Cancer in Saudi Arabia
1989; King Faisal Specialist Hospital and Research Centre; Volume: 9; Issue: 1 Linguagem: Italiano
10.5144/0256-4947.1989.55
ISSN0975-4466
Autores Tópico(s)Global Cancer Incidence and Screening
ResumoClinical ReviewCancer in Saudi Arabia Zohair A. SebaiMB, BS, MPH, DrPH Zohair A. Sebai Address reprint requests and correspondence to Dr. Sebai: P.O. Box 40024, Al-Khobar 31952, Saudi Arabia. From the Department of Family and Community Medicine, College of Medicine and Medical Sciences, King Faisal University, Dammam Search for more papers by this author Published Online:1 Jan 1989https://doi.org/10.5144/0256-4947.1989.55SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractThis article reviews the literature on the problem of cancer in Saudi Arabia. Several studies on cancer have been undertaken in Saudi Arabia, mostly of an epidemiologic nature, to define the magnitude of the problem. In the absence of a national survey or national cancer registration, these studies are the only source of information to date on cancer in the Kingdom. A comparison of prevalence or incidence between Saudi Arabia and other countries is quite difficult because of a lack of information on the base population and differences in the age distribution. Cancer in Saudi Arabia is an ever-increasing problem as people change their life style and longevity increases. The incidence of cancer is estimated at around 800 new cases per million population per year. More than 70% of the cancer patients are admitted to hospitals in an advanced stage. Health education programs for the public and health professionals should promote awareness, early diagnosis, and prompt treatment.IntroductionSeveral studies on cancer have been undertaken in Saudi Arabia, mostly of an epidemiologic nature, to define the magnitude of the problem (Table 1). All the studies were hospital based; thus, the results are not representative of a region or the country as a whole. Patients were by and large Saudis with a small minority of non-Saudis included. In the absence of a national survey or national cancer registration, these studies are the only source of information to date on cancer in the Kingdom. A comparison of prevalence or incidence between Saudi Arabia and other countries is quite difficult because of lack of information on the base population and differences in age distribution. Even so, these studies still illustrate certain features of cancer in Saudi Arabia.Table 1. Main studies published on cancer in Saudi Arabia.Table 1. Main studies published on cancer in Saudi Arabia.A 1986 study by El-Akkad et al1 which included 7251 new cases of cancer seen over a 6-year period (1979-1984) at the King Faisal Specialist Hospital and Research Centre in Riyadh (the main referral hospital for cancer patients in Saudi Arabia) showed the crude relative frequencies of cancer at various primary sites according to rank and order and sex (Table 2).The most prevalent cancers among males are non-Hodgkin's lymphomas, and cancer of the esophagus, lung, liver, and stomach; among females, they are breast cancer, non-Hodgkin's lymphomas, and cancer of the thyroid, esophagus, and cervix. Mahboubi,2 in his analysis of 11,204 cases of cancer referred to King Faisal Specialist Hospital (1975-1985), found almost the same relative frequency as El-Akkad.1 When the KFSH results are compared with those of Taylor,3 who, 25 years previously, published the first paper on cancer in Saudi Arabia based on the Aramco (Arabian American Oil Company) hospital statistics the difference in the size of the problem and the rank order of the 14 top cancers can be seen (Table 3). Twenty-five years ago, the Aramco hospital was almost the only referral hospital for cancer patients in Saudi Arabia.Table 2. Crude relative frequency (CRF) and rank order of 7251 cancer patients seen at KFSH (1979–1984).*Table 2. Crude relative frequency (CRF) and rank order of 7251 cancer patients seen at KFSH (1979–1984).*Table 3. Rank order of cancers among males in two studies.Table 3. Rank order of cancers among males in two studies.In Taylor's study (1950-1961), the male-to-female ratio was 2.7:1, and the peak incidence occurred in the age group of 41-50 years for males and 21-40 for females.3 By 1984, the peak age of incidence had become 60-64 years for males and 50-54 years for females, and the sex ratio was 1.3:1.1 The peak incidence of age in these three studies is still low for both sexes compared to that in Western societies. This could be due to a shorter life expectancy,4 a generally younger population, or a higher incidence of lymphomas and leukemias which affect young age groups.The differences between Taylor's study1 and the more recent KFSH reports2,3 may be due to the variations in location, lifespan of the people involved, methods of diagnosis, availability of health services, and improved public awareness. Taylor in 1963 wrote,3 “Saudi women are resistant to medical examination. They were particularly resistant when they had tumors of the breast or genitalia and when male doctors were involved in further diagnosis and treatment. … Husbands have something to say about this and frequently refuse further medical attention for their wives.” Women in the 1980s apparently have become more accepting of medical examination and treatment.In the following sections, the epidemiology of the predominant types of cancers in Saudi Arabia will be discussed in light of the available literature. It is quite apparent that there are noticeable differences in the relative frequency of cancers between different regions of Saudi Arabia, which may reflect the diversity of the geography, climate, level of urbanization, availability of medical care, dietary patterns, educational level, and life style of the people in different parts of the Kingdom.LYMPHOMASTaylor3 observed the predominant incidence of tumors of the hemic and lymphatic systems among the Aramco hospital patients. When counted together, they totaled 70 cases in a series of 264 cases (26.5%), an unusually high incidence of cancer of these systems as judged by Western standards. Perrine and Juma'a,5 in their 1975 follow-up study of Aramco patients, found several changes from Taylor's findings, but lymphomas and leukemias were still the most common cancers.Gelpi6 published his study of 43 patients with malignant lymphomas diagnosed over a 15-year period (1953-1967) in the Aramco hospital in Dhahran. The majority of the cases (53%) were lymphosarcomas. Of the entire group, 42% presented with primary abdominal lymphomas.Stirling et al,7,8 in their study conducted in Jeddah, found that malignant lymphoma comprised 15% of all malignant tumors. Of the lymphomas, 33% presented as primary abdominal malignancies.The 100 cases of childhood non-Hodgkin's lymphoma examined by Bin-Ahmed and Sabbah9 comprised 17% of all malignant tumors seen over 5 years at King Faisal Specialist Hospital. Of the total, 79% presented with the abdominal form. Sixteen cases had Burkitt's lymphoma; nine of these were referred from the Southern Province where malaria is common.10Lymphomas may be the most frequent type of malignancy encountered, not only in Saudi Arabia but also in other Middle Eastern countries. They comprise 17.5% of all malignant diseases in Jordan, Syria, and Lebanon,3 15.7% in Egypt,11 and 14% in South Yemen (formerly Aden).12 Except for a few African countries, the Middle East shows the highest incidence of lymphomas in the world.13,14El-Akkad, in two consecutive studies (1975-197815 and 1979-19841) found lymphomas at the top of the list among males and second only to breast cancer among females (Table 2). A high frequency of lymphomas was also reported in other studies conducted in Riyadh hospitals.16,17The predominance of lymphomas in the Middle East suggests ethnic or geographical factors, and further studies on the subject are required.CANCER OF THE BREASTIn Taylor's study (1950-1961),3 only eight cases of breast cancer were detected in 193 cancerous patients seen over 12 years. This startlingly low incidence of breast cancer in early published series was attributed to the resistance of female Saudis to physical examination. In later studies, breast cancer was reported as the most common cancer among females.1,7,15Jamjoom18 reported that 22 women seen at the King Abdul Aziz University Hospital in Jeddah had breast cancer. It was the most common malignancy, constituting 14% of the total number of cancers seen in the hospital over a 2-year period (1978-1979). Every third patient seen and treated for a breast condition was confirmed as having a malignancy. Patients were relatively young, and mostly presented in an advanced condition. On average, the duration of history was 6 months. This late presentation was attributed to shyness and fear on the part of the patients as well as to a shortage of medical facilities.CANCER OF THE ESOPHAGUSIn Saudi Arabia there is a high occurrence of cancer of the esophagus.7,15,16 El-Akkad et al1 found it to rank third after lymphomas and breast cancer. The disease showed a patchy distribution.In a 4-year period (1980-1983), 4761 cancer patients were treated at King Faisal Specialist Hospital in Riyadh, 258 of whom had esophageal cancer (5%).19 Among the referrals as well as others, 98 cases of confirmed carcinoma of the esophagus were studied in detail. Although only 4% of all cancer patients in the study came from the Qassim region, 20% of the esophageal cancer patients came from that region (P < 0.05).When esophageal cancer patients referred from Qassim were compared with those referred from other locations, no statistical differences were noted in various patient characteristics between the two groups except for the type and source of drinking water. Water analysis in Qassim confirmed the presence of traces of methane gas and a high concentration of metalliferous minerals such as silver, gold, and copper, which suggests the presence of other minerals and trace elements in the region. Water contamination from material such as petroleum oils, polycyclic hydrocarbons, or other trace elements may be the main reason for the higher frequency of cancer of the esophagus in Qassim.Other features in the same study19 were that a family history of cancer was found in only one patient, 22% of the patients were cachectic (less than 40 kg in weight), 35% had features of mild vitamin A deficiency, and most patients in this study drank more than 10 cups of extremely hot Arabic coffee per day.CANCER OF THE CERVIXTwenty-five years ago, the reluctance of Saudi women to undergo medical examination interfered with the diagnosis of cancer of the cervix. Only one of 264 patients with cancer in Taylor's study3 had cancer of the cervix. In three studies conducted more recently,1,5,15 cancer of the cervix ranked third to fifth among females. Its frequency in the study by El-Akkad et al1 was 7.2%, which is very moderate when compared to the frequency in other countries such as 38% in Lebanon, 21% in Iran, and 18.4% in Tunisia.15 The diverse effects of multiple pregnancies, low rate of female promiscuity, and male circumcision on the prevalence of cervical cancer in Saudi Arabia need to be investigated.CANCER OF THE LUNGIn Saudi Arabia the frequency of lung cancer has apparently increased with time. In Taylor's study,3 only five cases were reported in 264 cancerous patients over 12 years (1950-1961), whereas in the 1970s and 1980s lung cancer occupied the second and third positions in two different studies.1,5 The frequency among males was 5.6 times the frequency among females.5 This increase of frequency could be attributed to smoking habits, especially among young men. Smoking among young women recently became a sign of modernization, which, unless checked, might lead to a change in the pattern. The pollution which is increasing in the main cities in Saudi Arabia could also be a contributing factor. Smoking of sheesha and its relation to bronchogenic carcinoma is currently under study.20 Although there is a general awareness among Saudis of the hazards of smoking, people are still relaxed and fatalistic in their attitudes toward it: “If God wants a person to have cancer, he will have it, smoking or not smoking.” This fatalistic attitude (which has no sound religious grounds) dictates, in general, many Saudis' outlook toward health and disease.ORAL AND PHARYNGEAL CANCERSIn Saudi Arabia the frequency of oral cancer varied in the different studies according to location, time, and referral pattern. In the studies by both Taylor3 and Perrine and Juma'a,5 nasopharyngeal cancer ranked low among other tumors. On the other hand, in the 1983 study by El-Akkad,15 nasopharyngeal cancer ranked fifth (third among males and tenth among females).Stirling et al7 observed that the distribution of cancer of the gastrointestinal tract is almost the reverse of that encountered in the West, in that cancers of the mouth, tongue, and esophagus are more common than cancers of the lower intestinal tract. In a follow-up study, the authors found that cancer of the mouth was the third most common malignancy.Stirling et al21 studied the distribution of 147 oral cancers referred to the Central Laboratory in Jeddah. The ratio of males to females was 2.1:1. Eight of nine patients had a history of using shamma, which is a mixture of powdered tobacco leaf, carbonate of lime, and other substances including ash. It is used as a quid and retained in the buccal cavity. The habit is most prevalent in the southern part of Saudi Arabia, especially among men. El-Akkad et al1 observed that the frequency of oral cavity cancer in females from Asir (12.9%) was three times that in the country as a whole (4.4%), and in the males it was twice as high as in females (8.2% versus 4.1%). The high frequency of oral cavity cancer in Asir equals the rate in Bombay, one of the highest in the world, and is 8.5 times that in the United States.1 The authors also attribute the problem to the chewing of shamma. In a study conducted by Amer et al,22 33 of 68 patients with oral cancer referred to the King Faisal Specialist Hospital admitted to using shamma. Of these shamma users, 85% were referred from the Southern Province, particularly the Gizan area (73%).In another study,23 among 206 cases of neoplastic oral lesions, squamous cell carcinoma was the predominant lesion (74%). The tongue was the site most commonly affected, and the ratio of males to females was 3:2. There were no data available regarding oral habits.A Royal Decree was issued in 1983 prohibiting the use of shamma. Further studies are needed to explore etiologic factors including the role of vitamin A deficiency and Epstein-Barr virus.CANCER OF THE STOMACHThe frequency of stomach cancer in Saudi Arabia varied in different studies. Taylor, in the 1950s, found it the most common single type of tumor among Aramco patients.3 Perrine and Juma'a 5 found a high incidence in the Eastern Province, where it ranked third in males and fourth in females. In the study conducted by El-Akkad et al1 the tumor ranked seventh of all tumors among both sexes, being fifth among males and 12th among females. The highest frequency was among patients from the Central and Northern Provinces (5.8% of all tumors) and the lowest was among patients from Jeddah (2.8%). El-Akkad et al believed that the occurrence of the low rate in Jeddah was due to the impact of modernization. If this is true, the incidence of stomach cancer should decline in the future as it has in other parts of the world.THYROID CANCERThyroid cancer in Saudi Arabia ranks inconsistently among other tumors. In different studies it ranked 14th,7 13th,15 and eighth.1 The incidence was always higher in females than in males. The predominant type was papillary adenocarcinoma followed by the follicular type.24Macaron et al24 studied 35 Saudi patients with thyroid cancer (15 males and 20 females) who attended King Faisal Specialist Hospital during 1976-1978. Twenty-six patients had clinical evidence of metastasis. Nodular goiter and previous exposure to radiation therapy were excluded as predisposing factors; endemic goiter is very rare even in mountainous areas. It is possible that solar radiation may be a contributing factor. The authors believed that thyroid carcinoma occurred more frequently in Saudi Arabia than elsewhere.Koreich (personal communication) shares with Macaron et al their opinion of the relative high frequency of thyroid cancer. In this study of 1653 malignancies, there were 113 cases of carcinoma of the thyroid (6.8%), most of which occurred in females. The predominant type was papillary adenocarcinoma (51%) followed by follicular adenocarcinoma (25.6%); 55% of the patients came from the Central Region which could be due to the referral pattern.PRIMARY HEPATOCELLULAR CARCINOMAPrimary hepatocellular carcinoma is a rather common tumor in Saudi Arabia although it varies in frequency according to time and place. In various studies, it ranked fourth3,5 and 16th among other tumors. Factors influencing these variations, including the referral system, need to be investigated further.Monib,25 in his study of 67 cases of patients with gastrointestinal carcinoma, found a high incidence of cancer of the liver (48%). Most patients came in an advanced condition, and the mortality rate was 100%.Koreich and Al-Kuhaymi17 found that gastrointestinal malignancies account for about one fifth of all malignancies with a predominance of esophageal and liver cancers.Atiyeh and Ali's study26 of 54 cases of primary hepatocellular carcinoma has shed some light on the clinicopathologic aspects of the disease. The majority of patients were between 60 and 70 years old. The male-to-female ratio was 10:1. The most common presenting symptoms were upper abdominal pain, dyspepsia, abdominal swelling, and weight loss. A majority of the patients had hepatosplenomegaly, ascites, and jaundice, and only 6% had metastatic tumors. The duration of symptoms ranged from 1 to 16 months with an average of 6 months. In the last decade, it has been established that hepatitis B virus infection is the predominant cause of liver disease in areas of the world where the incidence of primary hepatocellular carcinoma is high.27In Atiyeh and Ali's study26 the evidence suggests a link between the primary hepatocellular carcinoma and hepatitis B. Of 54 patients, 30 (55%) were positive for hepatitis B surface antigen, which was higher than in matched controls (18%) or in the general population (8%). Some studies suggest schistosomiasis, a common disease in Saudi Arabia, as an important factor in liver cancer.28CANCER OF THE BLADDERBladder cancer in Saudi Arabia has shown a low frequency in most of the studies conducted so far. However, in a series of 7251 cases of cancer studied by El-Akkad et al,1 the Asir Province stood out as having a higher frequency of bladder cancer among males (6%) compared with the rest of the country (3.7%). The authors attributed the difference to the endemicity of schistosomiasis in Asir. Hanash et al29 reported bilharzial bladder cancer in 30 of 40 bladder cancer patients seen at King Faisal Specialist Hospital (1978-1981).CANCER OF THE SKINSaudi Arabia has one of the greatest solar energy intensities of the world. Data on skin cancer are rather inconsistent. Taylor3 reported 16 cases (10 squamous and six basal) in 264 cancer cases (6%). In his opinion, “This is lower than would be expected in an arid desert climate with most Saudis being exposed to the blazing desert sun for a lifetime.” However, he attributed this low rate to the short life expectancy of Saudis (39 years in 1963).El-Akkad15 also reported a low rate of skin cancer (3.4%), which ranked tenth among other cancers and 14th in his other study.1 This low rate was attributed to the cultural habits of avoiding exposure to solar ultraviolet radiation and wearing headdress. From the study of a total of 1296 cancer patients in King Faisal Specialist Hospital during 1982, only 2.7% of all cancer patients had cancer of the skin.30Woodhouse and Norton31 observed that Saudi people have a low body content of vitamin D and that Western expatriates living in the Central Region of Saudi Arabia do not experience sunburning. These observations might imply that there are factors, both cultural and environmental, playing a significant role in reducing the biological activities of solar ultraviolet radiation. Partial immunity of the Arabs to basal cell cancer has been suggested.12On the other hand, two other studies showed a high incidence of skin cancer in Saudi Arabia. Sayigh et al32 reviewed data on 3251 malignancy cases studied over 10 years by the Pathology Department, Central Laboratory in Riyadh. Skin cancer was the third most predominant malignancy (15%) after cancers of the lymphoreticular system (25%) and the gastrointestinal tract (20%). Stirling et al7 reported a high proportion of skin cancer (15.5%) among 1000 consecutive malignant neoplasms in Saudi residents in the Western Region of Saudi Arabia.Saudi Arabia, with its numerous sunny days, would appear to provide an ideal climate for cutaneous melanoma. However, melanoma of the skin is uncommon. Only 22 cases were seen at King Faisal Specialist Hospital between 1975 and 1982 (a denominator was not given). Most of the tumors were on the foot or the head, advanced at diagnosis, and rapidly fatal.33 Only one case of nevoid basal cell carcinoma was diagnosed at King Khalid University Hospital, Riyadh.34OTHER TYPES OF CANCERTwenty patients with retinoblastoma (14 boys and six girls) were seen at the King Faisal Specialist Hospital and Research Centre during 1976-1978.35 Since the survival rate is improving, it is believed that the genetic pool will increase and with it the incidence of retinoblastoma.From the experience at the King Faisal Specialist Hospital, neuroblastoma was the seventh commonest cancer found in a study of 500 children. The tumor accounted for 4.6% of these childhood cancers.36Single cases of a number of tumors have been reported, including malignant small round cell tumor of the thoracopulmonary region,37 leiomyosarcoma of the colon,38 and penile shaft carcinoma.39DISCUSSION AND CONCLUSIONCancer in Saudi Arabia is an ever-increasing problem as people change their life style and longevity increases. From the Aramco hospital in Dhahran in 1975 came the report, “Of all diseases malignancy is in recent years, the second major cause of death in Saudi Arabia employees (cardiovascular disease ranks first). Among Saudi Arab dependents malignancy as a cause of death has varied from second to fifth place.”5It is postulated that 50% of deaths from cancer, worldwide, could be prevented if existing medical and scientific knowledge were effectively used.40 A national cancer registry program is essential to define the rates of morbidity and mortality and to draw a distribution map. Further clinicoepidemiologic research should be carried out for better understanding of etiology, treatment, and methods of control. Saudi cancer patients usually seek treatment several months after the beginning of symptoms.41 From King Faisal Specialist Hospital records, it seems that more than 70% of the cancer patients are admitted in an advanced stage, usually beyond curative therapy.2,16,42 Therefore, health education programs for the public and health professionals should promote awareness, early diagnosis, and prompt treatment. Precautions should be taken against carcinogenic factors in the environment, such as smoking, excessive industrial pollution, and exposure to excessive ultraviolet radiation.The incidence of cancer in Saudi Arabia is estimated at around 800 new cases per million population per year compared with approximately 400 in Kuwait, 1000 in Iraq, and 4000 in the United States.43Taking into consideration population growth, increase of life expectancy at birth, and industrialization, there will undoubtedly be an increase in new cases of cancer every year. A balanced emphasis should be given to treatment and prevention in conducting research and carrying out control programs.ARTICLE REFERENCES:1. El-Akkad SM, Amer MH, Lin GS, et al. "Pattern of cancer in Saudi Arabs referred to King Faisal Specialist Hospital" . Cancer. 1986; 58 (5): 1172–8. Google Scholar2. Mahboubi E. "Epidemiology of cancer in Saudi Arabia, 1975-1985" . Ann Saudi Med. 1987; 7 (4): 267–76. Google Scholar3. Taylor JW. 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Volume 9, Issue 1January 1989 Metrics History Accepted17 February 1988Published online1 January 1989 ACKNOWLEDGMENTThis study was supported by King Abdul Aziz City for Science and Technology under grant AT-5-26.InformationCopyright © 1989, Annals of Saudi MedicinePDF download
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