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Common Cancers Among Kurdish People in the Northwest of Iran: Current Status and Future Prospects

  • Seyedeh Pardis Hosseini
  • AmirHossein Fereidunian
  • Parastoo Jamshidi
  • Mehdi Jafari
  • Jamal Ahmadpoor
Medicine
  • 63 Downloads
Part of the following topical collections:
  1. Topical Collection on Medicine

Abstract

Northwest of Iran is a high-risk area with the highest annual incidence of cancers. Despite the growing epidemic of incidence of cancers, little information is available about that in the Kurdistan region. This was a cross-sectional epidemiological study during 2010–2015. The crude incidence rates (CRs) and age-standardized incidence rates (ASRs) were calculated per 100,000 people by different categories. Of 9218 patients, 5320 (57.71%) were male. The mean ages were 63.4 (± 21.43) and 55.8 (± 18.50) for male and female, respectively. The most common cancer (cases/100,000, percentage) among male gender was stomach cancer (24.23, 22%) and among female gender was breast cancer (18.38, 24%). Besides skin cancer, other most common cancers were bladder (12.33, 11%), colorectal (11.78, 11%), and esophageal (11.14, 10%) cancers in men. Esophageal (9.57, 13%), colorectal (8.68, 11%), and stomach (8.34, 11%) were the common cancers among women. The overall ASR of cancers was 94.98 and 131.99 per 100,000 among females and males. The standard sex ratio (male to female) was 1.39. Broadly applying effective prevention measures such as vaccination, use of early detection tests, awareness campaign, and lifestyle modifications could be adopted by local health authority for the reduction of such important public health priority.

Keywords

Cancer Incidence Epidemiology Community health services Kurdistan 

Introduction

Cancer is an important factor in the global burden of disease, and their incidence rate is rapidly increasing [1]. The global rate of cancer incidence was 14 million person in 2012 [2], and cancer caused one of every six deaths in the world. So the 70% of the deaths as a result of cancers happened in the low- and middle-income countries. Over the next 15 years, it is estimated that the highest increase rate of cancer will probably be in the Eastern Mediterranean region; this region includes the most prevalent breast cancers among women and lung and bladder cancers among men [3, 4]. In Iran, 76% of the deaths were caused by non-communicable diseases. Of these, 13% were due to different types of cancers and these are the second causes of non-accidental deaths, following cardiovascular deaths [5, 6].

One third of the cancer-related deaths due to inappropriate diets and behaviors such as high body mass index, low consumption of vegetables and fruits, lack of physical activities, smoking, and alcohol consumption [7, 8]. False or late diagnosis is one of the factors of increased cancer deaths; in 2015, only 35% of the low- and middle-income countries performed early detection programs or cancer screening in their general populations. In addition, more than 90% of the high-income countries have provided treatment services compared to 30% of the low- and middle-income countries [3, 9].

Nevertheless, mortality from cancers have been reduced over the last decades. One reason for this may be the augmented people’s access to treatment services. So, this challenge leads to increasing burdens of diseases and also imposes costs for individuals and health-care system [10]. The purpose of this study was to investigate the annual trend of the incidence rate of common cancers in patients diagnosed in Kurdistan Province in the period 2010–2015. The results may be further understanding of cancer incidence and provide scientific clues for local health authority for cancer prevention and control. Thus, this study was conducted to assess the pattern and incidence of cancers in Kurdistan Province and provide preliminary data for interventions.

Materials and Methods

Participants

This cross-sectional study was conducted on patients registered in the Kurdistan Cancer Registry database from 2010 until 2015. People in this province speak Kurdish as their first language, and they are from the religious minorities (Sunni religion) in Iran.

Cancer Registry in Iran

National programs (pathology-based Cancer Registry) have been started in 1994. Until now, various programs have been established to record cancer cases and patients profile at the provincial (Golestan Province reports were published in CI5) and national levels and also in some research centers. Population-based Cancer Registry Program (PBCRP) is a new approach that cancer-diagnosed cases were be collected from the pathology departments, hospital records, mortality registries, and other regional sources (radiotherapy center, etc.). Each of these departments sends the cancer data (a web-based system) in an Excel file to the provincial Cancer Registry office. Then, the data will be imported to Persian CanReg 5 software (a software program prepared by Iranian Ministry of Health, based on the ICD10 coding system) in the provincial office. After performing corrective and analytical processes, the results will be archived. Finally, data are compiled and checked for duplicate entries at the provincial Cancer Registry offices, and then, these electronic reports will be sent to the national PBCR office on a monthly basis (Fig. S1) [11, 12].

Data Collection

The Department of Cancer Registry office affiliated to center for diseases control and management of Kurdistan University of Medical Sciences approved the study and data.

We exported the data from CanReg 5 into Excel software to check the duplicates. The process for deleting the repeated cases was completed by a manual review of the data. All data were alphabetically sorted, and duplicated cases were excluded before editing data of each city, and considering in mind that for deleting of repeated cases, similar cases should also be the same as morphology, topography, identity, and demographic information; eventually, this process was implemented for all province data by experienced manual reviewers. The morphology and topography of the cancers were determined according to the third edition of the International Classification of Diseases for Oncology (ICD-O-3), [13].

Data Analysis

The average population of the Kurdistan Province was used to calculate the CRs of the cancer incidence. Given that the National Institute of Statistics website (available through www.amar.org.ir) publishes population census results in every five years. In present study, census results of 2011 and 2016 were used as the first and the last populations for the analysis [14, 15]. The population was calculated by age and sex groups. The midyear 2011–2016 population estimations in age groups were used as the reference population for the annual incidence analysis. CRs and ASRs were examined per 100,000 people by type of cancers, gender, age groups, and cities. Direct adjustment method was used for computing the ASRs, and the world population has been used as standard one. The data were analyzed using Stata version 14 (Stata Corp.) software package and Microsoft Office Excel 2013.

Results

A total number of 9218 patients entered the study including 5320 (57.71%) male and 3898 (42.29%) female. The age means (± SD) of male and female were 63.4 (± 21.43) and 55.8 (± 18.50) years, respectively.

The most common cancer (per 100,000, percentage) among males was stomach cancer (24.23, 22%) and among females was breast cancer (18.38, 24%). Ignoring the skin cancer, other most common cancers were bladder (12.33, 11%), colorectal (11.78, 11%), esophageal (11.14, 10%), hematosis (8.27, 7%), prostate (7.82, 7%), lung (5.61, 5%), brain (3.34, 3%), and lymphoma (2.58, 2%) in males. Esophageal (9.57, 13%), colorectal (8.68, 11%), stomach (8.34, 11%), hematosis (4.31, 6%), bladder (3.16, 4%), lymphoma (2.49, 3%), thyroid (2.43, 3%), brain (2.41, 3%), and uterus (0.87, 1%) were common cancers in females (Table 1, Fig. 1). The ASR of all types of cancer was 94.98 and 131.99 per 100,000 in females and males. The crude sex ratio (male to female) was 1.34 and the standard ratio was 1.39.
Table 1

Annual crude and age-standardized cancer incidence rates per 100,000 by type of cancer

Site/type

2010–2011

2012–2013

2014–2015

Male

Female

Male

Female

Male

Female

N (%)

CRs

ASRs

N (%)

CRs

ASRs

N (%)

CRs

ASRs

N (%)

CRs

ASRs

N (%)

CRs

ASRs

N (%)

CRs

ASRs

Stomach

254 (14)

16.24

21.60

92 (8)

6

7.16

326 (18)

20.84

25.63

120 (9)

7.82

9.36

334 (19)

21.36

25.47

108 (8)

7.05

8.51

Breast

NA

NA

NA

246 (20)

16.05

17.32

NA

NA

NA

298 (23)

19.44

20.84

NA

NA

NA

242 (18)

15.79

16.99

Bladder

194 (11)

12.40

14.84

38 (3)

2.48

2.96

146 (8)

9.33

11.01

32 (2)

2.09

2.47

148 (9)

9.46

11.15

52 (4)

3.40

4.06

Esophagus

176 (10)

11.25

13.36

138 (11)

9

10.95

136 (8)

8.70

10.82

108 (8)

7.05

8.56

120 (7)

7.67

9.24

122 (9)

7.96

9.57

Colorectal

154 (9)

9.85

11.58

114 (9)

7.44

8.68

192 (11)

12.28

14.58

100 (8)

6.52

7.58

122 (7)

7.80

9.18

96 (7)

6.26

7.30

Prostate

150 (8)

9.59

11.31

NA

NA

NA

92 (5)

5.88

7.03

NA

NA

NA

68 (4)

4.35

5.11

NA

NA

NA

Hemato.sys

130 (7)

8.31

9.44

64 (5)

4.18

4.58

94 (5)

6.01

6.99

64 (5)

4.18

4.64

116 (7)

7.42

8.39

52 (4)

3.40

3.72

Lung

82 (5)

5.24

6.28

NA

NA

NA

88 (5)

5.63

6.74

NA

NA

NA

50 (3)

3.20

3.80

NA

NA

NA

Brain

52 (3)

3.32

3.49

54 (4)

3.52

3.70

58 (3)

3.71

3.88

52 (4)

3.39

3.58

40 (2)

2.56

2.66

NA

NA

NA

Lymphoma

32 (2)

2.05

2.06

28 (2)

1.82

1.92

40 (2)

2.56

2.56

30 (2)

1.96

2.20

48 (3)

3.10

3.11

46 (3)

3

3.35

Thyroid

NA

NA

NA

20 (2)

1.30

1.24

NA

NA

NA

40 (3)

2.61

2.63

NA

NA

NA

52 (4)

3.40

3.43

Uterus

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

36 (3)

2.35

2.62

Skin

280 (15)

17.90

22.28

160 (13)

10.44

12.90

286 (16)

18.29

22.90

196 (15)

12.79

15.92

338 (19)

21.61

27.22

232 (17)

15.14

18.88

Other

306 (17)

NA

NA

266 (22)

NA

NA

314 (18)

NA

NA

258 (20)

NA

NA

354 (20)

NA

NA

342 (25)

NA

NA

All cancers

1810

115.73

131.61

1220

79.60

89.02

1772

113.30

129.76

1298

84.69

96.02

1738

111.13

134.61

1380

90.01

99.92

N, number; CRs: crude incidence rates per 100,000; ASRs, age-standardized incidence rates per 100,000, using the world standard population; NA, not available

Fig. 1

Age-standardized incidence rate (ASR) of common cancers per 100,000 in male and female

Figure 2 plots the ASR of all types of cancers by age groups and genders. According to the results, with increase in the aging population, there was a surge in the incidence of cancer in both genders; this experience obviously changes ascended from 50 to 59 years old age group. Of the 70–79 women age group, the ASR of cancer incidence was declining.
Fig. 2

Age-standardized incidence rate of common cancers per 100,000 in both gender by age groups

The CRs and ASRs of cancer incidence by cities are given in Table 2. The ASR of cancer incidence in the cities of Kurdistan Province were as follows: Sanandaj (167.36, 19%), Divandareh (127.06.72, 14%), Marivan (113.12, 13%), Saghez (106.26, 12%), Dehgolan (102.19, 11%), Kamyaran (75.03, 8%), Bijar (57.91, 6%), Seroabad (49.41, 6%), Qorveh (54.77, 6%), and Baneh (45.20, 5%), respectively (Table 2, Fig. 3).
Table 2

Annual crude and age-standardized cancer incidence rates per 100,000 by cities

City

Average population

2010–2011

2012–2013

2014–2015

Male

Female

Male

Female

Male

Female

Male

Female

N (%)

CRs

ASRs

N (%)

CRs

ASRs

N (%)

CRs

ASRs

N (%)

CRs

ASRs

N (%)

CRs

ASRs

N (%)

CRs

ASRs

Baneh

73,883

71,745

88 (5)

59.55

68.56

32 (3)

22.30

24.98

68 (4)

46.02

52.68

40 (3)

27.88

31.70

72 (4)

48.73

55.85

48 (4)

33.45

37.44

Bijar

45,723

45,967

40 (2)

43.74

50.12

38 (3)

41.33

46.41

62 (4)

67.80

76.25

32 (3)

34.81

38.98

58 (3)

63.43

72.38

52 (4)

56.56

63.29

Dehgolan

32,233

31,197

52 (3)

80.66

90.09

48 (4)

76.93

86.03

66 (1)

102.38

115.83

42 (3)

67.31

75.13

76 (4)

117.89

134.77

62 (5)

99.37

111.31

Divandareh

40,952

40,050

128 (7)

156.28

172.63

56 (5)

69.91

78.41

124 (7)

151.40

170.48

78 (6)

97.38

109.07

104 (6)

126.98

145.06

62 (5)

77.40

86.72

Kamiyaran

53,299

51,127

112 (6)

105.07

120.29

72 (6)

70.41

78.87

60 (3)

56.28

64.14

38 (3)

37.16

41.62

76 (4)

71.30

81.69

58 (4)

56.72

63.55

Marivan

92,834

89,185

232 (13)

124.95

141.55

160 (13)

89.70

100.84

212 (12)

114.18

129.90

130 (10)

72.88

81.79

194 (11)

104.49

119.35

168 (12)

94.19

105.32

Qorveh

69,247

69,329

64 (4)

46.21

53.56

54 (4)

38.94

43.54

104 (6)

75.09

84.98

46 (4)

33.18

37.10

68 (4)

49.10

56.23

66 (5)

47.60

53.18

Saghez

109,618

109,018

268 (15)

122.24

138.91

172 (14)

78.89

88.59

244 (14)

111.30

126.61

164 (13)

75.22

84.27

276 (16)

125.89

144.27

142 (11)

65.13

72.89

Sanandaj

240,397

235,388

802 (44)

166.81

191.11

568 (47)

120.65

135.62

772 (44)

160.57

183.32

680 (54)

144.44

161.29

756 (44)

157.24

174.03

668 (50)

141.89

158.83

Seroabad

23,784

23,607

20 (1)

42.05

48.41

8 (1)

16.94

18.97

36 (2)

75.68

85.90

12 (1)

25.42

28.34

28 (16)

58.86

67.46

20 (1)

42.36

47.35

Total

781,970

766,613

1806 cases

1208 cases

1748 cases

1262 cases

1708 cases

1346 cases

N, number; CRs, crude incidence rates per 100,000; ASRs; age-standardized incidence rates per 100,000, using the world standard population

Fig. 3

Age-standardized incidence rate of common cancers per 100,000 in different cities by gender

Discussion

The total population of Kurdistan Province was 1,493,645 (751,156 (50.29%) male; 742,489 (49.71%) female), and it was increased to 1,603,011 (812,776 (50.70%) male; 790,235 (49.30%) female) people from 2011 to 2016. According to the population pyramid in Iran, the young Iranian population is declining and it is expected that the aged population will rise to the highest number before 2050 [16]. Results in some regions in Iran indicate that the incidence of cancers were increased [17, 18]. The main reasons for this situation may be due to providing the cancer screening system (colorectal, breast, and cervix) and improvement of diagnosis in the country’s health network system and/or expansion of the National Cancer Registration System. It is also expected to increase the incidence of cancers in recent decades with an increase in the elderly population.

Our finding indicated that there was an increasing trend of cancer incidence among females and in males; it was vice versa. This is while the standard ratio of cancers was 1.39 male/female. The findings of the current study revealed that the stomach cancer was the most common cancer in male and ranking third for female genders. The risk of stomach cancer in the north and northeast of Iran is higher than other regions. For instance, Golestan Province (located in the northeast of Iran) is in the third and ninth ranks of the stomach cancer incidence in males and females in the world [19]. The ASR of stomach cancer was 49.13 and 25.42 per 100,000 in male and female, respectively, in the Ardebil Province (located in the northwest of Iran) during 1996–1999 [20]. The most common cancers among Iranian men was stomach cancer (15 per 100,000) and among women was breast cancer (24 per 100,000) in a national study [21]. Another study reported that ASR of stomach cancer in Iranian females and males were 7.1 and 15.1 per 100,000 during 2003 to 2008 [22]. Some behavioral/environmental factors such as Helicobacter pylori infection, smoking, eating too much salt, diet with low levels of antioxidants, overeating, and consumption of bread and high-fat food are effective in the pathogenesis of stomach cancer among Iranian north-western population [20, 23, 24].

The second leading cancer in our study was skin cancer in both genders. ASR of skin cancer was 24.7 and 18.2 per 100,000 among Kurdish men and also in women in 2009 and the highest value observed in the Semnan, Esfahan, Tehran, and Hamadan Provinces (all located in center and west of Iran), and the sex ratio was more in men than women in all mentioned provinces. The results of previous national population-based registries showed that the trend of ASR was increased (7.22% annually) during 2003 until 2008 in Iran. This rising trend may be due to incomplete Cancer Registry Program in 2003 [25, 26]. Some factors such as ultraviolet solar radiation, decreasing latitude, smoking, high intake of alcohol, consumption of high-fat foods, genetic factor, and long-term activities in the outdoors are the predictors for skin cancer [27, 28, 29, 30].

Colorectal cancer (CRC) is also one of the most common cancers in Iran. In the last year, a national program for colon cancer screening has been implemented in all urban and rural health centers, the fecal occult blood test (FOBT)/ fecal immunochemical test (FIT) (a safe and highly acceptable method of screening CRC) done for over 50-year-old Iranian people who have CRC risk factors [31, 32]. In our study, the colorectal cancer was the third common cancer in both genders. National population-based studies reported a high incidence rate of colorectal cancer; it is the fourth common cancer in Iranian men (8.29 per 100,000) and the third one in women (7.75 per 100,000) [18, 21]. Some studies suggested that overweight/obesity, physical inactivity, smoking, alcohol use, family history, colorectal polyps, and inflammatory bowel disease could be considered predictor factors for CRC [33, 34].

Excluding skin cancers, breast cancer is the leading type of cancer in women in the Eastern Mediterranean region and the leading cause of cancer mortality worldwide. Breast cancer remains a common and frequently fatal disease [35]. The results of the 10-year NCR of Iran indicated that the ASR of breast cancer has increased from 23.1 to 27.4 per 100,000 among Iranian females during 2005 to 2010 [36]. This index estimated 18.38 per 100,000 in our study. Iran is among the lowest of breast cancer in the Middle East countries such as (cases/100,000) Lebanon 78.7 [37], Qatar 33.7 [38], Turkey 30.1 [39], and Iraq 31.5 [40]. Clinical examinations and mammography are the two effective measures for screening the breast cancer [36, 41]. Self-examination and mammography tests have recently been introduced in health centers and clinics affiliated with the public sector of Iranian universities. Patients with a previous history of cancer or a family history of breast cancer refer to these mentioned centers [42].

According to the GLOBOCAN statistics in 2012, Iran had the highest rate of esophageal cancer incidence after Malawi and Southern Africa in the world and also the most incidence rate was in the Asian and Middle Eastern countries [43]. In the present study, esophageal cancer ranked the fourth and second of the common cancers in men and women, respectively. Most of the morbid cases in Iran have been reported from the north and northeast regions of the country. In 1977, after reports of high incidence rate of esophageal cancer (150 per 100,000) in the Caspian littoral of Northern Iran (Province of Mazandaran), a survey has been launched as a collaborative research agreement between the International Agency for Research on Cancer (IARC) and the Iranian Ministry of Health and Medical Education (MOHME) [44, 45]; the results indicated that the contribution of the socio-ethnic ingredient of nutritional intake and habits such as drinking hot tea are predictors for high incidence of esophageal cancer in this region [46, 47].

In general, the incidence rate of cancers among Kurdish men is similar to the overall incidence in Iran (132/134 per 100,000); by the way, our finding indicated that the ASRs of cancers among Kurdish women were lower than the estimates in Iran (95/120 per 100,000) [48]. This may be due to the cultural differences between the people of Kurdistan and other regions of Iran, as most of them have a traditional lifestyle and natural diet [49].

Based on latest report from GLOBOCAN in 2012, the most common cancers in Iranian men were stomach, bladder, prostate, colorectal, and lung cancers, respectively, and among women were breast, colorectal, stomach, esophagus, and ovary cancers, respectively [48]. However, the pattern of cancer incidence is different in various geographical regions, mainly due to the differences in risk factors; the overview of most common cancers in the Kurdistan province is similar to the incidence of cancers in the country.

As our study showed, the positive relationship of cancer incidence with age is the best-known evidence of age-related genomic instability [50], so it is important to address this concern in societies where the population continues to age. Fortunately, most cancers are very curable diseases when founds early and treated [51]. Specialists need to consider the challenge of managing cancer pain in a patient over a potentially longer duration, as cancer is no longer considered a terminal disease [52, 53].

Conclusion

Similar to most regions of Iran, stomach, breast, skin, bladder, colorectal, and esophagus cancers were also common in Kurdistan Province. Since May 2014, a national Health Transformation Plan was implemented in Iran that consists of seven programs. The main goals of this project are to enhance the level of people’s health, reduce pocket payments, develop and promote community health indicators. Although efforts have been made to initiate and improve a cancer screening program controlled and organized by the MOHME [54], The majority of the Iranian population are in the age groups of 25–34; However, we will have the highest number of at-risk population of the next two decades. Broadly applying effective prevention measures such as vaccination, use of early detection tests, awareness campaign, and lifestyle modifications could be adopted by local health authority for the reduction of such important public health priority.

Limitation

This study had a few limitations. The data does not include patients who are diagnosed in the imaging centers, diagnosed in pathology laboratories that are not in cooperation with the MOHME, or patients who prefer traditional medical services. Although this might affect the estimates in this study.

In addition, our study has a few strengths as follows. First, this study provides an overview of the most common cancers including 9218 patients during the 6-year period. Second, we used the NCR data; this database uses several sources for data collection. However, the present data provided by the NCR are the most comprehensive and reliable data available for research.

Notes

Acknowledgments

The authors thank the staff of Kurdistan Cancer Registry for their contribution towards this research work.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that there is no conflict of interest to state.

Supplementary material

42399_2018_34_MOESM1_ESM.pdf (235 kb)
ESM 1 (PDF 234 kb)
42399_2018_34_MOESM2_ESM.pdf (250 kb)
ESM 2 (PDF 250 kb)

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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Department of Public Health, School of Public HealthHamadan University of Medical SciencesHamadanIran
  2. 2.Healthcare Officer, Health Center of QorvehKurdistan University of Medical SciencesSanandajIran
  3. 3.Department of Medicine, School of MedicineKermanshah University of Medical SciencesKermanshahIran
  4. 4.Department of Epidemiology, School of Public HealthKermanshah University of Medical SciencesKermanshahIran
  5. 5.Research Center for Improvement of Surgical Outcomes and ProceduresShariati HospitalTehranIran
  6. 6.Department of Epidemiology, School of Public HealthHamadan University of Medical SciencesHamadanIran

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