The main credit of this work would go to the team of cancer epidemiology department without them this report would have never come into light.

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2 Acknowledgment The main credit of this work would go to the team of cancer epidemiology department without them this report would have never come into light. Special appreciation goes to: Prof Amal Samy Ibrahim and Prof. Inas Alattar Prof. Manar Moneer & Ass. Prof. Dalia Bilal Dr(s). Maysaa Kamel, Dalia Negm,, Shimaa abdelaleem, Youssef Nagy, Rasha Mohamed, Omnia Abulazzam, Amira Ismail and Noura Atef Deepest gratitude to our colleagues at pathology department especially Prof. Magda Morad, Iman Gouda and Dr. Akram Nouh.

3 Content New patients workload between Case finding, reportability & confirming diagnosis Overview of cancer data in the 9 years Review of cancers of specific organs or sites Pediatric cancers Conclusion

4 A total of new patients at NCI ( ) Year New patients Cancer Average

5 Total number of new patients and cancer patients ( ) New Cancer

6 Total number of cancer patients by age ( ) pediatric Adults

7 Categories of new patients registered at NCI cancer registry bewteen Cancer cases Benign tumors Borderline Non tumor Others (lost FU, incomplete investigations, in-definite diagnosis) 45.8 % 5.1% 0.6% 29.6% 18.9%

8 Case Finding The sytematic method of locating and indentifying all eligible cases - It includes all points of service at NCI from which a patient may enter for either diagnosis and/or treatment for managment of cancer. - Points include all archieves in NCI, Cancer epidemiology department Radiotherapy department Pain clinic archieve Afernoon clinic Surgical oncology clinic The patient file with demographics is checked systematically and periodically for lists of patients without a diagnosis Diagnoses are made based on ICD-O third edition.

9 Repotable diagnoses All insitu (/2) and invasive (/3) histologies based on ICD-O manual Benign and borderline CNS tumors diagnosed after 2004 Pilocytic astrocytomas are reportable

10 Non-repotable diagnoses Carcinoma insitu (/2) of the cervix or CIN III Prostatic intrepithelial neoplasia III

11 Ambiguous terminology for reportability (reportable) Apparent, appears Comaparable with Consistent with Most likely Presumed Typical (of) Malignant appearing

12 Ambiguous terminology for reportability (not reportable) Ca not be ruled out Equivocal Potentially malignant Questionable Possible Worrisome Suggests Ignore modifiers such as strongly, highly

13 Diagnostic confirmation Microscopic confirmtion Direct visualization Radiology / other imaging techniques Clinical diagnosis only

14 Primary liver cancer Excision, Bx, FNAC Or radiologically proved hepatic focal with AFP 150 Or a lesion > 2cm on top of cirrhosis Or Triphasic CT study showing enhanced uptake and rapid wash-out Secondaries unknown primary are considered when Clinical documentation of a liver mass, advanced liver malignancy with no radiologic and/or lab evidences Radiologically proven but lacking the above criteria Highly suggestive of liver secondaries

15 cancer cases by gender ( ) Males Females M : F Total Total

16 % of cancer cases Age distribution by gender ( ) 16% 14% 12% Females Males 10% 8% 6% 4% 2% 0% <5 ' '15-19 ' Age Groups (years)

17 % of cancer cases Age distribution in females ( ) 18% 16% % 12% 10% 8% 6% 4% 2% 0% <5 ' '15-19 '10-14 Age Groups (years)

18 % of cancer cases Age distribution in males ( ) 16% 14% % 10% 8% 6% 4% 2% 0% <5 ' '15-19 '10-14 Age Groups (years)

19 Median age Median age at presentation by gender Males Females 10 0

20 Relative distribution of cancer cases according to residence 60 % MCA Middle Egypt Upper Egypt Delta & lower Egypt Suez canal Red Sea & Sinia N valey, matrouh, others

21 Review of the commonest cancers

22 Relative frequency of the common cancers in both sexes ( ) year Total Breast 19.1% 19.0% 19.0% 19.4% 19.2% 20.5% 20.2% 19.8% 19.7% 19.6% UB 10.2% 10.6% 9.6% 9.0% 8.3% 8.8% 8.3% 7.7% 7.2% 8.9% Liver 7.0% 6.9% 7.0% 7.3% 6.8% 6.7% 7.2% 8.2% 8.1% 7.2% Lynphomas 8.9% 8.3% 8.0% 8.4% 9.5% 8.6% 9.1% 8.4% 8.5% 8.6% Leukemias 6.7% 7.4% 7.4% 7.8% 7.7% 8.6% 8.2% 8.0% 7.2% 7.7% Colalorect 3.7% 3.7% 4.5% 4.1% 3.7% 4.2% 4.0% 4.5% 5.1% 4.2% Lung & bronchus Brain & meninges 3.9% 3.4% 3.7% 3.6% 4.1% 3.8% 4.0% 4.4% 4.8% 4.0% 1.9% 1.8% 1.9% 2.1% 1.9% 2.0% 3.0% 2.8% 3.5% 2.3% Pancreas 1.7% 2.1% 2.1% 2.2% 2.2% 2.1% 1.7% 1.9% 1.8% 2.0% Ovaries 2.0% 2.0% 1.9% 2.2% 2.2% 1.9% 1.9% 1.7% 1.9% 2.0% Stomach 1.8% 1.8% 1.8% 1.7% 1.8% 1.7% 1.7% 1.9% 2.1% 1.8% Skin 2.7% 3.0% 2.2% 2.4% 2.1% 1.9% 2.2% 2.1% 2.1% 2.3% Kidneys 1.5% 1.3% 1.4% 1.4% 1.6% 1.2% 1.6% 1.7% 1.8% 1.5% Bones 2.5% 1.9% 1.6% 1.6% 1.5% 1.6% 2.3% 1.7% 1.7% 1.8% Pleura 1.1% 1.3% 1.2% 1.4% 1.4% 1.0% 1.8% 1.7% 1.7% 1.4% SUP 4.6% 5.7% 6.1% 6.4% 7.4% 7.2% 4.7% 4.3% 5.0% 5.7% Thyroid 1.8% 1.8% 1.5% 1.5% 1.8% 1.3% 1.6% 1.4% 1.3% 1.6% Prostate 1.3% 1.3% 1.1% 1.1% 1.4% 1.3% 1.5% 1.6% 1.8% 1.4% ST 2.3% 3.4% 3.3% 3.4% 3.1% 2.3% 2.4% 3.0% 2.1% 2.8% Others 15.2% 13.4% 14.4% 13.1% 12.4% 13.3% 12.7% 13.1% 12.5% 13.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

23 Trends of the most common cancers in both sexes ( ) 20.0% Breast 15.0% 10.0% UB Liver Lynphomas Leukemias Colalorect Lung & bronchus Brain & meninges Pancreas Ovaries Stomach Skin 5.0%.0%

24 Relative frequency of the common cancers in females ( ) year Total Breast 38.0% 37.3% 35.6% 36.0% 36.2% 38.9% 38.1% 38.8% 38.8% 37.5% Lynphomas 6.9% 6.0% 6.2% 6.6% 7.5% 6.3% 7.5% 7.1% 6.5% 6.7% Leukemias 5.8% 6.3% 5.9% 6.3% 6.5% 7.0% 6.9% 6.8% 6.5% 6.5% Colalorect 3.8% 3.3% 4.3% 3.9% 3.2% 4.0% 3.6% 4.2% 4.7% 3.9% Liver 3.3% 3.3% 3.1% 4.0% 3.2% 3.1% 3.4% 3.6% 4.0% 3.4% Ovaries 4.2% 3.9% 3.7% 4.1% 4.1% 3.7% 3.6% 3.4% 3.7% 3.8% Brain & meninges 1.7% 1.8% 1.6% 1.7% 1.5% 1.7% 2.8% 2.3% 3.3% 2.0% UB 4.3% 4.5% 4.7% 3.7% 3.5% 3.3% 3.4% 2.8% 2.8% 3.7% Cervix uterii 2.7% 2.8% 3.2% 2.6% 2.4% 2.3% 1.9% 1.5% 1.7% 2.3% Lung & bronchus 1.4% 1.1% 1.7% 1.6% 1.7% 2.0% 1.6% 1.5% 1.8% 1.6% Pancreas 1.2% 1.5% 1.4% 1.7% 1.5% 1.5% 1.0% 1.4% 1.2% 1.4% Stomach 1.5% 1.5% 1.6% 1.4% 1.4% 1.2% 1.3% 1.6% 1.8% 1.5% Skin 2.2% 2.1% 1.9% 2.0% 1.7% 1.6% 1.8% 1.7% 1.5% 1.8% Kidneys 1.2% 1.2% 1.2% 1.1% 1.4% 1.1% 1.3% 1.1% 1.4% 1.2% Bones 2.0% 1.4% 1.3% 1.2% 1.1% 1.1% 2.0% 1.5% 1.1% 1.4% Pleura.8% 1.2% 1.1% 1.0% 1.3%.8% 1.6% 1.3% 1.4% 1.2% SUP 3.3% 4.9% 5.3% 5.1% 6.3% 5.9% 4.0% 3.5% 4.3% 4.7% Thyroid 2.2% 2.4% 1.9% 2.0% 2.7% 1.9% 2.2% 2.1% 1.8% 2.1% ST 2.0% 2.8% 2.7% 3.3% 3.0% 2.0% 2.0% 2.5% 1.7% 2.5% Others 14.3% 13.4% 14.7% 13.3% 12.2% 12.8% 11.8% 12.8% 11.6% 13.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

25 Trends of the most common cancers in females ( ) 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0%.0% Breast UB Liver Lynphomas Leukemias Colalorect Lung & bronchus Pancreas Thyroid

26 Relative frequency of the commonest cancers in males ( ) year Total Liver 10.7% 10.4% 11.2% 11.0% 10.7% 10.6% 11.5% 12.7% 12.1% 11.2% UB 15.8% 16.6% 15.1% 14.8% 13.5% 14.7% 13.7% 12.5% 11.5% 14.3% Lynphomas 10.9% 10.6% 10.0% 10.4% 11.6% 11.1% 10.8% 9.7% 10.4% 10.6% Leukemias 7.7% 8.6% 9.1% 9.4% 8.9% 10.3% 9.5% 9.2% 8.0% 9.0% Lung & bronchus 6.3% 5.6% 6.0% 5.9% 6.7% 5.8% 6.5% 7.3% 7.9% 6.4% Colalorect 3.7% 4.2% 4.8% 4.4% 4.1% 4.4% 4.4% 4.9% 5.5% 4.5% Prostate 2.6% 2.5% 2.3% 2.3% 2.9% 2.6% 3.1% 3.2% 3.7% 2.8% Brain & meninges 2.2% 1.9% 2.3% 2.5% 2.4% 2.4% 3.1% 3.2% 3.6% 2.6% Skin 3.2% 3.9% 2.5% 2.8% 2.5% 2.2% 2.7% 2.5% 2.7% 2.8% Pancreas 2.1% 2.7% 2.8% 2.8% 2.9% 2.9% 2.5% 2.4% 2.4% 2.6% Stomach 2.0% 2.0% 2.0% 2.0% 2.2% 2.2% 2.2% 2.2% 2.4% 2.1% Kidneys 1.8% 1.3% 1.7% 1.9% 1.9% 1.3% 2.0% 2.4% 2.1% 1.8% Bones 3.0% 2.4% 2.0% 2.0% 1.9% 2.0% 2.6% 1.9% 2.2% 2.2% Pleura 1.4% 1.4% 1.4% 1.8% 1.6% 1.3% 2.0% 2.2% 2.0% 1.7% SUP 5.8% 6.4% 7.0% 7.7% 8.7% 8.5% 5.5% 5.0% 5.7% 6.7% Thyroid 1.4% 1.2% 1.1% 1.0%.9%.6%.9%.8%.8% 1.0% ST 2.5% 3.9% 3.9% 3.4% 3.2% 2.5% 2.8% 3.5% 2.5% 3.2% Others 16.0% 13.5% 14.2% 12.9% 12.5% 13.9% 13.6% 13.5% 13.4% 13.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

27 Trends of the commonest cancers in males ( ) 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% Urinary Bladder Liver Lynphomas Leukemias Colalorect Lung & bronchus Brain & meninges Pancreas Prostate Stomach Skin 2.0%.0%

28 Cancer of specific site(s) or organs(s) 1- Breast cancer 2- Liver cancer 3- Urinary bladder 4- Lymphomas & leukemias 6- Pediatric cancers

29 Breast cancer

30 Breast cancer, 19.6% in both genders (First) 38.8% in females (First), 0.9% in males PATIENT SEX F M Total Total

31 % Trends in relative frequency of Breast Cancer, Females Males /9/

32 Median age (year) Median age at presentation of breast cancer in both sexes, females males /9/

33 % of cancer cases 18% Age specific relative frequency of breast cancer ( ) 16% 14% 12% 10% 8% 6% 4% 2% Females Males 0% <5 ' '15-19 '10-14 Age Groups (years)

34 SEER Staging of 5278 breast cancer cases ( ) Carcinoma in situ, 0.5% Localized only, 22.8%.5 Regional by direct extension, 3.5% Regional by lymph nodes invovlved only, 34% Regional by both direct extension and regional LN, 8.7% Regional (NOS), Distant site(s)/node(s) involved, 17.2% Unknown if extension / or metastatic, 12.8%.5

35 Histopathologic types of female breast cancer Histology No % Duct carcinoma Lobular carcinoma Mixed duct & lobular Medullary Mucoid Phyllodes tumors Papillary Paget s disease Tubular Inflammtory Others / pathology not documented Total

36 Urinary bladder cancer

37 Urinary bladder cancer in 2010 is the fourth (7.2%) of both genders, second in males (11.5%) and 8 th in females (2.8%) PATIENT SEX M:F F M Total ratio Total

38 Relative frequency Trends in relative frequency of urinary bladder cancers ( ) Females Males /9/

39 Median age (year) Median age at presentation for urinary bladder cancer, Females Males 40 9/9/

40 Histopathologic types of 7403 bladder cancers ( ) Histology No % Transitional cell carcinoma Squamous cell carcinoma Verrocus Others / not documented Total

41 Relative frequency Trends in histopatholgic types of urinary bladder cancers ( ) SCC TCC /9/

42 Liver tumors

43 Liver cancer in 2010, third after lymphoma in both genders (8.1%), first in males (12.1%) and fifth in females (4.0%) PATIENT SEX M:F F M Total Ratio Total

44 % Trends in relative frequency of liver Cancer, Females Males /9/

45 Median age (year) Median age at presentation for liver cancer ( ) Females Males 45 9/9/

46 % of cancer cases Age specific relative frequency of liver tumors ( ) 25% 20% Females Median age = 57 yrs Males 15% 10% 5% 0% <5 ' '15-19 '10-14 Age Groups (years)

47 Diagnostic tools for liver cancers ( ) Diagnostic tool No % Histopathology Cytology (FNA) Slide revision Laboratory radiologic/imaging Others / not explicitly stated Total

48 Types of malignant liver tumors diagnosed with histologic examination ( ) type No % Hepatoblastoma HCC Adenocarcinoma Cholangiocarcinoma Others Total

49 Leukemias and Lymphomas (Lympho-hemopioetic system)

50 Lymphomas In all ages, both genders, lymphomas ranked the second after breast cancer (8.5%). In females, also together with leukemias, for all ages, it constituted 6.5% and coming the second after breast cancers. In males it is the third after liver and UB forming 10.4 % of all cancers for all ages

51 Leukemias In all ages, both genders, leukemias ranked the fourth together with UB (7.2%). In females, also together with lymphoma, for all ages, it constituted 6.5% and coming the second after breast cancers. In males it is the fourth after liver, UB, and lymphomas forming 8.0 % of all cancers for all ages

52 Frequency of malignancies of lymphohemopioetic system according to age groups Pediatric Adult Total Lymphomas (36.2%) (60.5%) 7216 Leukemias (63.8%) (39.5%) 6417 Total

53 Median age (years ) at presentation of malignancies of lympho-hemopioetic system according to age groups Lymphomas: Adult males 47 year Pediatric males 9 year Adult females 50 year Pediatric female 11 yr Leukemias Adult males 42 year Pediatric males 7 year Adult females 43 year Pediatric female 7 yr

54 Sex distrbution of 6417 case of leukemias all ages ( ) Gender M : F Ratio F M Total ALL CLL AL AML CML Other leukemias Leukemia NOS Total

55 Relative frequency Trends in Leukemias (all ages, all types) by gender ( ) Male Female 0 9/9/

56 Types of lymphoma in 7206 patient by age ( ) Age groups Adult:pediatric pediatric adult Total ratio Lymphomas, nodal Lymphomas, extranodal 187 (13.8%) 972 (20.7%) Nodal : extra ratio (19.17%) 5.20 Total Sites of extranodal lymphomas included: GIT (stomach, colon,..), bones, skin,breast, thyroid gland, brain,, female genital system, respiratory system.

57 Relative frequency Trends in lymphomas (all ages, all types) by gender ( ) Male Female 0 9/9/

58 Pediatric cancers 9/9/

59 Pediatric cancers Out of cases, 8464 (10.14%) were < 20 years Pediatric cancers as absolute and relative frequency showed minor flactuations between 2002 to 2009 but significant drop in absolute and relative frequency was in 2010 Male : female ratio decreased from 1.6 in 2002 to 1.2 in 2010

60 Adult to pediatric cancers between Age groups Adult:ped Pediatric Adult ratio Total (10.8%) (10.0) (9.3%) (10.4%) (10.8%) (11.0%) (9.7) (10.3%) (8.7%) Total 8464 (10.1%)

61 Sex distribution of 8464 pediatric patients between Age groups Females Males Total % 61.8% % 60.9% % 59.8% % 57.9% % 58.3% % 58.3% % 56.8% % 58.6% % 55.2% Total (41.3%) (58.7%) 1.42

62 Distribution of 8464 pediatric patients among children and adolescents Age groups < 15 years 15 - < 20 Total % 25.6% % 25.7% % 27.1% % 25.8% % 25.1% % 25.4% % 28.6% % 22.6% % 27.5% 639 Total 6279 (74.2%) 2185 (25.8%) 8464

63 Age distribution by sex in pediatric patients ( ) Median Age = 8 years

64 Comparative Relative Frequency (%) of Western* and Egyptian Pediatric Cancer Subclassified into Childhood (< 15 years) and Adolescent (15 - > 20 years). Tumor Western * NCI < 15 years Western* NCI (15 - <20) No % No % ALL AML NHL Hodgkin lymphoma Brain Tumors Neuroblastoma Wilms Tumor Rhabdomyhosarcoma Retinoblastoma Osteosarcoma Ewing sarcoma STS Hepatoblastoma Others Total

65 Conclusions Breast cancer is a priority problem in females An epidemic of liver cancer is expected in both males & females Leukemias, colorectal, and lung cancers are threating by an increasing trend