Urologic Oncology in the Middle East

The Emirates Oncology Conference and Pan-Arab Cancer Congress 2014 was held in Abu Dhabi, UAE as a joint program of the SEHA Health System in conjunction with Johns Hopkins International and its affiliate Tawam Hospital. While the conference covered a wide range of malignancies, there was a palpable focus on cancer care in the Middle East. In urologic oncology, the prevalence of renal cell, prostate and bladder cancers is different depending on the country and region – therefore, the treatments and outcomes can vary dramatically.

This blog will discuss differences in Renal Cell Carcinoma, Prostate Cancer and Bladder Cancer in countries of the Middle East. 

The incidence and mortality of urologic malignancies in the Middle East (Western Asia) and the more developed regions of the world including the United States and Europe.

RENAL CELL CARCINOMA

According to the WHO GLOBOCAN program, the annual incidence of RCC (renal cell carcinoma) is 213,924 people, with 90,802 deaths per year leaving a 5-year prevalence of 580,700 people. RCC is age-related (i.e. more common in older patients) and is most common in the more developed countries of the world like the United States and countries of Europe. In the United States, the ASR (age-specific rate) of RCC is 12.0 per 100,000 people (see Table below). While Israel has an ASR for RCC of 10.0, most Arab countries of the Middle East have rates between 2.0 and 3.0. Turkey has the highest ASR of 5.6 for RCC. 

The 20 highest age-specific rates of kidney cancer (per 100,000) in the countries of Western Asia from WHO GLOBOCAN.

Most of the figures are likely inaccurate and underestimate the true incidence of RCC as data in not consistently shared among countries and institutions within countries.  To address the shortcomings of systematic data collection in these countries, the Africa Middle-East Collaborative RCC Epidemiology Project was started as a cancer registry, collecting data from a number of countries including Algeria, Egypt, Jordan, Lebanon, Libya, Morocco, and Saudi Arabia. For instance, GLOBOCAN estimates the incidence of RCC in Lebanon to be approximately 2 per 100,000, while the actual data from the collaborative registry indicates the incidence in Lebanon is closer to 4.3 per 100,000.

Similar to other countries around the world, most RCC are low-grade, early stage tumors, however the significant proportion of patients that present with high-stage or metastatic disease mirrors the 20-30% seen globally.

 

PROSTATE CANCER

The prostate cancer data mirrors the data for RCC. The US has an ASR of 98.2 per 100,000 men; Turkey has the highest ASR of 40.6 in the Middle East. 

The 20 highest age-specific rates of prostate cancer (per 100,000) in the countries of Western Asia from WHO GLOBOCAN.

Interestingly, Lebanon has seen a dramatic rise in the incidence of prostate cancer due to a national screening campaign using PSA several years ago.

The increasing trends in prostate cancer in Lebanon coincide with a national PSA screening campaign.
From Shamseddine etal. [1]

In the United Arab Emirates, prostate cancer is the 3^rd most common malignancy. Most patients (77%) present with advanced disease and only approximately 20% receive radical local treatment (16.6% radiation treatment, 5.5% radical prostatectomy).[2] However, over the past decade there has been a tremendous shift toward a multidisciplinary approach to prostate cancer including oncology, urologic oncologists, robotic surgery, radiation oncology and cancer nursing. There are now approximately 30 daVinci Robotic Surgery Systems in the Middle East, with 12 in Saudi Arabia.

 

BLADDER CANCER

The ASR trends in bladder cancer are similar to those observed in RCC and prostate cancer. 

The 20 highest age-specific rates of bladder cancer (per 100,000) in the countries of Western Asia from WHO GLOBOCAN.

One of the more interesting trends in bladder cancer are the decreasing rates of schisosomiasis related squamous cell carcinomas of the bladder in Egypt (read more about schistosomiasis-related cancer of the bladder in our previous blog or click here). Control of schistosomiasis through antibilharzial campaigns have led to dramatic decreases in infestation rates and subsequent bladder cancer incidence. For instance, in Egypt the overall prevalence of schistosomiasis infection decreased from 37-48% to 3%, with a subsequent decrease in the proportion of bladder cancers from 31% to 12% of total cancers in the country.[3,4]

The second interesting trend in bladder cancer is the increasing incidence of cancers related to increasing rates of tobacco smoke. For instance, in Lebanon, the incidence of bladder cancer (13.7%) approaches that of prostate cancer (16.4%) – unheard of in most other countries! Recent data indicate that differences in the prevalence of drug metabolizing enzymes (S-transferases, N-acetyltransferases, and cytochromes P-450) in a number of ethnic groups may explain the susceptibility to bladder cancer in this population.[5]

	Age-specific Rate (per 100,000 population)
	Renal Cancer	Prostate Cancer	Bladder Cancer	Testis Cancer
United States of America	12.0	98.2	11.6	5.0
State of Palestine	3.1	15.2	7.6	1.6
Iraq	2.9	8.7	11.4	1.1
Israel	10.0	84.3	12.6	4.9
Jordan	3.2	15.3	7.1	1.7
Kuwait	2.2	14.5	5.5	0.6
Lebanon	3.2	37.2	16.6	2.4
Oman	2.1	10.2	4.8	0.4
Qatar	3.5	13.2	5.3	0.5
Saudi Arabia	2.3	9.5	3.6	0.6
Syrian Arab Republic	3.1	11.9	9.6	1.4
Turkey	5.6	40.6	15.2	3.2
United Arab Emirates	2.3	10.0	4.3	0.4
Yemen	0.6	2.7	1.8	0.1

 

SUMMARY

• The most common urologic malignancies (RCC, prostate and bladder cancer) are disease of older populations and more common in the most developed countries of the world.
• The incidence of these cancers is lower in all countries of the Middle East, although the true incidence may be underestimated by difficulties in gathering and sharing cancer data.
• A number of interesting trends in the incidence of urologic malignancies make the Middle East a fascinating frontier for investigating cancers of the genitourinary system.

 
This blog was inspired by the lecture, "Overview of Genito Urinary Malignancies in The MENA Region," by Professor Marwan Ghosn of Lebanon.
 
[1] Shamseddine A, Saleh A, Charafeddine M, Seoud M, Mukherji D, Temraz S, Sibai AM. Cancer trends in Lebanon: a review of incidence rates for the period of 2003-2008 and projections until 2018. Popul Health Metr. 2014 Mar 4;12(1):4. doi: 10.1186/1478-7954-12-4.
[2] Ghafoor M, Schuyten R, Bener A. Epidemiology of prostate cancer in United Arab Emirates. Med J Malaysia. 2003 Dec;58(5):712-6.
[3] Ministry of Health and Population, Department of Endemic Diseases, Prevalence of schistosomiasis in Egypt over time, Egypt, 2004.
[4] I. Gouda, N. Mokhtar, D. Bilal, T. El-Bolkainy, N.M. El-Bolkainy. Bilharziasis and bladder cancer: a time trend analysis of 9843 patients. J Egypt Natl Canc Inst, 19 (2) (2007), pp. 158–162
[5] Dhaini HR, Kobeissi L. Toxicogenetic profile and cancer risk in Lebanese. J Toxicol Environ Health B Crit Rev. 2014;17(2):95-125. doi: 10.1080/10937404.2013.878679.