Cancer And Breast Cancer In Arab Countries: Incidence, Prevalence, Mortality, Screening, And Risk Factors

Types of Cancer by Gender

Cancer Overview

Cancer encompasses diseases that involve abnormal growth of cells in localized areas of the body, while remaining liable to metastasis.[1] Benign tumours do not have the trait of spreading in the body. [2] Nearly 90 million individuals were suffering due to cancer in 2015 worldwide. [3], but in the year 2019, about 18 million cases happened. [4]. Every year about 8.8 million deaths remain attributed to the fatal cause of cancer. [5]

The type of cancer differs by gender, where common cancers recorded in males are prostate, long, stomach and colorectal cancers. [6]. In females, however, common cancers found are colorectal, breast, cervical and lung cancers. [7]

The risk of cancer development tends to increase by age, however, they tend to occur in children as well. Brain tumours and ‘Acute lymphoblastic leukemia’ are childhood cancers that occur commonly. In Africa, ‘non-Hodgkin lymphoma’ is found more for affected cases. [7]. In the year 2012, nearly 165,000 children under 15 years had been diagnosed with cancer disease. [7]. Developed countries tend to suffer more as compared to non-developing nations from higher cancer rates. [7]. Due to various unhealthy lifestyle modifications, the rates of cancer increase in the developing nations for increasing life expectancy.[8] In 2010, cancer costs reached up to 1.16 trillion USD every year as per estimations.

Cancer risk factors involve unhealthy lifestyle modifications like obesity, smoking and intake of alcohol. Contrary to healthy diets, vaccination against various infectious disorders limits consumption of red meat and processed meat, as well as limited exposure to sunlight happen to be factors of protection. [8]. Earlier detection through screening would be useful for colorectal, breast or cervical cancers. [9]

Screening should be prioritized in cancer for detecting it in earlier stages before pathology is initiated in the body, before the occurrence of symptoms.[10]

Screening of cancer can only be available for specific cancer types. However, that cannot be applied for everybody. Screening types would be mass screening involving the entire population [11], and higher risk screening selecting individuals at high risk, such as individuals with prevalent family histories. [11]. Various factors can be used for determining whether screening can be cost-effective. The factors involve:

1. Harm anticipated from screening tests.
2. Test validity
3. Cancer prevalence
4. Harm anticipated from procedures of follow-up.
5. Treatment availability
6. Impact of screening impact on the outcomes of treatment.
7. Checking the availability of tests for people.[11]

In Arab, cancer is seen to grow at alarming rates. The countries of ‘Eastern Mediterranean Region’ and Gulf states show a rise in cancer cases. By the year 2030, It can be projected that the incidence of cancer would increase 1.8 fold. [12]

 

Table 1: Incidence, Prevalence and Morality of worldwide cancer and the EMR (in 2002 and 2030) [12]

 

Table 2: Cancer types in women and men in Arab, Islamic countries in 2012. [12]

Breast cancer occurs usually in the epithelium of breast ducts and less commonly observed in lobules (15%) in the breast’s glandular tissues. In the start, the growth of cancer is limited to the lobule or duct (in situ), With time, the in-situ cancers can invade the tissues of the breast, and eventually spread to lymph nodes causing regional metastasis or other organs, causing distant metastasis. [13]

Cancer Risk Factors

Breast cancer symptoms are variable in nature. As per CDC, the signs of breast cancer include:

1. Lump in the armpit or breast
2. Nipple area pain
3. Nipple discharges accompanied by breast milk or blood
4. Changes in breast shape or size
5. Pain in the breast.

 

Fig 1: Breast Cancer signs

There were around 2.3 million cases of women affected with breast cancer worldwide. Around 60,000 mortalities were also noted. [13] Breast cancer has been presently recognized as a prevalent cancer type, representing 1/4^th of cancers that are diagnosed in females and a leading cause of death around the world. [15] By 2020, there has been 7.8 million females who were alive despite having diagnosed with breast cancer in the last 5 years.

 

Fig 2: Estimation of standardized mortality and incidence rates of breast cancer [Who, 2018]

Between the years 1990 and 2016, the occurrence of breast cancer in Arab has happened to increase gradually. The increase rate is similar to global trends. Without the presence of interventions, the incidence can be projected to continue to rise in 10 years, both in Arab and globally. Despite the noted increase in Arab, it is lesser than (28/100,000) the mean count globally (46/100,000) and also lower than occurances in Western Europe (148/ 100,000) [16]

 

Fig 3: Breast cancer noted in the Arab world between 1990 to 2016, including projections to the year 2025. [16]

Concerning the mortality and incidence in various Arab countries, Lebanon has been noted to have the highest rate of incidence, followed by the counties Bahrain and then Morocco. Countries like Egypt, Iraq and Morocco have large populations and a high death number. [16]

 

Table 3: Country-specific records of breast cancer, 2016 [16]

 1.2.4 Burden on Saudi Arabia

 In Saudi Arabia, women with breast cancer had increased from 1990 to 2010. The data is based on records obtained from “Saudi Cancer Registry” as well as “King Faisal hospital”. The distribution of percentages of breast cancer happens to increase. In the year 2008, there has been 1152 cases of breast cancer in females and in 2009, there had been 1308 cases. In the year 2010, the presence of 1473 cases had noted a yearly increase. Breast cancer is common in females representing 27.4% of the diagnosed cancers in females in 2010. The mean age of diagnosing breast cancer had been 48, ranging from 43-53.[17]

In Arab, the incidence rates of breast cancer among women have been increasing in the last decade, however, women are diagnosed with it in delayed patterns. The activities of screening have proven to reduce the mortality and morbidity by earlier detection and intervention practices. Still Arab women participate in the screening activities in a seemingly disappointing manner in comparison to western countries. [18]

 Breast cancer screening is conducted by utilization of the Mammogram. Mammography is essentially a low-dosage x-ray of breast tissues that has more accuracy over years as the earlier signs of mammographic pictures found on X-ray films could be replaced through digital technology. In this case, 2-D images of breast tissues remain captured electronically and can be viewed on the monitor. Digital mammography levies enhanced sensitivity for females under the age of 50, and the ones with dense breast tissues. [19]

Screening for Cancer

Breast cancer detection by using mammography lowers the risk of mortality of breast cancer and enhance the options of management, involving less aggressive modes of surgery and the utilization of chemotherapy with few side effects, and also the choice of skipping chemotherapy. The meta-analysis of various randomized trials in breast cancer have exhibited 20% reduction in deaths caused due to breast cancer. [20] Canada and Europe have been successful as organized programs of mammography in the countries have shown significant reduction of deaths, reaching more than 40% females who were screened. [21] [22]

Screening methods including MRI

Breast cancer MRI, use magnets of high power along with computers and radio waves. In the year 2007, the “American Cancer Society” recommended the utilization of MRI for screening the women imposed with high risks. [11]

Initiating at the age of 30, the annual MRI careening along with mammography has been recommended for females with estimated lifetime risks of breast cancer to be at least 20-25% for the presence of higher risk variations in the susceptibility genes of breast cancer.

Colorectal cancer (CRC) is a kind of cancer that progresses in the colon or rectum (parts of the large intestine) [9]. It is also known to be bowel cancer, colon cancer, or rectal cancer. Therefore, old age and lifestyle from the evolving nature of mankind, are such variables that have been responsible for such as poor food, obesity, smoking, and lack of physical activity are all risk factors. Red meat, processed meat, and alcohol are all dietary factors that enhance the risk [23].  

Colorectal cancer fatalities have risen dramatically from 490,000 deaths in 1990 to up to 715,000 deaths in 2010. Colorectal cancer which has been observed growing immensely, affects about one million people worldwide each year [24]. It is the second most prevalent cause of cancer in women (9.2% of diagnoses) and the third most common in males (9.2% of diagnoses) as of 2012. (10.0 per cent). However, the disease has been observed growing more rapidly in developed countries and thus have been a vast variable in high rated places like Australia, New Zealand, Europe, USA and the lower regions of Africa and Central Asia [25].

Over the years, there has been an alarming increase in colorectal cancer incidences. Between 1994 and 2010, there are millions of people who are diagnosed with colorectal cancer and which has been more than doubled in recent years due to negligence or poor medical systems [26]. According to the Saudi Cancer Registry, 253 cases of colorectal cancer were reported in 1994, while 1033 cases were reported in 2010 [27]. In 1994, the age-standardized rate (ASR) was 5.0/100000, but by 2010 it had risen to 9.6/100000 [28]. This is much lower than the US rate of 46.3/100,000 people. Over the same period of 1994–2010, the percentage of colorectal cancer cases among all diagnosed cancers more than quadrupled, rising from 4.8 per cent to 10.1 per cent. An increase in the number of illnesses documented is also related to an increase in the population of the elderly. From 68 years in 1990 to 73 years in 2010, life expectancy has risen steadily. Between 2001 and 2010, the ratio of people over 45 years old of age had tripled, rising from 10.9% to 28.9% [28].

Breast Cancer Symptoms and Prevalence

The Kingdom of Saudi Arabia Colorectal cancer has been a huge public health concern since 2002, as it is the furthermost frequent cancer which have been diagnosed in men and the third most common disease in women. It was the second most common cancer in both men and women. Colorectal cancer is more common than in Western countries, it is mentioned to be the third most common cancer in male and the second most common disease in women. Furthermore, it is greater than in undeveloped nations, where colorectal cancer was the fourth most prevalent among men and the fifth most common among women. Between 2005 and 2010, Saudi men had a developed rate of colorectal cancer than other men in the world, while women’s rates were equivalent to those in Western countries [27]. Riyadh, the Saudi capital, had the highest incidence which the data of the region is collected by local authorities or medical centers, at 14.5/100000 in 2010. Patients were on average 60 years old for men and 55 years old for women. More than a sector of patients had distant metastases at the time of presentation, and rectal cancer accounted for approximately 40% of all colorectal malignancies identified in 2010. For the years 1994–2004, the total 5-year survival rate was 44.6 per cent [27]. Olorectal

Fig 4: Colorectal Cancers % among Saudi Arabians

1.3.4 The screening of the colon cancer

The main cause of colon cancer has been seen evolving from the side of large intestines also known as adenomatous polyps [29]. Therefore, it has been detected by screening that these cancer cells are highly effective for early detection in humans. Any polyps found can be removed, usually through a colonoscopy or sigmoidoscopy, to reduce the risk of cancer. Colorectal cancer mortality can be reduced by 60% with screening [30]. Colonoscopy, fecal occult blood testing, and sigmoidoscopy are the most common screening tests. Every two years, fecal occult blood testing (FOBT) of the stool is usually suggested [31]. Participants should be referred for a follow-up colonoscopy examination if the FOBT results are abnormal. Screening decreases colorectal cancer mortality by 16 per cent when these recommendations are followed (FOBT), and colorectal cancer deaths can be decreased by up to a quarter among individuals who participate in screening [32].

Screening priorities of breast cancer and colon cancer in Saudi Arabia

According to data from the Saudi National Cancer Registry (1995-2014 AD), breast cancer has been the most common cancer among women in the Kingdom of Saudi Arabia for the past 15 years, accounting for more than 15% of all cancer cases. While colorectal cancer is the second most frequent disease in both men and women. However, there are a few points that help support the above statement to portray the high rate of the common disease in the kingdom.

• Due to the high-cost rate in the health system of Saudi Arabia, the cases of the disease creating cancer are often diagnosed in a delayed fashion, thus implementing cost-effective screening.
• Due to the lack of an apathetic culture of being diagnosed with high medical rates, the result of screening the average woman is of 47 to 50 years of age. However, the rates of diagnosis in other countries have been observed to be higher, which marks a major social crisis.
• Such disease results in high-risk factors, yet few preventive measures can be taken into consideration.
• Cancer is one of the high life risk diseases, has been a huge suffering case psychologically and financially both for families and individuals who are diagnosed with it.
• The community’s low participation in screening activities necessitates reaching out to them to raise awareness and increase engagement in screening activities.

 

Table 4: Common cancers in Saudi

Various objectives of colon cancer screening

• Eliminating the disease with education and basic medical knowledge to the distant regions of the Kingdom.
• To prevent and detect the disease at an early stage, which can be done by screening and thus the disease can be cured at a very early stage.
• Cancer-related deaths can be reduced by spreading basic medical knowledge and processing the need for early-stage screening if diagnosed with similar symptoms.
• Thus, following the step y step process of handling the matter of such crucial disease minutely can improve the quality of life in such affected regions.

Specific objectives of screening breast cancer

• To give the screened subjects’ statistics on a monthly and quarterly basis, therefore maintaining this process can better the lives of the people undergoing such diseases.
• To depict the target group’s journey from primary health care to the hospital until they are diagnosed.
• To detail the various methods (including mammography) used by the cancer breast detection program in the target group for early identification of breast cancer.

 Specific objectives of screening colon cancer

• To highlight the various procedures used by the colorectal cancer detection initiative for early identification of colon cancer in the target population.
• To give selected subject statistics on a monthly and quarterly basis, therefore the idle patient or the family member makes an idea of the treatment which has to be undergone psychologically and also get time to arrange themselves for financial backups.
• Through the pattern in describing the target group’s journey from primary health care to the hospital and finally to diagnosis.

Catchment area of the program of both breast cancer and colon cancer

Breast Cancer Incidence Rates in Arab Countries

 Target population

• Total population of Saudi Arabia = 35013414 (From General Authority for statistics)

(Saudi = 21645320) (Male = 11133670* Female = 10511650)

(Non-Saudi = 13368094) (Male = 9468279* Female = 4899815)

• Age group target for breast cancer screening in woman:

Female age group (40-69) in Saudi Arabia = 3375777

(Saudi = 2372213 *nom-Saudi = 1003564)

• Age group target for the Aseer region in Saudi Arabia:

Female age group (40-69) in Aseer Region = 245321 (Saudi = 228117 non -Saudi = 17204)

• Age group target for Colo-rectal cancer screening for both gender age between (45 – 74)

Both gender from age (45-74) = 6952556

(Saudi=4193302) (MALE=1978732* FEMALE=2214570)

(non-Saudi =2759254) (MALE = 2509412 *FEMALE = 249842)

• Age group target for Colo-rectal cancer screening for both gender age between (45 – 74 in Aseer region:

Both gender from age (45-74) = 412870

(Saudi = 314310) (Male = 135547 * Female 178763

(non – Saudi = 98560) (Male = 83670 *Female = 14890

Programs of public education need to focus on receiving a proper understanding of the disorder, along with the benefits and importance of earlier detection. While adding to enhancement of healthcare for patients along with families, while making the best of its services.

3.3.1.3 Prevention:

Primordial cancer prevention through the elimination of risks can inevitably reduce pertinent risks. Lifestyle changes like diet, obesity avoidance, physical activity, and various preventive interventions for individuals having risks.

It is a useful and important area of inducing protection for diagnosing colon and breast cancer in earlier stages. It has been proven years ago for being associated positively with associated reduction in mortality for the disease.

It includes:

1. Early diagnosis through clinical or self-breast examinations.
2. Screening utilizing the mammogram.

For colon cancer, the following has been utilized for screening:

1. Faecal occult test of blood (“Faecal immunohistochemical tests”)
2. FIT test (for individuals with moderate risk)
3. Colonoscopy (for individuals with great risk and positive results in FIT tests)

 

Fig 4: Screening tests

The control programs for cancer should involve disease diagnosis at a really early stage. Treatment is effective in this case and recovery can be likely to be observed.

Breast cancer treatment, for instance, can be considered beyond the various surgical procedures including medical interventions like radiological procedures and drug therapy. Additionally, adjuvant therapies can be utilized for preventing cancer return. Finally, enhancing the available options of palliative care and psychosocial support can lead to improvement of the life quality for patients affected with cancer, along with their respected families.

 

Fig 4: Results of programs of screening

4.1 Results of breast cancer programs of screening

Tab (5): Comparison of the achieved % of the target population in 2020-2021

Increase in 4^th quarter due to enhanced efforts and declaring October as the awareness month.

 

Fig 5: Comparison of the achieved percentage in the targeted population in 2020, 2021.

 

Fig 6: Percentage of the target group as achieved in the 4 quarters of 2021.

 

Fig 7: Breast cancer cases percentages

 Results of Colon Cancer Screening programs

	2020	2021
1st quarter	2nd quarter	3rd quarter	4th  quarter
target	1500	750
Achieved	370	391	512	695	770
Percent	24.7%	52%	62%	93%	102.7%
77.4%
P value achieved between 2020 and 2021	0.001

Table 6: Comparison of the achieved percentage of targeted population in 2020, 2021

 

Fig 8: Comparison of achieved percentages of target population in 2020, 2021 (Colon Cancer)

 

Fig 9: Percentage of targeted group that is achieved in the 4 quarters of 2021 (colon cancer)

5.1 SWOT Analysis of Colon and Breast Cancer screening programs

Strengths

1. National programs with well-established data indicators and base (for every quarter in the year) and then continuously evaluated as well as monitored by teams solving obstacles.
2. Colon and breast cancer happen to be international priorities and March is assigned to be the month of colon cancer awareness.
3. Support received from managers as well as Ministry of Health for programs.
4. “Holy High Maqam” has particularly called October the month of awareness of breast cancer.

1. Deficiency in the number of radiologists and technicians for the enhanced demand during the pandemic of Covid-19.
2. Health teams were majorly allocated for dealing effectively with the pandemic.

1. Private sectors can ably participate in various campaigns of health awareness concerning the significance of colon and breast cancer screening. Moreover, the participation of the sector in provision of free services to backward socioeconomic groups as a portion of community participation while also promoting themselves has been noted.
2. Participation and inclusion of NGOs or “non-governmental organizations” to raise awareness in activities of screening.

1. Demographic transitions cause an increase in risks of cancer for a large proportion of the elderly.
2. Misconceptions and rumours prevailing in the society.

 Obstacles in the screening program of breast cancer and ways they were overcome

Obstacles	Ways it was overcome
Mammography unit number at the work beginning were only 3 (Aseer Central hospital, Sara Evada Hospital, Ahad Rafida hospital)	Communication with the ministry and manager had been conducted.  The catchment area size and the target number of women had been clarified. The mammography units number rose to 7 ( Mahael Central Hospital, Abha Central hospital, Khmes Meshest hospital for children)
Aseer Catchment Area’s large size on being divided into 18 health sectors.	Meetings had been conducted with the supervisors of the health sector and a plan had been set for directing all health sectors to the nearest unit of mammography.
Difficulty to read mammography X-rays by available health teams.	Conduction of meetings with members of radiography units as well as the departmental heads of the radiography units.
Aseer region accessibility problems	Continuous meeting with the heads of “Ministry of Health” utilizing “Microsoft teams” The obstacles had been clarified on getting approval of the Health minister to equip mobile clinics for serving the distant areas of the Aseer region such as El-Barak, El- Kahema, and Sahel Eltohama. Action plans had been set and the mobile clinic would be soon sent.

 6.2 Obstacles in the Screening program of colon cancer and ways of overcoming issues.

Obstacles	Ways to overcome it
Limited kits and screening devices FIT tests (Faecal immunochemical tests) in the initiation of work was quite deficient. The presence of just 3 devices distributed across Hemes, Abha, Mahael and Meshat has been noted, despite Aseer region having 244 health care centres primarily divided into 18 sectors of health.	Communication had been done with the Health Ministry. Nine devices have been requested. However, two devices were sent and added to the “Ahed Rofida Sector of Health” and “Barak Health Sector”. The decision had been made by program supervisors for the presence of a large population.
Confirmation after Colonoscopy screening was problematic for the presence of just one unit of colonoscopy in Aseer’s central hospital.
The process of referral was quite tedious, and appointments were taking nearly 6 months for patients to completely undergo colonoscopy.	A meeting had been held with Dr Abdala El-Kadah, the colonoscopic unit head at the Aseer hospital named as Dr. Abdela El Sarey” and the head of internal medicinal department, namely Dr Ali-El-Emary, with me Dr Neif. The issue was resolved through proposing a model of special manual for he suspected cases, where the patients are directly transferred for performing endoscopy in the week’s maximum period. Wednesday was reserved for suspected cases and pertinent high-risk cases. Thursday was reserved in Ahad Rafada hospital, where meeting reports were made and disseminated for the Ahad Rafaida and Aseer hospital, along with the sectors of health for the operating program. Moreover, unified referral forms for the hospitals had been prepared by me, Dr Neif. Cases can be divided into the Aseer hospital for transferring cases from Mahayel, Abha, and Bariq health sectors. The Ahud Rofaida hospital has been the recipient for suspected cases from the sectors of Uhud Rufaydah and Khamis Mushait.
There were issues with the health sector’s commitment lack for activating programs, as it has been recognized to an extensive program of examination, causing a burden on them.	Weekly targets were established for all sectors, on the basis of various considerations, including the number of doctors in every sector, the number of health centres, the target ages, that are sent every week during the beginning of the week and followed up by supervisors of the program. Discussion had been held with health sectors if indicators had declined for identifying reasons, finding solutions and disseminating information to decision makers.

 Main achievements and accomplishments of the program coordinator (Dr Neif)

1. Weekly targets were established for every sector on the basis of considerations of every sector for ensuring the establishment of the target and the improvement of the commitment of different sectors through solving hindrances and levying direct supervision.
2. Referral pathways had been set for reducing delays to offer efficient patient care.
3. Increasing number of kits and devices needed for screening.
4. Communication with decision makers for solving obstacles and providing mobile clinics in the near future.
5. Aseer region indicators had been improved in comparison to the last yea, in comparison to other regions.

 

Fig 10: Referral pathways for screening of breast cancer

Conclusion

Cancer has been noted to emerge as a significant global concern. As there is inconsistency observed in the cancer registry system in Saudi, cancer’s epidemiology is dispersed in the nation still. The diversity of cancers recorded in Saudi Arabia has had increased magnitude in the last 3 years. The increase can be due to the attributes of lifestyles noticed in people in the country. Lack of awareness, screening, early programs of detection, and social barriers towards investigations of cancer can be considered to be causes. Genetics, obesity, sedentary lifestyle pattens, viral infections and tobacco use aggravate risk factors of cancer in the country. The literature obtained from multiple cancer types, majorly breast and colon cancer were utilized in affiliation to Saudi Arabia, without the use of filters for electronic searches. A significant improvement has been noted in the year 2021 in Aseer region in comparison to the year 2020 in relation to colon and breast cancer screening. This rise is due to the combined efforts of Dr Neif and the members of his team. Its success is due to the numerous opportunities and strengths of the program. Although it does require efforts because of its risks and weaknesses.

• There should be an increase in the national campaign that raises awareness on the significance of breast and colon cancer screening.
• Because they are cost-effective there should be an increase in the budget that is allocated.
• providing and distributing greater amounts of kits and devices for screening in different hospitals, this will increase accesses to the screening services.
• Introducing more mobile clinics which can reach areas that are far and can not access hospitals and fixed clinics.
• There should be an addition of options in the electronic sheets which can predicts that the patient of a target age group has been screened prior to visiting the physician’s office. This can prove to be very cost-effective, because the government can lose substantial amounts of money for surgery, rehabilitation and medications.

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