|Ahead of print publication
Epidemiology and trends of gastrointestinal cancer in Iran (2004–2008)
Fatemeh Sadat Asgarian1, Mehrdad Mahdian2, Neda Amori3
1 Social Determinants of Health Research Center, Kashan University of Medical Sciences, Kashan, Iran
2 Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
3 Abadan Faculty of Medical Sciences, Abadan, Iran
|Date of Submission||21-Jul-2019|
|Date of Decision||13-Oct-2019|
|Date of Acceptance||01-Dec-2019|
|Date of Web Publication||09-Oct-2020|
Abadan Faculty of Medical Sciences, Abadan
Source of Support: None, Conflict of Interest: None
Aim: Gastrointestinal (GI) cancer is among the most common cancers in Iran. The main purpose of this study was to evaluate changes in the time trends of stomach, colon and rectum, and esophageal cancer during the past decade in Iran.
Materials and Methods: In this cross-sectional study, the study population was all cases of GI cancers diagnosed in Iran between 2004 and 2008. Cancer incidence data for the years 2004–2008 were obtained from the cancer registry system of the Ministry of Health. All incidence rates were directly age standardized to the world standard population. Age-Satndardized incidence rate (ASR)per 105 persons was calculated using direct standardization and the world standard population. The crude rate was calculated in this study. Data were analyzed using SPSS (version 17) and Microsoft Office Excel 2007.
Results: During the 2004–2008 period, the ASR and crude rates of GI cancers, including esophagus, stomach, colon and rectum, among males were 5.05, 15.02, and 8.29 and 4.01, 11.81, and 6.4, respectively, and among females were 6.52, 7.055, and 7.75 and 4.40, 4.85, and 5.49, respectively. The most common cancers in women were colon and rectum, and stomach cancer had the highest incidence in males. In this study, most cases of stomach cancer were adenocarcinoma adenocarcinoma (Nos) in both women and men. The most common type of colorectal cancer was adenocarcinoma, which was greater in men than women. The most common type of esophageal cancer was squamous cell carcinoma in both sexes. The north and northwestern regions of Iran have the highest risk of GI cancer.
Conclusion: According to this study, a significant increase was observed in the incidence of cancers in the north and western regions of Iran. Hence, screening and early detection programs are highly recommended in these high-risk areas.
Keywords: Cancer, epidemiology, gastrointestinal, Iran
| > Introduction|| |
After cardiovascular disease and stroke, cancer is the most common cause of death in Iran. The incidence of cancer is increasing in developing countries as a result of population aging and cancer-associated lifestyles such as smoking, physical inactivity, obesity, and stress. Increasing the number of new cases of cancer from 10 million per year in 2000 to 15 million in 2020 is expected, and nearly 60% of them occurs in developing countries.
Cancer refers to a variety of diseases resulting from uncontrolled growth of cells in the body. It is caused by environmental and genetic factors. It is the third leading cause of death and responsible for 9% of deaths in the world and also the third cause of death in Iran, and more than 30,000 people die each year from cancer.
The epidemiological trend of cancer is a major issue with this disease and its subsequent deaths in the world. Deaths from cancer will increase in Asia (including Iran) about 150% by 2020. Gastrointestinal (GI) cancers are the most common cancers in the world and worrying public health issues. Esophagus, Stomach, colon and rectum cancer have attracted special attention due to relatively high mortality.,
As previously mentioned, the global burden of cancer is increasing with increasing elderly population, changing lifestyles, and promoting carcinogenic behaviors. Knowing information on the statistics of cancer and temporal trends in different geographical areas to apply prevention and control methods of the disease is effective. In Iran, While the northern and northwestern parts of Iran are considered high risk areas for gastric cancer, in other geographical areas several intermediate and low risk populations are living. Two main factors namely the obvious change of gastric cancer risk in different geographical areas and significant differences in frequency of possible environmental risk factors make Iran a good case for research on GI cancer etiology.
Epidemiological transition and increasing trend of disease such as cancer, are factors that have forced countries to have plans for controlling cancer. It has been attempted to respond to cancer needs by preventing, detecting, treatment and providing care for population suffering from this disease. More balanced, efficient and equitable use of limited resources are made possible using cancer control strategy. If a plan is to be effective in a lower resource setting like our country, it should take a primary health care as an approach and gradual affordable and cost-effective interventions must be implemented. Early detection of cancer, efficient treatment and sedative care programs are regarded as primary purposes of programs for controlling cancer. In sedative care programs there is no limitation of age, ethnicity, sex, and race for the target population. In conclusion, It is necessary to know the incidence of cancer statistics and its trend to acquire evidences for planning primary preventive and control programs. Meanwhile it helps to estimate the future effects of cancer and to apply appropriate policies for reducing the prevalence of disease.
| > Materials and Methods|| |
This was a cross-sectional study of all diagnosed cancer cases in the whole of the country between 2004 and 2008. Data on cancer patients were mainly collected from 49 medical universities, 799 active pathology laboratories, medical records, and death certificates registered in the towns and villages.
Cancer registry data were entered into a software program based on ICD-10 coding system and prepared by the Ministry of Health of Iran. After entering data in the software, all information on demographic characteristics, including age, sex, cause of death, cancer type, and location, were alphabetically sorted, and duplicates were excluded by the registry system. In calculating incidence, people who had a different residence were excluded from the study. Data were evaluated using SPSS version 19 software and Excel programs.
The cancer registry system is the main tool to manage and control cancer. This source of information is needed not only for epidemiologic studies on cancers but also for planning and forecasting of events and investigating appropriate measurement and the impact of interventions. Development, implementation, and durability of any cancer control program are possible with a cancer registry system with defined standards. Iranian Cancer Registry (ICR-version 2) is based on ICD-10, Windows program, and International recognized principles of Cancer Registry (ICR). Records were collected from various sources (pathology, hospital death certificate, etc.). In this program, each patient and each tumor recorded are considered as a follow-up unit. To remove duplicate data, the unique profiles such as national code were used; if any case is found, it specifies marked “*”. Otherwise, the search is done according to other characteristics, including the patient's name, father's name, age, sex, and city location.
Recording and abstracting data are also conducted to assess the validity of information recorded in cancer registry. In other words, a small volume of information is used to assess independently the reproducibility and the validity of the data. To evaluate the data, methods of diagnostic criteria and internal consistency were used.
This study was funded and supported by Abadan University of Medical Sciences (IR.ABADANUMS.REC), Iran. Grant No: 228.
Data were analyzed using SPSS (version 17.0; SPSS, Chicago, IL, USA) Software Package and Microsoft Office Excel 2007. The crude incidence rate of cancers was calculated per 100,000 people by age groups and sex. Age-standardized incidence rates (ASRs) were calculated using direct standardization and the world standard population.
| > Results|| |
In this study, from a total of 301,055 cancer cases diagnosed, 132,272 (44%) cases were female and 168,783 (56%) cases were male [Table 1]. Most cases of stomach cancer were adenocarcinoma NOS in both women and men. The prevalence was higher in men (63.04) than women (58.96) [Table 1]. In terms of type of cancer, the most common type of colorectal cancer was adenocarcinoma, which was greater in men (80.2) than women (75.63) [Table 1]. The most common type of esophageal cancer was squamous cell carcinoma in both sexes (76.4 in women and 80.2 in men) [Table 1].
|Table 1: Morphology of common gastrointestinal cancers in men and female in Iran|
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Stomach, esophagus, and colorectal cancers have increased from 2004 to 2008 [Figure 1]. Stomach cancer had the highest incidence in males in 2008 with ASR = 19.16. ASRs of colorectal and esophagus cancers were 12.7 and 7.66, respectively. Colon and rectum had the highest incidence in 2008 with ASR = 11.12. ASRs of the stomach and esophageal cancers were 10 and 7.77 in females [Figure 1], [Figure 2], [Figure 3]. In esophageal cancer, ASR during the 4 years showed fluctuations, and its incidence was higher in women.
|Figure 1: Age-standardized incidence rate of cancers per 100,000 populations in Iran, 2004–2008|
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|Figure 2: Age-standardized incidence rates of gastrointestinal cancers in Iran in women, 2004–2008|
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|Figure 3: Age-standardized incidence rates of gastrointestinal cancers in Iran in men, 2004–2008|
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In gastric cancer, during the study period, trends of ASRs showed a steady stabilized pattern. The ASR was higher at the end of the study period (10 in females and 19.16 in males). In colon and rectum cancer, the incidence of rectal cancer increased during the study period. The ASR was 6.75 in 2004 and 12.7 in 2008 in males and 6.63 in 2004 and 11.12 in 2008 in females.
Crude and age-standardized incidence rates per 100,000 for GI cancers in females and males are shown in [Table 2] and [Table 3].
|Table 2: Crude and age-standardized incidence rate per 100000 Age-Satndardized incidence rate (ASR) of gastrointestinal cancers in females in Iran, 2004-2008|
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|Table 3: Crude and age-standardized incidence rate per 100,000 Age-Satndardized incidence rate (ASR) of gastrointestinal cancers in men in Iran, 2004-2008|
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The north and northwestern regions (provinces of Ardabil, Semnan, Golestan, East Azarbaijan, and Tehran) have the highest risk of stomach cancer. In contrast, the risk was moderate in the western and the central provinces. The southern areas, such as Kerman, have least dangerous of stomach cancer. However, the highest ASR has been reported from Ardebil., Most types of cancer reported in Iran were adenocarcinoma, and in terms of histology, diffuse type was the most frequent.
North, northwest, and northeast counties have a higher risk of esophageal cancer than other counties.
| > Discussion|| |
Of GI cancer types, stomach cancer is the most common cancer in men and women. Most of the cases are adenocarcinoma NOS in men and women, so that the prevalence is higher in men than women. The occurrence of the disease is different in various parts of the world. More than 70% of stomach cancer cases occur in developing countries. Eastern Asia, Western Europe, and parts of Central and South America are areas with high risks of the disease, with ASR more than 20 per 100,000. In contrast, the incidence in South Asia, North and East Africa, North America, Australia, and New Zealand is low. Stomach cancer is the most common malignant disease in Iran and Oman, and it occurs nearly 7 times more frequently in Iran than in Iraq. It was found that the morphology of stomach cancer was more in men and most cases were seen in those aged over 50 years.,
About the risk factors of stomach cancer in Iran, numerous studies have been conducted. In these studies, Helicobacter pylori infection, atrophic gastritis, gastric-esophagus reflux, smoking, family history of stomach cancer, nutritional factors, such as salt and salted foods, low intake of fruit and fresh vegetables, red meat, and risk of nitrate in agricultural products are known as risk factors.
In the present study, colorectal cancer was another most common cancer, and diagnosed men were higher than women. Colorectal cancer is the third most fatal after lung and stomach cancers, and in Iran, it ranks as the third and fourth cause of death in men and women, respectively. In many studies, the incidence of the cancer was more in males than females. In terms of type of cancer, the most common type of colorectal cancer was adenocarcinoma. The current finding was consistent with reference books and other studies., The incidence of colon and rectal cancers is different from 42/100,000 in Slovakia to 2/100,000 in Africa. The highest incidence of the cancer in men was reported from South Korea, Slovakia, Hungary, and Australia and in women was in New Zealand, Norway, Israel, and the Netherlands. The lowest incidence in both sexes has been observed in Central African countries, India, Bangladesh, and Yemen.
Information available from population-based cancer registry in Iran indicated that the incidence in the northern provinces, such as Golestan and Mazandaran, was higher than central and southern provinces, as same as South Asia and Western Europe. This type of cancer will be two or three times in the next decades. Different factors influencing the cancer include demographic changes (an increase in the median age and migration from areas of low risk to high risk), changes in people's behaviors, obesity, nutrition, and smoking. Based on the previous studies, two risk factors, including hypoactivity and occupational exposure, are considered as the specific risk of colorectal cancers, respectively. According to various studies, increased physical activity, weight loss, use of the Mediterranean diet (containing low meat and fat, more whole grains, fruits, and dairy), stopping smoking, and alcohol can reduce colorectal cancer.
In this study, another common digestive cancer was esophagus (ASR: 6.52 in females and 5.05 in males).
The incidence of esophageal cancer in Iran is higher compared to the global rate in both sexes. Iran is in the fifth and eighth ranks among all cancer sites with age standardized rate of 0.88 and 6.15 for females and males respectively.
Geographically, the occurrence of esophageal cancer has a different distribution. This may be due to environmental and genetic factors. Iran as one of the countries on a belt of esophagus cancer is known with very high incidence of the cancer. Provinces of Mazandaran, Golestan, and Khorasan in the north of the country with common borders such as Turkmenistan and Afghanistan have the highest incidence of the cancer. Areas with high incidence of esophageal cancer of squamous cell carcinoma were the Middle Asia (on the belt from Central Asia to the North of Iran), some parts of China, Japan, India, France, Italy, Belgium, Iceland, South America, and Eastern and Southern Africa.
According to a study conducted in Iran, Gonbad Kavous (Golestan province, Iran) with ASR of 100/100,000 has the highest incidence in the world and in the country. Kerman province with ASR about 3/100,000 is a region with the lowest risk in the world. However, there are differences in the results of studies. A study conducted in Kerman showed that although the risk of upper esophagus cancer is lower than the national average, increased trend of adenocarcinoma in this province is similar to the Western and developed countries.,,
One of the main limitations of the present study is the data limited to the type of cancer, incidence, age and sex, collected from the Cancer Registry of Ministry of Health. Lack of information pertinent to the subjects' lifestyles, education, jobs and socio- economic status is another limitation of this study.
This study has some limitations in a sense that the registration might be incomplete, or there is lack of patient's information, or the urban and rural populations are not fully covered for the study. Performing proper screening and training people who are at risk, as well as investigating the age pattern of cancer in the following years seems necessary. It helps us to control the disease in the community.
Because the results of the present study are based on data which obtained from the National Cancer Data Registry, extensive studies in all areas ranging from north, south, east, west, and center of the country are needed among all ages and ethnic groups to determine epidemiological aspects of the disease, in particular pathology and morphology of GI cancer.
| > Conclusion|| |
In conclusion, (GI) cancer in Iran was increasing steadily all over the period 2004-2008. Assessing long term trends of (GI) cancer in Iran using complete data, providing it is available, is suggested. In order to find related risk factors, conducting concentrated investigations in the regions with high (GI) cancer prevalence is necessary. The fields of interest for future studies could be the inclusion of factors such as alcohol and tobacco, unhealthy nutrition, socioeconomic status, or malnutrition and genetic agents.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]