PATTERN OF ADMITTED CANCER CASES IN BASRAH GENERAL HOSPITAL DURING 2005-2008

Background: At the present time, a national strategy is adopted in Iraq by the Iraqi Cancer Board to control cancer. The strategy consists of six approaches to deal with the problem of cancer in Iraq. One of these approaches is to establish a population based cancer registration. Among the important sources of data for such registry are hospital based cancer registries. Objective: To evaluate the cancer registry in Basrah General Hospital over a 4-year period (2005-2008) and to study the pattern of cancer cases admitted to the same hospital during the same period. Patients & methods: A descriptive retrospective record based study involving all diagnosed cancer cases admitted to Basrah General Hospital over a four-year period (2005-2008) was carried out. Cancer cases were identified by examining inpatients records that are available in each of the studied wards. Further the information related to each cancer case derived from the inpatients records and compared with data recorded and compiled by the cancer registration unit in Basrah General Hospital. This was performed to assess the reliability and adequacy of hospital cancer registry as an important source of data about cancer cases diagnosed or admitted to the hospital. Results: The total admitted cancer cases identified during 2005-2008 were 1207. Male cancer cases represented 61.4% of the total cases, while females represented 38.6%. The most frequent age group among males was 65-74 years compared to a younger age group for females (45-54 years). Majority of patients were inhabitants of Basrah governorate (70.8%).The total admitted cancer cases during 2005, 27006, 2007 and 2008 were 263, 288, 353 and 303 respectively. The most frequent type of admitted cancer cases to Basrah General Hospital was urinary bladder cancer forming 43.8% of total admitted cases. It ranked as the first male cancer accounting for 53.9% of total males' cases. Breast cancer ranked as second type of cancer (11.9%), it was the first female cancer representing 28.1% of total females' cancer. The effort of the hospital registration unit to register cancer cases was very limited with a very low coverage for all sorts of cancer during 2005-2008. Conclusion: while interesting information on cancer pattern has been derived from Basrah General Hospital data, they are still incomplete and may represent a selective and biased sample of the patient population. INTRODUCTION ancer is the second most common cause of death in the western world after cardiovascular diseases. The International Agency for Research on Cancer (IARC) estimated that globally nearly 11 million new cases of cancer, 6.7 million deaths and 24.6 million persons live with cancer (within 5 years of diagnosis) in the year 2002. [2] In developing countries cancer is emerging as a public health problem. This has been attributed to the rapid improvement in the field of health care, in addition to the control of communicable diseases, increase life expectancy at birth and the rapid socio-economic changes resulting in modified life style. In Iraq, cancer is the third leading cause of death and the seventh leading cause of morbidity. In a study conducted by MOH of Iraq over a 5-year period (2000-2004), the top 5 primary tumors were: breast, lung & bronchus, leukemia, bladder, and brain & CNS. In Basrah, previous research work and growing impressions among doctors and lay people suggest that cancer is increasing in Basrah after the 1991 war. However, these suggestions faced a lot of criticism for being inadequate to prove real increase in cancer risk simply because of incomplete case registration and/or inaccurate population denominators. Some of the results, however, are substantive enough to convince that the evidence on cancer increase is fairly reasonable. Yacoub et al 1999 reported an increasing incidence of malignancies over the period extending from 1990-1997. Habib et al reported an annual C MJBU, VOL 30, No.1, 2012___________________________________________________________________________________________________ 8 incidence rate of cancer in Basrah for the year 2005 at 74.3 per 100000 population. In a more recent report they presented a comprehensive account on cancer in Basrah over the period 2005-2008 and estimated the annual crude incidence rate at 70.7 per 100000 population. They suggested increase rates of certain cancers such as breast cancer and leukemia. At the present time, a national strategy is adopted in Iraq by the Iraqi Cancer Board to control cancer. The strategy consists of six approaches to deal with the problem of cancer in Iraq. One of these approaches is to establish a population based cancer registration. Among the important sources of data for such registry are hospital based cancer registries. Therefore, in Basrah four hospital based registration units were established since 2004 (in Al-Sadr teaching hospital, Basrah general hospital, Basrah maternity and children hospital, and AlMawanie hospital). Each unit registers new cancer cases diagnosed at and/or admitted to the hospital. Therefore, the present study was carried out to evaluate the cancer registry in Basrah General Hospital over a 4-year period (2005-2008) and to study the pattern of cancer cases admitted to the same hospital during the same four-year period. PATIENTS AND METHODS This is a descriptive, retrospective, record-based study involving all diagnosed cancer cases admitted to Basrah General Hospital over fouryear period (2005-2008). All cancer cases admitted to the general surgery, ENT, orthopedics, and medical wards, during the study period were included in the study. In addition, the records of the cancer registration unit in Basrah general hospital for the same period were also examined. Cancer cases were identified by examining inpatients records that are available in each of the studied wards. For each case the following information were abstracted: personal identifiers and demographic information (name, age, sex and place of residence); tumor details (date of admission, topography). The information related to each cancer case derived from the inpatients records were compared with data recorded and compiled by the hospital cancer registration unit. This comparison was made to assess the reliability and adequacy of hospital cancer registry as an important source of data about cancer cases diagnosed or admitted to the hospital. The data were analyzed using SPSS (Statistical Package for Social Sciences computer file version 15). Total numbers and relative frequencies were used for analysis and comparisons. X-test was used to find out statistical associations, P-value <0.05 was considered significant. RESULTS Age and sex distribution During the four-year study period (2005-2008), the total number of cancer cases admitted to Basrah General Hospital were 1207, 741 were males forming 61.4 %, while the remaining 466 were females forming 38.6% of total cases. Overall male to female ratio was (1.6:1). The most frequent age group among males was 6574 years compared to a younger age group for females (45-54 years). (Table-1). ___________________________________________________________________________________________________MJBU, VOL 30, No.1, 2012 9 Place of residence Basrah ThiQar Missan Other governorates Table 1. Distribution of cancer cases to Basrah General Hospital (2005-2008) according to age and sex. Total Females Males Age (years)


INTRODUCTION
ancer is the second most common cause of death in the western world after cardiovascular diseases. [1]The International Agency for Research on Cancer (IARC) estimated that globally nearly 11 million new cases of cancer, 6.7 million deaths and 24.6 million persons live with cancer (within 5 years of diagnosis) in the year 2002. [2]n developing countries cancer is emerging as a public health problem.This has been attributed to the rapid improvement in the field of health care, in addition to the control of communicable diseases, increase life expectancy at birth and the rapid socio-economic changes resulting in modified life style. [3]In Iraq, cancer is the third leading cause of death and the seventh leading cause of morbidity.In a study conducted by MOH of Iraq over a 5-year period (2000-2004), the top 5 primary tumors were: breast, lung & bronchus, leukemia, bladder, and brain & CNS. [4]In Basrah, previous research work and growing impressions among doctors and lay people suggest that cancer is increasing in Basrah after the 1991 war.However, these suggestions faced a lot of criticism for being inadequate to prove real increase in cancer risk simply because of incomplete case registration and/or inaccurate population denominators.Some of the results, however, are substantive enough to convince that the evidence on cancer increase is fairly reasonable.Yacoub et al 1999 [5,6] reported an increasing incidence of malignancies over the period extending from 1990-1997.Habib et al [7] reported an annual C incidence rate of cancer in Basrah for the year 2005 at 74.3 per 100000 population.In a more recent report they presented a comprehensive account on cancer in Basrah over the period 2005-2008 and estimated the annual crude incidence rate at 70.7 per 100000 population.They suggested increase rates of certain cancers such as breast cancer and leukemia. [8]At the present time, a national strategy is adopted in Iraq by the Iraqi Cancer Board to control cancer.The strategy consists of six approaches to deal with the problem of cancer in Iraq. [9]One of these approaches is to establish a population based cancer registration.Among the important sources of data for such registry are hospital based cancer registries.Therefore, in Basrah four hospital based registration units were established since 2004 (in Al-Sadr teaching hospital, Basrah general hospital, Basrah maternity and children hospital, and Al-Mawanie hospital).Each unit registers new cancer cases diagnosed at and/or admitted to the hospital. [9]Therefore, the present study was carried out to evaluate the cancer registry in Basrah General Hospital over a 4-year period (2005-2008) and to study the pattern of cancer cases admitted to the same hospital during the same four-year period.

PATIENTS AND METHODS
This is a descriptive, retrospective, record-based study involving all diagnosed cancer cases admitted to Basrah General Hospital over fouryear period (2005-2008).All cancer cases admitted to the general surgery, ENT, orthopedics, and medical wards, during the study period were included in the study.In addition, the records of the cancer registration unit in Basrah general hospital for the same period were also examined.Cancer cases were identified by examining inpatients records that are available in each of the studied wards.For each case the following information were abstracted: personal identifiers and demographic information (name, age, sex and place of residence); tumor details (date of admission, topography).The information related to each cancer case derived from the inpatients records were compared with data recorded and compiled by the hospital cancer registration unit.This comparison was made to assess the reliability and adequacy of hospital cancer registry as an important source of data about cancer cases diagnosed or admitted to the hospital.The data were analyzed using SPSS (Statistical Package for Social Sciences computer file version 15).Total numbers and relative frequencies were used for analysis and comparisons.X 2 -test was used to find out statistical associations, P-value <0.05 was considered significant.

Age and sex distribution
During the four-year study period (2005-2008), the total number of cancer cases admitted to Basrah General Hospital were 1207, 741 were males forming 61.4 %, while the remaining 466 were females forming 38.6% of total cases.Overall male to female ratio was (1.6:1).The most frequent age group among males was 65-74 years compared to a younger age group for females (45-54 years).(Table -

Cancer registration in Basrah General Hospital 2005-2008
Comparison between the wards records and cancer registry records for the four-year study period revealed that out of the total of 1207 cancer cases admitted to Basrah General Hospital over the four-year period (2005-2008),only 110(9.1%)cancer cases were registered.The distribution of registered cancer cases according to year of registration did not show any improvement in the adequacy of registration over the four-year study period.(Table-6).Cancers of gastrointestinal tract (stomach and colo-rectal cancers) and breast cancer showed higher rates of registration compared to all other cancers.In addition, a significantly higher registration rate was observed for female cancers (13.7%) as compared to male cancers (6.2%).Similarly, the registration rate varied for cancer cases of different age groups.The highest registration rate was for those in the age group 35-44 years (15.2%), while the lowest registration rate was for those 75 years or older.

DISCUSSION
Epidemiology is an invaluable tool for providing the rational basis on which effective preventive programmes can be planned and implemented. [10]Descriptive epidemiology helped in understanding the causes of cancer by examining the pattern of distribution of cases by age, sex, social class, geography and so on. [2]any descriptive studies raised hypotheses about factors that cause or prevent cancer, which are then tested further in basic-clinical and analytical epidemiological studies. [10]The present study is a descriptive epidemiological study carried out to study the pattern of admitted cancer cases in one of the main hospitals in Basrah and to find out whether it reflects the pattern of the predominant cancers in Basrah governorate.The results of the study showed an increase in the number of admitted cancer cases to Basrah General Hospital between 2005 and 2007 with about 148% increase in the number of admitted female cancer cases between the two years.This increase in the number of admitted cancer cases may reflect a real increase in cancer incidence in Basrah particularly among females due to an increase in the incidence of breast cancer. [8]rinary bladder cancer alone accounted for more than half of admitted cancer cases (53.8%), ranking as the first male cancer and the second female cancer.The high frequency of bladder cancer is partly due to the fact that Basrah General Hospital has the largest urosurgical department in Basrah governorate with large number of specialists in this field.Therefore, it is expected that it receives the majority if not all patients with urological problems particularly cancer.In addition to that urinary bladder cancer is the second most common cancer in Basrah governorate and the first male cancer in Basrah during the period 2005-2008. [8]Urinary bladder cancer is also the second male cancer in Iraq over the period from 2000-2004. [4]Urinary bladder cancer rate is high in many parts of the world.It is high in parts of Africa where bladder cancer, particularly of sequamous cell type is linked to chronic infection with schistosoma hematobium and in many Southern and Eastern European countries where smoking in men has been prevalent.On the other hand, in developed countries the high risk of urinary bladder cancer is attributed to occupational exposure to carcinogens. [2]Breast cancer was the second leading cancer of admitted cancer cases to Basrah General Hospital during the study period, while it is the first leading cancer in Basrah and in Iraq.However, breast cancer ranked as the first female cancer as it is in Basrah and in Iraq. [4,7]However, the leading cancers in males and females according to the present study are somewhat different from those reported for Basrah governorate.The leading cancers in males in Basrah during 2005-2008 were cancers of urinary bladder, lung, and lymphomas and those for females were cancers of breast, uterus and cervix, and skin. [8]While among cancer cases admitted to Basrah General Hospital over the same period, lung cancer was not among the ten leading cancers in males and uterus and cervix cancer was the ninth leading cancer in females.It is well known that in general, there are several limitations in describing patterns of cancer in individual institutions.The leading sites of cancer in a given institution are dependent on a number of factors, such as, the popularity of a particular department and/or treating physicians; the availability of a particular diagnostic or treatment facility; the affordability of the patients and so on.For example, in Basrah, chest surgery department is located in another hospital and it is expected to attract lung cancer cases.Despite these limitations, the patterns observed in most of the cancer centers that function as referral institutions for care of cancer patients may reflect the predominant cancers in the region. [11]ancer registries are a unique source of information for any cancer control programme and for developing strategies for cancer health programmes.The main source of information will usually be hospitals or cancer centers. [11]he task of a population-based registry will obviously be much easier when there are collaborating hospital registries which contribute relevant information. [11]Evaluation of the cancer registry in Basrah General Hospital showed that registration of cancer cases admitted to the hospital was incomplete and the registry was highly inadequate source of morbidity data for all types of cancer at least until the year 2008.
In conclusion, while interesting information on cancer pattern has been derived from Basrah General Hospital data, they are still incomplete and may represent a selective and biased sample of the patient population.However from accumulated evidence, it seems that ensuring hospital, histopathological and other oncology centers registration will enhance populationbased cancer registration to substantial extent and facilitate reasonable estimates of cancer epidemiological parameters. [7,8]

Figure 1 .
Figure 1.Distribution of cancer cases to Basrah General Hospital (2005-2008) according to place of residence.