Global Journal of Health Science; Vol. 8, No. 3; 2016
ISSN 1916-9736
E-ISSN 1916-9744
Published by Canadian Center of Science and Education
Incidence Trend and Epidemiology of Common Cancers in the Center
of Iran
Hosein Rafiemanesh1, Narjes Rajaei-Behbahani2, Yousef Khani3, Sayedehafagh Hosseini4, Zahra pournamdar5,
Abdollah Mohammadian-Hafshejani6, Shahin Soltani7, Seyedeh Akram Hosseini8, Salman Khazaei9 & Hamid
salehiniya10,11
1
School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
2
Department of Epidemiology and Biostatistics, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3
Alborz University of Medical Sciences, Karaj, Iran
4
Endometriosis Research Center, Iran University of Medical Sciences, Tehran, Iran
5
Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
6
Department of Epidemiology and Biostatistics, School of Public Health, Isfahan University of Medical
Sciences, Isfahan, Iran
7
Department of Health Management and Economics, School of public Health, Tehran University of Medical
Sciences, Tehran, Iran
8
Mashhad University of Medical Sciences, nursing collage of Quchan, Quchan, Iran
9
Department of Epidemiology & Biostatistics, School of Public Health, Hamadan University of Medical
Sciences, Hamadan, Iran
10
Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
11
Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical
Sciences, Tehran, Iran
Correspondence: Hamid Salehiniya, Department of Epidemiology and Biostatistics, School of Public Health,
Tehran University of medical sciences, Tehran, Iran. Tel: 98-935-775-0428. E-mail: alesaleh70@yahoo.com
Received: May 4, 2015
Accepted: June 17, 2015
doi:10.5539/gjhs.v8n3p146
Online Published: July 13, 2015
URL: http://dx.doi.org/10.5539/gjhs.v8n3p146
Abstract
Introduction: Cancer is a major public health problem in Iran and many other parts of the world. The cancer
incidence is different in various countries and in country provinces. Geographical differences in the cancer
incidence lead to be important to conduct an epidemiological study of the disease. This study aimed to
investigate cancer epidemiology and trend in the province of Qom, located in center of Iran.
Method: This is an analytical cross-sectional study carried out based on re-analysis cancer registry report and
the disease management center of health ministry from 2004 to 2008 in the province of Qom. To describe
incidence time trends, we carried out join point regression analysis using the software Join point Regression
Program, Version 4.1.1.1.
Results: There were 3,029 registered cases of cancer during 5 years studied. Sex ratio was 1.32 (male to female).
Considering the frequency and mean standardized incidence, the most common cancer in women were breast,
skin, colorectal, stomach, and esophagus, respectively while in men the most common cancers included skin,
stomach, colorectal, bladder, and prostate, respectively. There was an increasing and significant trend, according
to the annual percentage change (APC) equal to 8.08% (CI: 5.1-11.1) for all site cancer in women.
Conclusion: The incidence trend of all cancers was increasing in this area. Hence, planning for identifying risk
factors and performing programs for dealing with the disease are essential.
Keywords: incidence, cancer, trend, epidemiology, Iran
1. Introduction
Cancer is a major public health problem in Iran (Keyghobadi et al., 2015) and many other parts of the world.
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Approximately 14 million new cases of cancer and 8.2 million cancer deaths occurred worldwide. Based on
GLOBOCAN in 2011, the Age-Standardized incidence Rate (ASR) of all cancers were105 and 165 per 100,000
person-years in men and women, respectively. Nearly 57% of new cancer cases and 65% of cancer deaths
occurred in less developed regions (http://www.who.int/mediacentre/factsheets/fs297/en/, de Martel, 2012;
Globocan, 2012; Malcolm, 2014; Negar Sadat Taheri et al., 2014).
The incidence of cancer is different in various countries. Ten common cancers in men in the world included lung,
prostate, pancreas, lymph nodes, hematopoietic system, esophagus, stomach, bladder, kidney, and throat, but in
women were lung, breast, pancreas, lymph nodes, hematopoietic system, stomach, cervix, kidney, rectum, and
bladder (Joyce, 2007). According to the national report of cancer registry in 2009, 55.58% and 44.41% of cancer
cases took place in Iran in men and women, respectively. Sex ratio was 1.25. As well, ten common cancers in
Iranian men consisted of skin, stomach, prostate, bladder, colorectal, hematopoietic system, lung, esophagus,
non-Hodgkin lymphoma, and brain and in women breast, skin, colorectal, stomach, esophagus, thyroid,
hematopoietic system, ovary, brain, urinary tract (Iran Summer, 2011). Geographical differences in the cancer
incidence lead to be important to conduct an epidemiological study of the disease. It is possible to find
significant differences between developed and developing countries according to prevalence of cancers.
Iran is an ancient and developing countries country located in the Middle East, a region between Asia, Europe,
and Africa. Iran is located in a special geostrategic situation by connecting the eastern and western parts of the
world (Map 1).This country in recent years experiment the rapid development of modernity and industrialization,
and changes in the environment and people's lifestyles , that this change may affect epidemiological patterns of
different types of cancers (Elsayed, 2009; Abdolhassan Talaiezadeh, 2013; Marzieh Rohani-Rasaf, 2013; Almasi
et al., 2015).
The area of Iran is 1,648,195 Km2 that makes it the 17th largest country in the world. Iran divided into 30
provinces and 336 districts. Iran with a population of almost 70 million, of which more than 65% are urban
dwellers, Iran’s population is young; almost one third of the population is less than 15 years old and only almost
5% is over 60 years. The population annual growth rate in 2006 was 1.2%. According to official data, more than
90% of Iranian people are under the coverage of at least one kind of health insurance. Cardiovascular diseases
are the first cause of mortality in Iran with more than 45% of deaths; the second cause of mortality is accidents,
with almost 18% of all deaths. The third causes of mortality were cancer with 14% of total deaths; so that 98
cases daily die from cancer in Iran (Iavari, 2006; Negar Sadat Taheri et al., 2014)
Qom is one of the provinces of Iran with 11,237 km², it is in the north of the country, and its provincial capital is
the city of Qom. In 2011, this province had a population of 1,151,672 out of which 95.2% resided in urban areas
and 4.8% in rural vicinities. The province contains 1 city, 4 counties, 9 rural districts, and 256 villages. There
was a little information about the trend of cancer incidence in this provinces. Since the first step to dealing with
the diseases and planning for the prevention, having knowledge of conditions and trends of cancer in any society,
this study aimed to investigate cancer incidence in Qom between 2004 and 2008.
2. Methods
2.1 Study Design
This was an analytical cross-sectional study carried out based on re-analysis Cancer Registry Center report of
health deputy which is based on Iran ministry of health guidelines, from 2004 to 2008 in the province of Qom in
Iran.
Map 1: Iran location in the word
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2.2 Cancer Registry System in Iran
This analytic study was done based on longitudinal program in Iran that Similar to many countries in the world
that have national registry of cancer (NCR) is trying to identify all cases of cancer occurring in Iran from 2004 to
2008. Data used in this study was obtained from a national registry of cancer (NCR), and Disease Control and
Prevention (CDC) of ministry of Health and Medical Education in Iran for 2004 to 2008 (16). In 2008 in Iran,
there are 30 provinces and 41 Medical Universities. Deputy for health of each university is responsible for health
issues of the population and all health activities are managed by these deputies. All deputies for health have been
included in the NCR. Registrar would apply the national registration software which was developed by CDC.
For pathologic centers, without software, the cancer records were gathered manually. The Cancer Office of CDC
should provide techniques and funding supports. The data are transmitted every 3 months, by electronic file and
also hard copy of ‘Cancer Registry Data Collection Form’; this form is comprised of three parts: part I, regarding
patient's identity characteristics in addition to the name of biopsy-taker physician, name of hospital, location of
which the biopsy is taken, clinical diagnosis and date of biopsy sent to histological laboratory and demographic
information of the patients includes race and residence. Part II includes the most important findings of patient's
clinical history. Part III includes preclinical findings. The information includes primary location of tumor, date of
cancer diagnosis, morphology and histology and its behavior and diagnosis method. Physicians fill the form of
clinical data and the official personnel fill the identity and demographic information. Quality control has been
coordinated in five main areas by Cancer Office of CDC: (i) regarding completeness of coverage; (ii)
completeness of details; (iii) accuracy of data; (iv) accuracy of reports; (v) accuracy of interpretation and (vi)
repeated cases are deleted from national data. Surveillance of pathology is based on the cancer record in several
selected provinces to compare it with the present pathology cancer record for a general and complete evaluation
and also for the accuracy of the collected data. IARC software provides a way to identify inaccuracies in data
coding. Accordance of The International Classification of Diseases for Oncology (ICD-OC: topography with
ICD-OM: morphology) is done manually and also by considering age and sex groups (pathology file of fatal
error has been revised by the Scientific Society of Pathology of Iran and also by two masters in pathology).
Method for deleting repeated cases: for the lack of any classified National Identification Numbers, the process
for deleting the repeated cases was completed by a manual review of the record. After editing data of each
province and considering in mind that for deleting of repeated cases, similar cases should also be the same as
morphology, topography, identity and demographic information; deletion of the repeated cases would be done
separately in each province and finally in all over country by experienced manual reviewers.
2.3 Statistical Methods
The average annual age-standardized incidence rate (ASR) per 100 000 person-years was calculated by the direct
method using the World Standard Population.To describe incidence time trends, we carried out join point
regression analysis using the software Join point Regression Program, Version 4.1.1.1 October 2014. The
analysis included logarithmic transformation of the rates, standard error, maximum number of one join points,
and minimum of four years between zero join points. Like the least squares regression method, the joinpoint
program is used to find the best-fit line through several years of data. However, the joinpoint program uses an
algorithm that tests whether a multi-segmented line is a significantly better fit then a straight or less-segmented
line. The test of significance uses a Monte Carlo Permutation method (i.e., it finds “the best fit” line). Like the
least squares regression method, the joinpoint program is used to find the best-fit line through several years of
data. joinpoint regression analysis involves fitting a series of joined straight lines on a log scale to the trends. The
aim of the approach is to identify possible joinpoints where a significant change in the trend occurs. In this study
0 joinpiont (Full model) was a significant model. All other program parameters were set to default values. All
statistical tests were two sided. The significance level was considered as 0.05. Common cancers were defined as
the number of reported cases and standardized incidence rates.
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Center
University
Receive the information
file from the University and
Reading the data in
software (provisional data)
Start
Information received from
the lab and entering the soft
Repetition of data and
Final repetition and transfer
in permanent information
marking
Send to center
Preparing and sending the
Receive the update data
files of update permanent
file permanent and enter in
End process
Diagram 1: Process of data collection of cancer cause in Iran
3. Results
Overall, there was 3,029 registered cancer cases, of which 1383 case (43.1%) were women and 1826 cases
(56.9%) men. Sex ratio was 1.32 (male to female). ASR was high in men than women. ASR was obtained about
70.09 per 100,000 people in women and 89.87 per 100,000 people in men. Considering mean standardized
incidence, the most common cancer in women were breast, skin, colorectal, stomach and esophagus, while in
men the most common cancers included skin, stomach, colorectal, bladder, and prostate. Five common cancers
in men and women constituted 58.53% and 59.44%, respectively, from all cancers attributed to both sexes (Table
1).
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Table 1. Frequency and standardized incidence of all sites and five common cancers by sex, during the years
2004 to 2008
2004
Sex
Cancer
N
All Site
Female
ASR N
2006
ASR N
2007
ASR N
2008
ASR N
Mean
ASR
Total
Count
ASR 2004-2008 2004-2008
212 66.69 256 67.74 279 74.84 298 81.53 338 89.67 76.09
1383
57
17.07 57
14.15 76
20.41 93
24.36 98
24.8
20.16
381
30
11.34 34
9.63
26
8.08
35
10.63 34
9.07
9.75
159
3 Colorectal 15
5.75
15
4.35
13
3.71
26
7.34
32
8.86
6.00
101
4 Stomach
13
3.99
18
4.87
22
6.24
17
4.79
26
7.96
5.57
96
5 Esophagus 15
4.94
18
4.99
15
4.29
20
6.28
17
4.49
5.00
85
Five Common 1 Breast
Cancer
2 Skin
Total Five Cancer
130 43.09 142 37.99 152 42.73 191 53.4
All Site
Male
2005
Five Common 1 Skin
Cancer
2 Stomach
343 94.4
207 55.18 46.48
323 75.35 379 92.61 371 89.87 410 96.66 89.78
822
1826
62
17.79 57
14.43 57
14.32 49
13.01 61
14.19 14.75
286
42
12.30 58
13.64 63
15.86 59
14.36 58
13.87 14.01
280
3 Colorectal 28
7.62
29
6.97
34
8.40
46
10.79 42
10.12 8.78
179
4 Bladder
39
10.46 34
7.30
28
6.82
35
9.49
38
9.80
8.77
174
5 Prostate
24
6.60
4.78
24
5.69
35
8.00
39
8.85
6.78
144
Total Five Cancer
22
195 54.77 200 47.12 206 51.09 224 55.65 238 56.83 53.09
1063
4. Cancers in Women
There was an increasing and significant trend, according to the annual percentage change (APC) equal to 8.08%
(CI: 5.1-11.1). The trend of five common cancers was 8.7% in women, which was not significant. Of five
common cancers in women, breast, colorectal, and stomach increased, with APC of 13.8%, 1.3%, and 11.6%,
respectively. Skin cancer (APC equal to -3.4%) had decreasing trend, while a constant trend was seen for
esophagus cancer with APC of 0.4%). In above cancers, none of the trends in women showed significant changes.
(p>0.05) (Table 2).
Table 2. Join point analysis for incidence of all site and five common cancer by sex in Qom, Iran, 2004-2008;
ASR– age-standardized rate per 100 000 (using world standard population)
2004 - 2008
Sex
Cancer
Female
Five
Common
Cancer
APC
95% CI
All Site
8.1^
5.1 to 11.1
1
Breast
13.8
-1.7 to 31.6
2
Skin
-3.4
-16.1 to 11.2
3
Colorectal
14.9
-17.4 to 59.9
4
Stomach
14.6
-4.8 to 38.0
5
Esophagus
0.4
-15.4 to 19.1
8.7
-2.0 to 20.6
All Site
2.3
-8.2 to 13.9
1
Skin
-5.4
-13.3 to 3.2
2
Stomach
3.0
-6.1 to 12.9
3
Colorectal
10.6
-1.0 to 23.5
4
Bladder
1.3
-18.7 to 26.3
Total Five Cancer
Male
Five
Common
Cancer
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Prostate
Total Five Cancer
Vol. 8, No. 3; 2016
11.6
-9.3 to 37.4
2.4
-5.2 to 10.7
^.APC and AAPC is significantly different from zero at alpha = 0.05.
Cancers in men
There was an increasing and significant trend, according to the annual percentage change (APC) equal to 2.3%
(CI: -8.2-13.9). The trend of five common cancers was 2.4% in women, which was not significant. Of five
common cancers in women, stomach, colorectal, bladder, and prostate increased, with APC of 3.8%, 10.6%, and
14.6%, respectively. Skin cancer (APC equal to -5.4%) had decreasing trend. In above cancers, none of the
trends in women showed significant changes. (p>0.05) (Table 2).
Figure 1. Overall trend of the five common cancers in men and women during 2004 to 2008 in Qom
4. Discussion
In this study, most patients were males (56.9%) and sex ratio was 1.32 (male to female). The prevalence of most
of common cancers was high in men than women. Considering the mean standardized incidence, the most
common cancer in women were breast, skin, colorectal, stomach and esophagus while in men the most common
cancers included skin, stomach, colorectal, bladder and prostate, respectively. There was an increasing and
significant trend, according to the annual percentage change (APC) equal to 8.08% (CI: 5.1-11.1) for all site
cancer in women.
Based on the national report of cancer registry in 2009, most of patients were men (55.58%). The sex ratio of
cancer incidence in the country was 125 (MoHotIRo, Summer 2011) and similar to other studies (JM, 1991;
Jalali, 2005; Samareh Pahlavan, 2006), male patients were high. Maisinneuve and Lowenfels reported that the
prevalence of cancer was twice in men than women (Lowenfels, 2006). Studies performed in Belgium in 2003
(Buntinx, 2003), Canada and the United States (Asulin, 2004), and Western Europe(Black, 1997) indicted
consistent findings, but the opposite occurred in Eastern Europe, except French (Black, 1997).
In our study, ASR was 89.87 per 100,000 in men and 76.09 per 100,000 in women. Based on the national report
of cancer registry in 2009, ASR was 132.19 in men and 123.55 in women (MoHotIRo, Summer 2011). Cancer
incidence in Europe was 446 in men and 284 in women, but the incidence was 303 in men and 204 in women per
100,000 people in the world (Buntinx, 2003), while the incidence was lower in Mediterranean countries
(Trichopoulou, 2000). In Ardebil (the region in North West of Iran), cancer incidence was 132 per 100,000 in
men and 96 per 100,000 in women (Sajadi, 2003). In Polynesia, located in French, the incidence was 186 and
209 in men and women, respectively. The incidence was 132.6 and 133 in Pakistan in men and women,
respectively (Gleize, 2000; Bhurgri, 2002). ASR was 153 and 156 per 100,000 people in Khuzestan (the
province in Western South of Iran) in men and women, respectively (Neda Amoori, 2014). ASR for all cancers
was 164.3 and 130.9 in Western Azerbaijan, located in North West of Iran, in men and women,
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respectively(Mohammad, 2008). Therefore, the incidence of cancer in Iran, was lower than some areas in the
word. It seems that the cancer incidence estimated in Iran wasn’t real, and in dead we under estimate the
incidence and mortality of cancer in Iran, due to problems such as The Low Quality of cancer registry System
in Iran and this fact that in many cases we don’t biopsy and therefore undiagnosed of disease in this case.
However, national data in Iran, show an increasing trend in incidence and mortality of cancer (Mohagheghi et al.,
2009). In contrast to the situation, in certain developed countries in last decade the incidence and mortality of
cancers were decreasing trend (Mousavi et al., 2007; Jemal et al., 2010; Bray et al., 2012). This difference might
be due to fast changes in lifestyle, exposure to risk factors, aggregation of carcinogens, and air and environment
pollution in Iran that led to increasing trend in cancer incidence.
The incidence of cancer is different in various regions. Five common cancers in men in the world are: lung,
prostate, colorectal, stomach, and liver and in women, including breast, colorectal, lung, cervical, and stomach
(Organization, 2012). In the country (Iran), five common cancers in men are skin, stomach, prostate, bladder, and
colorectal cancer, while in women, breast, skin, colorectal, stomach, and esophagus (MoHotIRo., Summer 2011).
Based on the national report of cancer registry in 2009, five common cancers in men were skin, stomach,
colorectal, bladder, and lung, while in women, breast, colorectal, skin, stomach, and esophagus in Qom
(MoHotIRo., Summer 2011). A study, conducted in East Azerbaijan, showed that five common cancer in men
included stomach, skin, bladder, esophagus, and colorectal and in women breast, skin, esophagus, stomach, and
colorectal (Mohammad, 2008). A study in Khuzestan indicated that the most common cancers in men comprised
skin, stomach, lung, blood, prostate, and bladder and in women, breast, skin, colorectal, lung, and bladder (Neda
Amoori, 2014).
In our study, five common cancers in men were skin, stomach, colorectal, bladder, and prostate and in women,
breast, skin, colorectal, stomach and esophagus. There was a small difference between our results and national
reports, but a considerable difference between them and world reports. The differences in the incidence of cancer
should be investigated to perform identifying related risk factors. Other studies also expressed high incidence of
stomach cancer in men and breast cancer in women. However, the differences in incidence of lung and colorectal
cancers between our findings, and national and world statistics can relate to lifestyles and features of the area.
Therefore, it is necessary to identification risk factors associated with these cancers and developing screening
program. According to the high prevalence of stomach cancer in the country and Qom, it is required to
endoscopy and detailed examination for individuals at risk. In recent decades, breast cancer is the first common
cancer in women in the country and world, and is increasing. Other studies emphasized an increasing trend of the
cancer (Afsoon Taghavi, 2012; Aboulfazl Afsharfard, 2013; Mitra Rahimzadeh, 2014; Neda Amoori, 2014).
Our findings, similar to other studies (Krittika Suwanrungruang, 2006; Seyed Reza Fatemi, 2010; Edris Abdifard,
2013; Nikbakht Roya, 2013), showed that colorectal cancer is enhancing in both sexes and the trend is high in
men than women. This may be due to dietary habits and changes in life style. Several studies indicated that
high-fat diet, obesity, tobacco use, and lack of physical activity are risk factors for this cancer. Since colorectal
cancer is the preventable disease, it is necessary to more investigate about risk factors affecting the cancer in
Qom.
In our study, the incidence of bladder cancer was increasing in men so that the cancer was one of the common
cancers in males in this region. Some studies also showed that the incidence of cancer is higher in men than
women(Alireza Salehi, 2011; Mohammad Ahmadi, 2012). This may be due to high consumption of tobacco and
Opium, and exposure to occupational carcinogens in men than women.
Our results revealed that the incidence of stomach cancer is increasing in both sex ,so in 2004-2008 was the
second cancer in men and Third in women. Another study stated that the incidence of the stomach cancer have
Increasing trend (Krittika Suwanrungruang, 2006). In the study, carried out in Khuzestan (one province of Iran),
higher incidence of the cancer was seen in women than men (Neda Amoori, 2014). Risk factors attributed to the
cancer are Helicobacter pylori, genetics, diet, and environmental factors. Hence, endoscopy and accurate
examinations are essential for detection individuals at the risk factors.
5. Limitations
There were some limitations in our study. Data in our registry were limited to pathology, residency, sex, and age
while other related variables like feeding pattern, job, and other lifestyle and socioeconomic factors have an
important role in susceptibility to cancer. Additionally registration in that period of time was limited to the
pathology system so a large number of cancers were missed. it should be stated that the cancer registry system in
Iran is still not fully and equally in all area and sometimes the differences in the quality and coverage of data is
observed.
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6. Conclusion
It can conclude that the incidence of all cancer is increasing in this area. Therefore, the plan for the control and
prevention of this disease must be a high priority for health policy makers. Our findings was obtained from the
descriptive study on the incidence trend of the disease in recent years and it is recommended that analytical
studies should be conducted to obtain a causal relationship and solve problems related to the disease.
Conflict of Interests
Authors have no conflict of interests.
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