National Cancer RegistryPast, Present and Future Presented by: Ali Shamseddine, MD. Professor, Head Hematology Oncology AUB VP /NCR
Population-based CR • Seek to collect data on all new cases occurring in a well defined population. • Objective: -Produce statistics on the occurrence of cancer in a defined population (Incidence, prevalence, CFR) -Provide a framework for assessing and controlling the impact of cancer in the community
The idea of establishing a National Cancer Registry started in the 1970 • Other registries in the Arab world at that time: Kuwait, Egypt, Iraq • Meanwhile efforts started to establish hospital-based cancer registries
National Based Studies • The only national-based study was that of Abou Daoud in 1966. • Pathology Reports of 8 Medical Institutions in Lebanon (1 year from 01/08/1964-31/07/1965): • Sample Size:1,950 cases (1,507 Lebanese, 443 Non-Lebanese) • Results: • Males: Skin (17.0%), Bladder (9.1%), Lung (7.1%), Larynx (5.7%) • Females: Breast (16.4%), Cervix and Uterine (14.1%), Skin (10.7%) • Cancer Incidence Rates: • 74.9 per 100,000 for males • 75.6 per 100,000 for females • Adjusted Crude Incidence Rates: • 102.8 per 100,000 for males • 104.1 per 100,000 for females Abou Daoud KT; Cancer; 19: 1293-1300, 1966.
Mir Amin Meeting, 1994--- special committee was set up to create a NCR under the auspices of MOPH This committee met for about 5 years without any practical results.
The Lebanese National Cancer Registry The Present (1998-2008)
Overview • 1998 :The establishment of the LCEG • 2001: The Italian Cooperation signed an agreement with the Ministry of Public Health (MOPH) of Lebanon to fund in 2002 activities leading to a National Cancer Registry in Lebanon. • Report 2002:The report 2002 was supported by the NCDP and MOPH • Report 2003: Funded and supported by LSMO and the Italian Cooperation under the umbrella of MOPH. • 2005: NCR oversight committee. • 2008: Reports 2003(Revised) and 2004,collection of 2005,2006 and 2007 data.
The Lebanese Cancer Epidemiology Group (LCEG) • Founded in 1998 • A network of all hospitals with oncology specialists and all pathology laboratories. • To study cancer caseload and to estimate incidence rates at the national level. • All cases diagnosed in the year 1993, and for each 5-year interval thereafter, are registered.
The Lebanese Cancer Epidemiology Group • Fifteen Hospitals: • American University of Beirut-Medical Center • Hotel-Dieu de France University Hospital • St George University Hospital • Hammoud Hospital • Hopital Libanais • Hopital Notred-Same des Secours • Khoury General Hospital • Makassed Hoapital • Middle-East Hospiatl • Rizk Hospital • Sacre-Coeur Hospital • St Geaorge Hospital • Sahel Hospital • Zahraa’ Hospital • Barbir Hospital Pathology Laboratories: Dr. Albert Aoun Dr. Fady Assi Dr. Akram El-Ahadab Dr. Mouin Soussi
Cancer incidence in postwar Lebanon:The first population-based estimates, 1993 and 1998. Shamseddine et al. Annals of Epidemiology, 2004 (1998 data)The Lebanese Cancer Epidemiology Group
Findings were based on 2856 and 4388 incident cases reported and registered in Lebanon in the year 1998 and 1993 respectively.Crude and age-standardized rates (ASRs) per 100,000 population were calculated and results were contrasted with estimates from developed and developing countries in the region. Crude Incidence Rates (1993-1998)
Cancer incidence 1993 and 1998Breast Cancer • Breast cancer was the most frequent malignancy in females in Lebanon (Over one third of all female cancers). • Same rates observed in all earlier hospital-based studies in the country. Azar HA. Cancer in Lebanon and the near east. Cancer January-February 1962;15:66-74. Ghosn M et al. The cancer registry at the Hotel Dieu de France Hospital. Leb Med J 1992;40:4-10. El-Saghir NS et al. Cancer in Lebanon: analysis of 10220 cases from the American University of Beirut Medical Center. Leb Med J 1998;46:4-10. • ASR (38.9 per 100,000, 1998) • Lower than that observed for the US (90.7), UK (68.8), France (78.8) or Israel (77.4) • Much higher than other developing countries of the region such as Algeria
Breast Cancer • The age pattern at diagnosis is typical of that in low-risk countries • Increase in the rate up to the 5th decade, around menopause, and a decrease thereafter. Rodriguez-Cuevas Et al. Breast carcinoma presents a decade earlier in Mexican women than in women in the United States or European countries. Cancer 2001;91:863-868 • Median age at diagnosis was 52 years (range 22-92) • Around 43% of cases presenting before the age 50 compared to median age of 63 years for developed countries such as the US. Bosch X. Early development of breast cancer in Mexican women. The Lancet Oncology 2001;2:194
Public Health Implications • Breast Cancer In Lebanon; causes for the rise: • Screening programs are widely adopted by most academic and health centers • Changes in certain reproductive factors: • Mean age at marriage of women has increased from 23.2 years in 1970 to 27.5 in 1996 • Total fertility rate has steadily declined from 4.4 to 2.5 United Nations. Health and reproduction. In: The female and male in Lebanon: a statistical profile. The Lebanese Republic, 2000 pp.57-65
Should we screen for breast cancer among younger age groups (below 40 years) and what type of screening should we adopt? • Screening of high-risk groups (MRI). • Unification of the screening programs and training of the radiology technicians.
Tobacco Associated Cancers • Bladder Cancer • Lung Cancer
Public Health ImplicationsBladder Cancer • Incidence rates in Lebanon are high, in particular among males. • Incidence rates parallel those observed in developed countries such France, the USA, UK and Israel. • Rates have always been this high in national and hospital based studies in the country.Abou-Daoud KT. Morbidity from cancer in Lebanon. Cancer 1966;19:1293-300. Azar HA. Cancer in Lebanon and the near east. Cancer January-February 1962;15:66-74. Ghosn M et al. The cancer registry at the Hotel Dieu de France Hospital. Leb Med J 1992;40:4-10. El-Saghir NS et al. Cancer in Lebanon: analysis of 10220 cases from the American University of Beirut Medical Center. Leb Med J 1998;46:4-10. • Tobacco smoking was identified as a major risk factor for bladder cancer.Abou- Daoud KT. Cancer of the bladder and cigarette smoking, coffee and alcohol drinking in Lebanon. Leb Med J 1980;3:251-257.
Bladder Cancer • Internationally, a stronger relationship between smoking and bladder cancer is reported in women than in men. Brennan P et al. The contribution of cigarette smoking to bladder cancer in women pooled European data. Cancer Causes Control 2001;12:411-7 • A small proportion of bladder cancer can be attributed to coffee drinking especially in nonsmokers.Sala M et al. Coffee consumption and bladder cancer in non-smokers: a pooled analysis of case-control studies in European countries. Cancer Causes Control 2001;11:925-31 • Other causative agents: • Bilharsia (Egypt, Iraq) • Exposures to paint components, polycyclic aromatic hydrocarbons, diesel exhausts, and aromatic aminesZeegers Mpet al. Occupational risk factors for male bladder cancer: results from a population based case cohort study in the Netherlands. Occcup Envoron Med 2001;58:590-6
Public Health ImplicationsBladder Cancer • Role of HPV in bladder cancer!! □ Two of the HPVs (16 and 18) are known to be high risk for the incidence of bladder cancer. The association between bladder cancer and HPVs was found to be ranging between 2.5-81%. Soulitzis N et al. p53 Codon 72 Polymorphism and its Association with Bladder Cancer. Cancer Letters, 2002. Lopez-Batran A et al. Human Papillomavirus and Bladder Cancer. Biomed and Pharmacother, 1997. • The role of HPV among Bladder Cancer should be investigated. • Should we design a retrospective cohort study on bladder cancer patients?
Public Health ImplicationsLung Cancer • Lung cancer has long been closely linked to tobacco smoking. Doll R, Peto R. The cause of cancer. Oxford: Oxford University Press, 1981 • In countries with prolonged smoking history, about 90% of cases of lung cancer in men are related to tobacco. Parkin DM. Global cancer statistics in the year 2000. The Lancet Oncology 2001;2:533-542 • In various countries, national trends in lung cancer incidence and mortality reflect the maturity of the smoking epidemic. Gilliland FD, Samet JM. Lung cancer. Cancer Surv 1994;19-20:175-95
Public Health Implications Lung Cancer • Lebanon may have reached this maturity in men, the trend in women is certainly still increasing. • Smoking prevalence rates among men have long been in the range of 50-60%.Khogali M et al. Dar el fatwa, Aisha Bakar, CVD Project. Spring-Summer 1999 • In women, smoking prevalence have considerably increased: • 1960s: 28%Abou- Daoud KT. Cancer of the bladder and cigarette smoking, coffee and alcohol drinking in Lebanon. Leb Med J 1980;3:251-257 • 1992: 35%Nuwayhid I et al. In: Deeb M, ed. Beirut: a health profile 1984-1994. Beirut, AUB, 1997 • 1999: 47% & 57%Khogali M et al. Dar el fatwa, Aisha Bakar, CVD Project. Spring-Summer 1999.Chidiac C. The profile of the Lebanese smoker: prevalence, characteristics and risk factors. USJ 1998 (unpublished paper)
Public Health Implications Lung Cancer • Lung cancer rate among women doubled during recent years and this can be expected to continue its rise as smoking is increasingly seen in successive birth cohorts with prevalence rates: • 30-39 years: 54% • Over 60 years: 16% Nuwayhid I et al. Morbidity, mortality and risk factors. In: Deeb M, ed. Beirut: a health profile 1984-1994. Beirut, AUB, 1997
Primary PreventionLung Cancer • Effective anti-smoking programmes should be implemented to prevent future rise. School children and women should be particularly targeted. • Distribution channels should include mass media, MOPH institutions, Ministry of Social Affairs institutions, schools, NGOs and places of work.
Public Health ImplicationsProstate Cancer • Significant increase in the crude incidence of prostate cancer from 1993 to 1998 (9.1 and 17.6 per 100,000 respectively). • The second most common type of malignancy in men. • Surveillance and detection bias • National awareness campaigns promoting screening for prostate cancer in 1994
Distribution of the 5 most common Male cancers diagnosed and or treated at AUBMC during 1983-2000 (N=4220)
Public Health ImplicationsColorectal Cancer • Rise of colon cancer in females from 2.8 per 100,000 in 1993 to 6.7 in 1998. • ASRs were lower than in the USA, France, and Israel and higher than in Kuwait and Algeria. • The major influences on colon cancer: • Environmental exposures • Sedentary lifestyle • Alcohol • Dietary habits: high fat consumption and low fruit, vegetable, and fiber intake • The risk may be decreased among recent post-menopausal HRT users. Nanda K et al. Hormone replacement therapy and the risk of colonrectal cancer: a meta-analysis. Obstet Gynecol 1999;93:880-8
Colorectal Cancer • Large increase in the number of endoscopy suites (from less than 10 in 1990 to over 30 in 2001). • Over 30,000 gastroscopies and colonoscopies done yearly. Soweid A et al. GI endoscopy in Lebanon: past, present and future. Gastrointest Endosc 2001;54:279-281 • Recent increase in the use of HRT in Lebanon, promoted as a preventive measure against osteoporosis.
Public Health ImplicationsBrain Cancer • Significant increase in Brain cancer among females between 1993-1998. • Cellular phones’ effects!!! □ Radio-frequency radiation emitted by cell phones and brain tumors?? Some studies show increased risk of brain tumors with an OR of 2.4 for ipsilateral use of cell phones (Hardell L. et al Ionizing radiation, cellular telephones and the risk for brain tumours. European Journal of Cancer Prevention, 2001).While other studies do not show that the hand-held cellular telephones causes brain tumors, they admit that their data are not sufficient to evaluate the risks among long-term, heavy users. Inskip P et al. Cellular-Telephone Use and Brain Tumors. The New England Journal of Medicine 2001, Johanssen C et al. Cellular telephone and cancer- a nationwide cohort study in Denmark. J Natl Cancer Inst, 2001. Researchers conclude that “even small risks would be of considerable public health importance”.Inskip P.
NCR Report 2002 • NCR obtained its data in 2002 from only one source, that of the MOPH Drug Dispensing Center (DDC). NCR presented its 2002 report, admitting that it had covered no more than 40% of all cases. Salim Adib, 2004
Limitations 1. Incompleteness of data: only 40% of the cases were captured in the 2002 report 2. Epidemiological measures: only relative frequencies no incident measures 3. Incompleteness of cancer-specific data specifically for cancer pathology 4. Data retrieval: there is a need for a unified and systematic process for cancer data retrieval
Data Collection 2003 • In 2003, LSMO in cooperation with LCEG decided to continue their support of the 2003 data collection (5 years from the 1998 data). At the same time, the NCDP and MOPH continued their efforts to gather the 2003 data. • Funds provided by the Italian Cooperation in Lebanon and LSMO. • These efforts led to a better data collection for the year 2003.
NCR Committee • In May 2005 the decree 230/1 was issued from the HE Dr. Mohammad Jawad Khalifeh, Minister of Public Health, creating an oversight Committee for the National Cancer Registry in Lebanon.
The Lebanese National Cancer Registry (NTR)Function • Define the size of the cancer problem • Determine patterns of occurrence of various cancers • Monitor cancer trends over time. • Guide planning and evaluation of cancer control programs: • Prevention • Screening • Treatment • Help set priorities for allocating health resources. • Advance clinical, epidemiologic and health services research.