Prostate Cancer in Saudi Arabia: A Review of the Literature (1975-1996)
1997; King Faisal Specialist Hospital and Research Centre; Volume: 17; Issue: 5 Linguagem: Inglês
10.5144/0256-4947.1997.510
ISSN0975-4466
Autores Tópico(s)Genetic factors in colorectal cancer
ResumoOriginal ArticlesProstate Cancer in Saudi Arabia: A Review of the Literature (1975-1996) Hisham A.M. MosliFRCSC, FACS Hisham A.M. Mosli Address reprint requests and correspondence to Dr. H.A.M. Mosli, Department of Urology, King Abdulaziz University Hospital, P.O. Box 6615, Jeddah 21452, Saudi Arabia. From the Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia Search for more papers by this author Published Online::1 Nov 1997https://doi.org/10.5144/0256-4947.1997.510SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractThis paper presents the current available information on prostate cancer in Saudi Arabia. This review of the literature includes most epidemiological studies on cancer in Saudi Arabia that were published in the Saudi medical literature. The reviewed papers presented the experience of medical centers in the Central, Eastern, Western and Southern regions of Saudi Arabia. Papers on prostate cancer that were presented during the annual Saudi Urological Meetings were also analyzed. There was no single paper previously published on this specific cancer in the Saudi medical literature. Four papers related to local experience of prostate cancer were presented in the annual Saudi Urological Conferences, and all reported infrequent encounters with this disease. The data gathered from multiple medical centers in the different regions of the Kingdom indicates that the reported incidence of prostate cancer has been steadily falling in Saudi Arabia over the past 20 years. The information presented here sheds some light on this cancer, and calls for the close observation of any future changes in the frequency of this disease and its related morbidity and mortality.IntroductionThe incidence of prostate cancer has been carefully monitored in the USA and Europe over the last two decades, since it was recognized that this particular cancer had become highly prevalent among American and European men during that time.1–9 The incidence of prostate cancer peaked in 1992, when it was declared to be the most common newly diagnosed cancer in American men.1,2 The lowest incidence of prostate cancer was seen among Chinese3 and Indonesian men,4 and the highest in black Americans.5 The incidence of prostate cancer has, however, been reported to be low in neighboring Kuwait, rating at 4.4 cases per 100,000 men in 1985.3The purpose of this study was to analyze information on prostate cancer in Saudi Arabia. We reviewed the data from available studies published in the local medical literature in the past two decades, as well as papers presented at the Saudi urological conferences.MATERIALS AND METHODSTwelve published articles and four papers presented at Saudi urological meetings were reviewed. There has been no previously published paper on this specific cancer in the Saudi medical literature. The available published articles provided information on cancer in Saudi Arabia in general, while the data presented in the conference papers provided more specific and clinical information. The number of prostate cancer cases were extracted and tabulated (Table 1). In the previous epidemiological studies, the crude relative frequency (CRF) was calculated by the original authors to reflect the frequency of the cases seen in relation to other types of tumors in the study population during the specified period of time. Subsequently, this cancer type was placed in a rank order. All these studies derived the data from hospital-based experience, except for one national-based report. The reviewed papers presented the experience of medical centers in the Central, Eastern, Western and Southern region of Saudi Arabia. This current review covers the cases reported between 1975 and 1996 (Table 1).Table 1. Summary of the number and distribution of prostate cancer cases reported in Saudi Arabia.Table 1. Summary of the number and distribution of prostate cancer cases reported in Saudi Arabia.RESULTSOf the papers reviewed, three were from Riyadh Armed Forces Hospital (RAFH).9–11 The data contained in these papers was cumulative, and the last paper presented by Al-Otaiby et al. at the Ninth Saudi Urological Conference in November 1995, was the latest and most comprehensive.11 However, in 1992 the RAFH group reported 59 Saudi patients with prostate cancer. The Oncology Department had been opened since 1981.9,10 It is likely that those 59 patients had been seen over the 11-year period.10 In 1993, the same group reported the profile of the first 5000 cancer patients seen in RAFH.10 Prostate cancer patients constituted 2% of 2940 male cancer patients (n=59).10 In 1995 the number of patients increased to a total of 256 cases.11 The data was reported to represent cases encountered between 1983 and 1995. The representation of the data focused on the calculation of prostate cancer rates among the total number of 370,284 patients seen at RAFH during this period, coming to a very low figure of 0.06%. However, prostate cancer ranked second among all urological tumors and sixteenth among all tumors seen at RAFH.11 In an analysis of 126 patients from the same series, 108 patients were Saudis, 16 were non-Saudi Arabs and 2 were Pakistanis. Forty-seven patients had well-differentiated adenocarcinoma (11 with metastatic disease at presentation), 34 had moderately well-differentiated adenocarcinoma (20 with metastatic disease at presentation), and 45 patients had poorly differentiated adenocarcinoma of the prostate (29 with metastatic disease at presentation). The total number of patients who presented with metastatic disease was 60 (48%).11A more recent paper was presented from King Fahad National Guard Hospital in Riyadh during the Tenth Saudi Urological Conference held in November 1996.12 Seventy-four patients were seen over a 12-year-period, during which 16,617 adult males over the age of 45 years were admitted to the hospital. This represented 0.44% of all admissions. Five were non-Saudis, with ages ranging from 50 to 105 years (mean age 76.8 years). Twenty patients were younger than 65 years of age. Prostatism was the most common mode of presentation. Staging had been established for 59 patients: 14 patients were in stage A, 2 in stage B (early stages A + B = 16 patients, i.e., 27%), 12 in stage C and 31 in stage D (advanced stages C + D = 43 patients, i.e., 73%).12 The histopathological patterns of the cancer tissues were not reported.12In a review study on the problem of cancer in Saudi Arabia, it was generalized that “more than 70% of the cancer patients are admitted to hospitals in an advanced stage.”13 This study also estimated the incidence of cancer to be around 800 new cases per million population per year.13 It was shown in another study that the knowledge about cancer was disappointingly poor and the level of misperceptions significantly high.14There were two reports from King Faisal Specialist Hospital and Research Centre (KFSH&RC) in Riyadh on the epidemiology of cancer in Saudi Arabia, encompassing 11,204 cases between 1975-198515 and 22,836 cases between 1976-1993,16 with a slight overlap in the data. A total of 121 prostate cancer cases were seen in the first 10 years following the opening of this hospital.15 Fifty-three (44%) patients were under 70 years of age, and 68 (56%) were over 70 years.15 Prostate cancer was the 20th in rank among all cancer seen in male patients.15 In the second report, no importance whatsoever was given to prostate cancer, possibly because of its rarity.16 It was not in the list of the top 10 most commonly encountered cancers in any of the age groups or regions presented.16 Ranking adult (male and female) cancer cases by system revealed that there were 1192 (5.2%) cases of cancer of the urinary system, ranked in the 9th position, and 568 (2.5%) cases of cancer of the male reproductive system, ranked in the 12th position.16There was one report from King Khalid University Hospital (KKUH) in Riyadh.17 The report presented data on 1196 newly diagnosed cancer patients between September 1985 and August 1990.17 There were 27 cases (relative frequency rate of 6.20%) with prostate cancer among 435 males, therefore it was placed among the top 10 most common cancers, ranking in the sixth position of all tumors. The age range was from 47 to 90 years, with a median age of 70 years.17 In another study presented at the Ninth Saudi Urological Conference in November 1995, Al-Jasser et al. from the Security Forces Hospital (SFH) in Riyadh reported the results of screening 300 patients with benign prostatic hypertrophy (BPH) for cancer during the period between July 1993 and July 1995.8 Their methods of cancer detection included digital rectal examination (DRE), prostate-specific antigen (PSA), and the occasional transabdominal ultrasonographic examination of the prostate. No transrectal ultrasound (TRUS) was done for any of the patients. Perineal core needle biopsy was done for suspicious cases. Cancer was detected in 12 (4%) specimens. All patients were older than 70 years of age.There were three reports on cancer from the Southern region of Saudi Arabia.18–20 Tandon et al. reported on cancer cases seen at King Fahad Central Hospital (KFCH) in Gizan in 1995.18 The study population was 2370 patients (1398 males and 972 females), seen over 11 years between 1982 and 1992. Among the patients were 55 cases of prostate cancer with a crude relative frequency of 3.93% and ranked in sixth position of all cancers in males. Willèn and Petterson from King Fahad Hospital at Al-Baha published their experience with cancer cases in 1989.20 The cases seen totaled 582 (336 males and 246 females) over seven years between 1981 and 1987. The total number of prostate cancer cases was 14, with a crude relative frequency of 4.2% and ranked ninth among all cancers in males. In 1991, Khan et al. reported 697 cases (425 males and 272 females) seen at Asir Central Hospital in Abha over a three-year period between 1987 and 1989. There were only ten cases of prostate cancer, with a crude relative frequency of 2.3% and ranked tenth among all cancer cases in males. In addition to those three reports on cancer in the Southern region, in a review of 253 patients presenting with BPH at Asir Central Hospital (ACH), Ghali et al. reported incidental adenocarcinoma of the prostate in 1.7% of 258 prostatectomy specimens obtained.7 The overall cancer rate in this group of BPH patients seen over a seven-year period was 6.8% (n=17), but 13 patients (5.1%) were clinically suspected to have had cancer preoperatively.7From the Eastern region, a study of 428 newly diagnosed patients (241 males and 187 females) revealed 18 cases of prostate cancer seen during the period between January 1981 and December 1985. Prostate cancer ranked 11th (4.2%) among cancers in all patients, and 5th (7.5%) among cancers of male patients.21In one of the earlier studies from the Western region, seven cases of prostate cancer were seen among 1000 consecutive malignant neoplasms diagnosed in Saudis between 1975 and 1977.22 The need for a national cancer registry was stressed in 1987.23 The National Cancer Registry (NCR) was established in 1992 by the Ministry of Health (MOH) and recently produced its first report on all cancer patients in the Kingdom of Saudi Arabia from the beginning of January 1994.24 In 1994, there were 137 cases of prostate cancer among Saudis. These cases accounted for 2.7% of all newly diagnosed cases. This cancer ranked sixth for males. The crude incidence rate is 2.1 per 100,000 for that year.24DISCUSSIONOnly a small number of prostate cancer cases have been uniformly reported from most medical centers in Saudi Arabia over the last 20 years. What determines the need for conducting a screening program on a population for a specific disease is the recognition of increased morbidity and mortality from that disease.6,25 The efforts and expenditure spent on such programs would then be justified in view of the benefit gained. Once we recognize that prostate cancer occurs in a very low rate in our community, based on careful studies and calculations, then the question of whether screening for prostate cancer is necessary in Saudi Arabia should be easy to answer.8Table 1 summarizes the distribution and number of prostate cancer cases reported previously in Saudi Arabia. However, there are still circumstances where screening is required, for example, when patients are at a high risk, such as those with a family history of prostate cancer. Screening is also encouraged by PSA for those between 50-70 years presenting with symptoms of BPH. In our discussion, we will attempt to explore the question of why prostate cancer appears in such low rates in Saudi males.11,23 Are these low frequencies due to underreporting, or is prostate cancer truly an infrequent disease among Saudis?11,23 This question leads to the assumption that the risk factors for developing prostate cancer are lacking in this country, at least at this point in time. The uniform data presented here indicating the low “cancer detection” rates even in patients undergoing prostatectomy for BPH from different regions, is against this argument of underreporting. Further analysis of the various known risk factors for developing prostate cancer will help to show if there is enough information to answer these questions. Subsequently, two major benefits will be obtained from this analysis. First, the impression that prostate cancer is infrequent will either be verified or weakened, depending on the identification of the presence or absence of those risk factors. Secondly, any change of trend over a period of time will be noticed when some of these risk factors become applicable.The two well-known risk factors for developing prostate cancer are increased aging and the presence of gonadal and androgenic hormones.1 Other factors recently studied are hereditary and familial factors, for example, high fat diet, smoking, alcohol intake, vitamin D deficiency, and prior vasectomy, as well as the increased use of TURP for BPH and the widespread use of PSA as a screening tool for prostate cancer.Autopsy studies performed in the USA revealed that microscopic foci of well-differentiated adenocarcinoma of the prostate are highly prevalent in men over the age of 50.1 Subsequently, it was realized that this cancer is more prevalent in the older population than in the young.1,6,24,25 With improvement in general living conditions and medical care, it is expected that the age distribution will change globally towards an increase in the life expectancy.3 The current population in Saudi Arabia consists mostly of younger age groups.10,17,20,24 Therefore, the low current prostate cancer detection rate is consistent with the small number of elderly males in this country.The presence of gonadal androgenic hormones is required for prostate cancer development, and in the absence of gonadal androgens, the prepubertal prostate atrophies and cancer does not develop. Androgen deprivation is a well-established method to control prostate cancer.1 It has been postulated that low fat diets may lead to lower serum testosterone levels.1 To establish any relationship between hormonal levels in the different age groups and the risk of development of prostate cancer, extensive research is required. However, several studies have shown the Mediterranean-style diet to be protective against endocrine cancer.26–28 It appears that prostate cancer results from an interplay between endogenous hormones and environmental influences that include, most prominently, dietary fat.26 Even the different types of fat may play different roles.27 Olive oil seems protective, but the link of pork fat to this cancer has not been established.27 On the contrary, Jews who do not eat pork still had a higher incidence of prostate cancer than non-Jews living in Palestine.27 The current Saudi diet is rich in non-pork red meat and is not devoid of fat. It is hard to speculate the long-term impact of the current dietary habits of the present predominantly young generation on the future development of prostate cancer.Black American men represent a particularly high-risk group for the development of prostate cancer and they have the highest incidence of prostate cancer in the world.5,29,30 In this group of men, and in those with positive family history, the general recommendation to undergo annual screening for prostate cancer with DRE and PSA for men above the age of 50 is modified to start at a much earlier age. Whether the high risk of prostate cancer is limited to black Americans or generalized to include other black populations in mixed racial cultures deserves to be pursued. In our population with mixed Arab-Asian-African races, the cancer registry should consider the ethnic and racial variations.5,24,27–30With regard to family history, prostate cancer is believed to occur in three forms: 1) sporadic, occurring randomly in the population; 2) familial, the unpredictable clustering of the disease in families; and 3) hereditary, the early onset of disease and clustering in individual families.31–35 The effect of consanguinity, commonly seen in Saudi marriages, should be studied in the light of the current knowledge of the hereditary aspects of prostate cancer. It is imperative that family history be carefully taken and recorded in every case for future analysis.Data has been presented to show that neither smoking nor alcohol consumption seriously increases the risk of prostate cancer.34 A history of vasectomy, an operation rarely performed in this country, did not appear to influence the incidence of prostate cancer, neither did the characteristics of sex life.35 In another study, the correlations between the incidence rates of prostate cancer and those of TURP suggest that increased treatment of BPH has led to increased detection of prostate cancer.36 An increase in the diagnosis of early stages and incidental adenocarcinomas recovered by TURP may indicate early detection rather than elevated risk.36 We note that more than half the prostate cancer cases reported from RAFH11 are at the early stages, but the method of biopsy was not reported. Based on the previous discussion indicating the high prevalence of microscopic cancer with advanced age, increased rates of pathological examinations of prostatic tissues obtained by resection or biopsy in elderly men will no doubt be associated with increased cancer detection rates.1,36 This risk factor is anticipated in this country with the significant improvement of medical care and the increased number of both urologic surgeons trained to perform TURP and the increased number of elderly males undergoing TURP for symptomatic BPH.1,36Data was presented to support the hypothesis that the exposure to ultraviolet (UV) rays and abundance of vitamin D may protect against clinical prostate cancer.37 However, it is disappointing to realize that our own studies have shown that the Saudi population is at a significant risk of vitamin D deficiency.38 The traditional Arabic attire and head cover may play a role in diminished exposure to UV rays.22 During the sunniest seasons, exposure to UV rays was found to be minimal, due to the avoidance of the associated heat.39 Vitamin D deficiency and lack of exposure to UV is an established risk factor for developing prostate cancer, which paradoxically may work against the low rate of prostate cancer seen in this sunny country.Screening based on PSA identifies some men with prostate cancer who have a significantly increased proportion of organ-confined tumors, compared to those detected through evaluation for an abnormal DRE alone.40 A subsequent study reported that increased incidence of prostate cancer is likely a result of widespread use of PSA.41 However, a survey conducted in the Western region of Saudi Arabia to examine the current practice in evaluating prostatic diseases revealed that 47% of the surveyed centers do not use PSA freely.42 The low rate of prostate cancer detection, at least in one major region of Saudi Arabia, is consistent with the current limited use of PSA as a screening tool. In regions of the country where PSA is currently liberally used, medical centers are expected to report an increased number of prostatic cancer cases. This will be analyzed in future reports from other regions when PSA is anticipated to become more frequently utilized.CONCLUSIONPutting aside the debate about the need for conducting a population-based screening program and the fear of overdiagnosing latent and clinically insignificant prostate cancer, we are under the impression that the rate of prostate cancer in Saudi Arabia is low at this time.6,24,25 While we are satisfied with this conclusion, we are aware of the fact that the risk factors for the development of this disease are time and environment-related. An increase in the cancer detection rate is anticipated in the future because of increased aging, performance of more TURPs and biopsies, and the widespread use of PSA as a screening tool. Therefore, we recommend continuous monitoring of the newly diagnosed cases, measuring of the morbidity caused by this disease and keeping an eye on its mortality rates. If there are any changes in the current low numbers, then every effort should be made for the appropriate measures to be taken towards possible prevention, by avoiding some of the risk factors, such as high dietary animal fat. Recognition of unusually high morbidity and mortality rates would justify the screening for early detection of this disease and serious attempts to seek effective and curative treatment at the early stages.ARTICLE REFERENCES:1. Grittes RF. "Carcinoma of the prostate" . N Engl J Med. 1991; 324:236–45. Google Scholar2. Stephenson RA, Smart CR, et al.. "The fall in incidence of prostate carcinoma: on the side of a prostatic specific antigen-induced peak in incidence data from the Utah Cancer Registry" . Cancer. 1996; 77:1342–8. Google Scholar3. Boyle P, Maisonneuve P, Napalkov P. 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"Detection of organ-confined prostate cancer is increased through prostate-specific antigen-based screening" . JAMA. 1993; 270:948–54. Google Scholar41. Demers RY, Swanson GW, Weiss LK, Kau TY. "Increasing incidence of cancer of the prostate: the experience of black and white men in the Detroit Metropolitan area" . Arch Intern Med. 1994; 154:1211–6. Google Scholar42. Mosli HA. "Survey of urological centres and review of the current practice in the evaluation and treatment of prostatic diseases in the Kingdom of Saudi Arabia" . Saudi Med J. 1996; 17:718–24. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byMosli H (2019) Prostate Cancer: Experience at King Abdulaziz University Hospital, Jeddah, Annals of Saudi Medicine , 17:6, (590-594), Online publication date: 1-Nov-1997. Volume 17, Issue 5September 1997 Metrics History Received28 December 1996Accepted22 June 1997Published online1 November 1997 InformationCopyright © 1997, Annals of Saudi MedicinePDF download
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