ot

Amal S. Ibrahim Nabiel N.H. Mikhail Hussein Khaled Hoda Baraka Mohammed Abdeen Amir Bishara Sayed Abdel Wahed Ahmed Abdel Lateef

April 2010

Cancer Profile in Aswan, Egypt Methodology and Results Chart Book

2008

Amal S. Ibrahim, Nabiel N. H. Mikhail, Hussein Khaled, Hoda Baraka,

Mohammed Abdeen, Amir Bishara, Sayed Abdel Wahed, Ahmed Abdel Lateef

Cancer Profile in Aswan, Egypt

Methodology and Results

Chart book

2008

Preface

The present report of the National Cancer Registry Program of Egypt

covers the first year of activity of the Population-based Cancer Registry in Governorate of Aswan. This chart book highlights the important methodological considerations and the main findings of 2008 incident cancer patients in Aswan.

The National Cancer Registry Program of Egypt was initiated through an protocol of cooperation between the ministries of Communication and Information Technology, Health, and Higher Education. The first phase of the program started in 2008 and covered the Governorate of Aswan. Starting 2009, Population-based cancer registries were established in the Governorates of Menia, Beheira and Damietta. Results of these registries will be published during the last quarter of 2010. The Governorate of Gharbiah already has a registry that was established 10 years ago and will be included in the national registry program in a subsequent phase.

Data collected by Aswan registry, and eventually by other peripheral registries, are checked for completeness and subjected for validity checks and duplicate elimination. Data files are then sent to the central registry in the National Cancer Institute in Cairo. Cases diagnosed in centers outside the governorate are actively collected and added to the data set. Analysis is done centrally and published as a joint publication of the central and regional registries.

The main emphasis of this report is on incidence rates and the pattern of incident cancer cases among Aswan residents diagnosed within or outside the governorate for 1 year starting January 1st, 2008. It attempts to give clues to the burden and pattern of cancer in Southern Egypt. Future publication of results of other registries that are geographically distributed over Egypt; namely Menia, Beheira, Damietta and Gharbiah, will give a fair idea of the burden of cancer in Egypt and present a base for decision making in cancer control and management and would pave the way for further studies on cancer treatment and prevention.

April, 2010

Amal Samy Ibrahim, MD, DrPH Director, National Cancer Registry Program of Egypt Professor of Epidemiology, National cancer Institute, Cairo University

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CONTENTS Executive Summary 9 Part 1: Background Information 15 National Cancer Registry Program of Egypt 16 Aswan Governorate 18 Aswan Population-based Cancer Registry 20 The Registry Population 22 Sources of Data 24 Data Collection 26 Data Flow and Processing 28 Data Analysis and Calculation of Proportions and Rates 30 Part 2: Cancer Incidence: An overview and Profile of frequent cancers 33 Incidence rates: total and gender-specific 34 Incidence rates 46 Distribution of registered cases by sources of data 50 Basis of diagnosis 50 Staging of cancer 54 Part 3: Profile of frequent cancers 57 The more frequent cancers in males 60 The more frequent cancers in females 62 Change in frequency of cancer by age 64 Change by age in males 64 Change by age in females 66 Breast Cancer (C50) 68 Liver Cancer (C22) 78 Bladder Cancer (C67) 86 Leukemia (C91-C95) 94 Lung Cancer (C34) 100 Brain and Nervous System Cancer (C70-C72) 110 Ovarian Cancer (C56) 118 Colorectal Cancer (C18-C20) 126 Prostate Cancer (C61) 134 Part 4: Less Frequent Cancers: Facts and Figures 141 Bone Cancer (C40-C41) 144 Pancreatic Cancer (C25) 146 Esophageal Cancer (C15) 148 Connective, Subcutaneous and Soft Tissue Cancer (C47; C49) 150 Stomach Cancer (C16) 152 Thyroid Cancer (C73) 154

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Laryngeal Cancer (C32) 156 Uterine Cancer (C54-C55) 158 Oral Cavity Cancer (C00-C06) 160 Gall Bladder Cancer (C23-C24) 162 Skin Cancer (Non-Melanoma) (C44) 164 Hodgkin Lymphoma (C81) 166 Non-Hodgkin Lymphoma (C82-C85; C96) 168 Kidney and Renal Pelvis Cancer (C64-C65) 170 Part 5: Pediatric Malignancies 173 Incidence 174 Basis of Diagnosis 176 Stage at Diagnosis 178 Frequency by Site 180 Incidence Rates 182 Childhood Leukemias (ICCC Group I) 184 Childhood Lymphomas (ICCC Group II) 186 Childhood Brain and Miscellaneous intracranial and intraspinal

Neoplasms (ICCC Group III) 188

Annex 191 Annex I: Statistical Methods 192 Annex II: Classification and Coding 194 Annex III: Age Grouping 202 Annex IV: Comparison of Cancer Incidence in Aswan, 2008 and Gharbiah

2000-2002 204

Epilogue 209

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LIST OF TABLES Table 1.1: Number of Persons by 5-Year Age Groups and Sex, World

Standard 22

Table 1.2: Number of Persons by 5-Year Age Groups and Sex, Aswan, 2008 23 Table 2.1: Number and Proportion of Incident Cases, by Site and 5-Year Age

Group, Males, Aswan, 2008 38

Table 2.2: Number and Proportion of Incident Cases, by Site and 5-Year Age Group, Females, Aswan, 2008

40

Table 2.3: Age Specific Incidence Rates, Crude Rates and ASR (World), Males, Aswan, 2008

42

Table 2.4: Age Specific Incidence Rates, Crude Rates and ASR (World), Females, Aswan, 2008

44

Table 2.5: Sources of Data, Aswan, 2008 48 Table 2.6: Basis of Diagnosis of Incident Cases, Aswan, 2008 50 Table 2.7: Proportion of Microscopic Confirmation by Site and Sex for Main

Cancer Sites, Aswan, 2008 52

Table 2.8: Distribution of Incident Cases according to SEER Summary Staging, Aswan, 2008

54

Table 3.1: Proportions of the more Frequent Cancers, Both Sexes, Aswan, 2008 (1150 Cases)

59

Table 3.2: Percentage of the more Frequent Cancers, Males, Aswan, 2008 (525 Cases)

60

Table 3.3: Percentage of the more Frequent Cancers, Females, Aswan, 2008 (625 Cases)

62

Table 3.4: Breast Cancer frequency and crude and age standardized rates (world) per 100,000 Population by Sex, Aswan, 2008

69

Table 3.5: Number & Age Specific Incidence Rates of female Breast Cancer per 100,000 Population by 5-Year Age Groups, Aswan, 2008

70

Table 3.6: Subsite Distribution of Female Breast Cancer, Aswan, 2008 72 Table 3.7: Pathological Diagnosis of Female Breast Cancer, Aswan, 2008 74 Table 3.8: Frequency and crude and age-standardized incidence Rates of

Liver Cancer per 100,000 by Sex, Aswan, 2008 79

Table 3.9: Frequency and Age Specific Incidence Rates of Liver Cancer per 100,000 Population by 5-Year Age Groups and Sex, Aswan, 2008

80

Table 3.10: Pathological Diagnosis of Liver Cancer, Aswan, 2008 82 Table 3.11: Frequency and crude and Age standardized Incidence Rates of

Bladder Cancer per 100,000 Population, Aswan, 2008 87

Table 3.12: Number & Age Specific Incidence Rates of Bladder Cancer per 100,000 Population by 5-Year Age Groups and Sex, Aswan, 2008

88

Table 3.13: Subsite Distribution of Bladder Cancer, Aswan, 2008 90 Table 3.14: Pathological Diagnosis of Bladder Cancer, Aswan, 2008 91 Table 3.15: Frequency and crude and Age standardized Incidence Rates of

Leukemia per 100,000 Population, Aswan, 2008 95

Table 3.16: Frequency and Age Specific Incidence Rates of Leukemia per 100,000 Population by 5-Year Age Groups and Sex, Aswan, 2008

96

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Table 3.17: Pathological Diagnosis of Leukemia, Aswan, 2008 98 Table 3.18: Frequency and crude and Age standardized Incidence Rates of

Lung Cancer per 100,000 Population, Aswan, 2008 101

Table 3.19: Number & Age Specific Incidence Rates of Lung Cancer per 100,000 Population by 5-Year Age Groups and Sex, Aswan, 2008

102

Table 3.20: Subsite Distribution of Lung Cancer, Aswan, 2008 106 Table 3.21: Pathological Diagnosis of Lung Cancer, Aswan, 2008 107 Table 3.22: Frequency and crude and Age standardized Incidence Rates of

Brain and Nervous System Cancer per 100,000 Population, Aswan, 2008

111

Table 3.23: Number and Age Specific Incidence Rates of Brain and nervous system Cancer per 100,000 Population by 5-Year Age Groups and Sex, Aswan, 2008

112

Table 3.24: Subsite Distribution of Brain and Nervous System Cancer, Aswan, 2008

114

Table 3.25: Pathological Diagnosis of Brain and Nervous System Cancer, Aswan, 2008

116

Table 3.26: Frequency and crude and Age standardized Incidence Rates of Ovarian Cancer per 100,000 Population, Aswan, 2008

120

Table 3.27: Pathological Diagnosis of Ovarian Cancer, Aswan, 2008 122 Table 3.28: Frequency, crude and Age standardized Incidence Rates of

Colorectal Cancer per 100,000 Population, Aswan, 2008 127

Table 3.29: Number & Age Specific Incidence Rates of Colorectal Cancer per 100,000 Population by 5-Year Age Groups and Sex, Aswan, 2008

128

Table 3.30: Subsite Distribution of Colorectal Cancer, Aswan, 2008 130 Table 3.31: Pathological Diagnosis of Colorectal Cancer, Aswan, 2008 132 Table 3.32: Frequency and crude and Age standardized Incidence Rates of

Prostate Cancer per 100,000 Population, Aswan, 2008 136

Table 4.1: Frequency, Ratios and Rates of less frequent Cancers, Aswan, 2008

142

Table 4.2: Site Distribution of Primary Extranodal Lymphoma, Aswan, 2008 Table 5.1: Number of Incident Cases of Childhood Cancers, Aswan, 2008 174 Table 5.2: Basis of Diagnosis of Childhood Cancers, Aswan, 2008 176 Table 5.3: Distribution of Childhood Cancer, according to SEER Summary

Staging, Aswan, 2008 178

Table 5.4: Frequency of childhood cancer according ICCC by Sex, Aswan, 2008

180

Table 5.5: Crude and Age Standardized Incidence Rates of childhood cancer (per million) by ICCC Site, Aswan, 2008

182

Table 5.6: Pathological Diagnoses of Childhood Leukemia, Aswan, 2008 184 Table 5.7: Pathological Diagnoses of Childhood Lymphoma, Aswan, 2008 186 Table 5.8: Subsite Distribution of Childhood Brain and Miscellaneous

intracranial and intraspinal Neoplasms, Aswan, 2008 188

Table 6.1: The Most Frequent Cancers, Males, Gharbiah, 2000-2002 Compared to Aswan 2008

206

Table 6.2: The Most Frequent Cancers, Females, Gharbiah, 2000-2002 Compared to Aswan 2008

206

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LIST OF FIGURES Fig. 1.1: Organizational Structure of phase 1 of the registry program 17 Fig. 1.2: Map of Egypt Showing the Location of Aswan Governorate and the

other registries (*) scheduled to be launched during 2008 – 2009 19

Fig. 1.3: Map of Aswan Governorate and its districts 21 Fig. 1.4: Organizational Chart of Aswan Cancer Registry 21 Fig. 1.5: Age Distribution of Population, Aswan, 2008 23 Fig. 1.6: Flow of Patients in Aswan 25 Fig. 1.7: Cancer Registry Data Form 27 Fig. 1.8: Data Flow and Processing 29 Fig. 1.9: Age-adjusted Incidence Rates 31 Fig. 2.1: Incidence Rates, Aswan, 2008 35 Fig. 2.2: Incidence Rates of the more Frequent Cancers, Both sexes, Aswan,

2008 35

Fig. 2.3: Incidence Rates of Ten Most Frequent Cancers, Males, Aswan, 2008 37 Fig. 2.4: Incidence Rates of Ten Most Frequent Cancers, Females, Aswan,

2008 37

Fig. 2.5: Age Specific Incidence Rates of all Sites of Cancer per 100,000 Population, Aswan, 2008

47

Fig. 2.6: Sources of Data of Incident Cases, Aswan, 2008 49 Fig. 2.7: Distribution of Population and Cancer Cases Between Different

Districts of Aswan, 2008 49

Fig. 2.8: Basis of Diagnosis of Incident Cancer Cases, Aswan, 2008 51 Fig. 2.9: Proportion of Microscopic Confirmation of Selected Sites, Aswan, 2008

53

Fig. 2.10: Distribution of Incident Cancer Cases according to SEER Summary Staging, Aswan, 2008

55

Fig. 3.1: The more Frequent Cancers, Both Sexes, Aswan, 2008 (1150 Cases) 59 Fig. 3.2: The Ten Most Frequent Cancers, Males, Aswan, 2008 (525 Cases) 61 Fig. 3.3: The Most Frequent Cancers, Females, Aswan, 2008 (625 Cases) 63 Fig. 3.4: The most frequent Cancers in Males by age, Aswan, 2008 65 Fig. 3.5: The most frequent Cancers in Females by age, Aswan, 2008 67 Fig. 3.6: Incidence of Female Breast Cancer, GLOBOCAN 2002 69 Fig. 3.7: Age Specific Incidence Rates of Breast Cancer per 100,000 Population

for each Sex, Aswan, 2008 71

Fig. 3.8: Laterality Distribution of Female Breast Cancer, Aswan, 2008 73 Fig. 3.9: Basis of Diagnosis of Female Breast Cancer, Aswan, 2008 75 Fig. 3.10: Grade Distribution of Female Breast Cancer, Aswan, 2008 (241

Cases) 77

Fig. 3.11: Stage Distribution of Female Breast Cancer, Aswan, 2008 (241 Cases)

77

Fig. 3.12: Incidence of Liver Cancer, GLOBOCAN 2002 79 Fig. 3.13: Age Specific Incidence Rates of Liver Cancer per 100,000

population for each Sex, Aswan, 2008 81

Fig. 3.14: Basis of Diagnosis of Liver Cancer, Aswan, 2008 83 Fig. 3.15: Stage Distribution of Liver Cancer, Aswan, 2008 (87 Cases) 85 Fig. 3.16: Incidence of Bladder Cancer, GLOBOCAN 2002 87 Fig. 3.17: Age Specific Incidence Rates of Bladder Cancer per 100,000

Population for each Sex, Aswan, 2008 89

Fig. 3.18: Basis of Diagnosis of Bladder Cancer, Aswan, 2008 91

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Fig. 3.19: Grade Distribution of Bladder Cancer, Aswan, 2008 (87 Cases) 93 Fig. 3.20: Stage Distribution of Bladder Cancer, Aswan, 2008 (87 Cases) 93 Fig. 3.21: Incidence of Leukemia, GLOBOCAN 2002 95 Fig. 3.22: Age Specific Incidence Rates of Leukemia per 100,000 Population

for each Sex, Aswan, 2008 97

Fig. 3.23: Basis of Diagnosis of Leukemia, Aswan, 2008 99 Fig. 3.24: Incidence of Lung Cancer, GLOBOCAN 2002 101 Fig. 3.25: Age Specific Incidence Rates of Lung Cancer per 100,000

Population for each Sex, Aswan, 2008 103

Fig. 3.26: Laterality Distribution of Lung Cancer, Aswan, 2008 (52 Cases) 105 Fig. 3.27: Basis of Diagnosis of Lung Cancer, Aswan, 2008 107 Fig. 3.28: Stage Distribution of Lung Cancer, Aswan, 2008 (52 Cases) 109 Fig. 3.29: Incidence of Brain Cancer, GLOBOCAN 2002 111 Fig. 3.30: Age Specific Incidence Rates of Brain and Nervous System Cancer

per 100,000 Population for each Sex, Aswan, 2008 113

Fig. 3.31: Basis of Diagnosis of Brain and Nervous System Cancer, Aswan, 2008

115

Fig. 3.32: Stage Distribution of Brain and Nervous System Cancer, Aswan, 2008 (38 Cases)

117

Fig. 3.33: Incidence of Ovarian Cancer, GLOBOCAN 2002 119 Fig. 3.34: Age Specific Incidence Rates of Ovarian Cancer per 100,000

Population, Aswan, 2008 121

Fig. 3.35: Laterality Distribution of Ovarian Cancer, Aswan, 2008 123 Fig. 3.36: Basis of Diagnosis of Ovarian Cancer, Aswan, 2008 123 Fig. 3.37: Stage Distribution of Ovarian Cancer, Aswan, 2008 (35 Cases) 125 Fig. 3.38: Incidence of Colorectal Cancer, GLOBOCAN 2002 127 Fig. 3.39: Age Specific Incidence Rates of Colorectal Cancer per 100,000

population for each Sex, Aswan, 2008 129

Fig. 3.40: Basis of Diagnosis of Colorectal Cancer, Aswan, 2008 131 Fig. 3.41: Stage Distribution of Colorectal Cancer, Aswan, 2008 (35 Cases) 133 Fig. 3.42: Incidence of Prostate Cancer, GLOBOCAN 2002 135 Fig. 3.43: Age Specific Incidence Rates of Prostate Cancer per 100,000

Population, Aswan, 2008 137

Fig. 3.44: Basis of Diagnosis of Prostate Cancer, Aswan, 2008 139 Fig. 3.45: Stage Distribution of Prostate Cancer, Aswan, 2008 (31 Cases) 139 Fig. 4.1: Incidence Rates of the less Frequent Cancers, Both sexes, Aswan,

2008 143

Fig. 4.2: Age Specific Incidence Rates of Bone Cancer Per 100,000 Population, Aswan, 2008 (31 cases)

145

Fig. 4.3: Age Specific Incidence Rates of Pancreatic Cancer Per 100,000 Population, Aswan, 2008 (29 cases)

147

Fig. 4.4: Age Specific Incidence Rates of Esophageal Cancer Per 100,000 Population, Aswan, 2008 (28 cases)

149

Fig. 4.5: Age Specific Incidence Rates of Connective and Soft Tissue Cancer per 100,000 Population, Aswan, 2008 (28 cases)

151

Fig. 4.6: Age Specific Incidence Rates of Stomach Cancer Per 100,000 Population, Aswan, 2008 (25 cases)

153

Fig. 4.7: Age Specific Incidence Rates of Thyroid Cancer per 100,000 Population, Aswan, 2008 (24 cases)

155

Fig. 4.8: Age Specific Incidence Rates of Laryngeal Cancer per 100,000 Population, Aswan, 2008 (23 cases)

157

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Fig. 4.9: Age Specific Incidence Rates of Uterine Cancer per 100,000

Population, Aswan, 2008 (22 cases) 159

Fig. 4.10: Age Specific Incidence Rates of Oral Cancer per 100,000 Population, Aswan, 2008 (21 cases)

161

Fig. 4.11: Age Specific Incidence Rates of Gall Bladder Cancer per 100,000 Population, Aswan, 2008 (17 cases)

163

Fig. 4.12: Age Specific Incidence Rates of Skin Cancer (Non-Melanoma) per 100,000 Population, Aswan, 2008 (15 cases)

165

Fig. 4.13: Age Specific Incidence Rates of Hodgkin Lymphoma per 100,000 Population, Aswan, 2008 (13 cases)

167

Fig. 4.14: Age Specific Incidence Rates of Nodal Non-Hodgkin Lymphoma per 100,000 Population, Aswan, 2008 13 cases)

169

Fig. 4.15: Age Specific Incidence Rates of Kidney and Renal Pelvis Cancer per 100,000 Population, Aswan, 2008 (12 cases)

171

Fig. 5.1: Distribution of Childhood Cancers by 5-Year Age Groups, Aswan, 2008 (59 cases)

175

Fig. 5.2: Population Structure of Children by 5-Year Age Groups, Aswan, 2008 175 Fig. 5.3: Basis of Diagnosis of Childhood Cancers Aswan, 2008 (59 cases) 177 Fig. 5.4: Stage Distribution of Childhood Cancer, Aswan, 2008 (59 cases) 179 Fig. 5.5: Relative Frequency of Childhood Cancer (ICCC classification),

Aswan, 2008 (59 cases) 181

Fig. 5.6: Incidence Rates of Most Frequent Childhood Cancers, Males, Aswan, 2008

183

Fig. 5.7: Incidence Rates of Most Frequent Childhood Cancers, Females, Aswan, 2008

183

Fig. 5.8: Age Distribution of Childhood Leukemia, Aswan, 2008 185 Fig. 5.9: Pathological Diagnosis of Childhood Leukemia, Aswan, 2008 185 Fig. 5.10: Age Distribution of Childhood Lymphoma Aswan, 2008 187 Fig. 5.11: Morphological Diagnosis of Childhood Lymphoma, Aswan, 2008 187 Fig. 5.12: Age Distribution of Childhood Brain and Miscellaneous intracranial

and intraspinal Neoplasms, Aswan, 2008 189

Fig. 6.1: Steps of Age Standardization 193 Fig. 6.2: Structure of Disease Code 195 Fig. 6.3: Structure of Topography Code 197 Fig. 6.4: Structure of a Morphology Code 197 Fig. 6.5: Example of coding by ICCC-3 based on ICD-O-3 codes 199 Fig. 6.6: Tumor Stages 201 Fig. 6.7: An example of the effect of age grouping on the shape of incidence

figure 203

Fig. 6.8: Age Distribution of Population 205 Fig. 6.9: ASR of the Ten Most Frequent Cancers in Gharbiah Males compared

to Aswan Rates 207

Fig. 6.10: ASR of the Ten Most Frequent Cancers in Gharbiah Females compared to Aswan Rates

209

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EXECUTIVE SUMMARY

This publication details results of the population-based registry in Aswan and the methodology of data collection and processing. It includes 5 parts, namely: Part one: Background information, Part two: Cancer incidence: An overview, Part three: Profile of frequent cancers, Part four: Less frequent cancers: Facts and figures, and Part five: Pediatric malignancies, with an annex with methodological considerations. Part One: Background information

This part introduces the national registry that was established through protocol of cooperation between the Ministries of Communications and Information Technology, Health, and Higher Education. The Governorate of Aswan was selected to be the first of the 5 registries that constitute the national population based cancer registry program. The governorate consists of 5 districts (Markaz) with a population of about 1.1 millions.

Facilities for cancer management are mainly located in Aswan city. The district hospital in Edfu is equipped with a CT scan. Suspected cancer cases are referred for confirmation of diagnosis and management, mostly in Aswan city. A standardized data form is used for recording of patients’ data. The form consists of 5 sections that cover Patient Identification, Patient demographics, Cancer specific data, Hospital specific data and Follow-up/Recurrence/Death.

MD abstractors actively collect data from all centers suspecting, diagnosing, or treating cancer patients, both inside the governorate whether governmental, insurance or private; or outside the governorate, mainly in the National Cancer Institute in Cairo, Nasser Institute, and South Egypt Cancer Institute in Assiut. Death certificates were checked regularly in health offices for cancer as a cause of death. Deceased patients who were not reported before to the registry were recorded as death certificate only (DCO) cases.

Completed data forms are sent to the cancer registry office located in Aswan Cancer Center. Records are manually checked by the data manager for completeness and inconsistencies with re-abstracting if necessary. A tailored version of Abstract plus developed by US Center of Disease Control (CDC) was used for Data management. Special programs were developed by the registration program to supplement the package

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for duplicate elimination and for analysis and calculation of incidence rates and for tabulation and reporting.

Part Two: Cancer Incidence: an overview

During 2008, 1150 incident cancer cases were registered, 525 males (45.7%) and 625 females. The male: female ratio was 1:1.2.

The crude incidence rate, excluding non melanoma skin cancer (C44), was 106.0 /100,000 for both genders together. The rate was 96.2/100,000 males and 115.2/100,000 females. The age-standardized (world) incidence rate, C44 excluded, was 152.4 /100,000 for both genders together. The rate was 140.7/100,000 males and 164.0/100,000 females. For all individual sites of cancer according to ICD10, the frequency and age-specific Incidence rates by 5 year age groups are tabulated. The crude and age standardized incidence rates are shown in the tables.

The 10 most common cancer sites among males were bladder (18.6%), liver (17.4%), lung (11.2%), leukemia (7.8%), prostate (9.2%), brain and nervous tissue (6.3%), esophagus (5.7%), larynx (6.0%), pancreas (5.7%) and colorectal cancer (5.0%). They accounted for 64.8% of cancer in males.

Among females the most common sites were breast (63.9%), ovary (9.1%), liver (8.7%), leukemia (6.6%), bone (5.9%), uterus (5.9%), bladder (6.6%), thyroid (4.5%), colorectum (4.8%) and lung (3.8%). They accounted for 72.3% of cancer in males. Incidence showed substantial increase with age for both males and females. The increase was more evident after the age of 49 with a peak of incidence in age group 75+ years. Mean age at diagnosis for males was 53.9 years with a median age of 57. Mean age at diagnosis for females was 51.4 with a median age of 52. Microscopic diagnosis was achieved in more than 50% of cases. One fifth of cases was diagnosed by non microscopic methods mainly radiology or other imaging techniques. Diagnosis was clinical only in less than 5% of cases. DCO was the basis of diagnosis in 8.2%.

The proportion of cases diagnosed microscopically varied between different sites of cancer. It was 100% of cases of Non-Hodgkin lymphoma and Myeloma and immuno-proliferative diseases, 85% of Hodgkin disease and leukemia cases and less than 25% of cases of cancer of the liver and gall bladder and pancreas.

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Based on the SEER staging system, 30% of cases were localized, 26.4% were spread regionally and 23.6% had distant spread. For 26.4% of cases, it was not clear if the disease was an extension or a metastasis.

Part Three: Profile of frequent cancers

This part deals with the more frequent cancers namely breast, liver, urinary bladder, leukemia, lung, brain, ovary, colorectum, prostate and bone. These cancers represented 62.1% of all malignancies in both genders together.

Breast cancer, though mainly a cancer of women, was still the most frequent for both genders together representing more than 1/5 of incident cases. Breast cancer was not only the most frequent cancer but also the cancer with the highest crude and age adjusted incidence rates (23.0 and 32.9 respectively). Cancer of the liver, bladder and leukemia represented another 1/5 of cases for both genders together. Other cancers were much less frequent’ each representing less than 5% of incident cases.

Among males, bladder and liver cancer occupied the top 2 ranks with almost same frequency and very close crude and age standardized rates. They both represented approximately ¼ of incident cancer cases. Another ¼ of incident cancers was represented by lung, leukemia, prostate, and brain. The 10 more frequent cancers included also the esophagus, larynx, pancreas and colorectal cancer; each with a proportion around 5%. They all represented 64.8%of male incident cancers

Cancer of breast, ovary, liver, leukemia, urinary bladder, bone, thyroid, colorectum, lung and brain accounted for 74.4% of incident cancers in females. Breast cancer was by far the most frequent cancer representing approximately 40% of all incident cancers. Frequency of all other cancers did not exceed 5% each except for ovary and liver cancer that were 5.6% and 5.1% respectively. Incidence rates of breast cancer, both crude and age-standardized, were high compared to all other cancers being almost 6-7 times the rates of ovary and liver cancer.

These frequent sites of cancers are described in detail in this part. For each site a brief overview of its epidemiologic features is given based mainly upon WHO publication of “World Cancer Report”, 2008. This is followed by registry results that covered incidence rates, laterality and sub-site distribution, basis of diagnosis, pathological diagnosis, grade and stage of disease according to SEER staging system.

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In both males and females, the frequency of cancer of different sites markedly changed by age. Leukemia predominated in young age groups as detailed in the part dealing with pediatric malignancies. Change in frequency for each site by gender is detailed in the sections dealing with each individual site. Part Four: Less frequent cancers. Facts and figures

This part deals with less frequent cancers that are not included in the previous part. Results are shown as statistics in bulleted format without comments starting by number of cases and sex and age distribution. These are followed by sub-site distribution, morphological diagnosis, and SEER stage at diagnosis. For each site a curve of age-specific incidence rates by gender is shown. Due to the small number of cases, age was divided in broad categories instead of 5-year age groups in the age specific incidence rates charts. The age groups we used were 0-14, 15-34, 35-54, 55-64, 65-74 and 75+.

Part Five: Pediatric malignancies

The total number of malignancies reported during 2008 among children under age of 15 years was 59 cases; 36 males (61.0%) and 23 females (39.0%) with male: female ratio of 1.6: 1. These cases represented 5.1% of all incident cancers (total of 1150 cases).

The Mean age at diagnosis was 4.8 years with a median of 4 years for both sexes together. For males, the mean age at diagnosis was 4.5 years with a median of 4 years while for females; the mean age at diagnosis was 5.2 years with a median of 4 years also. The highest frequency was in the age group 1-4 years (44.4% for males, 52.2% for females and 47.5% for both sexes together).

More than half the cases were reported in the age group < 5 years. About one third of cases were in the age group 5-9 years and one tenth was older than 9 years. Analysis in the rest of this part is not detailed due to the limited number of cancer cases in these age groups in one year of registration in an approximately one million-population.

Microscopic diagnosis was reported in 30 cases (67.8%) Non microscopic basis of diagnosis was reported in 17.0% of cases. Diagnosis was based on death Certificate only (DCO) in 5 cases (8.5%). No basis for diagnosis was available to the rest of cases (4.0%).

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Stage at diagnosis was recorded for 44 cases (74.6%). Metastatic disease was the commonest presentation accounting for 63.6%. This relatively high proportion of metastatic disease could be attributed to both late presentation and coding all cases of leukemia as metastatic according to SEER staging system. Excluding leukemia, the frequency of metastatic disease dropped to 13.9%.

Site distribution used in the analysis is based upon International Classification of Childhood Cancer (ICCC). See Annex II for more information. The most frequent cancer was leukemia (35.6%) followed by CNS and intracranial neoplasms (8.5%) and lymphomas (8.5%). Proportions between 5-7% were reported for neuroblastoma (6.8%), hepatic tumors (5.1%), renal tumors (5.1%) and soft tissue sarcomas (5.1%). Frequencies of other cancers were less than 4%

The ASR (world) was 85 per million for male children and 51 per million for female children. Analysis of individual sites is very limited due to the small number of registered cases in 1 year.

Results of leukemia (21 cases), lymphomas (5 cases) and brain and nervous system (5 cases) are detailed in the part. These results should be carefully interpreted taking into consideration the limited number of cases that also limits further analysis of data.

The annex gives an overview of the coding systems used, mainly ICD-O, ICD-10 and SEER staging system. Methods of calculation of rates are detailed. The part ends by a comparison between results of Aswan and Gharbiah. The comparison showed that the profile of Aswan was characterized by higher ASR rates of breast, ovary and liver cancer compared to Gharbiah. On the contrary, ASR of non-Hodgkin lymphoma was very low compared to Gharbiah. These interesting observations need to be confirmed with collection of more cases from Aswan in subsequent years.

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15

Part 1 Background Information

1- B

ackg

roun

d In

form

atio

n

16

National Cancer Registry Program of Egypt

The National Cancer Registry Program of Egypt was initiated through an protocol of cooperation between the ministries of Communication and Information Technology, Health, and Higher Education. The Supreme Committee of the Program decided to start by population-based registration of incident cancer cases and to explore the possibility of establishing a national cancer database through hospital based registries.

The first phase of the program started in 2008 and covered Aswan

Governorate. Population-based cancer registries are scheduled to be included in the program in the Governorates of Menia, Beheira and Damietta. Results of these registries will be published during the last quarter of 2010. Governorate of Gharbiah already has a registry that was established 10 years ago and will be included in the national registry program in a subsequent phase. By the end of the current phase, Egypt will be covered by a network of population based registries that fairly represents the entire country. Sinai and Cairo are not included due to logistic difficulties. Comparison of program results with those of the National Cancer Institute in Cairo would give a clue to the profile of cancer in greater Cairo Area.

The administrative structure of the program is represented in figure 1.1.

The program is governed by a Supreme Committee chaired by Professor Hossam Kamel and co-chaired by Professors Hoda Baraka and Hussein Khaled. The committee includes Professor Amal Samy Ibrahim, program Director, representatives of the concerned ministries and directors of the peripheral registries.

Peripheral registries are directed by directors of the cancer centers in

different governorates with daily follow-up of work by a data manger; an MD trained for this post. Data collection is done actively by 2-4 abstractors (MDs) helped by a team of data entry and supportive staff. The number of personnel depends on population size. The entire staff is seconded to the program on part-time basis.

The program is supported by a strong technical unit from the Ministry

of communications and information technology. The unit is responsible for the establishment of the national cancer network, customization of National Cancer Registry applications, development of data analysis and reporting tools, training of program staff, and building Egypt National Cancer Registry Portal for program sustainability.

1- Background Inform

ation

17

Fig. 1.1: Organizational Structure of Phase 1 of the Registry Program `

President Professor Hossam Kamel

Program Director Professor Amal Samy Ibrahim

Vice President Professor Hoda Baraka

Vice President Professor Hussein Khaled

Technical Unit

Central Registry

Aswan Registry

Communication and Information

Technology

Health

Higher Education

Director Professor

Salah Abdel Hady

Supervisor Prof. Nelly Hassan

Data Managers

Data Abstractors

Data entry staff

Director Professor

Mohamed Abdeen

Data Manger Dr. Amir Bishara

Abstractors

Data entry staff

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Aswan Governorate

The Governorate of Aswan is the farthest southern governorate of Egypt. The capital of the governorate is Aswan city, 982 km to the South of Cairo. It borders Governorate of Qena to the North, Governorate of Red Sea to the East, Governorate of New Valley to the West, and Sudan to the South.

The population of the governorate is 1,074,131 (2008). Its area is 34,608 km². It consists of 5 administrative districts (markaz) namely • Aswan, (303,508) • Kom Ambo, (268,870) • Daraw, (93,242) • Edfu, (333,460) and • Nasr Elnoba (75,051).

Facilities for cancer management are mainly located in Aswan city. The district hospital in Edfu is equipped with a CT scan. Suspected cancer cases from Edfu center are referred for confirmation of diagnosis and management, mostly in Aswan city.

The Governorate of Aswan was selected to be the first of the 5 registries that constitute the national population based cancer registry program. Parallel to these population based registries, a group of tertiary care facilities volunteered to share in initiation of network of cancer registries that will eventually lead to a national cancer database. These centers include Nasser Institute, Madinat Es-Salam Cancer Center, Pediatric Cancer Hospital 57357, and Faculty of Medicine of Suez Canal University. These centers were equipped with hardware and software if needed with training of local staff. However, there results will not be included in the National Database during the current phase. An attempt will be made to initiate standardized hospital-based registries in these centers. Eventually, a nucleus for national cancer database will be established.

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Fig. 1.2: Map of Egypt Showing the Location of Aswan Governorate and the other Registries ( ) scheduled to be launched

during 2008 – 2009

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Aswan Population-based Cancer Registry

The Aswan Cancer Registry, a population based registry covering Governorate of Aswan, was established in 2007 within the context of the National Cancer Registry Program of Egypt. It is located in Aswan Cancer Center of the Ministry of Health. In 2008, the registry started registering all incident cancer cases among the approximately 1.1 million residents of Aswan diagnosed within and outside the Governorate of Aswan.

The registry is the first of the five regional registries planned to be launched during the first phase of the program. In addition to Aswan; these registries cover the Governorates of Menia in the middle of Upper Egypt, Beheira close to Alexandria on the Mediterranean coast, the costal Governorate of Damietta; as well as Gharbiah in the middle of the Nile delta that already has a population based registry.

Director of the registry is Professor Mohammed Abdeen, Professor of Clinical Oncology in the Faculty of Medicine of Cairo University and Director of Aswan Cancer Center of the Ministry of Health. The data manager is Dr Amir Bishara, Surgery Consultant in Aswan Cancer Center.

Data abstractors during 2008 were: - Dr. Amir Bishara - Dr. Mohammed Hassan - Dr. Ibrahim Abdel Hamid Data entry was achieved by: - Mr. Mourad Salah Fawzi - Mrs. Doaa Aly Abd El Rahman The entire staff is seconded on part-

time basis from Aswan Cancer Center that offered the premises and covered its running expenses.

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Fig. 1.3: Map of Aswan Governorate and its districts

Fig. 1.4: Organizational Chart of Aswan Cancer Registry

Aswan Cancer Registry

Director Prof. Mohamed Abdeen

Data Manger Dr. Amir Bishara

Abstractors Data Entry Staff

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The Registry Population

The current report covers the year 2008. Rates are calculated based upon the population structure, shown in 5-year age groups in table 1.2 and figure 1.5. The relatively young age structure of the population is apparent. The percentage of individuals under 20 years was 50.1% of Aswan population. Conversely, the percentage of those over 65 years was less than 4%.

Age-specific incidence rates were calculated for 5 year age groups.

These rates were used to calculate the age-standardized incidence rates using the standard world population. Due to the relatively small number of expected incident cancer cases in some 5-year age groups due to the small population size; age groups were combined together into 6 age groups, namely 0-14, 15-34, 35-54, 55-64, 65-74 and 75+ for cancer sites with less frequency. The population structure used for calculation of age specific incidence rates of cancer is shown below.

Table 1.1: Number of Persons by 5-Year Age Groups and Sex,

World Standard

Age Group Total Male Female All ages 2,000,000 1,000,000 1,000,000 00-04 y 240,000 120,000 120,000 05-09 y 200,000 100,000 100,000 10-14 y 180,000 90,000 90,000 15-19 y 180,000 90,000 90,000 20-24 y 160,000 80,000 80,000 25-29 y 160,000 80,000 80,000 30-34 y 120,000 60,000 60,000 35-39 y 120,000 60,000 60,000 40-44 y 120,000 60,000 60,000 45-49 y 120,000 60,000 60,000 50-54 y 100,000 50,000 50,000 55-59 y 80,000 40,000 40,000 60-64 y 80,000 40,000 40,000 65-69 y 60,000 30,000 30,000 70-74 y 60,000 20,000 20,000 75+ y 40,000 20,000 20,000

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Table 1.2: Number of Persons by 5-Year Age Groups and Sex, Aswan, 2008

Age Group Total Male Female All ages 1,074,131 539,617 534,514 00-04 y 123,344 62,929 60,415 05-09 y 143,618 73,608 70,010 10-14 y 144,684 74,218 70,466 15-19 y 126,982 65,097 61,885 20-24 y 94,841 46,995 47,846 25-29 y 81,733 38,070 43,663 30-34 y 67,849 33,248 34,601 35-39 y 66,254 31,636 34,618 40-44 y 51,348 24,925 26,423 45-49 y 46,987 22,762 24,225 50-54 y 31,437 15,127 16,310 55-59 y 25,664 13,426 12,238 60-64 y 27,115 14,103 13,012 65-69 y 18,260 10,555 7,705 70-74 y 13,066 7,022 6,044 75+ y 10,949 5,896 5,053

Fig. 1.5: Age Distribution of Population,

Aswan, 2008

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Sources of Data

Governmental Sector

- Aswan Cancer Center “Main Source” Aswan

- Health Insurance Hospital - Aswan Teaching Hospital - Mubark Military Hospital - Fever Hospital - Chest Hospital

Central hospital in each Markaz Daraw, Kom Ambo,and Nasr Elnoba

Edfu - Edfu Central Hospital - El Sebaia Hospital - El Redisia Hospital - El Bisilia Hospital Insurance Cases Health insurance hospitals in Aswan and 6th October hospital in Cairo Patients treated on Government expenses Death Certificates Data was collected from 11 health offices in Aswan and other cities. Private Sector Private Clinics do not deal with cancer. Their cases are usually referred to Aswan Cancer Center and less frequently to centers outside Aswan. Main Referral Centers outside Aswan Governorate

- Assuit University hospital and South Egypt Cancer Institute - National Cancer Institute in Cairo - Ein Shams University Hospital - Nasser Institute. - Pediatric Hospital 57357

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Fig. 1.6: Flow of Patients in Aswan

Aswan Cancer Patients

Diagnosed and

treated in Aswan Cancer Center

Diagnosed in other centers (clinically or

radiologically)

Seek private care (private labs and

hospitals)

Do not seek medical care

Very few are transferred to

NCI

Referred to Aswan Cancer

Center or Outside the Governorate

Most of them will eventually be transferred to Aswan Center

Registered only

by death certificate (DCO)

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Data Collection

Medical doctors of Aswan Cancer Center actively collected data through regular visits to all governmental, non-governmental, and private centers and laboratories dealing with cancer patients. Data were also collected from death certificates (death certificate only cases).

Centers outside Aswan that deal with cancer patients, mainly the National Cancer Institute, South Egypt Cancer Institute, 57357 Children Cancer Hospital and Nasser Institute were visited regularly to collect data on Aswan patients who might be treated there. The main bulk of cases were in the National Cancer Institute. Cases were searched manually in centers without automated medical records system such as Nasser Institute.

A standardized data form was used for recording of patients’ data.

The form consists of 5 sections: A. Patient Identification B. Patient demographics C. Cancer specific data D. Hospital specific data E. Follow-up/Recurrence/Death Patients’ identification and patients’ demographic data were

completed in Arabic. Emphasis was made on patients’ identification using the national ID number. Collaborating centers were asked to make this number mandatory in all patients’ records.

The rest of the form was pre-coded to simplify abstracting.

Abstractors were trained on use of terminology compatible with ICD-O-3 coding system. Actual coding was done during data entry through the help of the computer package. Abstractors were trained to avoid ambiguous terminology in clinical diagnosis and were given a pocket guide for SEER staging of most common sites of cancer. Detailed manual explaining each data field was available as hard copy and on the computer system.

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Fig. 1.7: Cancer Registry Data Form

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Data Flow and Processing Completed data forms sent to the center are checked by the data manager for completeness and inconsistencies. Re-abstracting is done if necessary. Emphasis is on the mandatory fields needed to consider the data form as complete. These mandatory fields include: registry patient number, registry identification number, sequence number, age at diagnosis, date of birth, sex, residential status (current), date of diagnosis, diagnostic confirmation, primary site and morphology code (ICD-O-3), behavior, grade and summary stage at diagnosis (SEER Summary Staging Manual 2000).

The registry is equipped with 2 PCs, 1 scanner, 1 printer and fast ADSL internet connection. A tailored version of “CDC Abstract plus” software is used that does limited validity checks. A special program was developed to complete these validity checks.

Data forms are also completed for cases diagnosed outside Aswan Cancer center; both locally in the governorate or in centers outside Aswan, mainly the National Cancer Institute in Cairo.

Another program developed to complete the data processing cycle is “Double Minus” used to detect duplicate cases. Duplicate forms are shown on the screen for the data manager to complete one form and discard the other or include the 2 forms as double primary with adjustment of sequence number. The sequence number is initially coded to 00 (only one tumor) and in case of double primary it is changed to 01 for the first tumor and 02 for the second.

Completed cases are exported periodically to the central database at the National Cancer Institute and the backup database at the Ministry of Communication and Information Technology. Data managers apply data validation and check tools to assure the quality of the database used for analysis and reporting.

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Abstract Plus

(Data Entry) Double Minus Duplicates Elimination

Abstract Plus Double Minus

Abstract Plus Double Minus

Analysis tool (Statistical Reports)

Abstract Plus (Central Database) Double Minus

(Central Duplicate Elimination)

Developed tool (Double Minus) to import data

into Abstract Plus

Other resources

Treatment by the

Government

Fig. 1.8: Data Flow and Processing

Remote Registries Central Registry

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Data Analysis and Calculation of Proportions and Rates

Data are presented for individual sites of cancer based on ICD-10

codes. Special computer software was developed for conversion from ICD-O-3 coding system. Data for all sites of cancer are expressed twice; with and without non melanoma skin cancer (C44).

Three incidence rates were used for presentation of data, namely: the

crude, age-specific, and age-standardized incidence rates. All these rates are expressed / 100,000 population except for rates of childhood cancer (up to age 14 years) that are expressed / 1,000,000 (Annex I).

Crude incidence is the simplest rate that represents the actual burden

of the disease. It is equal to the number of incident cases divided by the midyear population. The age-specific incidence rate (ASIR) is the crude incidence rates within small age groups; usually groups of 5 years. The crude incidence rate could be used to estimate prevalence of the disease if multiplied by the duration. Usually, an arbitrary figure between 2 and 3 is used.

The age-standardized incidence rate (ASR) is a simple tool for

comparison of different populations taking into consideration differences in age structure. The direct method of calculation of ASR was used. By this method the age-specific incidence rates are applied to the standard world population that was mentioned earlier. The resulting rate nullifies the effect of differences in age structure. It is based on the expected number of cases in this world population if exposed to the rates of Egypt. Although the resulting rate does not represent the actual incidence in a given population, yet it is the simplest way of comparison between populations that might differ in age structure.

Categorical characteristics like gender, topography and morphology were expressed as percent of total number. Ratios were mainly used for gender (male: female ratio).

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Fig. 1.9: Age-adjusted Incidence Rates

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Part 2 Cancer Incidence

An Overview and

Profile of Frequent Cancers

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Incidence rates: total and gender-specific:

During 2008, 1150 incident cancer cases were registered, 525

males (45.7%) and 625 females. The male: female ratio was 1:1.2. The crude incidence rate, C44 excluded (non melanoma skin

cancer), was 106.0 /100,000 for both genders together. The rate was 96.2/100,000 males and 115.2/100,000 females.

The crude incidence rate, C44 included, was 107.1/100,000 for

both genders together. The rate was 97.3/100,000 males and 116.9/100,000 females.

The age-standardized (world) incidence rate, C44 excluded, was

152.4 /100,000 for both genders together. The rate was 140.7/100,000 males and 164.0/100,000 females.

The age-standardized (world) incidence rate, C44 included, was

154.7 /100,000 for both genders together. The rate was 142.5/100,000 males and 166.8/100,000 females.

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Fig. 2.1: Incidence Rates, Aswan, 2008

Fig. 2.2: Incidence Rates of the more Frequent Cancers, Both sexes, Aswan, 2008

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The 10 most common cancer sites among males were bladder,

liver, lung, leukemia, prostate, brain and nervous tissue, esophagus, larynx, pancreas and colorectal cancer. They accounted for 64.8% of incident male cancer cases. Among females the most common sites were breast, ovary, liver, leukemia, bone, uterus, bladder, thyroid, colorectal and lung, accounting for 72.3% of female incident cancer cases. For both genders together, these sites were breast, liver, bladder, leukemia, lung, brain and nervous tissue, ovary, colorectal, prostate and bone. They accounted for 62.2% of all incident cancer cases.

Tables in the following pages depict the number of cases per site

(according to ICD10) and 5 year age groups for males and females. Totals are expressed twice, with C44 included and excluded. These frequency tables are followed by similar tables of rates for males and females; with and without C44. All rates are expressed /100,000 population.

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Fig. 2.3: Incidence Rates of Ten Most Frequent Cancers, Males,

Aswan, 2008

Fig. 2.4: Incidence Rates of Ten Most Frequent Cancers, Females, Aswan, 2008

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Table 2.1: Number and Proportion of Incident Cases, by Site and 5-Year Age Group, Males, Aswan, 2008

Site All Ages UK 0-4 5-9 10-14 15-19 20-24 25-29 30-34

Lip 2 0 0 0 0 0 0 0 0 Tongue 6 1 0 0 0 0 0 0 0 Mouth 7 0 0 0 0 0 0 0 0 Salivary glands 3 0 0 0 0 0 0 0 0 Tonsil 0 0 0 0 0 0 0 0 0 Other oropharynx 1 0 0 0 0 0 0 0 0 Nasopharynx 4 0 0 0 0 1 0 0 0 Hypopharynx 3 0 0 0 0 0 0 0 0 Pharynx unspec. 1 0 0 0 0 0 0 0 0 Esophagus 22 2 0 0 0 0 0 1 1 Stomach 14 0 0 0 0 0 0 0 0 Small intestine 1 0 0 0 0 0 0 0 0 Colon 14 0 0 0 0 1 0 1 0 Rectum 4 0 0 0 0 0 0 1 0 Anus 2 0 0 0 0 0 0 0 0 Liver 62 1 2 0 0 1 0 0 1 Gallbladder etc. 7 0 0 0 0 0 0 0 0 Pancreas 20 0 0 0 0 0 0 0 1 Nose, sinuses etc. 3 0 0 0 0 0 0 0 0 Larynx 21 1 0 0 0 0 0 0 0 Trachea, Bronchus, Lung 39 0 1 0 0 1 0 0 1 Other Thoracic organs 5 0 0 0 0 0 1 0 0 Bone 9 0 0 1 0 1 3 2 0 Melanoma of skin 0 0 0 0 0 0 0 0 0 Other skin 6 0 0 0 0 0 0 0 0 Mesothelioma 0 0 0 0 0 0 0 0 0 Kaposi sarcoma 0 0 0 0 0 0 0 0 0 Connective, Soft tissue 17 1 0 0 0 1 0 1 1 Breast 6 0 0 0 0 0 0 0 0 Penis 0 0 0 0 0 0 0 0 0 Prostate 31 1 0 0 0 0 0 0 1 Testis 2 0 0 0 0 0 0 0 0 Other male genital 0 0 0 0 0 0 0 0 0 Kidney 5 0 2 0 0 0 0 0 0 Renal pelvis 2 0 0 0 0 0 0 0 0 Ureter 0 0 0 0 0 0 0 0 0 Bladder 65 3 0 0 0 0 0 1 0 Other urinary organs 1 0 0 0 0 0 0 0 0 Eye 4 1 2 0 0 0 0 0 0 Brain, Nervous tissue 26 1 1 3 1 1 2 3 1 Thyroid 4 0 0 0 0 0 1 0 0 Adrenal gland 3 0 1 1 0 0 0 0 0 Other endocrine 1 0 0 0 0 0 0 0 0 Hodgkin disease 8 1 0 2 1 0 0 2 0 Non-Hodgkin lymphoma 7 0 0 0 0 0 0 0 0 Immunoproliferative dis. 0 0 0 0 0 0 0 0 0 Multiple myeloma 1 0 0 0 0 0 0 0 0 Lymphoid leukemia 18 2 6 5 0 0 4 0 0 Myeloid Leukemia 10 0 1 0 0 1 1 0 0 Leukemia unspec. 8 1 1 1 0 1 1 0 1 Other & unspecified 50 1 3 1 0 1 0 0 2 All sites Total 525 17 20 14 2 10 13 12 10 All sites but C44 519 17 20 14 2 10 13 12 10

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Table 2.1 (cont.): Number and Proportion of Incident Cases, by Site and 5-Year Age Group, Males, Aswan, 2008

35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ % Total

ICD (10th)

0 0 0 0 0 0 1 1 0 0.4% C00 0 0 2 1 1 0 0 0 1 1.1% C01-C02 1 1 1 1 2 0 1 0 0 1.3% C03-C06 0 0 0 0 1 0 0 1 1 0.6% C07-C08 0 0 0 0 0 0 0 0 0 0.0% C09 0 0 0 0 1 0 0 0 0 0.2% C10 0 0 0 2 0 0 0 0 1 0.8% C11 0 1 0 1 1 0 0 0 0 0.6% C12-C13 0 0 1 0 0 0 0 0 0 0.2% C14 0 1 1 1 1 4 3 3 4 4.2% C15 0 0 3 1 2 2 2 2 2 2.7% C16 0 1 0 0 0 0 0 0 0 0.2% C17 1 0 1 2 1 1 2 2 2 2.7% C18 0 0 0 0 2 0 0 1 0 0.8% C19-C20 0 0 1 0 0 0 1 0 0 0.4% C21 2 1 7 10 8 11 6 6 6 11.8% C22 0 0 0 2 0 0 1 2 2 1.3% C23-C24 0 0 4 4 4 6 1 0 0 3.8% C25 0 1 0 1 0 0 0 0 1 0.6% C30-C31 0 0 4 4 2 2 1 3 4 4.0% C32 2 0 3 9 6 5 3 4 4 7.4% C33-C34 0 0 0 1 2 1 0 0 0 1.0% C37-C38 0 1 0 0 0 0 0 0 1 1.7% C40-C41 0 0 0 0 0 0 0 0 0 0.0% C43 0 1 0 2 1 0 0 1 1 1.1% C44 0 0 0 0 0 0 0 0 0 0.0% C45 0 0 0 0 0 0 0 0 0 0.0% C46 1 1 5 1 1 1 0 2 1 3.2% C47;C49 1 0 0 1 0 1 1 0 2 1.1% C50 0 0 0 0 0 0 0 0 0 0.0% C60 0 0 0 1 0 4 4 6 14 5.9% C61 1 0 0 0 0 0 0 0 1 0.4% C62 0 0 0 0 0 0 0 0 0 0.0% C63 0 0 0 2 0 0 1 0 0 1.0% C64 0 1 0 0 1 0 0 0 0 0.4% C65 0 0 0 0 0 0 0 0 0 0.0% C66 0 0 4 7 10 7 11 9 13 12.4% C67 0 0 0 0 0 1 0 0 0 0.2% C68 0 0 1 0 0 0 0 0 0 0.8% C69 2 0 1 5 3 0 0 2 0 0.5% C70-C72 0 0 0 0 2 0 0 1 0 0.8% C73 0 0 0 0 1 0 0 0 0 0.6% C74 0 0 1 0 0 0 0 0 0 0.2% C75 0 1 0 0 0 1 0 0 0 1.5% C81 0 0 1 2 0 2 0 0 2 1.3% C82-C85;C96 0 0 0 0 0 0 0 0 0 0.0% C88 0 0 1 0 0 0 0 0 0 0.2% C90 0 0 0 0 0 0 1 0 0 3.4% C91 1 1 1 3 0 0 0 1 0 1.9% C92-C94 0 0 0 0 0 1 0 1 0 1.5% C95 2 0 6 4 6 8 7 6 3 9.5% Other

14 12 49 68 59 58 47 54 66 100.0% All 14 11 49 66 58 58 47 53 65 98.9% All not C44

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Table 2.2: Number and Proportion of Incident Cases, by Site and 5-Year Age Group, Females, Aswan, 2008

Site All Ages UK 0-4 5-9 10-14 15-19 20-24 25-29 30-34

Lip 1 0 0 0 0 0 0 0 0 Tongue 0 0 0 0 0 0 0 0 0 Mouth 5 0 0 0 0 0 0 0 0 Salivary glands 1 0 0 0 0 0 0 0 0 Tonsil 0 0 0 0 0 0 0 0 0 Other oropharynx 1 0 0 0 0 0 0 0 0 Nasopharynx 1 0 1 0 0 0 0 0 0 Hypopharynx 3 0 0 0 0 0 0 0 0 Pharynx unspec. 0 0 0 0 0 0 0 0 0 Esophagus 6 1 0 0 0 0 0 0 0 Stomach 11 0 0 0 0 0 0 0 1 Small intestine 3 0 0 0 0 0 0 0 0 Colon 13 1 0 0 0 0 1 0 1 Rectum 4 0 0 0 0 0 0 0 0 Anus 1 0 0 0 0 0 0 0 0 Liver 32 3 2 0 0 0 0 1 1 Gallbladder etc. 10 0 0 0 0 0 0 0 0 Pancreas 9 2 0 0 0 0 0 0 0 Nose, sinuses etc. 1 0 0 0 0 0 0 0 0 Larynx 2 0 0 0 0 0 0 0 0 Trachea, Bronchus, Lung 13 0 0 0 0 0 0 2 0 Other Thoracic organs 3 0 0 0 0 0 0 0 0 Bone 22 1 0 0 1 2 1 1 0 Melanoma of skin 0 0 0 0 0 0 0 0 0 Other skin 9 0 0 0 0 0 0 1 0 Mesothelioma 0 0 0 0 0 0 0 0 0 Kaposi sarcoma 0 0 0 0 0 0 0 0 0 Connective, Soft tissue 11 1 0 1 0 1 1 1 0 Breast 241 13 0 0 0 0 2 6 10 Vulva 0 0 0 0 0 0 0 0 0 Vagina 3 0 0 0 0 0 0 0 0 Cervix Uteri 3 0 0 0 0 0 0 0 0 Corpus Uteri 9 0 0 0 0 0 0 0 0 Uterus unspec. 13 0 0 0 0 0 0 1 0 Ovary 35 3 0 0 0 1 1 0 0 Other female genital 2 0 0 0 0 0 0 0 0 Placenta 1 0 0 0 0 0 0 1 0 Kidney 4 0 1 0 0 0 0 0 1 Renal pelvis 1 0 0 0 0 0 0 1 0 Ureter 0 0 0 0 0 0 0 0 0 Bladder 22 1 1 0 0 1 0 0 0 Other urinary organs 0 0 0 0 0 0 0 0 0 Eye 1 0 0 0 0 0 0 0 1 Brain, Nervous tissue 13 1 0 1 1 0 3 0 1 Thyroid 20 3 0 0 0 0 1 0 2 Adrenal gland 1 0 1 0 0 0 0 0 0 Other endocrine 1 0 0 0 0 0 0 0 0 Hodgkin disease 5 0 0 0 0 1 2 2 0 Non-Hodgkin lymphoma 6 0 0 1 0 0 1 0 0 Immunoproliferative dis. 0 0 0 0 0 0 0 0 0 Multiple myeloma 1 1 0 0 0 0 0 0 0 Lymphoid leukemia 9 0 6 1 1 1 0 0 0 Myeloid Leukemia 10 0 0 0 0 1 0 0 0 Leukemia unspec. 9 1 0 1 0 1 0 0 0 Other & unspecified 53 4 1 1 1 2 3 1 1 All sites Total 625 36 13 6 4 11 16 18 19 All sites but C44 616 36 13 6 4 11 16 17 19

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Table 2.2 (cont.): Number and Proportion of Incident Cases, by Site and 5-Year Age Group, Females, Aswan, 2008

35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ % Total

ICD (10th)

0 0 0 0 1 0 0 0 0 0.2% C00 0 0 0 0 0 0 0 0 0 0.0% C01-C02 0 0 2 0 0 1 1 1 0 0.8% C03-C06 0 0 0 0 0 0 1 0 0 0.2% C07-C08 0 0 0 0 0 0 0 0 0 0.0% C09 0 0 0 0 1 0 0 0 0 0.2% C10 0 0 0 0 0 0 0 0 0 0.2% C11 0 0 1 1 0 0 1 0 0 0.5% C12-C13 0 0 0 0 0 0 0 0 0 0.0% C14 0 1 0 0 1 2 1 0 0 1.0% C15 0 1 1 1 1 1 1 3 1 1.8% C16 0 0 1 1 0 0 0 1 0 0.5% C17 0 2 1 2 0 1 3 0 1 2.1% C18 0 0 1 0 1 1 0 0 1 0.6% C19-C20 0 0 0 1 0 0 0 0 0 0.2% C21 0 1 3 4 6 4 1 3 3 5.1% C22 0 1 1 1 3 2 1 1 0 1.6% C23-C24 0 0 1 1 0 1 0 3 1 1.4% C25 0 1 0 0 0 0 0 0 0 0.2% C30-C31 0 0 0 0 0 0 0 1 1 0.3% C32 1 0 2 3 1 1 2 0 1 2.1% C33-C34 0 0 0 0 0 0 2 1 0 0.5% C37-C38 1 1 1 4 0 3 2 1 3 3.5% C40-C41 0 0 0 0 0 0 0 0 0 0.0% C43 0 1 2 0 0 1 0 0 4 1.4% C44 0 0 0 0 0 0 0 0 0 0.0% C45 0 0 0 0 0 0 0 0 0 0.0% C46 1 2 1 1 0 0 0 0 1 1.8% C47;C49

20 37 24 36 27 24 14 13 15 38.6% C50 0 0 0 0 0 0 0 0 0 0.0% C51 0 0 0 0 0 2 1 0 0 0.5% C52 0 0 1 1 0 1 0 0 0 0.5% C53 0 0 0 0 3 4 0 1 1 1.4% C54 0 2 2 1 1 0 1 5 0 2.1% C55 2 4 4 8 8 0 0 2 2 5.6% C56 1 0 0 0 0 0 0 0 1 0.3% C57 0 0 0 0 0 0 0 0 0 0.2% C58 0 0 0 0 0 1 1 0 0 0.6% C64 0 0 0 0 0 0 0 0 0 0.2% C65 0 0 0 0 0 0 0 0 0 0.0% C66 1 0 3 0 3 3 4 1 4 3.5% C67 0 0 0 0 0 0 0 0 0 0.0% C68 0 0 0 0 0 0 0 0 0 0.2% C69 1 1 0 1 0 0 0 3 0 2.1% C70-C72 2 3 0 5 1 0 0 1 2 3.2% C73 0 0 0 0 0 0 0 0 0 0.2% C74 0 1 0 0 0 0 0 0 0 0.2% C75 0 0 0 0 0 0 0 0 0 0.8% C81 1 0 1 0 0 1 1 0 0 1.0% C82-C85;C96 0 0 0 0 0 0 0 0 0 0.0% C88 0 0 0 0 0 0 0 0 0 0.2% C90 0 0 0 0 0 0 0 0 0 1.4% C91 3 0 0 1 2 0 2 0 1 1.6% C92-C94 2 0 1 1 1 1 0 0 0 1.4% C95 2 4 3 1 4 9 2 8 6 8.5% Other

38 63 57 75 65 64 42 49 49 100.0% All 38 62 55 75 65 63 42 49 45 98.6% All not C44

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Table 2.3: Age Specific Incidence Rates, Crude Rates and ASR (World), Males, Aswan, 2008

Site All Ages 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39

Lip 2 - - - - - - - - Tongue 6 - - - - - - - - Mouth 7 - - - - - - - 3.2 Salivary glands 3 - - - - - - - - Tonsil 0 - - - - - - - - Other oropharynx 1 - - - - - - - - Nasopharynx 4 - - - 1.5 - - - - Hypopharynx 3 - - - - - - - - Pharynx unspec. 1 - - - - - - - - Esophagus 22 - - - - - 2.6 3.0 - Stomach 14 - - - - - - - - Small intestine 1 - - - - - - - - Colon 14 - - - 1.5 - 2.6 - 3.2 Rectum 4 - - - - - 2.6 - - Anus 2 - - - - - - - - Liver 62 3.2 - - 1.5 - - 3.0 6.3 Gallbladder etc. 7 - - - - - - - - Pancreas 20 - - - - - - 3.0 - Nose, sinuses etc. 3 - - - - - - - - Larynx 21 - - - - - - - - Trachea, Bronchus, Lung 39 1.6 - - 1.5 - - 3.0 6.3 Other Thoracic organs 5 - - - - 2.1 - - - Bone 9 - 1.4 - 1.5 6.4 5.3 - - Melanoma of skin 0 - - - - - - - - Other skin 6 - - - - - - - - Mesothelioma 0 - - - - - - - - Kaposi sarcoma 0 - - - - - - - - Connective, Soft tissue 17 - - - 1.5 - 2.6 3.0 3.2 Breast 6 - - - - - - - 3.2 Penis 0 - - - - - - - - Prostate 31 - - - - - - 3.0 - Testis 2 - - - - - - - 3.2 Other male genital 0 - - - - - - - - Kidney 5 3.2 - - - - - - - Renal pelvis 2 - - - - - - - - Ureter 0 - - - - - - - - Bladder 65 - - - - - 2.6 - - Other urinary organs 1 - - - - - - - - Eye 4 3.2 - - - - - - - Brain, Nervous tissue 26 1.6 4.1 1.3 1.5 4.3 7.9 3.0 6.3 Thyroid 4 - - - - 2.1 - - - Adrenal gland 3 1.6 1.4 - - - - - - Other endocrine 1 - - - - - - - - Hodgkin disease 8 - 2.7 1.3 - - 5.3 - - Non-Hodgkin lymphoma 7 - - - - - - - - Immunoproliferative dis. 0 - - - - - - - - Multiple myeloma 1 - - - - - - - - Lymphoid leukemia 18 9.5 6.8 - - 8.5 - - - Myeloid Leukemia 10 1.6 - - 1.5 2.1 - - 3.2 Leukemia unspec. 8 1.6 1.4 - 1.5 2.1 - 3.0 - Other & unspecified 50 4.8 1.4 - 1.5 - - 6 6.3 All sites Total 525 31.8 19 2.7 15.4 27.7 31.5 30.1 44.3 All sites but C44 519 31.8 19 2.7 15.4 27.7 31.5 30.1 44.3

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Table 2.3 (cont.): Age Specific Incidence Rates, Crude Rates and ASR (World), Males, Aswan, 2008

40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ Crude rate

ASR world

ICD (10th)

- - - - - 9.5 14.2 - 0.4 0.6 C00 - 8.8 6.6 7.4 - - - 17.0 1.1 1.5 C01-C02

4.0 4.4 6.6 14.9 - 9.5 - - 1.3 1.9 C03-C06 - - - 7.4 - - 14.2 17.0 0.6 0.9 C07-C08 - - - - - - - - 0.0 0;0 C09 - - - 7.4 - - - - 0.2 0.3 C10 - - 13.2 - - - - 17.0 0.7 1.1 C11 4 - 6.6 7.4 - - - - 0.6 0.9 C12-C13 - 4.4 - - - - - - 0.2 0.3 C14

4.0 4.4 6.6 7.4 28.4 28.4 42.7 67.8 4.1 5.7 C15 - 13.2 6.6 14.9 14.2 18.9 28.5 33.9 2.6 4.1 C16

4.0 - - - - - - - 0.2 0.2 C17 - 4.4 13.2 7.4 7.1 18.9 28.5 33.9 2.6 3.9 C18 - - - 14.9 - - 14.2 - 0.7 1.1 C19-C20 - 4.4 - - - 9.5 - - 0.4 0.5 C21

4.0 30.8 66.1 59.6 78.0 56.8 85.4 101.8 11.5 17.4 C22 - - 13.2 - - 9.5 28.5 33.9 1.3 2.2 C23-C24 - 17.6 26.4 29.8 42.5 9.5 - - 3.7 5.7 C25

4.0 - 6.6 - - - - 17.0 0.6 0.9 C30-C31 - 17.6 26.4 14.9 14.2 9.5 42.7 67.8 3.9 6.0 C32 - 13.2 59.5 44.7 35.5 28.4 57 67.8 7.2 11.2 C33-C34 - - 6.6 14.9 7.1 - - - 0.9 1.4 C37-C38

4.0 - - - - - - 17.0 1.7 2.0 C40-C41 - - - - - - - - 0.0 0.0 C43

4.0 - 13.2 7.4 - - 14.2 17.0 1.1 1.8 C44 - - - - - - - - 0.0 0.0 C45 - - - - - - - - 0.0 0.0 C46

4.0 22 6.6 7.4 7.1 - 28.5 17.0 3.2 4.1 C47;C49 - - 6.6 - 7.1 9.5 - 33.9 1.1 1.8 C50 - - - - - - - - 0 0 C60 - - 6.6 - 28.4 37.9 85.4 237.4 5.7 9.2 C61 - - - - - - - 17.0 0.4 0.5 C62 - - - - - - - - 0 0 C63 - - 13.2 - - 9.5 - - 0.9 1.3 C64

4.0 - - 7.4 - - - - 0.4 0.5 C65 - - - - - - - - 0.0 0.0 C66 - 17.6 46.3 74.5 49.6 104.2 128.2 220.5 12 18.6 C67 - - - - 7.1 - - - 0.2 0.3 C68 - 4.4 - - - - - - 0.7 0.6 C69 - 4.4 33.1 22.3 - - 28.5 - 4.8 6.3 C70-C72 - - - 14.9 - - 14.2 - 0.7 1.1 C73 - - - 7.4 - - - - 0.6 0.8 C74 - 4.4 - - - - - - 0.2 0.3 C75

4.0 - - - 7.1 - - - 1.5 1.7 C81 - 4.4 13.2 - 14.2 - - 33.9 1.3 2.2 C82-C85;C96 - - - - - - - - 0.0 0.0 C88 - 4.4 - - - - - - 0.2 0.3 C90 - - - - - 9.5 - - 3.3 3.7 C91

4.0 4.4 19.8 - - - 14.2 - 1.9 2.5 C92-C94 - - - - 7.1 - 14.2 - 1.5 1.6 C95 - 26.4 26.4 44.7 56.7 66.3 85.4 50.9 9.3 13.4 Other

48.1 215.3 449.5 439.4 411.3 445.3 769 1119.4 97.3 142.5 All 44.1 215.3 436.3 432 411.3 445.3 754.8 1102.4 96.2 140.7 All not C44

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Table 2.4: Age Specific Incidence Rates, Crude Rates and ASR (World), Females, Aswan, 2008

Site All Ages 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39

Lip 1 - - - - - - - - Tongue 0 - - - - - - - - Mouth 5 - - - - - - - - Salivary glands 1 - - - - - - - - Tonsil 0 - - - - - - - - Other oropharynx 1 - - - - - - - - Nasopharynx 1 1.7 - - - - - - - Hypopharynx 3 - - - - - - - - Pharynx unspec. 0 - - - - - - - - Esophagus 6 - - - - - - - - Stomach 11 - - - - - - 2.9 - Small intestine 3 - - - - - - - - Colon 13 - - - - 2.1 - 2.9 - Rectum 4 - - - - - - - - Anus 1 - - - - - - - - Liver 32 3.3 - - - - 2.3 2.9 - Gallbladder etc. 10 - - - - - - - - Pancreas 9 - - - - - - - - Nose, sinuses etc. 1 - - - - - - - - Larynx 2 - - - - - - - - Trachea, Bronchus, Lung 13 - - - - - 4.6 - 2.9 Other Thoracic organs 3 - - - - - - - - Bone 22 - - 1.4 3.2 2.1 2.3 - 2.9 Melanoma of skin 0 - - - - - - - - Other skin 9 - - - - - 2.3 - - Mesothelioma 0 - - - - - - - - Kaposi sarcoma 0 - - - - - - - - Connective, Soft tissue 11 - 1.4 - 1.6 2.1 2.3 - 2.9 Breast 241 - - - - 4.2 13.7 28.9 57.8 Vulva 0 - - - - - - - - Vagina 3 - - - - - - - - Cervix Uteri 3 - - - - - - - - Corpus Uteri 9 - - - - - - - - Uterus unspec. 13 - - - - - 2.3 - - Ovary 35 - - - 1.6 2.1 - - 5.8 Other female genital 2 - - - - - - - 2.9 Placenta 1 - - - - - 2.3 - - Kidney 4 1.7 - - - - - 2.9 - Renal pelvis 1 - - - - - 2.3 - - Ureter 0 - - - - - - - - Bladder 22 1.7 - - 1.6 - - - 2.9 Other urinary organs 0 - - - - - - - - Eye 1 - - - - - - 2.9 - Brain, Nervous tissue 13 - 1.4 1.4 - 6.3 - 2.9 2.9 Thyroid 20 - - - - 2.1 - 5.8 5.8 Adrenal gland 1 1.7 - - - - - - - Other endocrine 1 - - - - - - - - Hodgkin disease 5 - - - 1.6 4.2 4.6 - - Non-Hodgkin lymphoma 6 - 1.4 - - 2.1 - - 2.9 Immunoproliferative dis. 0 - - - - - - - - Multiple myeloma 1 - - - - - - - - Lymphoid leukemia 9 9.9 1.4 1.4 1.6 - - - - Myeloid Leukemia 10 - - - 1.6 - - - 8.7 Leukemia unspec. 9 - 1.4 - 1.6 - - - 5.8 Other & unspecified 53 1.7 1.4 1.4 3.2 6.3 2.3 2.9 5.8 All sites Total 625 21.5 8.6 5.7 17.8 33.4 41.2 54.9 109.8 All sites but C44 616 21.5 8.6 5.7 17.8 33.4 38.9 54.9 109.8

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Table 2.4 (cont.): Age Specific Incidence Rates, Crude Rates and ASR (World), Females, Aswan, 2008

40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ Crude rate

ASR world

ICD (10th)

- - - 8.2 - - - - 0.2 0.3 C00 - - - - - - - - 0.0 0.0 C01-C02 - 8.3 - - 7.7 13.0 16.5 - 0.9 1.5 C03-C06 - - - - - 13.0 - - 0.2 0.4 C07-C08 - - - - - - - - 0.0 0.0 C09 - - - 8.2 - - - - 0.2 0.3 C10 - - - - - - - - 0.2 0.2 C11 - 4.1 6.1 - - 13.0 - - 0.6 0.9 C12-C13 - - - - - - - - 0.0 0.0 C14

3.8 - - 8.2 15.4 13.0 - - 1.1 1.6 C15 3.8 4.1 6.1 8.2 7.7 13.0 49.6 19.8 2.1 3.4 C16 - 4.1 6.1 - - - 16.5 - 0.6 0.9 C17

7.6 4.1 12.3 - 7.7 38.9 - 19.8 2.4 3.5 C18 - 4.1 - 8.2 7.7 - - 19.8 0.7 1.3 C19-C20 - - 6.1 - - - - - 0.2 0.3 C21

3.8 12.4 24.5 49.0 30.7 13.0 49.6 59.4 6.0 8.7 C22 3.8 4.1 6.1 24.5 15.4 13.0 16.5 - 1.9 3.1 C23-C24 - 4.1 6.1 - 7.7 - 49.6 19.8 1.7 2.3 C25

3.8 - - - - - - - 0.2 0.2 C30-C31 - - - - - - 16.5 19.8 0.4 0.7 C32 - 8.3 18.4 8.2 7.7 26.0 - 19.8 2.4 3.8 C33-C34 - - - - - 26.0 16.5 - 0.6 1.1 C37-C38

3.8 4.1 24.5 - 23.1 26.0 16.5 59.4 4.1 5.9 C40-C41 - - - - - - - - 0.0 0.0 C43

3.8 8.3 - - 7.7 - - 79.2 1.7 2.8 C44 - - - - - - - - 0.0 0.0 C45 - - - - - - - - 0.0 0.0 C46

7.6 4.1 6.1 - - - - 19.8 2.1 2.4 C47;C49 140.0 99.1 220.7 220.6 184.4 181.7 215.1 296.9 45.1 63.9 C50

- - - - - - - - 0.0 0.0 C51 - - - - 15.4 13.0 - - 0.6 1.0 C52 - 4.1 6.1 - 7.7 - - - 0.6 0.9 C53 - - - 24.5 30.7 - 16.5 19.8 1.7 2.9 C54

7.6 8.3 6.1 8.2 - 13.0 82.7 - 2.4 3.8 C55 15.1 16.5 49 65.4 - - 33.1 39.6 6.5 9.1 C56

- - - - - - - 19.8 0.4 0.6 C57 - - - - - - - - 0.2 0.2 C58 - - - - 7.7 13.0 - - 0.7 1.1 C64 - - - - - - - - 0.2 0.2 C65 - - - - - - - - 0.0 0.0 C66 - 12.4 - 24.5 23.1 51.9 16.5 79.2 4.1 6.6 C67 - - - - - - - - 0.0 0.0 C68 - - - - - - - - 0.2 0.2 C69

3.8 - 6.1 - - - 49.6 - 2.4 2.8 C70-C72 11.4 - 30.7 8.2 - - 16.5 39.6 3.7 4.5 C73

- - - - - - - - 0.2 0.2 C74 3.8 - - - - - - - 0.2 0.2 C75 - - - - - - - - 0.9 0.8 C81 - 4.1 - - 7.7 13.0 - - 1.1 1.6 C82-C85;C96 - - - - - - - - 0.0 0.0 C88 - - - - - - - - 0.2 0.0 C90 - - - - - - - - 1.7 1.8 C91 - - 6.1 16.3 - 26.0 - 19.8 1.9 2.8 C92-C94 - 4.1 6.1 8.2 7.7 - - - 1.7 2.0 C95

15.1 12.4 6.1 32.7 69.2 26.0 132.4 118.7 9.9 14.0 Other 238.4 235.3 459.8 531.1 491.9 545.1 810.7 969.7 116.9 166.8 All 234.6 227 459.8 531.1 484.2 545.1 810.7 890.6 115.2 164 All not C44

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Incidence Rates

For all cancer sites, C44 excluded, the ASR (world) was

140.7/100,000 males 164.0/100,000 females.

Incidence showed substantial increase with age for both males and females. The increase was more evident after the age of 49 with a peak of incidence in age group 75+ years (Figure 2.5).

Mean age at diagnosis for males was 53.9 years with a median age of 57. Mean age at diagnosis for females was 51.4 with a median age of 52.

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Fig. 2.5: Age Specific Incidence Rates of all Sites of Cancer per 100,000 Population,

Aswan, 2008

* C44 cases were excluded in the figure

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Distribution of registered cases by sources of data

During 2008, 1150 incident cancer cases were registered. The

majority of these cases was diagnosed and/or managed in Aswan Cancer Center (74.6%) followed by Aswan Health Insurance Hospital and National Cancer Institute in Cairo (5.7% and 5.4% respectively). South Egypt Cancer Institute in Assiut diagnosed 2.4% of cases. Few cases were registered from private clinics/labs (2.1%). The source of data was death certificates only (DCO) for 8.2% of cases. Some of these DCO cases might have been incident cases in years before 2008.

Distribution of cases by residence within the governorate is shown

in Figure 2.6 More cases were reported as residents in Aswan city when compared to expected numbers based upon population distribution by district. This could be attributed to misreporting of residence of patients managed in Aswan cancer center located in Aswan city. The possibility of under-reporting from districts without diagnostic facilities needs further investigation with increase in number of cases accessed to the registry in successive years.

Table 2.5: Sources of Data, Aswan, 2008

Source of Data Frequency (%) Aswan Cancer Center 858 74.6 Aswan Health Insurance Hospital 66 5.7 National Cancer Institute (Cairo) 62 5.4 Aswan Health Office (DCO) 32 2.8 Kom Ambo Health Office (DCO) 29 2.5 South Egypt Cancer Institute (Assiut) 28 2.4 Edfu Health Office (DCO) 26 2.3 Private Labs (Aswan) 20 1.7 57357 Children Cancer Hospital (Cairo) 13 1.1 Daraw Health Office (DCO) 5 0.4 Other clinics 5 0.4 Teaching Hospital (Aswan) 4 0.3 Nasr El-Noba Health Office (DCO) 2 0.2 Total 1150 100.0

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Fig. 2.6: Sources of Data of Incident Cases, Aswan, 2008

Fig. 2.7: Distribution of Population and Cancer Cases

Between Different Districts of Aswan, 2008

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Basis of Diagnosis Microscopic examination was the most definite basis of diagnosis for the majority of cancer sites with few exceptions. This was achieved in more than 50% of cases. For 5% of cases this was based upon microscopic basis other than histological examination. One fifth of cases were diagnosed by non microscopic methods mainly radiology or other imaging techniques. Diagnosis was clinical in less than 5% of cases. DCO was the basis of diagnosis in 8.2%. As the first year of registration, some of these cases might have been diagnosed before 2008.

Table 2.6: Basis of Diagnosis of Incident Cases, Aswan, 2008

Description Frequency (%)

Microscopic (55.2%) Histology 578 50.3 Cytology / no Histology 56 4.9 Microscopic Confirmation, method not specified 1 0.1

Non Microscopic (20.1%) Laboratory test / marker study 48 4.2 Direct visualization without microscopic confirmation 1 0.1

Radiography or other imaging techniques 146 12.7

Clinical only 36 3.1

Unknown and Death Certificate Only (24.7%) Death Certificate Only 94 8.2 Unknown 190 16.5

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Fig. 2.8: Basis of Diagnosis of Incident Cancer Cases, Aswan, 2008

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All cases of non Non-Hodgkin lymphoma and Myeloma and

immuno-proliferative diseases were diagnosed microscopically. Diagnosis of Hodgkin disease and leukemia was microscopic in about 85%. Microscopic diagnosis was achieved in less than 25% of cases of cancer of the liver and gall bladder and pancreas. Percent of microscopic diagnosis of frequent sites of cancer is shown in figure 2.9.

Table 2.7: Proportion of Microscopic Confirmation by Site and Sex for Main Cancer Sites, Aswan, 2008

Site Total (%)

Male (%)

Female (%)

Oral cavity and pharynx 66.7 70.4 58.3 Esophagus 67.9 59.1 100.0 Stomach 52.0 57.1 45.5 Small intestine 25.0 0.0 33.3 Colon and rectum 76.3 80.0 72.2 Liver and gall bladder 21.6 21.7 21.4 Pancreas 24.1 25.0 22.2 Nose, sinuses, larynx 59.3 62.5 33.3 Trachea, bronchus, lung 51.7 45.5 68.8 Bones and Joints 32.3 33.3 31.8 Skin, soft and connective tissue 67.4 73.9 60.0 Breast 71.7 66.7 71.8 Urinary bladder 73.6 72.3 77.3 Other urinary organs 61.5 75.0 40.0 Eye, brain and nervous tissue 43.2 40.0 50.0 Thyroid 50.0 100.0 40.0 Other endocrine 66.7 50.0 100.0 Hodgkin disease 84.6 75.0 100.0 Non-Hodgkin lymphoma 100.0 100.0 100.0 Myeloma and immuoproliferative dis. 100.0 100.0 100.0 Leukemia 85.9 83.3 89.3 Other and unspecified 18.4 18.0 18.9 All sites 55.2 52.0 57.9

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Fig. 2.9: Proportion of Microscopic Confirmation of Selected Sites, Aswan, 2008

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Staging of cancer The SEER staging system is the one usually used in cancer registry reports. Although this system is not as fashionable among clinicians as other staging systems mainly TNM; abstractors were able to stage more than 90% of cases according to SEER staging system.

Details of summary stage of registered cases are shown in table 2.8 that shows that localized disease was reported in 30% of cases only. As shown in figure 2.10, disease was regional in 26.4%, and distant in 23.6% of cases. For 26.4% of cases, it was not clear if the disease is an extension or a metastasis.

Table 2.8: Distribution of Incident Cases according to SEER Summary Staging, Aswan, 2008

Stage Frequency (%) In Situ 4 0.4 Localized only 310 29.8 Regional by direct extension only 68 6.5 Regional by lymph nodes(s) involved only 117 11.2

Regional by both direct extension and regional lymph node(s) involved 18 1.7

Regional, NOS 4 0.4 Distant site(s) / node(s) involved 246 23.6 Unknown if extension or metastases 275 26.4

Total 1042 100.0 * For 108 cases (9.4%), no data was available

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Fig. 2.10: Distribution of Incident Cancer Cases according to SEER Summary Staging, Aswan, 2008

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Part 3 Profile of Frequent Cancers

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This part deals with the more frequent cancers namely cancer of the

breast, liver, urinary bladder, leukemia, lung, brain, ovary, colorectal, prostate and bone. These cancers represented 62.1% of all malignancies in both genders together. Table 3.1 shows the proportion of different sites as percent of total and crude and age standardized (world) rates per 100,000. Breast cancer, though mainly a cancer of women, was still the most frequent for both genders together representing more than 1/5 of incident cases. It had the highest crude and age adjusted incidence rates (23.0 and 32.9 respectively).

Cancer of the liver, bladder and leukemia represented another 1/5 of cases for both genders together. Other cancers were much less frequent, each representing less than 5% of incident cases.

Selected sites of cancers are described in more details in this part.

For each site a brief overview of its epidemiologic features is given based mainly upon WHO publication of “World Cancer Report”, 2008. This is followed by registry results.

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Table 3.1: The more Frequent Cancers, Both Sexes,

Aswan, 2008 (1150 Cases)

Site Frequency % of Total

Total Crude Rate

ASR (World)

Breast (C50) 247 21.5 23.0 32.9 Liver (C22) 94 8.2 8.8 13.1 Bladder (C67) 87 7.6 8.1 12.6 Leukemia (C91-C95) 64 5.6 6.0 7.3 Lung (C34) 52 4.5 4.8 7.5 Brain (C70) 39 3.4 3.6 4.6 Ovary (C56) 35 3.0 3.3 4.5 Colorectal (C18-C20) 35 3.0 3.2 4.9 Prostate (C61) 31 2.7 2.9 4.6 Bone (C40-C41) 31 2.7 2.9 4.0 Total 715 62.1 66.6 96.0

Fig. 3.1: Proportions of the more Frequent Cancers, Both Sexes,

Aswan, 2008 (1150 Cases)

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The more Frequent Cancers in Males

Among males, bladder and liver cancer occupied the top 2 ranks with almost same frequency and very close crude and age standardized rates. They both represented approximately ¼ of incident cancer cases. Another ¼ of incident cancers was represented by lung, leukemias, prostate, and brain. The 6 cancers represented almost half incident cancer cases. The 10 more frequent cancers included also the esophagus, larynx, pancreas and colorectal cancer; each with a proportion less than 5%. They all represented 64.8% of male incident cancers (Table 3.2 and Figure 3.2).

Table 3.2: The more Frequent Cancers, Males,

Aswan, 2008 (525 Cases)

Site Frequency % of Total

Crude* Rate

ASR*

(World) Bladder (C67) 65 12.4 12.0 18.6

Liver (C22) 62 11.8 11.5 17.4

Lung (C34) 39 7.4 7.2 11.2

Leukemia (C91-C95) 36 6.9 6.7 7.8

Prostate (C61) 31 5.9 5.7 9.2

Brain (C70-C72) 26 5.0 4.8 6.3

Esophagus (C15) 22 4.2 4.1 5.7

Larynx (C32) 21 4.0 3.9 6.0

Pancreas (C25) 20 3.8 3.7 5.7

Colorectal (C18-C20) 18 3.4 3.3 5.0

* Rates are expressed per 100,000 population

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Fig. 3.2: Percentage of the Ten Most Frequent Cancers, Males, Aswan, 2008 (525 Cases)

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The more Frequent Cancers in Females Cancers represented in the table of the more frequent cancers in

females represented 74.4% of females’ incident cancers. These cancers were cancer of the breast, ovary, liver, leukemia, urinary bladder, bone, uterus, thyroid, colorectum, lung and brain (Table 3.3 and Figure 3.3).

Breast cancer was by far the most frequent cancer among females representing approximately 40% of all incident cancers. Frequency of all other cancers did not exceed 5% each except for cancers of the ovary and liver that were around 5% (5.6% and 5.1% respectively).

Incidence rates of breast cancer, both crude and age-standardized, were high compared to all other cancers being almost 6-7 times the rates of ovary and liver cancer. Rates of other cancers did not exceed 5/100,000.

Table 3.3: The more Frequent Cancers, Females,

Aswan, 2008 (625 Cases)

Site Frequency % of Total

Crude* Rate

ASR*

(World) Breast (C50) 241 38.6 45.1 63.9

Ovary C56) 35 5.6 6.5 9.1

Liver (C22) 32 5.1 6.0 8.7

Leukemia (C91-C95) 28 4.5 5.3 6.6

Bladder (C67) 22 3.5 4.1 6.6

Bone (C40-C41) 22 3.5 4.1 5.9

Uterus (C54-C55) 22 3.5 4.1 5.9

Thyroid (C73) 20 3.2 3.7 4.5

Colorectal (C18-C20) 17 2.7 3.1 4.8

Lung (C33-C34) 13 2.1 2.4 3.8

Brain (C70-C72) 13 2.1 2.4 2.8

* Rates are expressed per 100,000 population

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Fig. 3.3: Percentage of the Most Frequent Cancers, Females, Aswan, 2008 (625 Cases)

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Changes in frequency of cancer by age

Figures 3.4 and 3.5 indicate the change in frequency of different sites of cancer by age. These changes reflect the age specific incidence rates by 5-year age groups detailed in subsequent sections. However, due to the limited number of cases for some sites of cancer and in certain age groups, it becomes necessary to add together some age groups. In this section, frequency of different cancers is shown in four 20-year age groups.

Below the age of 20 years the difference between the 2 genders

was not marked. The most frequent cancer was leukemia accounting for more than 1/3 of cancers in this age group. Cancer of the brain and nervous system accounted for 1/10 of cases. Cancer of bones and joints and Hodgkin’s disease accounted for around 5% each. These sites represented together about 2/3 of cases below the age of 20 years. Change by age in males In the age group 20-40 years, there was a marked decrease in frequency of leukemia to 16.3%. This was reflected on the frequency cancer of the brain and nervous system and bones that increased to 16.3% and 10.2% respectively. The frequency of cancer of the lung and colorectum became equal to that of liver cancer. After the age of 40, cancer of the liver and the urinary bladder were the most frequent cancers, representing together 25-30% of male cancers. Lung cancer accounted for 9.6% and 7.1% of male cancer in the age groups 40-60 and 60+ years respectively. Prostate cancer was as frequent as liver cancer after the age of 60, around 12% each.

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Fig. 3.4: The most frequent Cancers in Males by age, Aswan, 2008

Age 0-19 (46 cases) Age 20-39 (49 cases)

Age 40-59 (188 cases)

Age 60+ (225 cases)

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Change by age in females

As in males, the most frequent cancer below the age of 20 was leukemia. After the age of 20 years, breast cancer became the most frequent cancer with a peak in the age group 40-59 years. This high frequency of breast cancer masked the possible change in frequency of other cancer with the available cases (Figure 3.5). 3- Profile of frequent cancers

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Fig. 3.5: The most frequent Cancers in Females by age,

Aswan, 2008

Age 0-19 (34 cases) Age 20-39 (91 cases)

Age 40-59 (260 cases)

Age 60+ (204 cases)

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Breast Cancer (C50) Introduction

Breast cancer generally refers to a malignancy in women that arises from the terminal ductal-lobular units of epithelial tissue, which in the mature breast represent 10% of the total volume. Nonetheless, very few breast cancer cases appear in men with extremely low incidence worldwide.

Breast cancer is the most common cancer among women

worldwide. It was estimated that during 2002, more than 1,050,000 cases developed worldwide annually with nearly 580,000 incident cases occurred in developed countries and the remainder in developing countries. Breast cancer is also the most important cause of neoplastic deaths among women. The estimated number of deaths in 2002 was 410,000 worldwide. In terms of absolute numbers, the greatest contribution is now from developing countries.

The incidence of breast cancer has grown rapidly during the last decades in many developing countries, and slowly in developed countries. Mortality rates have remained fairly stable between 1960 and 1990 in most of Europe and the Americas, and then showed appreciable declines, which have reached 25-30% in northern Europe.

The incidence increases linearly with age up to menopause, after which increase is less marked, or almost absent in developing countries.

Figure 3.6 shows the incidence rates of female breast cancer

worldwide as mentioned in GLOBOCAN 2002.

Incidence Rates Breast cancer was the most frequent cancer among Aswan females,

accounting for 241 cases in 2008. It represented 38.6% of all newly diagnosed female cancers. Male breast cancer was rare, representing only 2.4% of all incident breast cancer (Table 3.4).

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Fig. 3.6: Incidence of Female Breast Cancer, GLOBOCAN 2002

Table 3.4: Breast Cancer Frequency and Crude and Age Standardized Rates (world) per 100,000 Population by Sex,

Aswan, 2008

Sex Frequency % of Total Crude Rate ASR (World)

Both sexes 247 21.5 23.0 32.9 Males 6 1.1 1.1 1.8

Females 241 38.6 45.1 63.9

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The ASR (world) was 63.9 for female population (Figure 3.7). The

highest rates were observed in the age group 50-59 years. The age standardized rates leveled to a plateau afterwards.

It appears that the incidence rate mentioned in GLOBOCAN 2002

is lower than what was noticed in Aswan, 2008.

Table 3.5: Number & Age Specific Incidence Rates of female Breast Cancer per 100,000 Population by 5-Year Age Groups,

Aswan, 2008

Age Group Females No. ASIR

< 20 0 - 20-24 2 4.2 25-29 6 13.7 30-34 10 28.9 35-39 20 57.8 40-44 37 140.0 45-49 24 99.1 50-54 36 220.7 55-59 27 220.6 60-64 24 184.4 65-69 14 181.4 70-74 13 181.7 75+ 15 215.1

Total 241 45.1* * Crude Incidence Rate/100,000

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Fig. 3.7: Age Specific Incidence Rates of Breast Cancer per 100,000 Population for each Sex, Aswan, 2008

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Laterality

Laterality was mentioned in 80.1% of registry records. Almost half of the lesions with known laterality (52.3%) affected the left breast. The right breast was affected in 47.2% of cases. In 0.5% of cases the lesions were bilateral (Figure 3.8).

Site Distribution

Site distribution within the breast was not mentioned in 75.1% of cases. Among cases with known subsite distribution (60 cases; 24.9%) the upper outer quadrant of the breast was the commonest location (46.7%) followed by the central portion (15%), lower outer quadrant (13.3%), upper inner quadrant (10%), overlapping lesion (6.7%) and axillary tail (5%). The lowest proportion was the nipple and areola in 1.7% and lower inner quadrant in 1.7% (Table 3.6).

Table 3.6: Subsite Distribution of Female Breast Cancer,

Aswan, 2008

Subsite Frequency % Upper-outer quadrant (C50.4) 28 46.7 Central portion (C50.1) 9 15.0 Lower-outer quadrant (C50.5) 8 13.3 Upper-inner quadrant (C50.2) 6 10.0 Overlapping lesion (C50.8) 4 6.7 Axillary tail (C50.6) 3 5.0 Nipple & areola (C50.0) 1 1.7 Lower-inner quadrant (C50.3) 1 1.7 Total 60 100

* 181 cases were breast, NOS (C50.9) representing 75.1% of total

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Fig. 3.8: Laterality Distribution of Female Breast Cancer, Aswan, 2008

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Basis of Diagnosis

The number of cases with available microscopic diagnosis was 173 (71.8%). Non microscopic basis of diagnosis was rare (clinical; 1.7%, radiological; 2.9%). In 23.6% of cases, diagnosis was either unknown or was based on death certificate only (DCO) (Table 2.7 and Figure 3.9). Pathological Diagnosis

Infiltrating duct carcinoma was the most predominant histological type constituting 76.4% of cases, followed by mixed infiltrating duct and lobular carcinoma (5.7%), lobular carcinoma (2.9%) and carcinoma NOS (2.3%). Proportion of 1.7% was observed for mucinous adenocarcinoma, comedo-carcinoma, medullary-carcinoma and mixed infiltrating duct carcinoma. Paget’s disease and other cancers represented 5.7% of all pathological diagnoses (Table 3.7).

Table 3.7: Pathological Diagnosis of Female Breast Cancer,

Aswan, 2008

Morphology Frequency % Infiltrating duct carcinoma, NOS (M 8500/3) 133 76.4 Infiltrating duct and lobular carcinoma (M 8522/3) 10 5.7 Lobular carcinoma, NOS (M 8520/3) 5 2.9 Carcinoma, NOS (M 8010/3) 4 2.3 Mucinous adenocarcinoma (M 8480/3) 3 1.7 Comedocarinoma, NOS (M 8501/3) 3 1.7 Medullary carcinoma, NOS (M 8510/3) 3 1.7 Infiltrating duct mixed with other types of carcinoma (M 8523/3) 3 1.7 Paget disease, mammary (M 8540/3) 2 1.1 All others 8 4.6 Total 174 100

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Fig. 3.9: Basis of Diagnosis of Female Breast Cancer, Aswan, 2008

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Grade at Diagnosis

Tumor grade was mentioned in 66% of registry records (159/241). The majority of cases were grade II and III (81.1% and 15.1%). Low proportions were recorded for grade I (3.1%) and grade IV (0.6%) (Figure 3.10). Stage at Diagnosis

SEER stage at diagnosis was available for 179 cases (74.3%). Early staged lesions, namely in situ and localized, constituted 38% of cases. Regional disease constituted 48.6% (regional by direct extension; 8.7%, regional by lymph nodes; 38.8% and regional by both, 1.6%). Metastatic lesions were reported for 13.4% of all lesions with known stage at diagnosis (Figure 3.11).

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Fig. 3.10: Grade Distribution of Female Breast Cancer, Aswan, 2008 (241 Cases)

Fig. 3.11: Stage Distribution of Female Breast Cancer, Aswan, 2008 (241 Cases)

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Liver Cancer (C22) Introduction

Worldwide, about 560,000 new cases of liver cancer, usually hepatocellular carcinoma occur annually. It accounts for approximately 6% of all new cancer cases diagnosed worldwide; ranking the fifth most common cancer among men and the eighth in women. The highest incidence rates are recorded in China (55% of the world total), Japan, South East Asia and Sub-Saharan Africa. Liver cancer contributes significantly to cancer mortality all over the world and ranks third amongst the organ-specific causes of cancer-related deaths in men.

Globally, men are about three times as likely as women to be

afflicted and the difference is higher in high-incidence than low incidence areas. Liver cancer is a major health problem in low-resource countries, where more than 80% of the worldwide total occurs (over 500,000 new annual cases).

Figure 3.12 shows the incidence rates of liver cancer as mentioned

in GLOBOCAN 2002. Incidence Rates

Over 2008, 94 liver cancer cases were registered. These cases were 62 males and 32 females with male to female ratio of 1.9:1. They represented 8.2% of all incident cancers, accounting for 11.8% and 5.1% of male and female cancers respectively (Table 3.8). Liver cancer ranked second in males and third in females.

Mean age at diagnosis in males was 56.8 years with a median of 59 years. Mean age at diagnosis in females was 54.5 with a median of 56 years.

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Fig. 3.12: Incidence of Liver Cancer, GLOBOCAN 2002

Table 3.8: Frequency and Crude and Age-standardized Incidence Rates of Liver Cancer per 100,000 by Sex,

Aswan, 2008

Sex Frequency % of Total Crude Rate ASR (World)

Both sexes 94 8.2 8.8 13.1 Males 62 11.8 11.5 17.4

Females 32 5.1 6.0 8.7

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The ASR (world) was 17.4/100,000 for male population and

8.7/100,000 for female population (Figure 3.13). Early onset of the disease was observed mainly in males. The highest age-specific incidence rate was observed in the age group 75+ years in both males and females.

It appears that incidence mentioned by GLOBOCAN 2002 is lower

than what was noticed in Aswan, 2008.

Table 3.9: Frequency and Age Specific Incidence Rates of Liver Cancer per 100,000 Population by 5-Year Age Groups and Sex,

Aswan, 2008

Age Group Males Females No. ASIR No. ASIR

0-4 2 3.2 2 3.3 5-9 0 - 0 -

10-14 0 - 0 - 15-19 1 1.5 0 - 20-24 0 - 0 - 25-29 0 - 1 2.3 30-34 1 3.0 1 2.9 35-39 2 6.3 0 - 40-44 1 4.0 1 3.8 45-49 7 30.8 3 12.4 50-54 10 66.1 4 24.5 55-59 8 59.6 6 49.0 60-64 11 78.0 4 30.7 65-69 6 56.8 1 13.0 70-74 6 85.4 3 49.6 75+ 6 101.8 3 59.4

Total 62 11.5* 32 6.0* * Crude Incidence Rate/100,000

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Fig. 3.13: Age Specific Incidence Rates of Liver Cancer per 100,000 Population for each Sex, Aswan, 2008

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Basis of Diagnosis

The number of cases with available microscopic diagnosis was 17 (18.1%). For cases with non microscopic diagnosis, radiological and specific markers were the most frequent basis of diagnosis in 26.6% and 25.5% of cases respectively. Clinical diagnosis was rare (2.1%). In the remaining cases (27.7%), basis of diagnosis was DCO or unknown (Table 2.7 and Figure 3.14) Pathological Diagnosis

Hepatocellular carcinoma was the most predominant histological type (89.2%), followed by adenocarcinoma (3.1%), then scirrhous carcinoma, adenocarcinoma and cholangiocarcinoma, hepatoblastoma and others (1.5% each) (Table 3.10).

Table 3.10: Pathological Diagnosis of Liver Cancer, Aswan, 2008

Morphology Frequency % Hepatocellular carcimoma, NOS (M 8170/3) 58 89.2 Adenocarcinoma, NOS (M8140/3) 2 3.1 Scirrhous adenocarcinoma (M 8141/3) 1 1.5 Cholangiocarcinoma (M 8160/3) 1 1.5 Hepatocellular carcinoma, clear cell type (M 8174/3) 1 1.5 Hepatoblastoma (M 8970/3) 1 1.5 All others 1 1.5 Total 65 100

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Fig. 3.14: Basis of Diagnosis of Liver Cancer, Aswan, 2008

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Stage at Diagnosis

Stage at diagnosis was recorded for 48 cases (57.1%) of which 83.3% were localized tumors. Regional disease constituted only 4.2% (regional by direct extension), whereas metastatic lesions constituted 12.5% of all lesions with known stage at diagnosis (Figure 3.15). 3- Profile of frequent cancers

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Fig. 3.15: Stage Distribution of Liver Cancer, Aswan, 2008 (87 Cases)

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Bladder Cancer (C67) Introduction

Bladder cancer is the ninth most common cancer worldwide. It accounts for approximately two-thirds of all urinary tract cancers. According to WHO estimate in World Cancer report, 2003; approximately 336,000 new cases occurred in 2000, two-thirds of which were in developed countries. Incidence and mortality rise sharply with age and about two-thirds of cases occur in people over the age of 65. The male to female ratio is approximately 3:1. About 132,000 people each year die from bladder cancer. Men throughout the world have a mortality rate of 10 per 100,000 population, and women 2.4. These values nearly double for developed countries.

In Egypt, the situation of bladder cancer is very special. It has been

and still is the most frequent malignancy among males and had always been related to schistosomal infestation. The picture is currently changing with almost complete eradication of the parasite. The main etiologic factor is no more schistosomal infection. Nevertheless, it is still the most frequent cancer among males.

Figure 3.16 shows the incidence rates of bladder cancer as

mentioned in GLOBOCAN 2002. Incidence Rates

Over 2008, 87 bladder cancer cases were registered. These cases were 65 males and 22 females with male to female ratio of 3:1. They represented 7.6% of all incident cancers, accounting for 12.4% and 3.5% of male and female cancers respectively (Table 3.11). Bladder cancer ranked first in males and fifth in females.

Mean age at diagnosis in males was 64.9 years with a median of 65 years. Mean age at diagnosis in females was 58.0 with a median of 62 years.

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Fig. 3.16: Incidence of Bladder Cancer, GLOBOCAN 2002

Table 3.11: Frequency and crude and Age standardized Incidence Rates of Bladder Cancer per 100,000 Population,

Aswan, 2008

Sex Frequency % of Total Crude Rate ASR (World)

Both sexes 87 7.6 8.1 12.6

Males 65 12.4 12.0 18.6

Females 22 3.5 4.1 6.6

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The ASR (world) was 18.6/100,000 for male population and 6.6/100,000 for female population (Figure 3.17). Disease starts around the age of 45 years and continued to increase steadily. The highest rate was observed in the age group 75+ years in males and females. Male predominance is marked.

Table 3.12: Number & Age Specific Incidence Rates of Bladder Cancer per 100,000 Population by 5-Year Age Groups and Sex,

Aswan, 2008

Age Group Males Females No. ASIR No. ASIR

0-4 0 - 1 1.7 5-9 0 - 0 -

10-14 0 - 0 - 15-19 0 - 1 1.6 20-24 0 - 0 - 25-29 1 2.6 0 - 30-34 0 - 0 - 35-39 0 - 1 2.9 40-44 0 - 0 - 45-49 4 17.6 3 12.4 50-54 7 46.3 0 - 55-59 10 74.5 3 24.5 60-64 7 49.6 3 23.1 65-69 11 104.2 4 51.9 70-74 9 128.2 1 16.5 75+ 13 220.5 4 79.2

Total 65 12.0* 22 4.1* * Crude Incidence Rate/100,000

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Fig. 3.17: Age Specific Incidence Rates of Bladder Cancer per 100,000 Population for each Sex, Aswan, 2008

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Topographical Diagnosis Location of tumors within the bladder was mentioned in 27 cases

(31%). Out of these cases, overlapping lesions were the commonest (40.7%), followed by lateral wall (18.5%), anterior wall (18.5%), posterior wall (7.4%), bladder neck (7.4%), trigone (3.7%) and dome of bladder (3.7%) as shown in table 3.13 Basis of Diagnosis

About 73.6% of cases were diagnoses microscopically (Table 2.7 and Figure 3.18). Pathological Diagnosis

Transitional cell carcinoma (all forms) was the most predominant histological type, constituting 80%, followed by squamous cell carcinoma (16.9%) and adenocarcinoma (1.5%) (Table 3.14).

Table 3.13: Subsite Distribution of Bladder Cancer, Aswan, 2008

Subsite Frequency % Overlapping lesion of bladder (C67.8) 11 40.7 Lateral wall of bladder (C67.2) 5 18.5 Anterior wall of bladder (C67.3) 5 18.5 Posterior wall of bladder (C67.4) 2 7.4 Bladder neck (C67.5) 2 7.4 Trigone of bladder (C67.0) 1 3.7 Dome of bladder (C67.1) 1 3.7 Total 27 100 % * 60 cases were Bladder, NOS (C67.9) representing 69.0% of total

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Fig. 3.18: Basis of Diagnosis of Bladder Cancer, Aswan, 2008

Table 3.14: Pathological Diagnosis of Bladder Cancer, Aswan, 2008

Morphology Frequency % Transitional cell carcinoma, NOS (M 8120/3) 52 80.0 Squamous cell carcinoma, NOS (M 8070/3) 11 16.9 Adenocarcinoma, NOS (M-8140) 1 1.5 Embryonal rhabdomyosarcoma, NOS (M 8910/3) 1 1.5 Total 65 100

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Grade at Diagnosis Tumor grade was mentioned in 66.7% of registry records (58/67).

The majority of cases were grade II and III (24.1% and 58.6% respectively). Low proportion was recorded in grade I and grade IV (8.6% each) (Figure 3.19). Stage at Diagnosis

Stage at diagnosis was recorded for 57 cases (66.5%). Early staged lesions namely localized constituted 56.1%. Regional disease constituted 35.1% (regionally by direct extension; 22.8%; regional by lymph nodes; 5.3% and regional by both; 7%), whereas metastatic lesions represented 8.8% of cases (Figure 3.20). No cases of in situ tumors were diagnosed in Aswan, 2008.

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Fig. 3.19: Grade Distribution of Bladder Cancer, Aswan, 2008 (87 Cases)

Fig. 3.20: Stage Distribution of Bladder Cancer, Aswan, 2008 (87 Cases)

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Leukemia (C91-C95) Introduction

Acute lymphoblastic leukemia is the most common childhood cancer, while over 80% of lymphoid leukemias occurring in adulthood are chronic lymphocytic leukemia. Incidence rates for chronic lymphocytic leukemia are difficult to interpret because it is often diagnosed incidentally or in the course of evaluating other conditions. Differences in medical care may therefore substantially bias incidence data. Bearing this possible ascertainment bias in mind, the highest rates of lymphoid leukemias are observed in areas of Canada, the USA, Western Europe and Oceania, and the lowest rates are in South America, the Caribbean, Asia and Africa. Rates tend to be lower in females although the male: female ratio is usually less than 2. Some increase in leukemia over time has been reported, although the extent to which these represent real increases in incidence is unclear. Some increasing incidence trends have been reported for both chronic and acute myeloid leukemia, although these are not consistent and may simply reflect changes in clinical practice.

Figure 3.21 shows the worldwide incidence rates of leukemia as

mentioned in GLOBOCAN 2002. Incidence Rates

Over 2008, 64 leukemia cases were registered. These cases were 36 males and 28 females with male to female ratio of 1.3:1. They represented 5.6% of all incident cancers, accounting for 6.9% and 4.5% of male and female cancers respectively (Table 3.15). Leukemia ranked fourth in males and females.

Mean age at diagnosis in males was 24.8 years with a median of 20 years. Mean age at diagnosis in females was 32.6 with a median of 36 years.

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Fig. 3.21: Incidence of Leukemia, GLOBOCAN 2002

Table 3.15: Frequency and Crude and Age standardized Incidence Rates of Leukemia per 100,000 Population,

Aswan, 2008

Sex Frequency % of Total Crude Rate ASR (World)

Both sexes 64 5.6 6.0 7.3 Males 36 6.9 6.7 7.7

Females 28 4.5 5.2 6.6

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The ASR (world) was 7.7/100,000 for male population and 6.6/100,000 for female population (Figure 3.22).

Figure 3.21 shows the incidence rates of leukemia as mentioned in GLOBOCAN 2002. It appears that this incidence is lower than what was noticed in Aswan, 2008. Table 3.16: Frequency and Age Specific Incidence Rates of Leukemia per 100,000 Population by 5-Year Age Groups and Sex,

Aswan, 2008

Age Group Males Females No. ASIR No. ASIR

0-4 8 12.7 6 9.9 5-9 6 8.2 2 2.9

10-14 0 - 1 1.4 15-19 2 3.1 3 4.8 20-24 6 14.9 0 - 25-29 0 - 0 - 30-34 1 3.0 0 - 35-39 1 3.2 5 14.4 40-44 1 4.0 0 - 45-49 1 4.4 1 4.1 50-54 3 19.8 2 12.3 55-59 0 - 3 24.5 60-64 1 7.1 1 7.7 65-69 1 9.5 2 26.0 70-74 2 28.5 0 - 75+ 0 - 1 19.8

Total 36 6.7* 28 5.2* * Crude Incidence Rate/100,000

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Fig. 3.22: Age Specific Incidence Rates of Leukemia per 100,000

Population for each Sex, Aswan, 2008

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Basis of Diagnosis

About 85.9% of cases were diagnosed microscopically (Table 2.7 and Figure 3.23). Pathological Diagnosis

Acute lymphoblastic leukemia (ALL) was the most predominant histological type, constituting 44.1%, followed by acute myeloid leukemia (16.9%) and chronic myeloid leukemia (13.6%). Other types were rare (Table 3.17).

Table 3.17: Pathological Diagnosis of Leukemia, Aswan, 2008

Morphology Frequency % Acute lymphoblastic leukemia 26 44.1 Acute myeloid leukemia 10 16.9 Chronic myeloid leukemia 8 13.6 Acute myelomonocytic leumkemia 2 3.4 Leukemia, NOS 1 1.7 Acute leukemia, NOS 1 1.7 Hairy cell leukemia 1 1.7 Other leukemias 10 16.9 Total 59 100

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Fig. 3.23: Basis of Diagnosis of Leukemia, Aswan, 2008

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Lung Cancer (C34) Introduction

Lung cancer was a rare disease until the beginning of the twentieth century. Since then, its occurrence has increased rapidly. This neoplasm has become the most frequent malignant neoplasm among men in most countries and represents the most important cause of cancer death worldwide. It accounts for an estimated 960 000 new cases among men and 340,000 cases among women. The deaths amounted to 850 000 deaths each year among men, and 230,000 deaths among women. Survival from lung cancer is poor (< 15% at five years). In most countries, lung cancer incidence is greater in lower socioeconomic classes. This pattern is largely explained by differences in the prevalence of smoking.

Figure 3.24 shows the incidence rates of lung cancer as mentioned

in GLOBOCAN 2002. Incidence Rates

Over 2008, 52 lung cancer cases were registered. These cases were 39 males and 13 females with male to female ratio of 3:1. They represented 4.5% of all incident cancers, accounting for 7.4% and 2.1% of male and female cancers respectively (Table 3.18). Lung cancer ranked third in males and tenth in females.

Mean age at diagnosis in males was 55.8 years with a median of 55 years. Mean age at diagnosis in females was 51.0 with a median of 52 years.

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Fig. 3.24: Incidence of Lung Cancer, GLOBOCAN 2002

Table 3.18: Frequency and Crude and Age standardized Incidence Rates of Lung Cancer per 100,000 Population,

Aswan, 2008

Sex Frequency % of Total Crude Rate ASR (World)

Both sexes 52 4.5 4.8 7.5 Males 39 7.4 7.2 11.2

Females 13 2.1 2.4 3.8

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The ASR (world) was 11.2/100,000 for males and 3.8/100,000 for

females (Figure 3.25). The highest rate was observed in the age group 75+ years in males and females.

Table 3.19: Number & Age Specific Incidence Rates of Lung Cancer per 100,000 Population by 5-Year Age Groups and Sex,

Aswan, 2008

Age Group Males Females No. ASIR No. ASIR

0-4 1 1.6 0 - 5-9 0 - 0 -

10-14 0 - 0 - 15-19 1 1.5 0 - 20-24 0 - 0 - 25-29 0 - 2 4.6 30-34 1 3.0 0 - 35-39 2 6.3 1 2.9 40-44 0 - 0 - 45-49 3 13.2 2 8.3 50-54 9 59.5 3 18.4 55-59 6 44.7 1 8.2 60-64 5 35.5 1 7.7 65-69 3 28.4 2 26.0 70-74 4 57.0 0 - 75+ 4 67.8 1 19.8

Total 39 7.2* 13 2.4* * Crude Incidence Rate/100,000

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Fig. 3.25: Age Specific Incidence Rates of Lung Cancer per 100,000 Population for each Sex, Aswan, 2008

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Laterality

Laterality was mentioned in 73.1% of registry records. About two thirds of the lesions (71.1%) affected the right lung, while the left lung was affected in 28.9% of cases (Figure 3.26).

Topographical Diagnosis

Location of lung tumors was mentioned in 22 cases (42.3%). Out of these cases, upper lobe lung lesions were the commonest (54.5%); followed by main bronchus lesions (18.2%), lower lobe (18.2%), middle lobe (9.1%), and overlapping lesions of lung (4.5%) as shown in table 3.20.

3- Frequent Cancer Sites

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Fig. 3.26: Laterality Distribution of Lung Cancer, Aswan, 2008 (52 Cases)

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Basis of Diagnosis

About 51.7% of cases were diagnosed microscopically (Table 2.7 and Figure 3.27) Pathological Diagnosis

Both adenocarcinoma, and squamous cell carcinoma, were the most predominant histological type (18.2% for each), followed by small cell carcinoma, and undifferentiated carcinoma (9.1% for each) and adenosquamous carcinoma (6.1%). The detailed distribution of different histological types is presented in Table 3.21.

Table 3.20: Subsite Distribution of Lung Cancer, Aswan, 2008

Subsite Frequency % Upper lobe, lung (C34.1) 11 54.5 Main bronchus (C34.0) 4 18.2 Lower lobe, lung (C34.3) 4 18.2 Middle lobe, lung (C34.2) 2 9.1 Overlapping lesion of lung (C34.8) 1 4.5 Total 22 100 %

* 30 cases were Lung, NOS (C34.9) representing 57.7% of total 3- Profile of frequent cancers

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Fig. 3.27: Basis of Diagnosis of Lung Cancer, Aswan, 2008

Table 3.21: Pathological Diagnosis of Lung Cancer, Aswan, 2008

Morphology Frequency % Adenocarcinoma, NOS (M 8140/3) 6 18.2 Squamous cell carcinoma, NOS (M 8070/3) 6 18.2 Small cell carcinoma, NOS (M 8041/3) 3 9.1 Carcinoma, undifferentiated, NOS (M 8020/3) 3 9.1 Adenosquamous carcinoma (M 8560/3) 2 6.1 Large cell carcinoma, NOS (M 8012/3) 1 3.0 Carcinoma, anaplastic, NOS (M 8021/3) 1 3.0 Transitional cell carcinoma, NOS (M 8120/3) 1 3.0 Carcinoid tumor, NOS (M 8240/3) 1 3.0 Papillary adenocarcinoma, NOS (M 8260/3) 1 3.0 Oxyphilic adenocarcinoma (M 8290/3) 1 3.0 All other 7 21.2 Total 33 100 %

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Grade at Diagnosis Tumor grade was mentioned in 30.8% of registry records (16/52).

The majority of cases were grade II, III and IV (31.3%, 37.5% and 25% respectively). Low proportion was grade I (6.3%). Stage at Diagnosis

Stage at diagnosis was recorded for 34 cases (65.4%). Metastatic lesions constituted 58.8%. Localized lesions constituted 23.5%, whereas regional lesions constituted 17.6% (regional by lymph nodes) as shown in figure 3.28.

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Fig. 3.28: Stage Distribution of Lung Cancer, Aswan, 2008 (52 Cases)

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Brain and Nervous System Cancer (C70-C72) Introduction

Worldwide, the age distribution of brain tumors is bimodal, with a peak incidence in children and a second larger peak in adults aged 45–70. In most developed countries, brain tumors are the 12th most frequent cause of cancer-related mortality in men.

The incidence of brain tumors is slightly higher in men than in women. During the last decades, incidence and mortality from brain tumors have increased in most developed countries, mainly in the older age groups. The increase in incidence was confined to the late 1970s and early 1980s and coincided with the introduction of improved diagnostic methods. Analysis of temporary trends in view of introduction of medical technologies and improved diagnosis of brain tumors shows that most if not all of the increase is attributable to (i) the introduction of high-resolution neuroimaging (e.g. CT Scan, Magnetic Resonance Imaging, PET Scan) in the last decades; (ii) variations in diagnostic and reporting procedures; and (iii) the brain as a frequent site of metastases, principally from breast and lung cancer. With more primitive imaging modalities, brain metastases may have been misclassified as primary brain tumor.

Figure 3.29 shows the incidence rates of brain cancer as mentioned

in GLOBOCAN 2002. Incidence Rates

Over 2008, 39 Brain and Nervous System cancer cases were registered. These cases were 26 males and 13 females with male to female ratio of 2:1. They represented 3.4% of all incident cancers, accounting for 5.0% and 2.1% of male and female cancers respectively (Table 3.22). Brain and Nervous System cancer ranked sixth in males and eleventh in females.

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Fig. 3.29: Incidence of Brain Cancer, GLOBOCAN 2002

Table 3.22: Frequency and Crude and Age Standardized Incidence Rates of Brain and Nervous System Cancer per 100,000 Population

Aswan, 2008

Sex Frequency % of Total Crude Rate ASR (World)

Both sexes 39 3.4 3.6 7.5 Males 26 5.0 4.8 6.3

Females 13 2.1 2.4 2.8

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Mean age at diagnosis in males was 36.2 years with a median of 37

years. Mean age at diagnosis in females was 38.8 with a median of 35 years.

The ASR (world) was 6.3/100,000 for male population and

2.8/100,000 for female population (Figure 3.30). The highest rate was observed in the age group 65-74 years in males and females.

Figure 3.29 shows the incidence rates of brain cancer as mentioned

in GLOBOCAN 2002. It appears that this incidence is lower than what was noticed in Aswan, 2008.

Table 3.23: Number and Age Specific Incidence Rates of Brain and Nervous System Cancer per 100,000 Population by 5-Year Age Groups

and Sex, Aswan, 2008

Age Group Males Females No. ASIR No. ASIR

0-4 1 1.6 0 - 5-9 3 4.1 1 1.4

10-14 1 1.3 1 1.4 15-19 1 1.5 0 - 20-24 2 4.3 3 6.3 25-29 3 7.9 0 - 30-34 1 3.0 1 2.9 35-39 2 6.3 1 2.9 40-44 0 - 1 3.8 45-49 1 4.4 0 - 50-54 5 33.1 1 6.1 55-59 3 22.3 0 - 60-64 0 - 0 - 65-69 0 - 0 - 70-74 2 28.5 3 49.6 75+ 0 - 0 -

Total 26 4.8* 13 2.4* * Crude Incidence Rate/100,000

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Fig. 3.30: Age Specific Incidence Rates of Brain and Nervous System Cancer per 100,000 Population for each Sex, Aswan, 2008

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Topographical Diagnosis

Location of brain tumors was mentioned in 23 cases (59%). Out of these cases, overlapping lesions of brain were the commonest (56.5%), followed by lesions in the cerebellum (17.4%), frontal lobe lesions (13.0%), followed by lesions in meninges, ventricles and brain stem (4.3% each) as shown in table 3.24 Basis of Diagnosis

About 57.1% of cases were diagnosed microscopically. The remaining cases were either diagnosed radiologically (35.7%) or clinically only (7.1%) as shown in Table 2.7 and Figure 3.31.

Table 3.24: Subsite Distribution of Brain and Nervous System Cancer, Aswan, 2008

Subsite Frequency % Overlapping lesion of brain (C71.8) 13 56.5 Cerebellum (C71.6) 4 17.4 Frontal lobe (C71.1) 3 13.0 Meninges, NOS (C70.9) 1 4.3 Ventricle, NOS (C71.5) 1 4.3 Brain stem (C71.7) 1 4.3 Total 23 100 %

* 16 cases were Brain, NOS (C71.9) representing 41.0% of total

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Fig. 3.31: Basis of Diagnosis of Brain and Nervous System Cancer, Aswan, 2008

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Pathological Diagnosis

Malignant gliomas were the most predominant histological type (15.4%), followed by astrocytoma, glioblastoma, medulloblastoma and malignant meningioma (11.5% for each). Details of pathological diagnosis are shown in Table 3.25.

Grade at Diagnosis

Tumor grade was mentioned in 30.8% of registry records (12/39). The majority of cases were grade II and IV (41.7% and 25% respectively). Low proportion was recorded in grade I and III (16.7%). Stage at Diagnosis

Stage at diagnosis was recorded for 27 cases (69.2%). Localized lesions constituted 92.6%. Regional by lymph nodes and metastatic lesions constituted 3.7% each (Figure 3.32).

Table 3.25: Pathological Diagnosis of Brain and Nervous System Cancer, Aswan, 2008

Morphology Frequency % Glioma, malignant (M 9380/3) 4 15.4 Astrocytoma, NOS (M 9400/3) 3 11.5 Glioblastoma, NOS (M 9440/3) 3 11.5 Medulloblastoma, NOS (M 9470/3) 3 11.5 Meningioma, malignant (M 9530/3) 3 11.5 Embryonal rhabdomyosarcoma, NOS (M 8910/3) 1 3.8 Gliomatosis cerebri (M 9381/3) 1 3.8 Mixed glioma (M 9382/3) 1 3.8 Ependymoma, NOS (M 9391/3) 1 3.8 Astrocytoma, anaplastic (M 9401/3) 1 3.8 Astroblastoma (M 9430/3) 1 3.8 Neuroblastoma, NOS (M 9500/3) 1 3.8 Meningothelial meningioma (M 9531/0) 1 3.8 Malignant lymphoma (M 9675/3) 1 3.8 All other 1 3.8 Total 26 100 %

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Fig. 3.32: Stage Distribution of Brain and Nervous System Cancer, Aswan, 2008 (38 Cases)

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Ovarian Cancer (C56) Introduction

Most malignant neoplasms of the ovary originate from the coelomic epithelium. Less frequent tumors originate from the germ cells (dysgerminomas and teratomas) and the follicular cells (granulosa cell tumors). In 2002 the estimated number of new cases worldwide was 204,000 with 125 000 cancer deaths, ranking ovarian cancer as the 6th most common cancer in women, and 7th most common cause of cancer death. High incidence rates (on the order of 10–12/100,000) are found in western and northern Europe and in North America; the lowest rates (<3/100 000) are from China and central Africa.

Figure 3.33 shows the incidence rates of ovarian cancer as

mentioned in GLOBOCAN 2002. Incidence Rates

Over 2008, 35 ovary cancer cases were registered in Aswan. They represented 5.6% of all incident female cancers. Ovary cancer ranked second in females.

Mean age at diagnosis was 51.1 years with a median of 52.5 years.

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Fig. 3.33: Incidence of Ovarian Cancer, GLOBOCAN 2002

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The ASR (world) was 9.1/100,000 for female population (Figure

3.34). The highest rate was observed in the age group 55-59 years. Figure 3.33 shows the incidence rates of ovary cancer as mentioned

in GLOBOCAN 2002. It appears that this incidence is lower than what was noticed in Aswan, 2008.

Table 3.26: Frequency, Crude and Age Standardized Incidence Rates of Ovarian Cancer per 100,000 Population,

Aswan, 2008

Age Group Females No. ASIR

0-4 0 - 5-9 0 -

10-14 0 - 15-19 1 1.6 20-24 1 2.1 25-29 0 - 30-34 0 - 35-39 2 5.8 40-44 4 15.1 45-49 4 16.5 50-54 8 49.0 55-59 8 65.4 60-64 0 - 65-69 0 - 70-74 2 33.1 75+ 2 39.6

Total 35 6.5* * Crude Incidence Rate/100,000

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Fig. 3.34: Age Specific Incidence Rates of Ovarian Cancer per 100,000

Population, Aswan, 2008

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Basis of Diagnosis About 85% of cases were diagnosed microscopically (Table 2.7

and Figure 3.36). Laterality

Laterality was mentioned in 42.9% of registry records. Sixty percent of the lesions affected the right ovary, while the left ovary was affected in 6.7% of cases. Bilateral lesions occurred in 33.3% of cases (Figure 3.35).

Pathological Diagnosis

About one third of cases were diagnosed as just malignant neoplasm (30.8%). Adenocarcinoma, papillary serous cyst-adenocarcinoma and malignant granulose cell tumor were diagnosed in 11.5% each. Details of pathological diagnosis are presented in Table 3.27.

Table 3.27: Pathological Diagnosis of Ovarian Cancer, Aswan, 2008

Morphology Frequency % Neoplasm, malignant (M 8000/3) 8 30.8 Adenocarcinoma, NOS (M 8140/3) 3 11.5 Papillary serous cystadenocarcinoma (M 8460/3) 3 11.5 Granulosa cell tumor, malignant (M 8620/3) 3 11.5 Carcinoma, undifferentiated, NOS (M 8020/3) 1 3.8 Transitional cell carcinoma, NOS (M 8120/3) 1 3.8 Adenocarcinoma in tubulovillus adenoma (M 8263/3) 1 3.8 Cystadenocarcinoma, NOS (M 8440/3) 1 3.8 Serous cystadenocarcinoma, NOS (M 8441/3) 1 3.8 Serous surface papillary carcinoma (M 8461/3) 1 3.8 Mucinous adenocarcinoma (M 8480/3) 1 3.8 Adenocarcinoma with squamous metaplasia (M 8570/3) 1 3.8 Mixed tumor, malignant, NOS (M 8940/3) 1 3.8 Total 26 100 %

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Fig. 3.35: Laterality Distribution of Ovarian Cancer, Aswan, 2008

Fig. 3.36: Basis of Diagnosis of Ovarian Cancer, Aswan, 2008

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Grade at Diagnosis

Tumor grade was mentioned in 28.6% of registry records (10/35). The majority of cases were grade II and III (40% each). Low proportion was recorded in grade I and IV (10% each). Stage at Diagnosis

Stage at diagnosis was recorded for 20 cases (57.1%). Distant lesions constituted 55% whereas localized lesions constituted 40%. Regional by direct spread constituted only 5% (Figure 3.37).

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Fig. 3.37: Stage Distribution of Ovarian Cancer, Aswan, 2008 (35 Cases)

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Colorectal Cancer (C18-C20) Introduction

Worldwide, incidence of colorectal cancer ranks fourth in men (after lung, prostate and stomach) and third in women, (after breast and cervix uteri), with over 1 million new cases occurring every year worldwide. The majority of cancers occurring in the colon and rectum are adenocarcinomas, which account for more than 90% of all large bowel tumors.

Figure 3.38 shows the incidence rates of colorectal cancer as

mentioned in GLOBOCAN 2002. Incidence Rates

Over 2008, 35 colorectal cancer cases were registered in Aswan registry. These cases were 18 males and 17 females with male to female ratio of 1.1:1. They represented 3.0% of all incident cancers, accounting for 3.4% and 2.7% of male and female cancers respectively (Table 3.28). Colorectal cancer ranked tenth in males and ninth in females.

Mean age at diagnosis in males was 55.3 years with a median of 57 years. Mean age at diagnosis in females was 54.6 with a median of 53.5 years.

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Fig. 3.38: Incidence of Colorectal Cancer, GLOBOCAN 2002

Table 3.28: Frequency and Crude and Age Standardized Incidence Rates of Colorectal Cancer per 100,000 Population,

Aswan, 2008

Sex Frequency % of Total Crude Rate ASR (World)

Both sexes 35 3.0 3.3 4.9 Males 18 3.4 3.3 5.0

Females 17 2.7 3.2 4.8

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The ASR (world) was 5.0/100,000 for male population and

4.8/100,000 for female population (Figure 3.39). The highest rate was observed in the age group 75+ years in males and females.

Table 3.29: Number & Age Specific Incidence Rates of Colorectal Cancer per 100,000 Population by 5-Year Age Groups and Sex,

Aswan, 2008

Age Group Males Females No. ASIR No. ASIR

0-4 0 - 0 - 5-9 0 - 0 -

10-14 0 - 0 - 15-19 1 1.5 0 - 20-24 0 - 1 2.1 25-29 2 5.3 0 - 30-34 0 - 1 2.9 35-39 1 3.2 0 - 40-44 0 - 2 7.6 45-49 1 4.4 2 8.3 50-54 2 13.2 2 12.3 55-59 3 22.3 1 8.2 60-64 1 7.1 2 15.4 65-69 2 18.9 3 38.9 70-74 3 42.7 0 - 75+ 2 33.9 2 39.6

Total 18 3.3* 17 3.2* * Crude Incidence Rate/100,000

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Fig. 3.39: Age Specific Incidence Rates of Colorectal Cancer per 100,000 Population for each Sex, Aswan, 2008

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Topographical Diagnosis

Location of tumor was mentioned in 25 cases (71.4%). Out of these cases, rectum lesions were the commonest (28%), followed by lesions in the sigmoid colon (24%), ascending colon (16%) and descending colon (8%). Lesions in cecum, hepatic flexure, transverse colon, splenic flexure, rectosigmoid and overlapping lesions occurred in 4% each as shown in table 3.30. Basis of Diagnosis

Microscopic diagnosis was available for 76.3% of cases (Table 2.7 and Figure 3.40).

Table 3.30: Subsite Distribution of Colorectal Cancer, Aswan, 2008

Subsite Frequency % Rectum, NOS (C20.9) 7 28.0 Sigmoid colon (C18.7) 6 24.0 Ascending colon (C18.2) 4 16.0 Descending colon (C18.6) 2 8.0 Cecum (C18.0) 1 4.0 Hepatic flexure of colon (C18.3) 1 4.0 Transverse colon (C18.4) 1 4.0 Splenic flexure of colon (C18.5) 1 4.0 Overlapping lesion of colon (C18.8) 1 4.0 Rectosigmoid junction (C19.9) 1 4.0 Total 25 100 %

* 10 cases were Colon, NOS (C18.9) representing 28.6% of total

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Fig. 3.40: Basis of Diagnosis of Colorectal Cancer, Aswan, 2008

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Pathological Diagnosis

About two thirds of cases were diagnosed as adenocarcinoma, NOS (60.6%). Detailed pathological diagnosis is presented in Table 3.31.

Grade at Diagnosis

Tumor grade was mentioned in 65.7% of registry records (23/35). The majority of cases were grade II (69.6%). Low proportion was recorded in grade III and I (26.1% and 4.3% respectively). Stage at Diagnosis

Stage at diagnosis was recorded for 26 cases (74.3%). Regional lesions constituted 57.7% (38.5% by lymph nodes, 11.5% by direct spread, 3.8% by both, and 3.8% NOS regional). Localized lesions constituted 23.1% of cases with known stage. Metastatic spread was reported for 19.2% of cases (Figure 3.41).

Table 3.31: Pathological Diagnosis of Colorectal Cancer, Aswan, 2008

Morphology Frequency % Adenocarcinoma, NOS (M 8140/3) 20 60.6 Neoplasm, malignant (M 8000/3) 7 21.2 Mucinous adenocarcinoma (M 8480/3) 4 12.1 Papillary adenocarcinoma, NOS (M 8260/3) 1 3.0 Signet ring cell carcinoma (M 8490/3) 1 3.0 Total 33 100 %

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Fig. 3.41: Stage Distribution of Colorectal Cancer, Aswan, 2008 (35 Cases)

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Prostate Cancer (C61)

Introduction

Urological cancers comprise approximately one third of all cancers diagnosed in men worldwide, and prostate cancer is the commonest of them all. The global burden of prostate cancer rose from 200,000 new cases each year in 1975 to reach an estimated 700,000 new cases in 2002. In Europe, it was estimated that in 2006 Prostate Cancer was the fourth commonest form of cancer diagnosed in men, with 345,900 new cases in 2006 and 87,400 deaths recorded.

Figure 3.42 shows the incidence rates of prostate cancer as

mentioned in GLOBOCAN 2002. Incidence Rates

Over 2008, 31 prostate cancer cases were registered. They represented 5.9% of all incident male cancers. Prostate cancer ranked fifth in males.

Mean age at diagnosis was 71.4 years with a median of 71.5 years.

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Fig. 3.42: Incidence of Prostate Cancer, GLOBOCAN 2002

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The ASR (world) was 9.2/100,000 for male population (Figure

3.43). The highest rate was observed in the age group 75+ years.

Table 3.32: Frequency, Crude and Age Standardized Incidence Rates of Prostate Cancer per 100,000 Population,

Aswan, 2008

Age Group Males No. ASIR

0-4 0 - 5-9 0 -

10-14 0 - 15-19 0 - 20-24 0 - 25-29 0 - 30-34 1 3.0 35-39 0 - 40-44 0 - 45-49 0 - 50-54 1 6.6 55-59 0 - 60-64 4 28.4 65-69 4 37.9 70-74 6 85.4 75+ 14 237.4

Total 31 5.7* * Crude Incidence Rate/100,000

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Fig. 3.43: Age Specific Incidence Rates of Prostate Cancer per 100,000 Population, Aswan, 2008

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Basis of Diagnosis About 52% of cases (16/31) were diagnosed microscopically,

whereas 40% of cases (12/31) were diagnosed by tumor marker studies (Table 2.8 and Figure 3.44). Pathological Diagnosis

About two thirds of cases (58.1%) were diagnosed as malignant neoplasms without mentioning the pathological diagnosis (18/31), whereas adenocarcinoma, NOS occurred in 25.8% of cases (8/31). Other diagnoses were less frequent, representing 16.1% (5/31).

Grade at Diagnosis

Tumor grade was mentioned in 22.6% of registry records (7/31). About half of cases were grade III (57.1). Low proportion was recorded in grade IV and II (28.6% and 14.3% respectively). Stage at Diagnosis

Stage at diagnosis was recorded for 22 cases (71%). Metastatic lesions constituted 50% (11/22 cases), whereas localized lesions constituted 45.5% (10/22). Regional lesions by both direct and lymph nodes spread constituted 4.5% (1/22) (Figure 3.45).

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Fig. 3.44: Basis of Diagnosis of Prostate Cancer, Aswan, 2008

Fig. 3.45: Stage Distribution of Prostate Cancer, Aswan, 2008 (31 Cases)

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Part 4 Less Frequent Cancers

Facts and Figures

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Table 4.1: Frequency, Rations and Rates of less Frequent Cancers, Aswan, 2008

Site Frequency % of Total

Crude Rate

ASR (World)

Bone (C40-C41) 31 2.7 2.9 4.0 Pancreas (C25) 29 2.5 2.7 4.0 Esophagus (C15) 28 2.4 2.6 3.7 Connective, Soft tissue (C47; C49) 28 2.4 2.6 3.3 Stomach (C16) 25 2.2 2.3 3.8 Thyroid (C73) 24 2.1 2.2 2.8 Larynx (C32) 23 2.0 2.1 3.4 Uterus (C54-C55) 22 1.9 2.0 3.3 Oral Cavity (C00-C06) 21 1.8 2.0 3.0 Gallbladder (C23-C24) 17 1.5 1.6 2.7 Skin, non-melanoma (C44) 15 1.3 1.4 2.3 Hodgkin disease (C81) 13 1.1 1.2 1.3 Non-Hodgkin lymphoma (C82-C85; C96) 13 1.2 1.9 1.9 Kidney and Renal Pelvis (C64-C65) 12 1.0 1.1 1.6

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Fig. 4.1: Incidence Rates of the less Frequent Cancers, Both sexes, Aswan, 2008

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Bone Cancer (C40-C41)

Frequency Total Cases

31

Sex Distribution Males Females Ratio

9

22 1:2.4

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

29.4 50.7

22.0 52.0

Topographical Diagnosis Known subsite Unknown subsite Bone, NOS Bone of limb, NOS

26 (83.9%)

3 (9.7%) 2 (6.4%)

Subsite Distribution Long bones of lower limb Bones of skull and face Mandible Pelvic bones Long bones of upper limb Short bones of upper limb Overlapping lesion Vertebral column Rib, sternum, clavicle Total (known subsites)

7 (26.9%) 4 (15.4%) 4 (15.4%) 4 (15.4%) 3 (11.5%)

1 (3.8%) 1 (3.8%) 1 (3.8%) 1 (3.8%)

26 (100%)

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Pathological Diagnosis Mentioned Not mentioned Osteosarcoma Ewing sarcoma All others Total

14 (45.2%) 17 (54.8%)

4 (28.6%) 3 (21.4%) 7 (50.0%)

14 (100%)

Stage at Diagnosis Mentioned Not mentioned

17 (75.9%) 14 (24.1%)

Stage Distribution Localized Distant

10 (58.8%)

7 (41.2%)

Fig. 4.2: Age Specific Incidence Rates of Bone Cancer Per 100,000 Population, Aswan, 2008 (31 cases)

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Pancreatic Cancer (C25)

Frequency Total Cases

29

Sex Distribution Males Females Ratio

20 9

2.2:1

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

55.0 65.9

55.0 72.0

Topographical Diagnosis Known subsite Unknown subsite Pancreas, NOS

21(69.9%)

8 (30.1%)

Subsite Distribution Head of pancreas Body of pancreas Overlapping lesion Total (known subsites)

19 (90.5%)

1(4.8%) 1 (4.8%)

21 (100%)

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Pathological Diagnosis Mentioned Not mentioned Adenocarcinoma Neuroendocrine carcinoma All others Total

14 (48.3%) 15 (51.7%)

3 (42.9%) 2 (28.6%) 2 (28.6%)

14 (100%)

Stage at Diagnosis Mentioned Not mentioned

22 (75.9%)

7 (24.1%)

Stage Distribution Localized Regional (direct) Regional (lymph node) Regional (NOS) Distant

1 (4.5%)

3 (13.6%) 1 (4.5%) 1 (4.5%)

16 (72.7%)

Fig. 4.3: Age Specific Incidence Rates of Pancreatic Cancer

Per 100,000 Population, Aswan, 2008 (29 cases)

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Esophageal Cancer (C15)

Frequency Total Cases

28

Sex Distribution Males Females Ratio

22 6

3.7:1

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

61.7 58.0

64.0 62.0

Topographical Diagnosis Known subsite Unknown subsite Esophagus, NOS

19 (67.9%)

9 (32.1%)

Subsite Distribution Lower third Middle third Overlapping lesion Total (known subsites)

13 (68.4%)

5 (26.3%) 1 (5.3%)

19 (100%)

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Pathological Diagnosis Mentioned Not mentioned Squamous cell carcinoma Adenocarcinoma Non-Hodgkin lymphoma Total

20 (71.4%)

8 (28.6%)

16 (80.0%) 3 (15.0%) 1 (5.0%)

20 (100%)

Stage at Diagnosis Mentioned Not mentioned

18 (64.3%) 10 (35.7%)

Stage Distribution Localized Regional (direct) Regional (lymph node) Regional (NOS) Distant

7 (38.9%) 5 (27.8%) 2 (11.1%)

1 (5.6%) 3 (16.7%)

Fig. 4.4: Age Specific Incidence Rates of Esophageal Cancer

Per 100,000 Population, Aswan, 2008 (28 cases)

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Connective, Subcutaneous and Soft Tissue Cancer (C47; C49)

Frequency Total Cases

28

Sex Distribution Males Females Ratio

17 11

1.5:1

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

49.6 37.1

48.0 40.0

Topographical Diagnosis Known subsite Unknown subsite

26 (92.9%)

2 (7.1%)

Subsite Distribution Lower limb and hip Abdomen Upper limb and shoulder Pelvis Trunk, NOS Overlapping lesion Total (known subsites)

14 (53.8%)

4 (15.4%) 3 (11.5%)

2 (7.7%) 2 (7.7%) 1(3.8%)

26 (100%)

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Pathological Diagnosis Mentioned Not mentioned Liposarcoma, NOS Myxoid liposarcoma Sarcoma, NOS Spindle cell sarcoma Fibrosarcoma, NOS Rhabdomyosarcoma, NOS All others Total

22 (78.6%)

6 (21.4%)

4 (18.2%) 4 (18.2%) 2 (9.1%) 2 (9.1%) 2 (9.1%) 2 (9.1%)

6 (27.3%) 22 (100%)

Stage at Diagnosis Mentioned Not mentioned

16 (57.1%) 12 (42.9%)

Stage Distribution Localized Distant

14 (87.5%)

2 (12.5%)

Fig. 4.5: Age Specific Incidence Rates of Connective and Soft Tissue Cancer per 100,000 Population,

Aswan, 2008 (28 cases)

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Stomach Cancer (C16)

Frequency Total Cases

25

Sex Distribution Males Females Ratio

14 11

1.3: 1

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

61.4 59.1

60.0 60.0

Topographical Diagnosis Known subsite Unknown subsite Stomach, NOS

9 (36.0%)

16 (64.0%)

Subsite Distribution Pylorus Cardia, NOS Fundus of stomach Overlapping lesion Total (known subsites)

5 (55.6%) 2 (22.2%) 1 (11.1%) 1 (11.1%) 9 (100%)

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Pathological Diagnosis Mentioned Not mentioned Adenocarcinoma Signet ring cell carcinoma Malignant lymphoma Stromal sarcoma Total

13 (52.0%) 12 (48.0%)

7 (53.8%) 3 (23.1%) 2 (15.4%)

1(7.7%) 13 (100%)

Stage at Diagnosis Mentioned Not mentioned

17 (60.7%) 11 (39.3%)

Stage Distribution Localized Regional (direct) Regional (lymph node) Distant

3 (17.6%) 2 (11.8%) 2 (11.8%) 8 (47.1%)

Fig. 4.6: Age Specific Incidence Rates of Stomach Cancer Per 100,000 Population, Aswan, 2008 (25 cases)

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Thyroid Cancer (C73)

Frequency Total Cases

24

Sex Distribution Males Females Ratio

4

20 1:5

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

51.5 49.4

56.0 50.0

Pathological Diagnosis Mentioned Not mentioned Papillary adenocarcinoma, NOS Papillary carcinoma, NOS Papillary carcinoma, follicular variant Squamous cell carcinoma, NOS Adenocarcinoma, NOS Follicular adenocarcinoma, NOS Total

11 (45.8%) 13 (54.2%)

4 (36.4%) 2 (18.2%) 2 (18.2%)

1 (9.1%) 1 (9.1%) 1 (9.1%)

11 (100%)

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Stage at Diagnosis Mentioned Not mentioned

15 (62.5%)

9 (37.5%)

Stage Distribution Localized Regional (direct) Regional (direct & lymph node) Distant

10 (66.74%)

1 (6.7%) 1 (6.7%)

3 (20.0%)

Fig. 4.7: Age Specific Incidence Rates of Thyroid Cancer per 100,000 Population, Aswan, 2008 (24 cases)

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Laryngeal Cancer (C32)

Frequency Total Cases

23

Sex Distribution Males Females Ratio

21 2

10.5:1

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

61.2 74.0

59.0 74.0

Topographical Diagnosis Known subsite Unknown subsite Larynx, NOS

14 (60.9%)

9 (39.1%)

Subsite Distribution Glottis Supraglottis Total (known subsites)

10 (71.4%)

4 (28.6%) 14 (100%)

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Pathological Diagnosis Mentioned Not mentioned Squamous cell carcinoma, NOS Squamous cell carcinoma, large cell, nonkeratinizing, NOS Total

14 (60.9%)

9 (39.1%) 13 (92.9%)

1 (7.1%)

14 (100%)

Stage at Diagnosis Mentioned Not mentioned

16 (69.6%)

7 (30.4%)

Stage Distribution Localized Regional (direct) Regional (lymph node) Regional (direct & lymph node)

7 (43.8%) 4 (25.0%) 3 (18.8%) 2 (12.5%)

Fig. 4.8: Age Specific Incidence Rates of Laryngeal Cancer per 100,000 Population, Aswan, 2008 (23 cases)

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Uterine Cancer (C54-C55)

Frequency Total Cases

22

Age at Diagnosis Mean age (years) Median age (years)

59.2 60.0

Topographical Diagnosis Known subsite Unknown subsite Uterus, NOS

9 (40.9%)

13 (59.1%)

Subsite Distribution Endometrium

9 (100%)

Pathological Diagnosis Mentioned Not mentioned Adenocarcinoma Papillary adenocarcinoma Choriocarcinoma Adenocarcinoma in tubulovillus adenoma Clear cell adenocarcinoma, NOS Papillary serous cystadenocarcinoma Myoma Mullerian mixed tumor Total

14 (63.6%)

8 (36.4%)

4 (28.6%) 2 (14.3%) 2 (14.3%) 2 (14.3%)

1 (7.1%) 1 (7.1%) 1 (7.1%) 1 (7.1%)

14 (100%)

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ancers

159

Stage at Diagnosis Mentioned Not mentioned

13 (59.1%) 9 (40.90%)

Stage Distribution Localized Regional (NOS) Distant

9 (69.2%)

1 (7.7%) 3 (23.1%)

Fig. 4.9: Age Specific Incidence Rates of Uterine Cancer per 100,000 Population, Aswan, 2008 (22 cases)

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Oral Cavity Cancer (C00-C06)

Frequency Total Cases

21

Sex Distribution Males Females Ratio

15 6

2.5:1

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

55.9 59.5

54.5 60.5

Topographical Diagnosis Known subsite Unknown subsite Mouth, NOS

18 (85.7%)

3 (14.3%)

Subsite Distribution Cheek mucosa Tongue External lower lip Dorsal surface of tongue Lower gum Base of tonuge Upper gum Floor of mouth Total (known subsites)

6 (33.3%) 3 (16.7%) 2 (11.1%) 2 (11.1%) 2 (11.1%)

1 (5.6%) 1 (5.6%) 1 (5.6%)

18 (100%)

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161

Pathological Diagnosis Mentioned Not mentioned Squamous cell carcinoma, NOS Adenocarcinoma, NOS Clear cell adenocarcinoma, NOS Total

14 (66.7%)

7 (33.3%)

12 (85.7%) 1 (7.1%) 1 (7.1%)

14 (100%)

Stage at Diagnosis Mentioned Not mentioned

14 (66.7%)

7 (33.3%)

Stage Distribution In situ Localized Regional (direct) Regional (lymph node) Regional (direct & lymph node)

1 (7.1%)

5 (35.7%) 4 (28.6%)

1 (7.1%) 3 (21.4%)

Fig. 4.10: Age Specific Incidence Rates of Oral Cancer

per 100,000 Population, Aswan, 2008 (21 cases)

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Gall Bladder Cancer (C23-C24)

Frequency Total Cases

17

Sex Distribution Males Females Ratio

7

10 1:2.4

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

67.3 56.9

71.0 58.0

Topographical Diagnosis Known subsite Unknown subsite Biliary tract, NOS

15 (88.2%)

2 (11.8%)

Subsite Distribution Gallbladder Extrahepatic bile duct Ampulla of vater Total (known subsites)

10 (66.7%)

3 (20.0%) 2 (13.3%)

15 (100%)

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Pathological Diagnosis Mentioned Not mentioned Cholangiocarcinoma Adenocarcinoma, NOS Carcinoma, anaplastic, NOS Papillary adenocarcinoma, NOS Total

8 (47.1%) 9 (52.9%) 4 (50.0%) 2 (25.0%) 1 (12.5%) 1 (12.5%) 8 (100%)

Stage at Diagnosis Mentioned Not mentioned

12 (70.6%)

5 (29.4%)

Stage Distribution Localized Regional (direct) Distant

3 (25.0%) 4 (33.3%) 5 (41.7%)

Fig. 4.11: Age Specific Incidence Rates of Gall Bladder Cancer per 100,000 Population, Aswan, 2008 (17 cases)

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Skin Cancer (Non-Melanoma) (C44)

Frequency Total Cases

15

Sex Distribution Males Females Ratio

6 9

1:1.5

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

59.0 62.7

55.0 61.0

Topographical Diagnosis Known subsite Unknown subsite

15 (100%)

0 (0.0%)

Subsite Distribution Face Scalp and neck Trunk Eyelid External ear Lower limb and hip Total (known subsites)

6 (40.0%) 4 (26.7%) 2 (13.3%)

1 (6.7%) 1 (6.7%) 1 (6.7%)

15 (100%)

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Pathological Diagnosis Mentioned Not mentioned Squamous cell carcinoma, NOS Basal cell carcinoma, NOS Dermatofibrosarcoma, NOS Total

11 (73.3%)

4 (26.7%)

5 (45.5%) 5 (45.5%) 1 (9.1%)

11 (100%)

Stage at Diagnosis Mentioned Not mentioned

10 (66.7%)

5 (33.3%)

Stage Distribution Localized Regional (direct) Distant

8 (80.0%) 1 (10.0%) 1 (10.0%)

Fig. 4.12: Age Specific Incidence Rates of Skin Cancer (Non-Melanoma) per 100,000 Population,

Aswan, 2008 (15 cases)

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Hodgkin Lymphoma (C81)

Frequency Total Cases

13

Sex Distribution Males Females Ratio

8 5

1.6:1

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

26.1 22.6

26.0 24.0

Topographical Diagnosis Known subsite Unknown subsite Lymph node, NOS

12 (92.3%)

1 (7.7%)

Subsite Distribution Nodes of head, face and neck Nodes of multiple regions Intrathoracic Nodes Nodes of axilla or arm Total (known subsites)

8 (66.7%) 2 (16.7%)

1 (8.3%) 1 (8.3%)

12 (100%)

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Pathological Diagnosis Mentioned Not mentioned Mixed cellularity, NOS Nodular lymphocyte predom. Nodular sclerosis, grade 1 Lymphocyte depletion, NOS Nodular sclerosis, NOS Total

8 (61.5%) 5 (38.5%)

2 (25.0%) 2 (25.0%) 2 (25.0%) 1 (12.5%) 1 (12.5%) 8 (100%)

Stage at Diagnosis Mentioned Not mentioned

9 (69.2%) 4 (30.8%)

Stage Distribution Localized Regional (lymph node) Distant

4 (44.4%) 1 (11.1%) 4 (44.4%)

Fig. 4.13: Age Specific Incidence Rates of Hodgkin Lymphoma per 100,000 Population, Aswan, 2008 (13 cases)

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Non-Hodgkin Lymphoma (C82-C85; C96)

Frequency Total Cases (Nodal NHL)

13

Sex Distribution Males Females Ratio

7 6

1.2:1

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

63.0 40.3

61.0 42.5

Topographical Diagnosis Known subsite Unknown subsite Lymph node, NOS

11 (84.6%)

2 (15.4%)

Subsite Distribution Nodes of multiple regions Nodesof head, face, neck Nodes of inguinal region or leg Intra-abdominal nodes Nodes of axilla or arm Total (known subsites)

5 (45.5%) 2 (18.2%) 2 (18.2%) 1 (9.1%) 1 (9.1%)

11 (100%)

Pathological Diagnosis NHL, large B-cell, diffuse, NOS NHL, mixed small and large cell, diffuse NHL small B lymphocytic, NOS Follicular lymphoma, grade 3 Precursor cell lymphoblastic lymphoma Total

7 (53.8%) 3 (23.1%) 1 (7.7%) 1 (7.7%) 1 (7.7%)

13 (100%)

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Stage at Diagnosis Mentioned Not mentioned

11 (84.6%)

2 (15.4%)

Stage Distribution Localized Regional (lymph node) Distant

4 (36.4%) 3 (27.3%) 4 (36.4%)

Table 4.2: Site Distribution of Primary Extranodal Lymphoma,

Aswan, 2008

Site Frequency (%) Stomach 2 33.3 Soft and Connective tissues 1 16.7 Bone 1 16.7 Nasopharynx 1 16.7 Brain 1 16.7

Total 6 100%

Fig. 4.14: Age Specific Incidence Rates of Nodal Non-Hodgkin Lymphoma per 100,000 Population, Aswan, 2008 (13 cases)

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Kidney and Renal Pelvis Cancer (C64-C65)

Frequency Total Cases

12

Sex Distribution Males Females Ratio

7 5

1.4:1

Age at Diagnosis Mean age (years) Males Females Median age (years) Males Females

38.3 38.6

50.0 32.0

Topographical Diagnosis Known subsite Unknown subsite

12 (100%)

0 (0.0%)

Subsite Distribution Kidney Renal Pelvis Total (known subsites)

9 (75.0%) 3 (25.0%)

12 (100%) 4- L

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Pathological Diagnosis Mentioned Not mentioned Renal cell carcinoma, NOS Nephroblastoma, NOS Papillary transitional cell carcinoma Squamous cell carcinoma, keratinizing, NOS Transitional cell carcinoma, NOS Total

10 (83.3%)

2 (16.7%)

3 (30.0%) 3 (30.0%) 2 (20.0%) 1 (10.0%) 1 (10.0%)

10 (100%)

Stage at Diagnosis Mentioned Not mentioned

9 (75.0%) 3 (25.0%)

Stage Distribution Localized Regional (direct) Distant

5 (55.6%) 1 (11.1%) 3 (33.3%)

Fig. 4.15: Age Specific Incidence Rates of Kidney and Renal Pelvis Cancer per 100,000 Population, Aswan, 2008 (12 cases)

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173

Part 5 Pediatric Malignancies

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Incidence

The total number of malignancies reported during 2008, among children under age of 15 years, was 59 cases; 36 males (61.0%) and 23 females (39.0%) with male: female ratio of 1.6: 1.

These cases represented 5.1% of all incident cancers (total of 1150

cases). The Mean age at diagnosis was 4.8 years with a median of 4 years for both sexes together. For males, the mean age at diagnosis was 4.5 years with a median of 4 years while for females the mean age at diagnosis was 5.2 years with a median of 4 years also. The highest frequency was in the age group 1-4 years (44.4% for males, 52.2% for females and 47.5% for both sexes together) as shown in table 5.1.

Figure 5.1 shows the distribution of childhood cancers by 5-year

age groups. More than half the cases were reported in the age group < 5 years. About one third of cases were in the age group 5-9 years and one tenth was older than 9 years. For comparison, the population structure in the 3 age groups is shown in figure 5.2. Analysis in the rest of this part is not detailed due to the limited number of cancer in these age groups in 1 year of registration in an approximately one million-population.

Table 5.1: Number of Incident Cases of Childhood Cancers Aswan, 2008

Age group Total Male Female <1 y 5 4 1 1-4 y 28 16 12 5-9 y 20 14 6 10-14 y 6 2 4 Total 59 36 23

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Fig. 5.1: Distribution of Childhood Cancers by 5-Year Age Groups, Aswan, 2008 (59 cases)

Fig. 5.2: Population Structure of Children by 5-Year Age Groups, Aswan, 2008

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Basis of Diagnosis

Microscopic diagnosis was reported in 30 cases (67.8%) Non microscopic basis of diagnosis was reported in 17.0% of cases. Diagnosis was based on death Certificate only (DCO) in 5 cases (8.5%). No basis for diagnosis was available for the rest of cases (4.0%). Details are shown in table 5.2 and figure 5.3.

Table 5.2: Basis of Diagnosis of Childhood Cancers, Aswan, 2008

Description Frequency (%)

Microscopic (67.8%) Histology 28 47.5 Cytology / no Histology 12 20.3

Non Microscopic (17.0%) Radiography or other imaging techniques 8 13.6 Clinical only 2 3.4

Unknown and Death Certificate Only (15.3%) Death Certificate Only 5 8.5 Unknown 4 6.8

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Fig. 5.3: Basis of Diagnosis of Childhood Cancers Aswan, 2008 (59 cases)

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Stage at Diagnosis Stage at diagnosis was available for 44 cases (74.6%). Metastatic

disease was the commonest presentation accounting for 63.6%. Details are shown in table 5.3.

It has to be mentioned that this relatively high proportion of

metastatic disease could be attributed to both late presentation and coding all cases of leukemia as metastatic according to SEER staging system. Excluding leukemias, the frequency of metastatic disease dropped to 13.9%.

Table 5.3: Distribution of Childhood Cancer, according to SEER Summary Staging,

Aswan, 2008

Stage Frequency (%) Localized only 11 20.8 Regional by direct extension only 4 7.5 Regional by lymph nodes(s) involved only 1 1.9 Distant site(s) / node(s) involved 28 52.8 Unknown if extension or metastases 9 17.0

Total 53 100.0 * For 6 cases (10.2%), no data is available

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Fig. 5.4: Stage Distribution of Childhood Cancer, Aswan, 2008 (59 cases)

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Frequency by Site Site distribution used in the analysis is based upon International

Classification of Childhood Cancer (ICCC). See Annex II for more information.

The most frequent cancer was leukemia (35.6%) followed by CNS

and intracranial neoplasms (8.5%) and lymphomas (8.5% each). Proportions between 5-7% were reported for neuroblastoma (6.8%), hepatic tumors (5.1%), renal tumors (5.1%) and soft tissue sarcomas (5.1%). Frequencies of other cancers were less than 4% (Table 5.4 and Figure 5.5). Table 5.4: Frequency of Childhood Cancer according to ICCC by Sex,

Aswan, 2008

Male Female

All Cancers 36 23 Leukemias, myeloproliferative diseases & myelodysplastic diseases 13 (36.1%) 8 (34.8%)

CNS & miscellaneous intracranial & intraspinal neoplasms 3 (8.3%) 2 (8.7%) Lymphomas & reticulendothelial system neoplasms 4 (11.1%) 1 (4.3%) Neuroblastoma and other peripheral nervous cell tumors 3 (8.3%) 1 (4.3%) Soft tissue and other extraosseous sarcomas 1 (2.8%) 2 (8.7%) Hepatic tumors 2 (5.6%) 1 (4.3%) Renal tumors 2 (5.6%) 1 (4.3%) Malignant bone tumors 1 (2.8%) 1 (4.3%) Retinoblastoma 2 (5.6%) 0 (0.0%) Other malignant epithelial neoplasms and malignant melanomas 0 (0.0%) 0 (0.0%)

Germ cell tumors, trophoblastic tumors & neoplasms of gonads 0 (0.0%) 0 (0.0%)

Other and unspecified malignant neoplasms 2 (5.6%) 3 (13.0%) Not Classified by ICCC or in situ or unknown 3 (8.3%) 3 (13.0%)

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Fig. 5.5: Relative Frequency of Childhood Cancer (ICCC classification), Aswan, 2008 (59 cases)

Site distribution was based upon International Classification of Childhood Cancer (ICCC).

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Incidence Rates

The ASR (world) was 85 per million for male children and 51 per

million for female children. Details are shown in table 5.5 that depicts both crude and ASR (world) by gender.

Table 5.5: Crude and Age Standardized Incidence Rates of Childhood Cancer (per million) by ICCC Site, Aswan, 2008

ICCC Site Crude Rate ASR (World) Male Female Male Female

All Cancers 171 114 85 51 Leukemias, myeloproliferative diseases & myelodysplastic diseases 62 40 32 17

CNS & miscellaneous intracranial & intraspinal neoplasms 14 10 8 5

Lymphomas & reticulendothelial system neoplasms 19 5 9 3

Neuroblastoma and other peripheral nervous cell tumors 14 5 6 2

Soft tissue and other extraosseous sarcomas 5 10 3 4 Hepatic tumors 9 5 4 2 Renal tumors 9 5 4 2 Malignant bone tumors 5 5 3 1 Retinoblastoma 9 - 4 - Other malignant epithelial neoplasms and malignant melanomas - - - -

Germ cell tumors, trophoblastic tumors & neoplasms of gonads - - - -

Other and unspecified malignant neoplasms 9 15 4

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Fig. 5.6: Incidence Rates of Most Frequent Childhood Cancers,

Males, Aswan, 2008

Site distribution was based upon International Classification of Childhood Cancer (ICCC).

Fig. 5.7: Incidence Rates of Most Frequent Childhood Cancers, Females, Aswan, 2008

Site distribution was based upon International Classification of Childhood Cancer (ICCC).

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Childhood Leukemias (ICCC Group I) During 2008, 21 leukemia cases were registered. These cases were

13 males and 8 females with male to female ratio of 1.6:1. They represented 35.6% of all incident childhood cancers, accounting for 36.1% and 34.8% of male and female cancers respectively. Leukemia ranked first in males and females.

Standardized for age using the world standard million, the ASR was 32/million for male children and 16/million for female children. The mean age at diagnosis was 4.6 years for males and 5.0 for females; with a median of 4 and 3.5 years for male and female children respectively. Figure 5.8 shows the distribution of childhood leukemias by age.

Table 5.6 and Figure 5.9 depict the morphological subtypes of childhood leukemias. The total number of childhood acute lymphoblastic leukemias (ALL) registered during 2008 was 19 cases. There was only one cases of acute myeloid leukemia (AML).

Table 5.6: Pathological Diagnoses of Childhood Leukemia, Aswan, 2008

Morphology Frequency (%) Acute lymphoblastic leukemias 19 90.5

Acute myeloid leukemias 1 4.8

Acute leukemia, NOS 1 4.8

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Fig. 5.8: Age Distribution of Childhood Leukemia,

Aswan, 2008

Fig. 5.9: Pathological Diagnosis of Childhood Leukemia, Aswan, 2008

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Childhood Lymphomas (ICCC Group II)

Over 2008, 5 lymphoma cases were registered. These cases were 4

males and one female with male to female ratio of 4:1. They represented 8.5% of all incident cancers in children, accounting for 11.1% and 4.3% of male and female cancers respectively.

Standardized for age using the world standard million, the ASR was 9/million for male children and 3/million for female children. The mean age at diagnosis was 6.3 years for male children and was 6.0 for female children with a median of 6.5 and 6 years for male and female children respectively. Figure 5.10 shows the distribution of childhood lymphoma by age.

Table 5.7 and Figure 5.11 show the morphological subtypes of childhood lymphomas. The total number of childhood Hodgkin lymphoma registered during 2008 was 3 cases. There were two cases of non-Hodgkin lymphoma (NHL).

Table 5.7: Pathological Diagnoses of Childhood Lymphoma, Aswan, 2008

Morphology Frequency (%) Hodgkin lymphoma 3 60.0 Non-Hodgkin lymphoma 2 40.0

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Fig. 5.10: Age Distribution of Childhood Lymphoma

Aswan, 2008

Fig. 5.11: Morphological Diagnosis of Childhood Lymphoma,

Aswan, 2008

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Childhood Brain and Miscellaneous intracranial and Intraspinal Neoplasms (ICCC Group III)

During 2008, 5 brain cancer cases were registered. These cases were 3 males and 2 females with male to female ratio of 1.5: 1. They represented 8.5% of all incident cancers, accounting for 8.3% and 8.7% of male and female cancers respectively.

Standardized for age using the world standard population, the ASR was 8/million for males and 5/million for females. The mean age at diagnosis was 5.3 years for male children and 9.5 for female children with a median of 6 and 9.5 years for males and females respectively.

Cerebellar and brain stem malignancies were the majority (3 cases and 1 case respectively). NOS lesions were reported in 1 case. (Table 5.8).

Three medulloblastomas were registered during 2008. There was one case of glioma. The remaining case was diagnosed as malignant with unknown pathology.

Figure 5.12 shows the distribution of childhood lymphoma by age.

Table 5.8: Subsite Distribution of Childhood Brain and Miscellaneous Intracranial and Intraspinal Neoplasms, Aswan, 2008

Subsite Frequency (%) Cerebellum 2 60.0 Brain stem 1 20.0 Brain, NOS 1 20.0

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Table 5.9: Pathological Diagnoses of Childhood Brain and

Miscellaneous Intracranial and Intraspinal Neoplasms, Aswan, 2008

Morphology Frequency (%) Medulloblastoma 3 60.0 Malignant glioma 1 20.0 Malignant neoplasm (unknown pathology) 1 20.0

Fig. 5.12: Age Distribution of Childhood Brain and Miscellaneous Intracranial and Intraspinal Neoplasms, Aswan, 2008

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Annex I

Statistical Methods Crude incidence rate:

The crude incidence is the rate at which new cases occur in a population during a specific period. This rate is classically expressed as the average number of cases occurring per 100,000 persons each year or 100,000 person-years. In this chart book numbers of cancer cases are reported for one year. Hence the crude incidence rate is computed with the following formula:

000,1002008in population Total

2008in observerd casescancer new ofNumber rate incidence Crude ×=

This rate is called crude because it relates to each population as a whole and is influenced by the age structure of each population. It cannot be used for comparison purposes.

Age specific incidence rate (ASIR): This is the rate at which new cases occur in specific age group in the

population during a specific period. For example, to calculate ASIR for age group 40-44, the following formula is used:

000,10044y-40in Population

44-40 agein observerd casescancer new ofNumber 44y -40 rate incidence specific Age ×=

Age-standardized incidence rate (ASR): The age-standardized rate is a summary of the individual age-specific

incidence rates (ASIR) using an external population called a standard population. This is the incidence that would be observed if the population had the age structure of the standard population, and corresponds to the crude incidence rate in the standard population. The age-standardized incidence rate is expressed, as is the crude incidence rate, as the number of new cases per 100,000 person-years. The calculation is a weighted average of age-specific rates.

Age standardized rate = (expressed/100,000)

so that (i) represents each age group,

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di the number of cases in the ith age group, yi the population size in the ith age group, and wi the weight applied for the ith age group, with di/yi being the age-specific rates for each ith category and the sum of wi being equal to 100,000 to express the age-standardized rate per 100,000 person-years.

It should be stressed that the objective of age standardization is essentially to establish rates for comparison purposes. The standard population used in this chart book is presented in Table 1.1, and steps of age standardization are presented in Figure 6.1.

Fig. 6.1: Steps of Age Standardization

1. Age specific Incidence Rates (di/yi)

2. World Population

3. Expected Number in World

Population (diwi/yi)

4. ASR Calculation

ASR = = 63.9

The rate is expressed per 100,000

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Annex II

Classification and Coding International Classification of Diseases (ICD): First published in 1893, it has been revised at roughly 10-year intervals, currently by the World Health Organization (WHO). The tenth edition (ICD-10) was published in 1992. The coding system consists of a core classification of three-digit codes. A fourth digit (in the first decimal place) provides an additional level of detail. Unlike previous revisions, ICD-10 allows enhancements to accommodate newly discovered diseases. WHO established an ongoing maintenance and updating process, ensuring input from member states as well as interested professional bodies. For more information about ICD-10, see the web site: http://www.who.int/classifications/icd/en/

The disease codes have four-character codes. A decimal point (.) separates

subdivisions of the three-character categories (Figure 6.2). Neoplasms form the second chapter of the codes that run from C00 to

D48. Malignant neoplasms run from C00 to C97, in situ neoplasms run from D00-D09, benign neoplasms run from D10-D36 and neoplasms of uncertain or unknown behavior run from D3-D48.

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Fig. 6.2: Structure of Disease Code

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International Classification of Diseases for Oncology (ICD-O): In 1976, WHO published the first edition of ICD-O and it was based on ICD-9. The second edition, published in 1990, is an extension of the neoplasm chapter of ICD-10. ICD-O combines a four-digit topography code based on ICD with a morphology code that includes a neoplasm behavior code and a code for histological grading and differentiation. In the most recent revision, ICD-O-3 has extensive additions and changes that reflect the ongoing changes in the nomenclature of malignant morphology. For more details about this classification, visit the web site: http://www.who.int/classifications/icd/adaptations/oncology/en/index.html

The topography section of ICD-O-3 has been adapted from the malignant

section of Chapter II of ICD-10. These topography terms have four-character codes that run from C00.0 to C80.9. A decimal point (.) separates subdivisions of the three-character categories (Figure 6.3).

Morphology terms of ICD-O-3 have five-digit codes ranging from M-8000/0 to M-9989/3. The first four digits indicate the specific histologic term (Figure 6.4). The fifth digit, after the slash or solidus (/), is a behavior code, which indicates whether a tumor is malignant, benign, in situ, or uncertain whether malignant or benign.

A separate one-digit code for histologic grading or differentiation is provided. For a lymphoma or leukemia, this element of the code is used to identify T, B-, Null-, and NK-cell origin.

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Fig. 6.3: Structure of Topography Code

Fig. 6.4: Structure of a Morphology Code

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International Classification of Childhood Cancer (ICCC):

The ICCC-3 classifies tumors coded according to the ICD-O-3 into 12 main groups, which are split further into 47 subgroups. This classification of childhood cancer is based on tumor morphology and primary site with emphasis on morphology rather than used for adults. The details of this classification are found in the web site: http://seer.cancer.gov/iccc/

The twelve main groups of ICCC-3 are:

1. Leukemias, myeloproliferative diseases and myelodysplastic diseases 2. Lymphomas and reticulendothelial system neoplasms 3. CNS and miscellaneous intracranial and intraspinal neoplasms 4. Neuroblastoma and other peripheral nervous cell tumors 5. Retinoblastoma 6. Renal tumors 7. Hepatic tumors 8. Malignant bone tumors 9. Soft tissue and other extraosseous sarcomas 10. Germ cell tumors, trophoblastic tumors and neoplasms of gonads 11. Other malignant epithelial neoplasms and malignant melanomas 12. Other and unspecified malignant neoplasms

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Fig. 6.5: Example of Coding by ICCC-3 based on ICD-O-3 Codes

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SEER Summary Staging (2000):

Summary staging is the most basic way of categorizing how far a cancer has spread from its point of origin. Summary staging has also been called General Staging, California Staging, and SEER Staging. The 2000 version of Summary Stage applies to every anatomic site, including the lymphomas and leukemias. Summary staging uses all information available in the medical record; in other words, it is a combination of the most precise clinical and pathological documentation of the extent of disease. For more information visit the site: http://www.seer.cancer.gov/tools/ssm/

The SEER stages are the following:

0 In situ 1 Localized (Stage I for Lymphomas) 2 Regional by direct extension 3 Regional by lymph nodes 4 Regional by both direct extension and lymph nodes 5 Regional, not otherwise specified (Stage II for Lymphomas) 7 Distant (Stage III or IV for Lymphomas) 9 Unknown, undetermined

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Fig. 6.6: Tumor Stages

Source: Young et al.: SEER Summary Staging Manual, 2000

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Annex III

Age Grouping

For this chart book, age was subdivided into 16 age groups, 0-4, 5-9, 10-14, ……. up to 75+ and this grouping was used for the calculation of ASR.

However, for the purpose of graphic presentation, the registry population is not very large; consequently, the numbers of cancer cases also are not very large. After subdivision into type of cancer and sex, the numbers of cases in each 5-year age group are in many cases small. Therefore, for some types of cancer, we have chosen age groups broader than 5 years to present the age-specific incidence rates. These broad ASIR were calculated and used for graphic presentation of the ASIR for all specific sites except breast, liver and bladder cancers (where there is sufficient number of cases).

The age groups we used were 0-14, 15-34, 35-54, 55-64, 65-74 and 75+.

An example of the effect of this age grouping on the figures of ASIR is present in Figure 6.6.

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Fig. 6.7: An Example of the Effect of Age Grouping on Smoothing of Age-Specific Incidence Rates

A- Before Age Grouping

B- After Age Grouping

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Annex IV

Comparison of Cancer Incidence in Aswan, 2008 and Gharbiah 2000-2002

Until very recently, Egypt was completely lacking any cancer incidence

data due to the lack of population-based cancer registries. With the establishment of a cancer registry in Gharbiah, it was possible to refer to cancer incidence in a governorate in Egypt for the first time. Unfortunately, data of Gharbiah was taken as that of Egypt despite the fact that Gharbiah could not be considered as a representative of Egypt; and this was the main stimulus for the establishment of the National Cancer Registry Program.

Aswan was the first registry in the new chain of registries, and was followed by registries in Menia, Beheira and Damietta; in addition to the already existent registry in Gharbiah. With the availability of Aswan’s results, it became possible to compare and contrast cancer incidence between 2 governorates in Egypt. The latest published cancer data for Gharbiah are those of the years 2000-2002 unlike Aswan with results available for 2008. However, with the small population in Aswan one would expect a smaller number of incident cancer cases compared to Gharbiah. Comparing Aswan and Gharbiah should be done cautiously awaiting for piling of more cases in Aswan, especially that 2008 is the first year of registration.

The crude incidence rate in Aswan (C44 excluded) was 106.0/100,000 for 2008. Gharbiah’s rate was 94.0/100,000 during 2000-2002. Due to the difference in population structure between Aswan and Gharbiah shown in figure 6.8; the age adjusted rates (world) were used for comparison. These rates were 152.4/100,000 and 141.2/100,000 population for Aswan and Gharbiah respectively.

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Fig. 6.8: Age Distribution of Population

A- Aswan, 2008

B- Gharbiah, 2000-2002

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The profile of Aswan was characterized by higher ASR rates of breast,

ovary, and liver cancer compared to Gharbiah. On the contrary, ASR of non-Hodgkin lymphoma was very low compared to Gharbiah. These interesting observations need to be confirmed with collection of more cases from Aswan in subsequent years.

Table 6.1: The Most Frequent Cancers, Males, Gharbiah, 2000-2002

Compared to Aswan 2008 Site Gharbiah ASR Aswan

ASR Bladder 26.9 18.6 Liver 21.7 17.4 Non-Hodgkin Lymphoma 17.1 2.2 Lung 13.6 11.2 Prostate 8.8 9.2 Colorectal 6.5 5.0 Leukemia 6.0 7.7 Brain and CNS 4.1 6.3 Larynx 4.0 6.0 Pancreas 3.9 5.7

Table 6.2: The Most Frequent Cancers, Females, Gharbiah, 2000-2002

Compared to Aswan 2008 Site Gharbiah

ASR Aswan ASR

Breast 41.9 63.9 Non-Hodgkin Lymphoma 9.9 1.6 Bladder 5.5 6.6 Ovary 5.2 9.1 Leukemia 4.6 6.6 Colorectal 4.2 4.8 Liver 4.2 8.7 Lung 3.6 3.8 Uterus 3.1 5.9 Brain and CNS 3.0 2.8

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Fig. 6.9: ASR of the Ten Most Frequent Cancers in Gharbiah Males

compared to Aswan Rates

Fig. 6.10: ASR of the Ten Most Frequent Cancers in Gharbiah Females compared to Aswan Rates

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Epilogue

I’m sure this document is a valuable addition to the literature related to cancer in Egypt. It details the methodology and results of the Population-based Cancer Registry in Aswan located in Aswan Cancer Center. This is the first time in which cancer incidence in Aswan is calculated. Pooling of Aswan results with those of other centers in the National Cancer Registry Program will lead to better understanding of the magnitude and profile of cancer in our country

The small size of the Governorate of Aswan is reflected on the results of this first year of registration. Registry staff did their best for case ascertainment. With accumulation of data in successive years, statistics and incidence rates will be based on good number of cases to better reflect the cancer profile in the Governorate of Aswan.

As director of Aswan Cancer Center, I like to commend the efforts of the staff of Aswan Cancer Center to achieve high quality of medical records that helped in better abstracting of registry data. I’m looking forward to seeing research and studies based on registry results. Professor Mohammed A. Abdeen, MD Professor of Medical Oncology, Faculty of Medicine, Cairo University Director, Aswan Cancer Center