Cancer in Gulf Countries: challenges and opportunities Saleh Al-Othman, MD, PhD, LLM

In January 2014 Gulf Center for Cancer Control published the Twelve

Year Cancer Incidence Report For the Nationals of the GCC States (1998 -2009),

There were 119,288 newly diagnosed cancer cases (49.1% Male and 50.8%Female). Number of cancer cases reported to GCCR by nationality and gender, 1998-2009. UAE

%74.9

KSA Qatar %9.5

Oman Kuwait Bahrain 0

20

40

60

80

Cancer incidence in GCC continues to increase over the twelve-year period. The total number of newly diagnosed increased by 1.47 folds. Trend of all cancers cases among national of the GCC 1998-2009 100 Male

Female

Linear (Male)

Linear (Female)

2004

2008

Rate per 100,000

90

80

70 1996

1998

2000

2002

2006

2010

In the Gulf region, the average ASR of cancer incidence is 82.9 for the period between 1998 and 2009 USA W Australia UK Norway South Africa Korea Kuwait Tunisia Bahrain Qatar Jordan Oman UAE Eygpt All GCC KSA

Even Though, cancer incidence in the Gulf region, is lower than developed countries, still considered as a major threat the Gulf Region. 0

20

40

60

80

100

120

140

160

Long-term projections of cancer incidence among nationals in the Gulf States, shows that by 2030 there would be more than 21000 new cancer cases . increase by 1.8 folds

21400 11894 1.8 FOLDS

1.47 FOLDS

2 0 0 9

8065 1 9 9 8

2 0 3 0

Actual and Predicted Number of Cancer Cases in the GCC

Population & Cancer Incidence

However, cancer incidence rate might go beyond that, as It is will know ageing is major factor for cancer

60%

75 +

1 7 2 ,5 6 5

70 -

1 3 8 ,8 0 5

65 -

1 5 9 ,6 6 7

60-

2 3 7 ,0 8 2

5 5 -

2 9 6 ,3 3 4

5 0-

3 6 7 ,5 1 4

45 -

4 8 1 ,2 9 8

40 -

6 2 2 ,3 0 0

35 -

7 6 2 ,8 9 0

30 -

9 1 4 ,3 1 1

x generations

25 -

1 ,1 6 7 ,6 0 1

20 -

1 ,4 4 5 ,3 5 0

15 -

1 ,7 1 9 ,3 5 6

10 -

1 ,9 8 3 ,2 1 9

5 -

2 ,2 8 4 ,9 7 0

0-

2 ,3 4 8 ,7 5 1

-20year 20

15

10

5

0

0

5

10

(% )

(% )

M a le

F e m a le

GCC 79-79

15

20

Are we ready? Population get older & Cancer Incidence increase

Most Common Cancer Sites The world of difference LUNG 13%

BREAST 11.8% BREAST 12%

OTHER 57%

BOWEL 10% PROSTAT 8%

Colorectal 8.4% OTHER 57%

NHL 7.4%

Leukamia 6.7%

Time of Diagnosis Among GCC Nationals

Major Issue Limited awareness and screening programs Incompetent referral system between primary, secondary and tertiary care systems Majority of cases presented with advanced tumors, only 23.3% of patients presented with localized tumors and less than 2% with in situ. Male Not Regional 18.9%

localized 22.1%

In-situ 1.0%

applicabl e 1.3%

Unknow n 28.9%

Distant metastas is 27.9%

In-situ 1.2% Regional 26.7%

localized 24.4%

Fema Not

applicabl e Unknown 0.8% 24.5%

Distant metastasi s 22.4%

In-situ 1.1% Regional 22.9%

localized 23.3%

All

Not applicabl e 1.0%

Unknow n 26.7%

Distant metastas is 25.1%

For the same period (1998 and 2009) Breast was the most common among GCC women accounted 24.4% of all cancer. The average ASR was 20.4 per 100,000 in females ranged between 16.9 in KSA and 55.9 in Bahrain. USA UK W… Norway

Bahrain Qatar

Breast cancer incidence continued to increase over the twelve-year period (1998 and 2009) by 1.4 folds

Kuwait Jordan

Eygpt Korea South… Tunisia

UAE All GCC Oman

Rate per 100,000

KSA

0

50

100

150

Moreover, GCC women appeared to develop breast cancer at younger age compared to women in developed countries. Where, more than 41.8% of women presented with breast cancers under the age of 45 years.

41.8%

Accepting screening These differences might programs in Arab be due to particular populations are below environmental expectations which might carcinogens, be due to lackdifferent of health lifestyle, and or cultural knowledge misleading social beliefs practices Brown R, 2012

-24 -29 -34 -39 -44 -49 -54 -59 -64 -69 -74 75+

12

8

4

0 1996

1998 Male

2000 Femel

Majority of the colorectal cancer presented with advanced stage (61.5% of cases), only 20.7% presented with localized disease 2002 2004 2006 2008 indicating absence of 2010screening (Male) Linear (Femel) andLinearearly detection programs.

Globally, the ASR of colorectal cancer in 2012 was 20.1 per 100,000 for males and 14.6 for females . In the GCC it ranked the second most common cancer with overall ASRs of 8.5 for males and 7.2 for females The incidence continues to increase between 1998 and 2009. The total number of newly diagnosed significantly increased by 3.4 folds in males and 2.1 folds in females.

10

Male

Female

Linear (Male)

Linear (Female)

8

The trend of liver cancer continued to 6 decline4 during the 12 year period. This could be due to: 2 1. The long national vaccination program 0 1996 1998 2000 2002 2004 2006 2008 2010 for HBV which was introduced in the early 1990s In the GCC States, liver cancer accounted for 5% of all newly 2. Inducing for period. hepatitis B and diagnosed cancers duringscreening the 12 year hepatitis C for all emigrant and work. B and The overall 3. ASRInducing of liver screening cancer forfor allhepatitis GCC States’ Nationals was 7.1 hepatitis C forper man and women before for males and 2.9 for males 100,000 populations. marriage Hepatitis B infection accounts for over 75% of all hepatocellular carcinoma. Globally, Liver cancer killed 700 000 people in 2008.

Lung Cancer in GCC The world of difference According to GLOBOCAN 2012, lung cancer was the most commonly diagnosed cancer and the most common cause of cancer deaths worldwide.

USA UK Korea Tunisia South Africa Norway

Lung cancer ranked seventh most common cancer in the GCC States, accounted for 4.7% from all cancers with an overall ASR of 7.2 for males and 2.2 for females. In males, the average ASR for lung cancer ranged between 5.9 in KSA and 29.0 in Bahrain, whereas in females, it ranged between 2.9 in UAE and 11.0 in Bahrain.

W Australia Bahrain Qatar

12

Jordan 9

Kuwait

6

Oman UAE

3

Eygpt 0 1995

All GCC

2000

2005

2010

KSA 0.0

20.0

40.0 Female

Male

60.0

80.0

Tobacco use is the single most important risk factor for cancer causing about 22% of global cancer deaths and about 71% of global lung cancer deaths.

Currently, all the GCC countries are In 2012, the average number of cigarettes per daily per aggressively moving towards more smoker in GCC was 23.4 cigarettes, more than the strict legislations: global average number which is 18 cigarettes. 1. Restricting smoking in all indoor Between 1996 and 2012 smoking prevalence for both public places and workplaces. sex increased more 12.5% in Saudi Arabia, 2.5% in 2. 1.8Implementing regulations on the Bahrain , and in Qatar. Equally, the estimated smoking prevalence declined in packaging and labeling of tobacco Kuwait by 8.3%, UAE by 3%, and Oman by 1.1% products; and banning tobacco advertisement. 3. Taxations were increased from 30 to 50%.

Country

Smoking prevalence: ASR for adult daily smokers of tobacco male 2012

Smoking prevalence: ASR for adult daily smokers of tobacco Female 2012

Bahrain Qatar

Smoking prevalence: ASR for adult daily smokers of tobacco (both sexes), 2012 17.5 15.5

23.9 19.3

5.9 1.4

UAE KSA Kuwait Oman

13.7 13.9 20.9 8.5

18.2 22.1 31.3 12.9

2.5 2.2 3.5 0.9

Smoking prevalence: Rate of Change (%), Both 1996 2012

Smoking prevalence Rate of Change (%), Male19662012

Smoking prevalence: Rate of Change (%), Female 1966-2012

2.5

-0.2

-2.2

1.8 -3 12.5 -8.3 -1.1

-0.3 -3.5 2.1 0.7 -2.1

-0.1 1.7 1.2 0.1 -0.3

Mean Annual Consump tion Per Capita

Mean Daily Consump tion Per Smoker

1180 921

17 13.9

1013 1912 1965 1113

17 35 21 33.5

Cervix Cancer in GCC More than 660 million people are annually infected by Cervical is (HPV), not among the herpes simplex virus and humancancer papillomavirus which associated with almost all cases of cervical most common cancers in the Gulf cancer.

region, and there are no screening In the GCC cancer cervix ranked eighth most common program in the region; cancer in GCC women, accounted for 2.9% from allwhich made women cancers with ASR of 2.6.of thean overall vaccine a questionable benefit from aspect, Eastern Mediterranean analysis of HPV cost-effect vaccination shows the vaccination very cost effective, as prevented however further evaluation is 29 000 cases of cervical cancer and 18 000 deaths required with changes in during their lifetime, at total costespecially of US$360 million. the countries lifestyles andthe HPV socioeconomic In 2012, All the Gulf have licensed vaccines. status in the region UAE was the first country in the region to implement the vaccination in Abu Dhabi, in 2008 for girls aged 15–17 years (voluntary).

Breast .1 Thyroid .2 Colorectal .3 NHL .4 Leukemia .5 Ovary .6

Corpus Uteri .7

Cervix Uteri .8 Liver .9 Other Skin .10

Obesity in Worldwide Overweight and obesity are the 5th leading risk for global deaths.

There will be 2.3 billion overweight adults in the world by 2015 and more than 700 million of them will be obese. At least 2.8 million adults die each year as a result of being overweight or obese. In addition, 41% of certain cancer burdens are related to overweight and obesity.

The World health statistics 2012 report

Obesity in Gulf Countries Fast food, and reduce activities have contributed dramatic increase of obesity prevalence in Gulf Evidence proved that body weight and countries . physical inactivity play an important role According to WHO reports, Gulf countries have the in cancer development and account highest rate of obesity, as Kuwait, Bahrain, Saudi Arabia approximately for one-third of the most and United Arab Emirates are among the top ten common cancers, such as breast, and countries worldwide. colon. Gulf countries should work together to Recent surveys have found that 28% of men and 44% of apply policies to overcome the increasing women are obese in Saudi Arabia . Similarly, 36% of prevalence of obesity men and 48% of women are obese in Kuwait. Ng SW, 2011. Karageorgi S, 2013

Healthcare systems in Gulf Countries Health services in Gulf countries have increased and improved significantly during recent Despite that, the Gulf countries In Gulf countries the Ministries of health are the major provider healthcare systems facing five and financer of health care services, with a total of 415 hospitals, major challenges: 65571 beds, 2648 primary health care center and 15 Radiotherapy 1. Rapid population growth , center. 2. Geo-demographic changes, Country Hospital Beds Clinics RT Centers RT unit Life-style changes, Govt. Private3.Govt. Private Total Beds Govt. Private Govt./ EBTE*/ (NO) (NO) (NO) (NO) per 10,000 (NO) (NO) Private BTE* 4. Advancements in treatment population modalities KSA 283 125 44,099 11,833 22 2,037 2,308 9/ 3 30/ 9 5. High inflation rates. UAE Kuwait

32 30

58 15

6,627 5,149

2,549 653

19 18

243 97

2,057 98

2/ 1 1

7/ 2 4/ 1

Qatar Oman Bahrain

5 55 10

4 5 13

2,564 5,430 1,702

394 189 384

14 19 19

30 217 24

177 817 NA

1 1 1

2/ 1 2/ 1 1/ 0

CONCLUSION Some of the challenges facing cancer care and control systems in the Gulf States have been highlighted in this talk. Some other challenges and opportunities will be discussed by my collogues in the next two days. However, many of these challenges discussed require urgent action including but not limited to: 1. Improved and increased prevention, awareness and screening programs at national and regional levels. 2. In addition there are clearly a need to provide comprehensive primary care services and an efficient referral system to specialized health care services.

ACKNOWLEDGMENTS

Amal Al-Madouj

Ms.Ebtisam Banaja

Thanks …