Epidemiology of Lung Cancer in

Middle East and in The Rest of

World

By

Prof. Mohsen Gadallah

Chairman of Community Medicine Department
Faculty of Medicine- Ain Shams University
Cairo – Egypt
 Outline

􀂃 Statistics for Lung Cancer: World,

North America, Europe, Asia, Africa,
Middle East, Arab Countries.

􀂃 Epidemiology of Lung Cancer

Risk Factors of Lung Cancer

 Source of Data
□ National Population-based Cancer Registries:

• Gulf Center for Cancer Registration, 2001

• Syria National Cancer Registry 2007

• Jordan, 2000
• Lebanon, Cancer Program-Tumor Registry, 2000
• Regional Population-based Cancer Registries:
􀂃 Egypt: NCI 2005
􀂃 Algeria: Algiers,
Tunisia: Tunis,
• EMRO - WHO
• Globocan 2002, IARC
• American Cancer Society, Global Cancer Statistics, 2002
Pattern of cancer distribution Worldwide

The four most common cancers in men are

lung, prostate, stomach and colorectal
cancers. Among Women the top four
cancers are breast, cervix utri , colorectal
and lung cancer.
 Lung cancer: how did it start?
 First described in 1420 in Schneeberg-
Austria after the opening of cobalt- and
nickel mines.
 Incidence was very low in the 19th
century.
 Is now worldwide the commonest form of
cancer in men, and the fourth most
frequent cancer in women.
 Lung Cancer Worldwide

-Lung cancer has been the most common cancer

worldwide since 1985, and by 2002 accounted for (12.4
percent of world total New Cases) and (17.6 percent of
world total Deaths)

-Just over half (50.1 percent) of lung cancer cases occur in

developed countries, a significant change since 1980, when
70 percent were in developed countries.
 Lung Cancer Worldwide

•􀂃 Global incidence of lung cancer is increasing at 0.5% per

year. 􀂃 A major contribution to this trend comes from the
East European and developing countries.

•􀂃 Although it is the most frequent cancer in men worldwide,

lung cancer is second to prostate cancer in incidence in
developed countries
World Estimated New Cancer Cases
and Age adjusted Incidence Rates,

Males Females

Number Age Number of Age

of New adjusted New adjusted
Cancer Incidenc Cancer Incidence
Cases e Rates Cases Rates

More 481,950 54.9 194,731 17.1

developed
Less 481,029 25.9 191,192 9.4

developed
Average Years of Life
Lost from Cancer
35
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 Lung Cancer in USA
• Estimated new cases and deaths from lung
cancer (non-small cell and small cell combined)
in the United States in 2008:

• New cases: 215,020

Males: 114,690
     Females: 100,330
• Deaths: 161,840
Males: 90,810
    Females: 71,030
 Lung Cancer in North America

􀂃 It is the second most common cancer among both men

and women after prostate cancer in men and breast cancer
in women
􀂃 It is the leading cause cancer-related deaths, accounting
for around 28% of all cancer deaths.
􀂃 It kills more people than breast, prostate, colon, and
pancreas cancers combined
􀂃 Nearly 60% of people diagnosed with lung cancer die
within 2 years. This had not improved in 10 years.
.
 Europe
􀂃
There is a wide variation in incidence and
death rates in Europe

• Central and Eastern Europe have the highest

incidence and death rates, 65.7/100,000 and
59.7/100,000.

• For men, incidence rates range from a low of

21.1/100,000 in Sweden to a high of
94.6/100,000 in Hungary. Death rates range
from 22.6/100,000 to 83.9/100,000
 Estimates of the cancer incidence and mortality in
Europe in 2006.
Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P.
Ann Oncol. 2007 Mar;18(3):581-92. Epub 2007 Feb 7.

RESULTS: In 2006 in Europe, there were an estimated

3,191,600 cancer cases diagnosed (excluding
nonmelanoma skin cancers) and 1,703,000 deaths from
cancer. The most common form of cancers was breast
cancer (429,900 cases, 13.5% of all cancer cases),
followed by colorectal cancers (412,900, 12.9%) and
lung cancer (386,300, 12.1%). Lung cancer, with an
estimated 334,800 deaths (19.7% of total), was the most
common cause of death from cancer, followed by
colorectal (207,400 deaths), breast (131,900) and
stomach (118,200) cancers.
 Estimates of the cancer incidence and mortality in
Europe in 2006.
Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P.

Ann Oncol. 2007 Mar;18(3):581-92. Epub 2007 Feb 7.

– CONCLUSIONS: The total number of new cases of

cancer in Europe appears to have increased by
300,000 since 2004. With an estimated 3.2 million
new cases (53% occurring in men, 47% in women)
and 1.7 million deaths (56% in men, 44% in women)
each year, cancer remains an important public health
problem in Europe and the ageing of the European
population will cause these numbers to continue to
increase even if age-specific rates remain constant.
 Estimates of the cancer incidence and mortality in
Europe in 2006.
Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P.

Ann Oncol. 2007 Mar;18(3):581-92. Epub 2007 Feb 7.

– Evidence-based public health measures exist

to reduce the mortality of breast and
colorectal cancer (Treatment & Screening )
while the incidence of lung cancer, and
several other forms of cancer, could be
diminished by improved tobacco control.
 Survival
The 1-year survival rate for lung cancer has increased
from 34% in 1975 to 42% in 1998.

􀂃 Despite major advances in understanding and treating

cancer, the 5-year relative survival rate is only 15%, a
rate that has improved only slightly over the last 30
Years

􀂃 According to the World Health Organization, three

people die every minute worldwide from lung cancer
5-Year Survival Rates by World Region
Japan 21

North America 20
Latin
America/Caribbean 14
Australia/New
Zealand 13

East Europe 12

South Africa 10

China 8
Middle East/North
Africa
8
Northwestern
Europe 7

0 5 10 15 20 25
 EMRO LUNG CANCER

 In 2004, around 300,000 from EMRO diagnosed with

lung cancer, and 200,000 will die from it
 It is the second most common cancer among men
 It is the leading cause cancer-related deaths, killing
more people than breast, liver, prostate, colon, and
pancreas cancers combined
Age-adjusted Incidence Rates for Men,
North Africa and Middle East

Syrian 37.7

Lebanon 28.9

Tunisia 28.6

Morocco 25.6

Algeria 24.4

Iraq 23

Kuwait 17.1

Jordan 16.7

0 10 20 30 40
Age Specific Incidence Rate (100,1000) in
Arab Countries and other African countries
Glubocan 2002
Country Crude ASR
Kenya 1.9 4.2
Rwanda 0.9 1.7
Mauritius 12.6 15.8
Chad 2.3 4.7
Algeria 9.8 16.9
Egypt 5.3 8.6
Libya 6.7 10.4
Morocco 11.9 20.1
Sudan 0.5 1.0
Tunisia 21.5 27.8
Age Specific Incidence Rate (100,1000) in
Arab Countries - Glubocan 2002
Country Crude ASR
Bahrain 15.9 30.5
Saudi
Arabia
6.0 10.3
Syria 14.4 32.9
Iraq 10.5 22.7
Yemen 1.4 4.1
Jordan 7.9 16.5
Kuwait 11.2 18.9
Lebanon 22.5 31.3
Oman 5.5 9.6
Qatar 14.3 19.9
United A
Emirates
11.6 13.7
 Type of Cancers in Egypt and
some Arab Countries, Males

Country 1st 2nd 3rd 4th 5th

Egypt Bladder Liver NHL Lung Colorectal

Algeria Lung Bladder Stomach Prostate Colorectal

Tunisia Lung Bladder Prostate Larynx Colorectal

Jordan Lung Bladder Prostate NHL Skin

Lebanon Bladder Lung Prostate Colorectal stomach

Yemen NHL HD Liver Leukemia Colorectal

 Frequency of Lung Cancer in
Egypt and other Arab Countries
Percent of cancer cases
Country Male % Female %
Egypt (Gharbiah & NCI) 14.3 3.7
Morocco 18.8 2.0
Tunisia 23.3 2.3
Lebanon 14.1 4.3
Iraq 15.7 4.7
Algeria 16.8 2.0
Jordan 11.2 2.3
Yemen 2.8 2.6
Histological types of lung cancer
 2 major types:
 small-cell lung cancer, and
 nonsmall-cell lung cancer, which is further
subdivided into:
 squamous cell carcinoma,
 adenocarcinoma, and
 large-cell carcinoma.
 Origin and characteristics of
various types of lung cancer
 Squamous cell lung cancer: commonest
type in males, central origin, manifests
early
 Adenocarcinoma: commonest type in
females, peripheral origin, manifests late
 Large cell lung cancer: least common
type, peripheral origin
 Small cell lung cancer: most aggressive
type, central origin, spreads quickly
 Lung cancer histology

• There are two main types of lung cancers:

around 20% are small cell lung cancers (SCLC)
and the remainder are non-small cell lung
cancers (NSCLC).
• The main types of NSCLC are squamous
cell carcinoma, adenocarcinoma and large cell
carcinoma, which account for approximately
35%, 27% and 10% of all lung cancer cases
respectively in the UK.
 Egypt

􀂃 Accurate epidemiological data on lung cancer in Egypt

is not available since a comprehensive national
population-based cancer registry is lacking.

􀂃 However, official statistics as well as institution and

hospital-based studies show that it is the second most
common cancer in men and second leading cause of
cancer death, after bladder cancer
 Descriptive Epidemiology:
Age

􀂃 Age-specific incidence rates increase

exponentially until the rates plateau and then decline
after the age of 80 in men and the age of 70 in
women

Only 5% to 10% of lung cancer cases are

diagnosed under 50 years of age
 Lung cancer incidence by age
and sex

• Lung cancer is rarely diagnosed in people

younger than 40, but incidence rises steeply
thereafter peaking in people aged 75-80 years.
Most cases (85%) occur in people over the age
of 60.
• In the 1950s the male/female ratio for lung
cancer cases was 6:1 but with decreasing male
rates and increasing female rates, the ratio is
now 7:5 (22,495 male cases and 15,818 female
cases in 2004). Overall, 13% of all new cases of
cancer are lung cancers
 Descriptive Epidemiology:
Gender
􀂃 Worldwide, age-adjusted incidence rates of lung
cancer among men exceed, twofold or more, than
among Women
 Descriptive Epidemiology:
Race
􀂃 The risk of lung cancer in United States black
men has been about 50% higher than in white men
in the past 10-15 years. During 1975 to 1990, the
age-adjusted lung cancer incidence in the United
States black women was 10% to 20% higher than
in white women.
 Genetic factors
 Smoking is the biggest risk factor, linked to nine
in 10 lung cancers . So genetics play a minor
role.
 Some people have a genetic risk or
predisposition for lung cancer. Anyone with a
first degree relative (parent, brother, sister) with
lung cancer has a higher risk of developing lung
cancer .
 Research is ongoing to further define the genetic
factors associated with lung cancer.
 Risk Factors
• Doctors cannot always explain why one
person develops lung cancer and another
does not. However, we do know that a
person with certain risk factors may be
more likely than others to develop lung
cancer. A risk factor is something that may
increase the chance of developing a
disease.
• Studies have found the following risk
factors for lung cancer:
 Risk factors
 1. Tobacco (and passive) smoking
 2. Air pollution in urban areas
 3. Chronic lung conditions: COPD
 4. Occupational exposure (man-made
mineral fibre)
 Smoking
The overwhelming role of smoking in the causation of lung
cancer has been repeatedly demonstrated over the past 50
years:

– 87% of lung cancer cases are thought to result from smoking

– The longer you smoke and the more packs per day you
smoke, the greater your risk
– Secondhand or environmental tobacco smoke increase the risk
– A nonsmoker married to a smoker has a 30% greater risk
– Workers exposed to tobacco smoke at the workplace are at a
higher risk
–– No evidence that low tar cigarettes reduces risk
 Smoking
• Tobacco use accounts for at least 30% of all
cancer deaths and 87% of lung cancer deaths.
(Source: Cancer Facts and Figures 2008).
• Each year, about 3,000 non-smoking adults die
of lung cancer as a result of breathing
secondhand smoke. Each year secondhand
smoke also causes an estimated 35,000 deaths
from heart disease in people who are not current
smokers. (Source: Cancer Facts and Figures
2008) 
 Cause and effect: cigarette
smoking  lung cancer
 Men started smoking cigarettes in 1920s
 20 years later, incidence of lung cancer
in men climbed sharply.
 In 1940s, women became cigarette
smokers  20 years later, a similar
dramatic increase in lung cancer among
women.
 Smoking
• Besides lung cancer, tobacco use also
causes increased risk for cancer of the
mouth, nasal cavities (nose), larynx (voice
box), pharynx (throat), esophagus
(swallowing tube), stomach, liver,
pancreas, kidney, bladder, uterine cervix,
and acute myeloid leukemia. (Source:
Cancer Facts and Figures 2008) 
 Smoking

􀂃 Smoking has been implicated in:

– 80% of lung cancer deaths in men
– 75% of lung cancer deaths in women
– 13% of lung cancer deaths in nonsmokers
– 28% of all cancer deaths
 Risk Factors
• Radon: Radon is a radioactive gas that
you cannot see, smell, or taste. It forms in
soil and rocks. People who work in mines
may be exposed to radon. Radon is found
in houses. Radon damages lung cells, and
people exposed to radon are at increased
risk of lung cancer. The risk of lung cancer
from radon is even higher for smokers.
 Risk Factors: Other “occupational carcinogens”
(cancer-causing agents found in workplace)
•􀂃 Radioactive ores such as uranium
•􀂃 Inhaled chemicals or minerals such as:
– Arsenic
– Vinyl chloride
– Nickel chromates
– Chloromethyl ethers
– Coal products
– Mustard gas
- Fuels such gasoline
- Diesel exhaust
 Risk Factors

• Asbestose and other substances: People who have

certain jobs (such as those who work in the construction
and chemical industries) have an increased risk of lung
cancer. Exposure to asbestos, arsenic, chromium,
nickel, soot, tar, and other substances can cause lung
cancer. The risk is highest for those with years of
exposure. The risk of lung cancer from these substances
is even higher for smokers.
Asbestos: Asbestos worker are about 7 times more
likely to die of lung cancer
 Risk Factors: other than smoking
􀂃
– People with silicosis and berylliosis (lung diseases
caused by breathing in certain minerals) also have a
higher risk

- Diet (vitamins A, C, E, β-carotene deficiencies)

 Risk Factors:

•􀂃 Marijuana :
It has been hard to prove a connection because it is not
easy to gather information about the use of illegal drugs –
Many marijuana also smoke cigarettes

•􀂃 Radiation therapy:
– Particularly if they smoke

•􀂃Recurring inflammation:
Tuberculosis and some types of pneumonia often leave
scars. This increases risk of adenocarcinoma type

􀂃
 Prevention of lung cancer
 80% of lung cancer  10% of lung cancer
cases are cases are
associated with associated with
many years of exposure to
tobacco smoking, occupational
and can therefore carcinogens, and
be AVOIDED. can therefore be
AVOIDED.
The estimated Proportion of
Preventable Cancer

Preventive
40%

Non
preventive
60%
 What are the Percent of such
Modifiable Risk Factors ?
• Smoking = 20 %
• Alcohol = 5 %
• Low Fruit and Vegetable Intake = 5 %
• Unsafe Sex = 2 %
• Lack of Exercise = 2%
• Others = 6%
 Remember
• Cancer kill around 8 Million people in
2007, three quarters of whom were in
developing Countries.

• Smoking is the main etiological factor

responsible for up to 90% of cases.

• Lung Cancer is the most preventable form

of cancer death.
Many Thanks