

Sub-National

Last data published 2003

Uses IMAPC software

Yemen

Aden cancer registry

Sub-National

2004 Not published

Uses CANREG4

GCCR: Oman, United Arab Emirates, Saudi Arabia, Kuwait, Qatar

Gulf Cancer Centre for Cancer Registration

Regional:

Last data published 1998–2005

All GCC countries: 19.5 million

Uses CANREG4

Adapted from cancer registration in EMR published by WHO (2012)

Some Important Steps Undertaken for Registering of Cancers in GCC

The countries of the GCC started an innovative and unique model for cancer registration referred as Gulf Cancer Centre for Cancer Registration (GCCR). The population-based cancer registry, GCCR, was created in the Gulf countries and started collecting data from 1st January 1998. Lung and prostate cancers in males, followed by thyroid and breast cancers in females are the most prevalent cancers in GCC countries. Non-Hodgkin’s lymphoma has also been included in the list of the top five cancers in the region (Al Hamdan et al. 2009).

Prevention

Cancer prevention involves eradication or reduction in exposure to modifiable risk factors of cancer. Primary prevention occurs by preventing the occurrence of cancer while secondary prevention by diagnosing cancer in the early stages to reduce associated complications and mortality. Screening is a key in secondary prevention. The two approaches that enable timely diagnosis and treatment of cancer include: (i) early diagnosis of cancer in symptomatic patients, and (ii) screening for the detection of cancer in asymptomatic healthy individuals (World Health Organization 2018a).

Benefits and Barriers of Early Cancer Detection

Despite substantial advancement in the healthcare system, cancer control is challenging for both high-income and middle– low-income countries. In resource-constrained settings, cancer is frequently identified at late-stages, leading to decreased survival rates, probably greater morbidity, and higher costs of care. Almost two-third of cancer related deaths globally occur in developing nations due to the late-stage presentation and lower access to healthcare facilities (Arnold et al. 2017). In the case of EMR, the mortality rate is higher (especially in less developed countries) as compared to Europe and the USA, due to late-stage presentation when cancer is likely to have metastasized (Figs. 3 and 4). Less mortality rate, reduction in cost of care, and morbidity as well as improved outcomes of the treatment can be achieved with early-stage detection of the cancer. Therefore, it is highly recommended to identify the potential barriers to early diagnosis, prevention, and treatment in the Eastern Mediterranean Region (EMR). An advisory meeting with national and international experts held in January 2016 proposed policies for the early detection and screening of five leading cancers (breast, prostate, lung, colorectal, and liver) in the EMR region (Lyons et al. 2018).

It is estimated that ~40% of cancers are preventable, ~40% of cancers are curable, and ~20% of cancers can be managed with proper cancer care. Early diagnosis and screening programs can detect cancers at early stages that are curable. The combination of early detection and optimal management has a high rate of cure or reduction of some cancers (e.g., of the breast, oral cavity, colon, and cervix). Most of the countries of the EMR do not integrate primary health care settings to secondary or tertiary healthcare centers. Focusing on prevention and early diagnosis, and an integrated health approach of primary, secondary, and tertiary healthcare settings in the region, can reduce the morbidity and mortality associated with various cancers (Al-Othman et al. 2015).

Delayed Presentation

A limited awareness of cancer or a lack of access or the availability of screening resources results in delayed presentation of the cancer (with advanced symptoms) in many patients, causing patients to seek emergency services instead of primary care services; this significantly impacts treatment outcomes (Elliss-Brookes et al. 2012). Public awareness programs related to common cancers in the EMR and the relevant screening strategies through publicity could improve early diagnosis of many cancers. Awareness of breast cancer can reduce the chances of metastasis. The delayed presentation of the cancer (e.g., oral cancer) is also related to a lack of training among the professionals (Altamimi et al. 2019; Gómez et al. 2010).

Screening

Cancer is a deadly disease; thus, the main goal of the screening is to reduce premature mortality (Smith et al. 2017). There are two types of cancer screenings: organized screening that is offered by the government and opportunistic screening which is requested by healthcare advisors. Organized screening is more effective as compared to opportunistic screening for most of the population. Organized screening programs can ensure improved equity and cost-effectiveness which are the keys to decreasing the burden of cancer (World Health Organization 2017). The screening practices of different cancers are described in Table 4.
Table 4

Cancer screening practices

Cancer site

Screening test

Screening interval

Main age range (Years)

Mortality reduction

Image-based screening

Breast

Mammography

1–3

50–69

yes

Lung

Low-dose computed tomography (CT)

1–2

55–74

yes

Stomach

Upper gastrointestinal X-ray Series

1–2

>40

Uncertain

Direct or endoscopic visual screening

Cervix

Visual inspection with acetic acid

1–3

30–49

yes

Oral

Direct visual inspection

1–3

>35

yes

Colon

Colonoscopy

5–10

50–69

yes

Colon

Flexible sigmoidoscopy

3–5

55–69

yes

Stomach

Upper gastrointestinal endoscopy

1–2

40–64

Uncertain

Clinical examination screening

Breast

Clinical breast Examination

1

40–69

Unknown

Breast

Breast self-examination

 

no

Cell sampling screening

Cervix

Cervical cytology

1–3

25–69

yes

Biomarker-based screening

Cervix

Human papillomavirus (HPV) testing

3–5

30–65

Yes

Colon

Fecal occult blood test (FOBT)

1–2

50–69

Yes

Stomach

Pepsinogen I/II

 

40–64

Unknown

Prostate

Prostate-specific antigen (PSA)

1–5

50–74

Uncertain

Liver

AFP

Every 6 months

High risk

Uncertain

Ovary

CA125

No

Adapted from World Cancer Report (2020)

Cancer Screening Programs in the EMR

In the EMR, both organized and opportunistic cancer screening programs are available. Opportunistic programs are available for the screening of breast, cervical, and colorectal cancers in some countries of the region (Pourghazian et al. 2019). Almost 179,681 patients were diagnosed with one of these three types of cancers during a single year in EMR (WHO GLOBOCAN 2018). The burden of cancer will be increased by up to 50% in 2050 due to an aging and growing population. Opportunistic screening programs are more common and do not reach the entire population suggesting that greater efforts should be made in this regard (World Health Organization 2017). The major screening programs in the EMR are aimed at breast cancer. A survey of NCDs reported that 73% countries in the world have breast screening programs, subsequently, the mortality associated with breast cancer has reduced approximately 20% with mammography screening in high-income countries (World Health Organization 2018a; Pourghazian et al. 2019). It is estimated that 76% countries in the world have cervical screening program and the mortality related to cervical cancer has decreased by cervical cytology screening in high-income countries (World Health Organization 2018a). Screening for colorectal cancer by colonoscopy and sigmoidoscopy reduces the incidence, diminishes mortality due to the cancer, and improves the health-related quality of life. A case-control study confirmed that colonoscopy decreases the risk of colorectal cancer (Azeem et al. 2015; Chen et al. 2017). These screening tests are widely practiced in many countries of the world.

Obesity, Tobacco, and Smoking as Risk Factors of Cancer in the EMR

Many determinants of cancers are modifiable, especially those related to the environment and lifestyles. The prevalence of tobacco smoking is above 30% among men in EMR (Fouad et al. 2020), and it is a well-established risk factor for cancers of lung, trachea, bronchi, urinary bladder, oral cavity, pharynx, esophagus, larynx, cervix, pancreas, and kidney (Lauby-Secretan et al. 2015). The high incidence of bladder cancer in Egypt has been associated with increased smoking (Bedwani et al. 1997). The increasing use of waterpipe smoking in Arab countries has also led to a higher incidence of lung cancer (Lyons et al. 2018).

Obesity and lack of physical activity are also well-established risk factors for most NCDs and its associated mortalities and morbidities. Obesity is also now recognized as a cause of many types of cancers, based on the direct association of a higher Body Mass Index (BMI) and the risk of liver, colorectal, esophageal, kidney, and breast cancer. Likewise, a high BMI can also be a possible cause of prostate, gall bladder, mouth, stomach, and pharynx and larynx cancer (World Cancer Research Fund (WCRF) and American Institute for Cancer Research (AICR) 2018). The mean BMI has increased worldwide since 1980, with the BMI in men increasing to 0.4 kg/cm2 per decade between 1980 and 2008 (Finucane et al. 2011). The WHO (2016) reported that almost 1.97 billion adults were overweight or obese and over 338 million children and adolescents were also reported with higher BMI than the normal. About 50% of men and 35% of women in the EMR are currently estimated to be overweight or obese (Amin et al. 2020; World Cancer Research Fund (WCRF) and American Institute for Cancer Research (AICR) 2018). The prevalence of physical inactivity among young adult was reported to be 44% in Qatar and 55% in Saudi Arabia (Aljayyousi et al. 2019; Al-Hazzaa 2018).

Recommendations for Prevention

Maintaining a healthy weight is recommended to prevent NCDs and possibly also many common cancers. The WCRF and AICR (2018) recommended BMI to be kept within the healthy range (BMI between 18.5 and 24.9 kg/m2). Overweight individuals can follow the reliable information available at WCRF network or consult the specialist to achieve the healthy BMI levels, e.g., by engaging in 150 min per week of moderate intensity of physical activities, e.g., walking, swimming, cycling, and household chores. A significant reduction of risk was found with moderate to vigorous leisure-time exercise training for breast, colorectal, esophagus, lung, liver, kidney, and bladder cancers (Moore et al. 2016).

Likewise, a diet rich in vegetables, fruits, whole grains, and beans is also desirable to reduce the risk of cancers and protect against obesity as well. Moreover, limiting the consumption of processed or convenience foods (which are high in fat and sugar content), alcohol, and smoking can contribute to prevention of a variety of cancers (World Cancer Research Fund (WCRF) and American Institute for Cancer Research (AICR) 2018) (Table 5).
Table 5

Evidence supporting the relationship of physical activity, sedentary behavior, and obesity and the risk of cancer

Cancer site

Physical activity

Sedentary behavior

Obesity

Colorectum

Strong evidence for decreased risk (Colon)

Limited evidence for increased risk (Colon)

Strong evidence for increased risk

Endometrium

Strong evidence for decreased risk

Limited evidence for increased risk

Strong evidence for increased risk

Breast (Premenopausal)

Strong evidence for decreased risk

Limited evidence for increased risk

Strong evidence for increased risk

Breast (Postmenopausal)

Strong evidence for decreased risk

Limited evidence for increased risk

Strong evidence for increased risk

Esophageal adenocarcinoma

Strong evidence for decreased risk

 

Strong evidence for increased risk

Kidney

Strong evidence for decreased risk

 

Strong evidence for increased risk

Bladder

Strong evidence for decreased risk

 

Strong evidence for increased risk

Gastric Cardia

Strong evidence for decreased risk

 

Strong evidence for increased risk

Liver

  

Strong evidence for increased risk

Lung

Limited evidence for decreased risk

Limited evidence for increased risk

Strong evidence for increased risk

Prostate

Limited evidence for decreased risk

 

Strong evidence for increased risk

Ovary

Limited evidence for decreased risk

 

Strong evidence for increased risk

Pancreas

Limited evidence for decreased risk

 

Strong evidence for increased risk

Gall bladder

  

Strong evidence for increased risk

Mouth pharynx, and larynx

  

Strong evidence for increased risk

Cervix

  

Limited evidence for increased risk

Thyroid

  

Limited evidence for increased risk

Multiple myeloma

  

Limited evidence for increased risk

Meningioma

  

Limited evidence for increased risk

Adapted from World Cancer Report (2020)

The Need for Action to Implement Effective Cancer Control Programs in the EMR

The burden of most of the cancers in the EMR is predicted to double by 2030 (Lyons et al. 2018), and after 15 years from now, the EMR will outstrip the incidence of cancer compared to all six regions of the WHO; this is largely due to population growth, aging, urbanization, industrialization, changing lifestyles, and increased exposure to carcinogens in the EMR (Pourghazian et al. 2019). The burden and types of cancers are quite variable in the EMR, making it difficult to implement uniform cancer control strategies (Lyons et al. 2018).

Barriers and Deficiencies for Implementation

Diversity in access to cancer treatment facilities is observed in the EMR. Eleven countries in the EMR do not have guidelines for cancer management and referral. Other barriers to treatment include lack of multidisciplinary teams, limited access to cancer surgery, radiotherapy, chemotherapy, and a deficiency of specialist surgeons, oncologists, and support staff. The primary healthcare settings are not integrated with secondary or tertiary healthcare in most of the countries of EMR. Likewise, access to palliative care is difficult due to a lack of trained staff, low resources, and limited access to pain relieving drugs (Lyons et al. 2018).

Palliative Care and Rehabilitation

Palliative care and rehabilitation can improve the quality of life and relieve the symptoms in people with life-threatening or life-limiting diseases (Smith et al. 2012). The delivery of palliative care can be in hospitals (outpatient clinics, inpatient units or mixed services), nursing homes, and community-based services. Palliative care is better suited to populations where accessibility or availability of curative aspects of cancer treatment is limited (Osman et al. 2017).

Patients often seek medical intervention in the late stages of cancer when the disease is likely to be incurable even with best available facilities. Palliative care frequently decreases suffering and improves the quality of life of cancer patients; sadly, palliative care is not offered in most countries of the EMR. Most countries of the EMR are just starting to establish palliative care services while some countries such as Saudi Arabia has developed advanced palliative care centers throughout the country. The main barriers identified for the lack of palliative care services in the EMR are an absence of national plans and policies, a lack of funds, limited number of trained personnel, limited access to pain relief medications, and a lack of awareness among policymakers (Fadhil et al. 2017; Osman et al. 2017).

Conclusion

Cancer in the Arab world has burgeoned into a significant health problem of immense proportion in both the middle-to-low income and high-income countries of the EMR. It is important for low-income countries to address the deficiencies and shortcomings in the screening and diagnosis of common cancers in the EMR and to improve treatment and palliative care of the cancer patients in the Arab region. Civil strife and conflicts in the Arab world compound the ongoing sociopolitical and economic destabilization which inevitably intensifies the burden of cancer on healthcare systems in some of the impoverished countries of the EMR region. Changes in lifestyle, expedited detection and diagnosis, easier access to inexpensive treatment, and greater availability of palliative care needs to be addressed on an urgent basis. This requires collaborative efforts from policy makers, healthcare professionals, and the general public in the EMR.

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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Ammar Ahmed Siddiqui
    • 1
    Email author
  • Junaid Amin
    • 2
  • Freah Alshammary
    • 3
  • Eman Afroze
    • 4
  • Sameer Shaikh
    • 5
  • Hassaan Anwer Rathore
    • 6
    • 7
  • Rabia Khan
    • 8
  1. 1.Division of Dental Public Health, Department of Preventive Dental SciencesCollege of Dentistry, University of Ha’ilHa’ilSaudi Arabia
  2. 2.Department of PhysiotherapyCollege of Applied Medical Sciences, University of Ha’ilHa’ilSaudi Arabia
  3. 3.Division of Pediatric Dentistry, Department of Preventive Dental SciencesCollege of Dentistry, University of Ha’ilHa’ilSaudi Arabia
  4. 4.General Practitioner, Private Dental PracticeIslamabadPakistan
  5. 5.Divisions of Oral Diagnosis and Oral Medicine, Department of OMFS and Diagnostic SciencesCollege of Dentistry, University of Ha’ilHa’ilSaudi Arabia
  6. 6.College of Pharmacy, University of Ha’ilHa’ilSaudi Arabia
  7. 7.School of Pharmaceutical SciencesUniversiti Sains MalaysiaPenangMalaysia
  8. 8.Department of Bio EngineeringLancaster UniversityLancasterUK

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