Journal of Cancer Epidemiology

Volume 2014 (2014), Article ID 437971, 18 pages

http://dx.doi.org/10.1155/2014/437971

Research Article

Cancer Incidence in Egypt: Results of the National Population-Based Cancer Registry Program

Amal S. Ibrahim,¹ Hussein M. Khaled,² Nabiel NH Mikhail,³ Hoda Baraka,⁴ and Hossam Kamel²

¹Department of Biostatistics and Cancer Epidemiology, National Cancer Institute, Cairo University, Cairo, Egypt

²Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt

³Department of Biostatistics and Cancer Epidemiology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt

⁴Department of Computer Engineering, Faculty of Engineering, Cairo University, Giza, Egypt

Received 7 June 2014; Revised 1 September 2014; Accepted 7 September 2014; Published 21 September 2014

Academic Editor: Lance A. Liotta

Copyright © 2014 Amal S. Ibrahim et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Background. This paper aims to present cancer incidence rates at national and regional level of Egypt, based upon results of National Cancer Registry Program (NCRP). Methods. NCRP stratified Egypt into 3 geographical strata: lower, middle, and upper. One governorate represented each region. Abstractors collected data from medical records of cancer centers, national tertiary care institutions, Health Insurance Organization, Government-Subsidized Treatment Program, and death records. Data entry was online. Incidence rates were calculated at a regional and a national level. Future projection up to 2050 was also calculated. Results. Age-standardized incidence rates per 100,000 were 166.6 (both sexes), 175.9 (males), and 157.0 (females). Commonest sites were liver (23.8%), breast (15.4%), and bladder (6.9%) (both sexes): liver (33.6%) and bladder (10.7%) among men, and breast (32.0%) and liver (13.5%) among women. By 2050, a 3-fold increase in incident cancer relative to 2013 was estimated. Conclusion. These data are the only available cancer rates at national and regional levels of Egypt. The pattern of cancer indicated the increased burden of liver cancer. Breast cancer occupied the second rank. Study of rates of individual sites of cancer might help in giving clues for preventive programs.

1. Introduction

Egypt was completely lacking incidence rates at national level until the results given in the current report were obtained. Available statistics were proportions derived from single or multicenter hospital registries that could not be used for calculation of incidence rates [1–7]. The only published incidence rates are those from a cancer registry in one district in Nile delta (Gharbiah governorate). The last internal reports of this registry are for 2002 [8, 9]. Incidence rates up to 2007 were published in Volumes IX and X of Cancer Incidence in Five Continents [10, 11], date of end of registry activities due to failure of sustainability. The published crude and age-standardized incidence rates from that registry are 96.5 and 132.6/100,000 males and 97.3 and 122.1/100,000 females. The commonest sites of cancer in males are liver (18.7%), bladder (12.7%), non-Hodgkin’s lymphoma (11.0%) and trachea, bronchus, and lung (8.2%). The 4 sites represent 50.6% of all cancer in males. The commonest sites in females are breast (38.8%), non-Hodgkin’s lymphoma (8.5%), liver (4.6%), and ovary (4.5%); all together represent 56.4% of cancer in females. There is no mention of rates of both sexes together. Studies are published using these Gharbiah data up to 2007 and are limited to specific sites of cancer mainly breast [12–15], gastrointestinal [16–18], hematopoietic [19], bladder [20], and gynecological cancers [21]. None of these geographically-limited studies and published rates could be considered as representative of Egypt, being based on results of one registry in a single delta governorate and do not have an impact on understanding the current situation of cancer at the national level.

The National Cancer Registry Program (NCRP) was established in 2008 and became the only source for cancer incidence in the country [22]. The main objective of the current publication is to present the incidence rates of cancer in Egypt in 2008–2011 based upon data of the National Cancer Registry Program of Egypt with estimated incidence of the disease up to 2050.

2. Materials and Methods

For registration purposes, Egypt was stratified into 3 geographical strata (regions), namely, Lower Egypt (north of Cairo), Middle Egypt (south of Cairo), and Upper Egypt (further south, reaching the southern frontier of the country). The current report covered three districts (governorate), each representing one of the 3 regions, namely, Damietta (Nile delta), Minya (Middle Egypt), and Aswan (Upper Egypt) (Figure 1). A population-based registry was established in each of the 3 governorates, located in the Ministry of Health Cancer Center.

Figure 1: Map of Egypt showing the location of the 5 peripheral registries of the national network of population-based cancer registries National Cancer Institute, Cairo, and South Egypt Cancer Institute, Assiut.

Trained medical doctors in the 3 registries abstracted records from their cancer centers and regularly visited establishments that dealt with cancer within the governorate for active data collection from medical records. Other sources of data were major tertiary centers on the national level as the National Cancer Institute of Cairo University, Pediatric Oncology Hospital in Cairo, and South Egypt Cancer Institute of Assiut University. Data managers in these institutions reported incident cancer cases among residents of the 3 governorates that were diagnosed/treated in these institutions. Health Insurance Organization and the Government-Subsidized Treatment Program periodically supplied their data. Death registers in local health directorates were regularly checked for cancer deaths from the 3 governorates.

A web-based software was developed for online data entry, validity checks, and data analysis. The database was centralized in the Ministry of Communication and Information Technology server (Figure 2) with backups in the Ministry of Health and the National Cancer Institute. Computer checks were achieved using DEPedits Conversion and Check Programs for Cancer Registries software [23]. Duplicates were eliminated using the National Identification Number and a clean database was achieved ready for analysis. Registration covered all invasive cancers (behavior code/3), in situ breast cancer (topography code C50._ and behavior code/2), in situ urinary bladder cancer (topography code C67._ and behavior code/2), and borderline tumors of the brain (topography code C71._ and behavior code/1) [24].

Figure 2: The NCRP Web Based System (3-Tier Architecture).

For the current report, we used data from Aswan (2008), Minya (2009), and Damietta (2009–2011) to represent the 3 geographical strata of Egypt (Table 1). Crude, age-specific, and world population age-standardized incidence rates were calculated and expressed/100,000 population. Statistics were published at the level of the 3-character ICD-10 codes [10]. The format of IARC publication: “Cancer Incidence in Five Continents, Vol. X” [11], was used for grouping of ICD codes. Statistics for all sites of cancer were expressed twice, with and without nonmelanoma skin cancer (C44). Confidence intervals were calculated following SEER methodology [25].

Table 1: Population parameters of the 3 regions of Egypt and corresponding registries used in the current report to calculate regional and national incidence rates.

Region characteristics
Upper Egypt
Middle Egypt
Lower Egypt

Regional Registry
Aswan
Minia
Damietta

Registration period
2008
2009
2009–2011

Registry Population
1,074,131
4,426,528
3,586,056**

Region population*
4,645,449
16,161,200
30,342,291

Based upon 2006 census.

Person years during the registration period.

We developed a model to use incidence data of the population-based registries of the 3 regions (Lower, Middle, and Upper Egypt) to get incidence rates for the entire country. The first step was to apply the age-specific incidence rates of each registry to the population of the stratum it represented to get the number per gender of incident cases in different age groups and for all ages together in this region using data of Egypt last census [26]. Then, we used these statistics to estimate the crude and age specific incidence rates (ASIR) of cancer in the 3 regions together, considered to be representative of the entire country. These rates were applied to the total population of Egypt to get number of incident cancers and crude rate and ASR (world) at national. This procedure was applied for each cancer site and for all sites together per gender. For projections up to 2050, the ASIRs were applied to the projected population of the corresponding year to get the number of patients/age group. Crude and ASR (world) could then be obtained. Steps of calculations are detailed in the Appendix.

3. Results

3.1. National Incidence Rates and Proportions

The crude incidence rates on the national level for all sites excluding nonmelanoma skin cancer (C44) were 113.1/100,000 (both sexes), 115.7/100,000 (males), and 110.3/100,000 (females). The age-standardized rates (world) were 166.6/100,000 (both sexes), 175.9/100,000 (males), and 157.0/100,000 (females) as shown in Table 2. Proportions, crude, age standardized incidence rates and detailed age-specific rates of cancer sites according to ICD-10 format are shown in Tables 3 and 4 for individual sites of cancer and for all sites together by gender. The age-specific rates are represented graphically in Figure 3 for all cancers and Figures 4, 5, and 6 for breast, liver, and bladder cancer as examples of some of the more frequent cancer sites.

Table 2: Incidence rates of Cancer in Egypt (/100,000 populations) classified by region and sex for all cancer sites with and without nonmelanoma skin cancer (C44).

Males
Females
All
Male : female ratio

Crude rate
ASR
Crude rate
ASR
Crude rate
ASR
Crude rate
ASR

(95% CI)
(95% CI)
(95% CI)
(95% CI)
(95% CI)
(95% CI)

All sites

(i) Upper Egypt
97.1
142.8
116.9
167.1
107.0
155.0
0.8 : 1
0.9 : 1

(89.1–105.8)
(133.1–153.2)
(108.1–126.5)
(156.5–178.4)
(101.0–113.3)
(147.7–162.6)

(ii) Middle Egypt
109.7
170.0
95.9
132.1
102.9
151.1
1.1 : 1
1.3 : 1

(105.4–114.1)
(164.7–175.5)
(91.1–100.2)
(127.4–137.0)
(100.0–106.0)
(147.5–154.8)

(iii) Lower Egypt
138.5
191.8
131.7
173.3
135.2
182.6
1.1 : 1
1.1 : 1

(133.2–144.0)
(185.6–198.2)
(126.5–137.2)
(167.3–179.6)
(131.4–139.1)
(178.2–187.1)

(iv) Calculated rates of Egypt
117.3
178.5
111.7
159.1
114.5
169.0
1.1 : 1
1.1 : 1

(116.0–118.6)
(176.9–180.2)
(110.4–113.0)
(157.6–160.7)
(113.6–115.5)
(167.9–170.2)

All sites (excluding nonmelanoma skin cancer C44)

(i) Upper Egypt
96.0
141.0
115.1
163.9
105.5
152.5
0.8 : 1
0.9 : 1

(88.1–1104.6)
(131.4–151.4)
(106.3–124.5)
(153.4–175.1)
(99.5–111.8)
(145.5–160.1)

(ii) Middle Egypt
108.0
167.2
94.9
130.7
101.6
149.0
1.1 : 1
1.3 : 1

(103.8–112.3)
(162.0–172.6)
(90.9–99.1)
(126.0–135.6)
98.7–104.6)
(145.5–152.6)

(iii) Lower Egypt
136.7
189.1
130.1
170.9
133.5
180.0
1.1 : 1
1.1 : 1

(131.5–142.2)
(182.9–195.5)
(124.8–135.5)
(164.9–177.1)
(129.7–137.3)
(175.7–184.4)

(iv) Calculated rates of Egypt
115.7
175.9
110.3
157.0
113.1
166.6
1 : 1
1.1 : 1

(114.4–117.0)
(174.3–177.5)
(109.0–111.6)
(155.4–158.5)
(112.2–114.0)
(165.5–167.8)

Table 3: Calculated age-specific incidence rates, crude rates, and ASR (World), males, Egypt 2008–2011.

Site
0–4
5–9
10–14
15–19
20–24
25–29
30–34
35–39
40–44
45–49
50–54
55–59
60–64
65–69
70–74
75+
Crude rate
ASR
%

Lip
—
—
—
—
—
—
0.5
—
0.3
—
0.8
1.4
0.6
1.8
8.7
1.5
0.3
0.4
0.23%

Tongue
—
—
—
—
—
—
—
—
0.3
1.4
1.3
3.1
1.9
1.8
—
2.2
0.3
0.5
0.27%

Mouth
—
—
—
0.1
—
—
0.2
0.5
0.8
1.5
2.5
4.6
0.6
2.6
1.4
—
0.5
0.6
0.41%

Salivary glands
—
—
0.1
—
0.1
—
—
0.2
—
—
0.7
1.4
2.0
2.6
4.5
5.2
0.3
0.5
0.25%

Tonsil
—
—
—
—
—
—
—
—
0.3
—
—
—
—
—
—
—
—
—
0.01%

Other oropharynx
—
—
—
—
0.1
—
—
—
—
—
0.4
0.6
—
0.8
2.8
—
0.1
0.1
0.07%

Nasopharynx
—
—
—
—
0.3
—
—
0.2
—
—
3.4
0.4
—
3.6
—
5.2
0.3
0.4
0.26%

Hypopharynx
—
—
—
0.1
—
—
—
—
0.3
—
0.9
1.4
0.6
—
1.4
1.5
0.2
0.2
0.13%

Pharynx unspec.
—
—
—
—
—
—
0.2
—
—
1.0
—
—
—
—
—
1.5
0.1
0.1
0.07%

Esophagus
—
—
—
—
0.3
0.2
0.3
—
1.4
1.8
6.1
4.1
11.2
10.8
24.4
14.7
1.4
2.3
1.20%

Stomach
—
0.1
0.1
—
0.3
0.2
0.7
0.5
2.0
2.6
5.0
6.0
11.9
6.4
21.5
14.1
1.5
2.3
1.26%

Small intestine
0.1
—
—
—
—
—
0.5
0.5
0.6
0.3
0.4
1.4
—
0.8
—
1.5
0.2
0.3
0.17%

Colon
—
—
—
0.1
0.3
0.7
2.1
2.5
1.9
6.5
14.2
11.0
19.8
18.9
31.5
32.6
3.1
4.7
2.63%

Rectum
—
—
—
0.1
0.7
1.2
0.7
1.2
2.2
2.0
3.4
4.1
3.4
2.6
8.7
1.5
1.0
1.3
0.84%

Anus
—
—
—
—
0.3
—
0.5
0.5
0.6
0.6
—
2.1
2.0
1.0
—
—
0.3
0.3
0.24%

Liver
0.3
0.4
0.4
0.2
0.3
1.3
1.4
6.1
21.2
76.3
174.2
258.7
323.1
313.8
327.1
363.5
39.5
61.8
33.63%

Gallbladder and so forth
—
—
—
—
—
0.4
—
0.5
0.6
0.6
1.0
1.0
5.9
1.0
4.7
7.4
0.5
0.7
0.40%

Pancreas
—
—
—
—
—
—
1.3
0.2
2.5
7.7
9.0
14.9
25.3
26.4
12.7
19.3
2.7
4.2
2.31%

Nose, sinuses and so forth
—
0.1
—
—
—
—
—
0.5
0.3
—
1.2
—
—
—
1.4
8.2
0.2
0.3
0.17%

Larynx
—
—
—
—
—
—
0.2
—
2.1
2.6
6.6
6.8
18.2
11.0
23.2
32.5
1.9
3.1
1.58%

Trachea, Bronchus, Lung
0.1
—
0.1
0.4
0.8
1.2
1.2
3.0
3.8
12.5
19.3
39.1
49.0
49.3
73.9
76.1
6.7
10.4
5.69%

Other Thoracic organs
0.3
—
—
0.1
0.2
0.2
—
—
0.6
1.2
2.8
3.5
3.2
7.1
9.8
8.9
0.8
1.2
0.65%

Bone
0.1
1.2
1.4
0.7
1.8
0.8
1.0
1.0
1.4
2.0
4.2
3.7
13.9
8.6
8.4
15.6
1.9
2.5
1.62%

Melanoma of skin
—
—
—
—
0.1
0.2
—
—
0.6
—
—
0.4
—
1.8
2.8
—
0.1
0.2
0.11%

Other skin
0.6
—
0.1
—
0.3
0.4
0.5
0.5
1.1
0.6
3.2
4.5
14.0
14.2
18.5
30.4
1.6
2.6
1.35%

Mesothelioma
—
—
—
—
—
—
—
—
—
0.8
0.5
1.4
—
0.8
—
—
0.1
0.2
0.10%

Kaposi sarcoma
—
—
—
—
—
—
0.2
—
—
—
1.1
—
1.3
0.8
1.4
—
0.1
0.2
0.10%

Connective, Soft tissue
0.3
0.1
0.1
0.6
1.1
2.0
1.3
1.3
3.1
3.5
3.6
8.3
4.6
6.1
18.8
2.2
1.7
2.2
1.47%

Breast
—
—
—
—
—
0.4
—
0.3
2.2
0.3
2.5
3.1
3.4
3.6
2.8
5.9
0.6
0.9
0.51%

Penis
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
0.00%

Prostate
—
—
—
—
—
0.2
0.3
—
0.3
1.3
4.1
11.2
24.6
47.5
90.3
216.5
5.0
9.3
4.27%

Testis
—
0.1
—
—
1.1
1.2
0.7
1.5
0.6
0.6
0.4
0.4
0.6
—
1.4
2.2
0.5
0.5
0.43%

Other male genital
—
—
—
—
—
—
—
—
—
—
0.4
—
—
0.8
1.4
—
—
0.1
0.04%

Kidney
1.2
0.1
—
—
—
0.2
0.2
0.5
0.5
3.4
6.9
9.8
7.9
16.9
14.1
22.3
1.8
2.7
1.53%

Renal pelvis
—
—
—
—
0.1
—
—
0.2
0.6
0.3
0.4
1.9
2.0
1.8
2.8
4.4
0.3
0.4
0.25%

Ureter
—
—
—
—
—
—
—
—
—
—
—
—
—
—
1.4
3.0
—
0.1
0.04%

Bladder
0.1
0.1
—
0.3
0.1
1.2
1.7
2.2
4.0
9.2
28.7
68.4
97.2
128.6
194.8
205.6
12.6
21.1
10.71%

Other urinary organs
—
—
—
—
—
—
—
—
—
—
—
—
0.6
—
—
—
—
—
0.01%

Eye
0.5
0.3
—
—
—
—
—
—
—
0.4
0.4
1.8
0.6
—
—
—
0.2
0.2
0.16%

Brain, Nervous tissue
2.9
3.0
1.8
1.7
1.5
3.3
4.2
6.8
7.3
7.3
15.5
14.5
27.2
30.4
46.7
91.4
6.4
9.0
5.48%

Thyroid
—
—
—
—
0.2
0.8
1.2
1.9
1.1
3.2
4.5
4.3
6.6
8.7
3.0
—
1.1
1.5
0.95%

Adrenal gland
0.3
0.1
—
—
—
—
—
—
—
—
—
0.6
—
0.8
1.4
—
0.1
0.1
0.08%

Other endocrine
0.5
—
0.1
—
0.3
—
—
0.5
0.3
1.0
0.4
1.3
0.6
—
2.8
—
0.3
0.4
0.25%

Hodgkin disease
0.5
1.7
1.7
1.5
1.5
1.4
—
0.2
1.7
2.5
2.0
1.4
5.3
6.1
2.8
1.5
1.5
1.7
1.29%

Non-Hodgkin lymphoma
1.1
1.2
1.5
1.0
2.2
2.5
2.1
3.6
5.8
16.6
24.4
36.0
33.8
29.5
38.1
28.8
6.4
8.8
5.48%

Immunoproliferative dis.
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
0.00%

Multiple myeloma
—
—
—
—
—
—
0.5
0.5
1.1
0.4
3.1
3.9
8.0
0.8
2.8
2.9
0.6
0.9
0.53%

Lymphoid leukemia
3.9
2.2
0.7
0.2
1.4
—
0.7
1.5
1.1
1.8
1.5
5.0
6.0
8.9
5.6
—
1.8
2.1
1.50%

Myeloid Leukemia
0.8
0.4
0.3
0.8
1.0
0.4
1.1
0.7
1.4
1.8
4.2
3.3
3.4
2.6
4.5
1.5
1.1
1.3
0.96%

Leukemia unspec.
1.0
1.2
1.1
0.6
2.1
2.2
1.7
0.5
2.1
4.7
1.8
6.0
8.0
3.5
7.3
20.8
2.1
2.6
1.80%

Other & unspecified
2.4
2.8
0.9
1.7
1.3
1.8
3.3
3.1
6.1
15.0
22.9
25.2
44.9
54.7
64.7
83.6
7.6
11.2
6.52%

All sites Total
17.1
15.4
10.5
10.5
20.1
23.9
30.6
42.8
83.8
195.4
389.6
582.4
793.5
840.2
1096.1
1335.6
117.3
178.5
100.00%

All sites but C44#
16.6
15.4
10.4
10.5
19.8
23.5
30.0
42.4
82.7
194.9
386.4
577.9
779.5
826.0
1077.5
1305.3
115.7
175.9
98.65%

Incidence rates do not include nonmelanoma skin cancer.

Table 4: Calculated age-specific incidence rates, crude rates, and ASR (World), females, Egypt 2008–2011.

Site
0–4
5–9
10–14
15–19
20–24
25–29
30–34
35–39
40–44
45–49
50–54
55–59
60–64
65–69
70–74
75+
Crude rate
ASR
%

Lip
—
—
—
—
—
—
—
—
0.3
1.4
0.8
0.5
1.6
0.8
1.3
4.7
0.2
0.4
0.21%

Tongue
—
—
—
—
—
0.5
—
—
—
0.4
0.4
1.2
0.7
—
—
15.4
0.3
0.5
0.26%

Mouth
—
0.1
0.1
—
—
—
—
—
0.3
1.0
0.8
0.5
1.4
2.9
6.1
2.7
0.3
0.5
0.28%

Salivary glands
—
—
0.3
—
—
—
—
—
—
0.7
—
2.9
0.7
2.9
—
—
0.2
0.3
0.18%

Tonsil
—
—
—
—
—
—
—
—
—
—
—
—
—
2.2
—
1.4
—
0.1
0.04%

Other oropharynx
—
—
—
—
—
—
—
—
—
0.3
—
0.7
—
0.8
—
—
—
0.1
0.04%

Nasopharynx
0.1
—
0.1
—
—
—
—
—
—
—
—
—
1.6
—
—
—
0.1
0.1
0.06%

Hypopharynx
—
—
—
—
—
0.2
—
0.4
0.3
1.0
0.9
0.5
—
1.1
—
—
0.2
0.2
0.16%

Pharynx unspec.
—
—
—
—
—
0.2
—
—
—
—
—
—
—
—
—
—
—
—
0.01%

Esophagus
—
—
—
—
—
0.2
—
—
2.0
1.3
0.8
3.7
11.1
10.6
9.2
5.4
0.9
1.5
0.79%

Stomach
—
0.1
—
—
—
—
2.0
1.4
3.1
5.1
5.7
5.1
9.7
16.3
18.7
14.8
1.8
2.7
1.65%

Small intestine
—
—
—
—
—
—
—
0.4
—
1.9
1.7
—
1.4
5.2
4.8
—
0.4
0.5
0.32%

Colon
—
—
—
—
0.5
0.5
1.0
2.4
2.9
7.9
9.4
7.9
10.4
25.2
16.2
29.4
2.5
3.8
2.28%

Rectum
—
—
—
—
0.1
1.1
1.2
0.7
1.9
1.7
1.9
2.9
3.0
3.9
4.4
5.4
0.8
1.1
0.72%

Anus
—
—
—
—
—
0.2
—
—
0.3
—
0.5
—
1.6
—
1.3
—
0.1
0.1
0.09%

Liver
1.0
—
0.5
—
—
0.9
2.0
3.3
12.5
25.2
43.2
89.3
129.3
143.9
167.9
150.4
15.1
24.4
13.54%

Gallbladder and so forth
—
—
—
—
0.3
—
0.5
0.5
0.3
1.3
2.5
3.3
2.2
3.7
6.9
6.0
0.6
0.9
0.55%

Pancreas
—
—
—
—
—
0.4
—
0.5
0.6
3.0
3.4
8.6
9.0
18.7
24.4
19.5
1.6
2.6
1.41%

Nose, sinuses and so forth
0.1
—
—
—
—
—
—
—
0.3
0.7
1.2
1.2
5.4
—
—
—
0.3
0.4
0.23%

Larynx
—
—
—
—
—
—
—
—
0.3
1.0
2.0
—
3.0
—
3.0
2.1
0.3
0.4
0.23%

Trachea, Bronchus, Lung
0.7
—
0.1
0.1
0.5
2.0
1.0
1.5
1.7
6.9
12.3
11.7
15.1
11.3
35.9
38.0
3.0
4.5
2.70%

Other Thoracic organs
—
—
—
—
—
—
—
—
0.8
1.7
1.6
2.6
1.6
3.0
1.3
10.7
0.5
0.7
0.42%

Bone
0.7
0.1
1.1
2.0
1.4
0.7
0.7
2.2
0.9
2.3
6.5
6.7
12.0
4.5
2.6
16.9
2.0
2.5
1.80%

Melanoma of skin
—
—
—
—
—
—
—
—
0.6
—
—
—
—
2.2
4.4
—
0.1
0.2
0.10%

Other skin
0.3
—
—
0.2
—
0.4
0.5
—
2.0
2.7
1.2
8.6
10.4
14.0
14.9
11.8
1.4
2.2
1.24%

Mesothelioma
—
—
—
—
—
—
—
—
—
—
1.2
0.5
3.0
1.1
4.8
—
0.2
0.3
0.17%

Kaposi sarcoma
—
—
—
—
—
—
—
—
—
—
—
—
—
0.8
—
—
—
—
0.01%

Connective, Soft tissue
1.2
0.3
0.7
0.4
1.5
2.1
1.7
1.2
2.0
2.0
2.9
2.4
6.2
3.9
3.1
13.4
1.6
1.9
1.42%

Breast
—
—
—
—
3.1
9.5
29.2
49.0
86.0
106.2
136.0
172.9
177.4
166.3
138.7
148.6
35.8
48.8
32.04%

Vulva
0.1
—
0.1
—
—
—
—
—
—
0.3
—
1.0
—
0.8
—
1.4
0.1
0.1
0.09%

Vagina
—
—
—
—
—
—
—
—
—
—
—
1.0
3.0
3.3
—
1.4
0.2
0.3
0.14%

Cervix Uteri
—
—
—
—
—
0.2
0.2
—
0.6
3.6
6.5
9.1
8.3
10.5
1—
9.4
1.3
2.0
1.17%

Corpus Uteri
—
—
—
—
—
—
0.5
0.2
0.6
1.3
0.7
8.1
4.3
3.0
3.0
12.1
0.7
1.1
0.62%

Uterus unspec.
—
—
—
0.5
1.2
0.4
0.7
0.5
1.8
1.6
11.1
9.5
21.5
20.4
31.4
21.2
2.5
3.9
2.27%

Ovary
—
—
0.5
0.4
0.8
1.5
1.5
3.3
8.7
17.2
20.3
24.0
19.6
17.2
2—
26.3
4.6
6.3
4.12%

Other female genital
—
—
—
—
—
—
—
0.3
—
—
—
—
—
—
1.3
2.1
0.1
0.1
0.05%

Placenta
—
—
—
—
—
0.4
—
—
—
—
—
—
—
—
—
—
—
—
0.03%

Kidney
1.5
0.1
—
—
—
0.5
0.8
0.5
0.6
2.9
2.3
1.0
10.4
10.7
1.3
7.3
1.1
1.6
0.97%

Renal pelvis
—
0.3
—
—
—
0.6
—
0.2
—
0.7
0.4
0.5
1.6
0.8
—
—
0.2
0.3
0.19%

Ureter
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
0.00%

Bladder
0.1
—
—
0.2
—
0.2
—
0.7
0.8
5.3
8.2
18.6
20.2
37.8
43.6
53.9
3.3
5.5
2.96%

Other urinary organs
—
—
—
—
—
—
—
—
—
—
—
—
—
2.2
—
—
—
0.1
0.03%

Eye
0.1
0.3
—
—
—
—
0.5
—
—
—
—
1.2
0.7
0.8
—
1.4
0.2
0.2
0.14%

Brain, Nervous tissue
3.3
2.1
1.9
0.8
2.9
0.7
4.5
6.5
6.6
9.5
11.3
12.1
31.4
26.3
33.1
72.2
5.8
8.0
5.18%

Thyroid
—
—
—
—
2.7
2.8
10.2
7.2
6.4
9.7
10.2
11.0
9.0
2.6
10.4
14.2
3.7
4.3
3.28%

Adrenal gland
1.5
0.1
—
—
—
—
—
—
—
—
—
1.2
—
—
—
1.4
0.2
0.3
0.20%

Other endocrine
—
0.1
—
0.1
0.1
0.3
—
0.5
0.3
0.3
0.4
1.0
0.7
0.8
—
—
0.2
0.2
0.19%

Hodgkin disease
—
0.6
0.4
1.9
1.3
0.4
1.2
0.7
0.6
0.4
—
1.2
3.8
—
—
—
0.8
0.8
0.70%

Non-Hodgkin lymphoma
0.9
0.7
—
1.1
0.8
1.2
1.7
3.3
3.8
8.6
16.0
23.4
24.1
16.8
31.3
36.7
4.2
6.1
3.80%

Immunoproliferative dis.
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
0.00%

Multiple myeloma
—
—
—
—
—
—
—
—
0.6
1.4
0.8
1.2
2.3
4.4
6.1
2.7
0.4
0.6
0.34%

Lymphoid leukemia
2.0
0.7
0.9
0.4
0.5
—
0.7
0.7
1.4
1.0
2.7
1.7
2.8
3.9
4.4
—
1.0
1.2
0.93%

Myeloid Leukemia
0.5
0.3
0.7
0.2
1.5
1.5
1.4
1.0
0.9
0.7
4.0
3.1
6.8
7.5
—
4.9
1.3
1.6
1.14%

Leukemia unspec.
0.4
0.7
0.7
1.3
0.9
1.7
1.5
0.7
1.4
2.7
3.3
5.5
6.1
8.3
7.4
14.8
1.7
2.2
1.55%

Other & unspecified
1.4
0.9
1.9
1.7
2.4
3.9
4.6
5.5
9.6
12.5
23.8
37.3
39.9
42.1
42.6
70.5
7.7
10.8
6.93%

All sites Total
16.1
7.8
10.1
11.4
22.4
34.9
69.7
95.2
163.7
255.3
359.1
506.5
633.7
665.8
715.9
850.5
111.7
159.1
100.00%

All sites but C44#
15.8
7.8
10.1
11.2
22.4
34.6
69.3
95.2
161.6
252.5
357.9
497.8
623.3
651.8
701.0
838.7
110.3
157.0
98.76%

Incidence rates do not include nonmelanoma skin cancer.

Figure 3: Calculated age specific incidence rates for Egypt 2008–2011.

Figure 4: Calculated age specific incidence rates for liver cancer in Egypt 2008–2011.

Figure 5: Calculated age specific incidence rates for breast cancer in Egypt 2008–2011.

Figure 6: Calculated age specific incidence rates for urinary bladder cancer in Egypt 2008–2011.

Table 5 depicts the proportions and rates of the most frequent cancer sites by gender. There was predominance of liver, breast, and bladder cancer that represented approximately 46% of all cancers. Liver and bladder cancers represented approximately 44% of cancer in males. In females, breast and liver cancer occupied the top ranks accounting for around 45% of all cancers.

Table 5: The most frequent cancers in Egypt estimated using the results of the National Population-Based Registry Program of Egypt 2008–2011.

Site
%
Crude rate
ASR

Males
Liver
33.63
39.5
61.8

Bladder
10.71
12.6
21.1

Lung#
5.69
6.7
10.4

Non-Hodgkin lymphoma
5.48
6.4
8.8

Brain##
5.48
6.4
8.8

Prostate
4.27
5.0
9.3

Females
Breast
32.04
35.8
48.8

Liver
13.54
15.1
24.4

Brain##
5.18
5.8
8.0

Ovary
4.12
4.6
6.3

Non-Hodgkin lymphoma
3.80
4.2
6.1

Thyroid
3.28
3.7
4.3

Both Sexes
Liver
23.81
27.5
43.6

Breast
15.41
17.8
24.3

Bladder
6.94
8.0
13.5

Brain##
5.29
6.1
8.5

Non-Hodgkin lymphoma
4.64
5.4
7.5

Lung#
4.22
4.9
7.5

Includes trachea, bronchus, and lung tumors.

##Includes brain and nervous system tumors.

3.2. Frequencies and Incidence Rates/Geographical Strata

The frequencies of individual sites of cancer and their incidence rates by geographical stratum and sex are detailed in Tables 6 and 7. Table 8 depicts the most common sites of cancer that accounted for approximately 3/4 of cases. For the 2 sexes together, the top 2 ranks in the 3 regions were liver and breast cancer. The proportions and ASR of liver cancer were highest in Lower Egypt (29.6% and 56.8/100,000), less in Middle, and least in Upper Egypt (8.2% and 13.1/100,000).

Table 6: Incidence rates/100,000 population of individual cancer sites in Lower, Middle, and Upper Egypt: males.

Primary site
Lower Egypt
Middle Egypt
Upper Egypt

2009–2011
2009
2008

Crude
ASR
%
Crude
ASR
%
Crude
ASR
%

Lip
0.4
0.4
0.28%
0.3
0.5
0.24%
0.4
0.6
0.38%

Tongue
0.3
0.3
0.20%
0.2
0.4
0.20%
1.1
1.5
1.15%

Mouth
0.2
0.3
0.16%
0.8
1.1
0.73%
1.3
1.9
1.34%

Salivary glands
0.3
0.4
0.20%
0.4
0.5
0.36%
0.6
0.9
0.57%

Tonsil
0.0
0.0
0.00%
0.0
0.1
0.04%
0.0
0.0
0.00%

Other oropharynx
0.0
0.0
0.00%
0.2
0.3
0.20%
0.2
0.3
0.19%

Nasopharynx
0.5
0.5
0.35%
0.1
0.1
0.12%
0.6
1.0
0.57%

Hypopharynx
0.0
0.0
0.00%
0.3
0.5
0.28%
0.6
0.9
0.57%

Pharynx unspec.
0.1
0.1
0.04%
0.1
0.1
0.08%
0.2
0.3
0.19%

Esophagus
1.0
1.3
0.71%
1.8
3.0
1.61%
3.9
5.5
4.01%

Stomach
1.4
2.0
0.98%
1.7
2.5
1.53%
2.4
3.8
2.48%

Small intestine
0.1
0.1
0.04%
0.5
0.6
0.44%
0.2
0.2
0.19%

Colon
4.0
5.4
2.91%
2.3
3.7
2.10%
2.4
3.7
2.48%

Rectum
0.9
1.1
0.67%
1.2
1.6
1.13%
0.7
1.1
0.76%

Anus
0.4
0.4
0.28%
0.2
0.2
0.16%
0.4
0.5
0.38%

Liver
57.8
81
41.71%
22.4
37.6
20.42%
11.5
17.5
11.83%

Gallbladder and so forth
0.5
0.5
0.39%
0.4
0.7
0.32%
1.3
2.2
1.34%

Pancreas
3.2
4.4
2.28%
2.1
3.5
1.94%
3.5
5.4
3.63%

Nose, sinuses and so forth
0.1
0.1
0.04%
0.4
0.6
0.32%
0.6
0.9
0.57%

Larynx
0.8
1.3
0.59%
3.3
5.7
3.03%
3.9
6.0
4.01%

Trachea, Bronchus, Lung
7.6
10.1
5.47%
6.3
10.8
5.77%
7.4
11.5
7.63%

Other Thoracic organs
1.0
1.3
0.71%
0.8
1.2
0.69%
0.6
0.8
0.57%

Bone
1.9
2.4
1.34%
2.3
3.4
2.10%
1.5
1.9
1.53%

Melanoma of skin
0.2
0.2
0.12%
0.1
0.1
0.12%
0.0
0.0
0.00%

Other skin
1.8
2.7
1.30%
1.7
2.8
1.53%
1.1
1.8
1.15%

Mesothelioma
0.0
0.0
0.00%
0.3
0.4
0.24%
0.4
0.6
0.38%

Kaposi sarcoma
0.1
0.1
0.08%
0.2
0.3
0.16%
0.0
0.0
0.00%

Connective, Soft tissue
2.5
2.6
1.77%
0.5
0.8
0.48%
3.0
3.8
3.05%

Breast
0.7
0.8
0.47%
0.4
0.6
0.32%
1.1
1.8
1.15%

Penis
0.0
0.0
0.00%
0.0
0.0
0.00%
0.0
0.0
0.00%

Prostate
6.7
11.7
4.84%
2.9
5.2
2.66%
5.7
9.2
5.92%

Testis
0.5
0.4
0.35%
0.5
0.7
0.48%
0.4
0.5
0.38%

Other male genital
0.0
0.0
0.00%
0.1
0.2
0.12%
0.0
0.0
0.00%

Kidney
2.2
3.2
1.61%
1.7
2.5
1.53%
0.9
1.3
0.95%

Renal pelvis
0.2
0.3
0.12%
0.5
0.8
0.48%
0.4
0.5
0.38%

Ureter
0.1
0.1
0.04%
0.0
0.1
0.04%
0.0
0.0
0.00%

Bladder
12.2
19
8.82%
15.6
26.4
14.25%
12.2
19.3
12.60%

Other urinary organs
0.0
0.0
0.00%
0.0
0.0
0.00%
0.2
0.3
0.19%

Eye
0.1
0.2
0.08%
0.3
0.4
0.24%
0.7
0.6
0.76%

Brain, Nervous tissue
6.2
8.1
4.49%
8.0
12.5
7.26%
5.2
6.7
5.34%

Thyroid
1.3
1.5
0.91%
1.2
1.7
1.05%
0.7
1.1
0.76%

Adrenal gland
0.0
0.0
0.00%
0.1
0.2
0.12%
0.6
0.8
0.57%

Other endocrine
0.1
0.1
0.08%
0.6
0.8
0.56%
0.4
0.4
0.38%

Hodgkin disease
1.6
1.8
1.18%
1.7
2.0
1.53%
1.5
1.5
1.53%

Non-Hodgkin lymphoma
8.3
10.3
6.03%
5.2
7.6
4.76%
2.8
4.2
2.86%

Immunoproliferative dis.
0.0
0.0
0.00%
0.0
0.0
0.00%
0.0
0.0
0.00%

Multiple myeloma
0.7
0.9
0.51%
0.7
1.1
0.61%
0.2
0.3
0.19%

Lymphoid leukemia
1.7
2.2
1.22%
1.8
2.3
1.61%
3.0
3.1
3.05%

Myeloid Leukemia
0.9
1.0
0.63%
1.6
1.8
1.45%
1.9
2.5
1.91%

Leukemia unspec.
2.4
3.1
1.73%
2.0
2.6
1.86%
1.1
1.1
1.15%

Other & unspecified
5.9
8.3
4.25%
13.9
17.6
12.67%
8.7
13
8.97%

All sites Total
138.5
191.8
100.00%
109.7
170
100.00%
97.1
142.8
100.00%

All sites but C44#
136.7
189.1
98.70%
108
167.2
98.47%
96
141
98.85%

Incidence rates do not include nonmelanoma skin cancer.

Table 7: Incidence rates/100,000 population of individual cancer sites in Lower, Middle, and Upper Egypt: females.

Primary site
Lower Egypt
Middle Egypt
Upper Egypt

2009–2011
2009
2008

Crude
ASR
%
Crude
ASR
%
Crude
ASR
%

Lip
0.3
0.4
0.26%
0.2
0.4
0.24%
0.0
0.0
0.00%

Tongue
0.3
0.5
0.26%
0.3
0.5
0.34%
0.2
0.2
0.16%

Mouth
0.1
0.2
0.09%
0.5
0.8
0.53%
0.9
1.5
0.80%

Salivary glands
0.2
0.2
0.13%
0.3
0.4
0.29%
0.2
0.4
0.16%

Tonsil
0.1
0.1
0.04%
0.0
0.1
0.05%
0.0
0.0
0.00%

Other oropharynx
0.0
0.0
0.00%
0.1
0.1
0.10%
0.2
0.3
0.16%

Nasopharynx
0.1
0.1
0.04%
0.0
0
0.05%
0.2
0.2
0.16%

Hypopharynx
0.0
0.0
0.00%
0.4
0.4
0.38%
0.6
0.9
0.48%

Pharynx unspec.
0.0
0.0
0.00%
0.0
0.0
0.05%
0.0
0.0
0.00%

Esophagus
0.9
1.2
0.65%
1.2
1.9
1.25%
1.1
1.6
0.96%

Stomach
2.3
3.2
1.73%
1.2
1.8
1.25%
1.9
3.1
1.60%

Small intestine
0.3
0.5
0.22%
0.4
0.6
0.43%
0.6
0.9
0.48%

Colon
3.0
4.2
2.30%
2.2
3.2
2.31%
2.4
3.5
2.08%

Rectum
0.9
1.0
0.65%
1.0
1.2
1.01%
0.7
1.3
0.64%

Anus
0.1
0.1
0.04%
0.1
0.2
0.14%
0.2
0.3
0.16%

Liver
21.6
32.6
16.37%
8.6
13.7
8.95%
6.0
8.7
5.12%

Gallbladder and so forth
0.5
0.5
0.35%
0.6
0.9
0.58%
1.9
3.1
1.60%

Pancreas
2.1
3.2
1.60%
0.9
1.4
0.91%
1.7
2.3
1.44%

Nose, sinuses and so forth
0.3
0.5
0.26%
0.1
0.2
0.14%
0.2
0.2
0.16%

Larynx
0.2
0.3
0.17%
0.3
0.4
0.29%
0.4
0.7
0.32%

Trachea, Bronchus, Lung
3.7
5.3
2.82%
2.2
3.1
2.26%
2.4
3.8
2.08%

Other Thoracic organs
0.6
0.8
0.43%
0.5
0.7
0.48%
0.0
0.0
0.00%

Bone
2.0
2.3
1.52%
1.8
2.4
1.92%
3.4
4.4
2.88%

Melanoma of skin
0.2
0.3
0.17%
0.0
0.1
0.05%
0.0
0.0
0.00%

Other skin
1.7
2.4
1.26%
1.0
1.5
1.06%
1.9
3.1
1.60%

Mesothelioma
0.3
0.3
0.22%
0.2
0.3
0.24%
0.4
0.7
0.32%

Kaposi sarcoma
0.0
0.0
0.00%
0.0
0.1
0.05%
0.0
0.0
0.00%

Connective, Soft tissue
2.3
2.6
1.78%
0.4
0.6
0.38%
1.9
2.2
1.60%

Breast
43.8
53
33.22%
25.8
35.6
26.84%
45.3
64.5
38.72%

Vulva
0.0
0.0
0.00%
0.3
0.4
0.34%
0.0
0.0
0.00%

Vagina
0.1
0.2
0.09%
0.1
0.2
0.14%
0.6
1.0
0.48%

Cervix Uteri
1.7
2.4
1.26%
1.0
1.5
1.06%
0.6
0.9
0.48%

Corpus Uteri
0.6
0.9
0.43%
0.6
0.9
0.67%
1.7
2.9
1.44%

Uterus unspec.
3.7
5.3
2.77%
1.0
1.3
1.06%
2.4
3.8
2.08%

Ovary
5.1
6.4
3.90%
3.6
5.0
3.75%
7.1
10.2
6.08%

Other female genital
0.0
0.0
0.00%
0.0
0.1
0.05%
0.4
0.6
0.32%

Placenta
0.0
0.0
0.00%
0.0
0.0
0.05%
0.2
0.2
0.16%

Kidney
1.1
1.6
0.87%
1.2
1.8
1.25%
0.7
1.1
0.64%

Renal pelvis
0.2
0.3
0.17%
0.2
0.3
0.19%
0.2
0.2
0.16%

Ureter
0.0
0.0
0.00%
0.0
0.0
0.00%
0.0
0.0
0.00%

Bladder
3.7
5.9
2.77%
3.1
4.9
3.27%
3.6
5.7
3.04%

Other urinary organs
0.1
0.1
0.04%
0.0
0.0
0.00%
0.0
0.0
0.00%

Eye
0.1
0.1
0.04%
0.3
0.5
0.34%
0.2
0.2
0.16%

Brain, Nervous tissue
5.8
7.4
4.42%
7.4
11.1
7.70%
2.4
2.9
2.08%

Thyroid
5.1
5.4
3.90%
1.6
2.1
1.64%
3.6
4.2
3.04%

Adrenal gland
0.2
0.3
0.17%
0.2
0.3
0.24%
0.2
0.2
0.16%

Other endocrine
0.1
0.0
0.04%
0.5
0.7
0.53%
0.2
0.2
0.16%

Hodgkin disease
1.0
0.7
0.74%
1.0
1.0
1.01%
0.9
0.9
0.80%

Non-Hodgkin lymphoma
5.4
6.7
4.11%
4.2
5.8
4.43%
2.6
3.8
2.24%

Immunoproliferative dis.
0.0
0.0
0.00%
0.0
0.0
0.00%
0.0
0.0
0.00%

Multiple myeloma
0.7
0.9
0.52%
0.1
0.3
0.14%
0.2
0.0
0.16%

Lymphoid leukemia
1.0
1.1
0.74%
1.2
1.6
1.25%
1.5
1.6
1.28%

Myeloid Leukemia
0.9
1.1
0.65%
1.7
2.0
1.78%
2.2
3.3
1.92%

Leukemia unspec.
1.8
2.4
1.34%
1.6
2.0
1.68%
1.9
2.3
1.60%

Other & unspecified
5.9
8.2
4.46%
14.3
15.5
14.86%
9.2
12.9
7.84%

All sites Total
131.7
173.3
100.00%
95.9
132.1
100.00%
116.9
167.1
100.00%

All sites but C44#
130.1
170.9
98.74%
94.9
130.7
98.94%
115.1
163.9
98.40%

Incidence rates do not include nonmelanoma skin cancer.

Table 8: Proportions and incidence rates of the most frequently observed cancers in the 3 regions of Egypt.

Lower Egypt
Middle Egypt
Upper Egypt

2009–2011
2009
2008

Site
%
Crude rate
ASR
Site
%
Crude rate
ASR
Site
%
Crude rate
ASR

Males
Liver
41.7
57.8
81.0
Liver
20.4
22.4
37.6
Bladder
12.6
12.2
19.3

Bladder
8.8
12.2
19.0
Bladder
14.2
15.6
26.4
Liver
11.8
11.5
17.5

NHL
6.0
8.3
10.3
Brain#
7.3
8.0
12.5
Lung##
7.6
7.4
11.5

Lung##
5.5
7.6
10.1
Lung##
5.8
6.3
10.8
Leukemia
6.1
6.0
6.7

Prostate
4.8
6.7
11.7
Leukemia
4.9
5.4
6.7
Prostate
5.9
5.7
9.2

Females
Breast
33.2
43.8
53.0
Breast
26.8
25.8
35.6
Breast
38.7
45.3
64.5

Liver
16.4
21.6
32.6
Liver
8.9
8.6
13.7
Ovary
6.1
7.1
10.2

Brain#
4.4
5.8
7.4
Brain#
7.7
7.4
11.1
Liver
5.1
6.0
8.7

NHL
4.1
5.4
6.7
Leukemia
4.7
4.5
5.6
Leukemia
4.8
5.6
7.2

Thyroid
3.9
5.1
5.4
NHL
4.4
4.2
5.8
Uterus
3.5
4.1
6.7

Both Sexes
Liver
29.6
40.1
56.8
Liver
15.2
15.6
25.7
Breast
21.6
23.1
33.2

Breast
16.1
21.7
26.9
Breast
12.4
12.8
18.1
Liver
8.2
8.8
13.1

Bladder
5.9
8.0
12.5
Bladder
9.2
9.5
15.7
Bladder
7.4
7.9
12.5

NHL
5.1
6.9
8.5
Brain#
7.5
7.7
11.8
Leukemia
5.4
5.7
7.0

Brain#
4.5
6.0
7.8
Leukemia
4.8
4.9
6.2
Lung##
4.6
4.9
7.7

Includes brain and nervous system tumors.

##Includes trachea, bronchus and lung tumors.

Among males in the 3 regions, liver and bladder cancer occupied the top 2 ranks. The proportion and ASR of liver cancer were highest in Lower Egypt (41.7% and 81.0/100,000) and lowest in Upper Egypt (11.8% and 17.5/100,000). Cancer of the lung occupied the third or fourth ranks representing 5–7% of cancers and Non-Hodgkin lymphoma was among the 5 most common cancers in Lower Egypt only having a proportion of 6.0% and ASR 10.3/100,000.

Among females, the pattern in the 3 regions was dominated by the high frequency of breast cancer and liver cancer. Proportion of liver cancer was highest in Lower Egypt (16.4%), less in Middle Egypt, and lowest in Upper Egypt (8.9% and 5.1% resp.).

3.3. Estimated Number of Incident Cancer Cases 2013–2050

During the period 2013–2050, population of Egypt is expected to increase to approximately 160% the 2013 population size. Applying the current age-specific incidence rates to successive populations would lead to a progressive increase in number of incident cases from 114,985 in 2013 to 331,169 in 2050, approximately 290% of 2013 incidence (Table 9 and Figure 7). This increase reflected both population growth and demographic change mainly due to ageing of population. Population growth alone would increase the number of incident cases by 55.2% in 2015. This fraction progressively decreased to become 32.8% in 2050. The fraction due to ageing gradually increased to reach 67.2% in 2050 (Figure 8).

Table 9: Estimated number of cancer cases, Egypt 2013–2050.

2013
2015
2020
2025
2050

Males
Females
Total
Males
Females
Total
Males
Females
Total
Males
Females
Total
Males
Females
Total

Lip
135
126
262
146
135
281
178
164
342
206
202
408
438
427
866

Tongue
155
175
330
164
185
349
186
231
417
219
296
515
417
763
1180

Mouth
228
163
391
243
178
420
275
216
491
314
261
575
544
528
1071

Salivary glands
147
108
255
158
117
275
189
130
319
222
153
375
495
265
760

Tonsil
6
31
37
6
33
40
9
41
50
11
54
65
13
129
142

Other oropharynx
42
25
67
45
28
73
54
30
85
63
37
100
132
65
198

Nasopharynx
145
32
178
154
34
188
171
40
211
207
42
249
428
68
496

Hypopharynx
72
80
152
76
85
161
88
96
184
102
111
213
200
173
372

Pharynx unspec.
35
7
42
36
7
43
42
7
48
55
7
62
94
8
102

Oesophagus
699
485
1184
746
525
1271
897
644
1542
1065
762
1827
2249
1504
3752

Stomach
726
969
1695
772
1045
1816
922
1249
2171
1080
1484
2565
2185
2877
5062

Small intestine
98
179
277
106
194
300
120
229
349
134
274
408
223
507
730

Colon
1522
1339
2862
1618
1437
3055
1893
1715
3608
2225
2063
4287
4465
4120
8585

Rectum
464
406
871
490
432
922
568
502
1070
645
584
1230
1097
1052
2149

Anus
133
50
183
142
53
195
162
65
227
178
71
249
291
127
418

Liver
19646
8345
27991
20932
9043
29975
24420
10900
35320
28580
12933
41513
59047
26425
85471

Gallbladder and so forth
235
324
559
248
350
598
297
413
710
348
488
835
715
967
1682

Pancreas
1350
876
2226
1440
957
2397
1676
1160
2836
1961
1405
3366
3912
2971
6883

Nose, sinuses and so forth
98
136
234
104
144
247
124
170
294
154
186
340
340
322
661

Larynx
933
134
1067
993
142
1136
1194
173
1367
1428
201
1629
3094
395
3489

Trachea, Bronchus, Lung
3304
1586
4890
3530
1703
5233
4168
2031
6198
4889
2404
7293
10176
4895
15071

Other Thoracic organs
368
260
628
393
277
670
464
335
798
551
415
966
1149
897
2046

Bone
889
957
1846
935
1011
1946
1068
1174
2242
1216
1330
2546
2212
2401
4613

Melanoma of skin
60
59
119
66
66
132
82
84
166
95
105
200
181
207
388

Other skin
797
749
1547
853
813
1666
1018
973
1990
1205
1160
2365
2641
2306
4947

Mesothelioma
55
106
161
58
116
174
65
143
207
76
161
238
135
321
456

Kaposi sarcoma
60
8
68
63
9
72
72
10
82
81
13
95
159
28
187

Connective, Soft tissue
801
751
1552
846
787
1633
981
901
1882
1113
1026
2139
1924
1796
3720

Breast
287
17905
18192
306
19105
19411
362
22320
22682
422
25793
26215
807
45243
46050

Vulva
0
52
52
0
56
56
0
63
63
0
76
76
0
146
146

Vagina
0
95
95
0
103
103
0
126
126
0
147
147
0
305
305

Cervix Uteri
0
701
701
0
752
752
0
882
882
0
1039
1039
0
2039
2039

Corpus Uteri
0
392
392
0
426
426
0
502
502
0
600
600
0
1256
1256

Uterus unspec.
0
1353
1353
0
1456
1456
0
1758
1758
0
2055
2055
0
4143
4143

Ovary
0
2288
2288
0
2434
2434
0
2830
2830
0
3311
3311
0
5957
5957

Other female genital
0
30
30
0
34
34
0
44
44
0
55
55
0
134
134

Placenta
0
14
14
0
14
14
0
14
14
0
15
15
0
18
18

Penis
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Prostate
2544
0
2544
2747
0
2747
3398
0
3398
4295
0
4295
10785
0
10785

Testis
229
0
229
240
0
240
266
0
266
291
0
291
425
0
425

Other male genital
21
0
21
22
0
22
28
0
28
33
0
33
73
0
73

Kidney
877
561
1438
934
594
1528
1080
693
1774
1274
801
2076
2628
1487
4115

Renal pelvis
141
99
240
152
103
255
183
115
297
214
126
341
446
196
642

Ureter
22
0
22
24
0
24
31
0
31
41
0
41
111
0
111

Bladder
6362
1872
8234
6852
2038
8891
8228
2481
10709
9746
3016
12762
21783
6554
28337

Other urinary organs
8
21
29
8
23
31
10
27
37
11
35
46
22
72
94

Eye
89
82
171
92
87
180
98
96
194
104
108
212
160
195
355

Brain, Nervous tissue
3072
2933
6004
3256
3133
6389
3779
3721
7500
4390
4351
8740
8439
8450
16888

Thyroid
547
1759
2306
582
1867
2448
661
2106
2767
748
2363
3111
1298
3814
5113

Adrenal gland
43
105
149
46
109
155
52
113
166
57
121
178
102
180
282

Other endocrine
129
95
224
136
100
236
156
114
269
174
125
300
273
188
462

Hodgkin disease
647
321
968
673
336
1008
751
371
1123
837
397
1234
1245
527
1772

Non-Hodgkin lymphoma
3053
2188
5241
3223
2345
5568
3689
2755
6444
4240
3202
7442
7749
6135
13884

Immunoproliferative dis.
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Multiple myeloma
316
200
516
334
218
552
386
264
650
432
321
753
819
644
1463

Lymphoid leukaemia
801
471
1272
841
493
1335
926
551
1477
1000
603
1604
1535
896
2431

Myeloid Leukaemia
511
614
1125
534
642
1176
595
727
1323
666
810
1476
1054
1358
2412

Leukemia unspec.
965
842
1807
1005
891
1896
1131
1027
2157
1295
1188
2483
2226
2169
4395

Other & unspecified
3692
3965
7657
3921
4232
8153
4573
4971
9543
5358
5793
11151
10582
11026
21607

All sites Total
57558
57426
114985
61288
61495
122783
71759
72496
144255
84045
84679
168723
171494
159675
331169

All sites but C44#
56761
56677
113438
60435
60683
121117
70742
71523
142265
82840
83519
166358
168854
157369
326223

Numbers do not include nonmelanoma skin cancer.

Figure 7: Estimated number of cases in Egypt (2013–2050).

Figure 8: Estimated number of cases in Egypt (2013–2050) and causes of the increase in cases.

4. Discussion

When the National Cancer Registry Program of Egypt was designed, there had been a number of challenges that were addressed. One of the most important challenges was design of a sample that could be representative of such a big country. Other challenges included complete capture of incident cancer cases among residents of selected governorates and best guarantee of quality of data and sustainability of the program to avoid going through survey-like data collection that need to be repeated, a methodology that proved to be inappropriate [27].

Dealing with population-based registration, the word national might be confusing. Actually, and with the exception of very few examples mainly old registries like that of Denmark and registries in small countries like Singapore, complete national coverage is not accomplished [27, 28]. The US is an example of a huge country with 18 population-based registries spread over the states without a central national registry [29]. Recently, national incidence rates of Turkey were published based on results of 8 geographically spread peripheral registries [30].

With this in mind, Egypt was geographically stratified for registration purposes into 3 regions: Lower Egypt, to the north of Cairo, and Middle, and Upper Egypt to the south. Three governorates were selected from the 3 regions representing 20.9% of the total population of Egypt. The greater Cairo, including the capital city, and Alexandria, the second capital (approximately 18 million population), were not included in the program due to difficulty in data collection and coverage of a population that daily migrates in and out of these 2 regions. Other regions that were not covered were frontier governorates; namely Matrooh, New Valley, Red Sea, and Sinai, together representing 3.3% of total population [26]. This exclusion was due to logistic reasons being mainly inhabited by nomads or internal migrants working in the tourist industry.

To ensure complete coverage of incident cancer patients in the selected governorates, data were actively collected from medical records of oncology centers within the governorates and from national referral centers like National Cancer Institute in Cairo. Registration covered health-insured patients and patients treated on government-subsidized treatment program would minimize under registration considered a point of strength of the registry. Also, regular check of death registers helped to decrease the possibility of under registration. Death certificate only cases (DCO) accounted for almost 8% of cases which could be considered an acceptable level for a newly established registry [28].

One of the elements that contributed to the National Cancer Registry Program of Egypt was the use of a unique national identification number for duplicate elimination to prevent over registration, which is a serious threat to population-based registries [7, 28]. A major concern during the development of a cancer registry especially population-based, is its sustainability. An alternative that was applied in Europe and the US was to conduct successive cancer surveys as with the US Health Interview and Examination surveys. Evaluation of these surveys was negative and this method was not recommended [28]. The main reason for lack of sustainability is unavailability of needed funding and lack of collaboration of treating physicians [28]. From the very beginning, the national cancer registry was planned to be a national program and not a project with start and end dates. During all stages of its development it was gradually incorporated within the infrastructure of the health system to gradually become part of everyday routine work [31]. Quality of data was assured through computer validation and regular manual checks on the peripheral and central levels.

We also developed a mathematical model to apply the regional age-specific incidence rates to the corresponding population structure to get national estimates of all cancers and for individual cancer sites for any specified year. Mathematical modeling is a common practice used to estimate national rates from statistics of regional registries. Recently, a model was developed for china to get national rates based upon regional registries [32]. The advantage of our Egyptian model was use of Egyptian national population-based data without importing data of adjacent countries [33].

Nonetheless, the program has its points of weakness. The data should be carefully interpreted in view of the short initial phase of registration that would be of better accuracy on successive years [28]. Furthermore, some private patients that are not covered by the Government-Subsidized Treatment Program might escape registration. This would be assumed to be a small proportion. With the rising cost of cancer treatment, most patients would seek government financial support which is a constriction right.

The results given in the current report are the first ever published incidence rates on a national and regional level for Egypt derived from a population-based cancer registry program. These incidence rates would replace the proportions that have always been derived from hospital-based results [1–5]. The results were those of Damietta (Lower Egypt), Minya (Middle Egypt), and Aswan (Upper Egypt). Damietta was selected to represent the Nile delta instead of Gharbiah registry that stopped its activities before establishment of the NCRP and needed some time to be restructured to join the program. Results of these governorates were used to compute regional rates that were used to get a national estimate based upon age-specific incidence rates and population structure.

The estimated incidence rates showed differences between the 3 regions that were mainly in the incidence of liver and bladder cancers. Among males, the proportion of incident liver cancer was highest in Lower Egypt (41.7%) and next in Middle Egypt (20.4%) and lowest in Upper Egypt (11.8%). Bladder cancer ranked next to liver cancer in Lower Egypt (8.8%). In Middle Egypt, the proportion was 14.2%, still lower than liver cancer. In Upper Egypt, liver cancer was still the most common cancer, with a small difference from bladder cancer (12.6%). These differences could be attributed to the high prevalence of hepatitis C viral infection (HCV), which is one of the highest prevalence rates worldwide [34, 35]. The distribution of liver cancer in the 3 regions followed the distribution of HCV, which is more frequent in Nile delta with decreasing prevalence going south [34]. The main risk factor for bladder cancer in Egypt was urinary Schistosomiasis which was more frequent in Upper Egypt and its prevalence decreased when going north [34]. Despite control of Schistosomiasis, its effect on bladder cancer needs time to disappear. Another difference between the 3 regions was the proportion of non-Hodgkin lymphoma that was distributed in a pattern similar to that of liver cancer [36, 37].

Among females, the pattern in Lower, Middle, and Upper Egypt was dominated by the high frequency of breast cancer (33.8%, 26.8% and 38.7% resp.) and liver cancer (16.4%, 8.9% and 5.1% resp.). This pattern of liver cancer was similar to that of males with similar relation to the prevalence of HCV. Other differences in site distribution between the 3 regions will be detailed in a separate publication [38].

The national age standardized incidence rates for all cancers in Egypt, excluding nonmelanoma skin cancer, were 175.9/100,000 for males, 157.0/100,000 for females, and 166.6/100,000 for both sexes. The age-standardized rates were intermediate between the rates of more and less developed countries [33, 39, 40]. For both sexes, the rates for all cancers excluding nonmelanoma skin cancer were 268.3/100,000 for more developed countries and 147.7/100,000 for less developed countries compared to 166.6/100,000 in Egypt. For males, the age-standardized rates were 308.7/100,000 for more developed countries and 163.0/100,000 for less developed countries compared to 175.9/100,000 in Egypt. The rates of females were 240.6/100,000 in more developed countries and 135.8/100,000 in less developed countries compared to 157.0/100,000 for Egypt.

The model used in our study revealed the seriousness of the liver cancer that ranked first among cancers in males (33.6%) and next to breast cancer. Among females the proportion of breast cancer was 32.0% followed by liver cancer (13.5%). The high prevalence of HCV especially genotype IV would explain this high incidence [34, 35]. The age-standardized rates for liver cancer for both genders were 5.4/100,000 in more developed countries, 12.0/100,000 in less developed countries compared to 43.6/100,000 in Egypt. Among males the rates were 8.6/100,000 in more developed countries, 17.8/100,000 in less developed countries compared to 61.8/100,000 in Egypt. Among females, the rates were 2.7/100,000 (more developed), 6.6/100,000 (less developed), and 24.4/100,000 (Egypt).

Incidence rate of bladder cancer that ranked next to liver cancer in males was also high. The age-standardized rates are 16.9/100,000 (more developed) and 5.3/100,000 (less developed) compared to 21.1/100,000 in Egypt. Breast cancer was the most frequent cancer among females. The age-standardized rates are 74.1/100,000 (more developed), 31.3/100,000 (less developed), and 48.8/100,000 (Egypt). Analysis of individual sites of cancers will be detailed in a separate publication [38].

Applying the model over successive years for the projected populations showed an increase in number of incident cases from approximately 115,000 patients in 2013 to more than 331,000 in 2050, almost 3-fold increase. The fraction of increase due to population growth gradually decreased over the years with a corresponding increase in the fraction due to demographic transition with ageing of the population. The cancer problem in Egypt would thus be expected to continue simply due to the inevitable ageing of the population with better standards of health care (Table 10).

Table 10: Estimated cancer incidence in the period 2013–2050 and causes of increase.

2013
2015
2020
2025
2050

Estimated population
85294388 (100%)
88487396 (103.7%)
96260017 (112.9%)
103742157 (121.6%)
137872522 (161.6%)

Number of cases#1
114985
122783 (106.8%)
144255 (125.5%)
168723 (146.7%)
331169 (288.0%)

Increased cases from 2013#2

7798 (6.8%)
29270 (25.5%)
53738 (46.7%)
216184 (188.0%)

Increased cases due to population growth#3

4303
14783
24869
70880

Increased cases due to population structure change#4

3494
14487
28869
145304

% Increase due to population growth#5

55.20%
50.50%
46.28%
32.79%

N.B.

#1Number of expected cases depending on 2013 rates of incidence.

#2Number of increased cases from 2013 number of cases.

#3Number of increased cases (from 2013) that is attributed to increase in population number (population growth).

#4Number of increased cases (from 2013) that is attributed to change in population structure (aging of population) and not to population growth.

#5Percent of increased number of cases (from 2013) that can be attributed to population growth only (not due to change in population structure).

Rates estimated by the model developed for the study were based on certain assumptions that should be considered in interpretation of results. These assumptions were: (a) constant age-specific rates during the study period; (b) populations of Greater Cairo and Alexandria would be considered a mosaic of the 3 registration regions and would affect the number of incident cases, and not rates; and (c) exclusion of frontier governorates (3.3% of total population of Egypt) that need special studies to get reliable cancer statistics.

5. Conclusion

These results are the first ever published incidence rates for Egypt on a national and regional level and clearly demonstrated the seriousness of the cancer problem of Egypt with age-adjusted incidence rates approaching those of the more developed countries. Liver cancer is a serious if not the most serious cancer problem in Egypt. Nonetheless, these rates should be carefully interpreted being based on a short initial phase of registration and a mathematical model that used regional incidence rates.

Appendix

Statistical Formulas Used in the Analysis

Step 1 (calculation of regional and national incident cases for census year 2006/sex). (1) Number of incident cancer cases in age group /region where is incidence rate and is population size:

(2) Total incident cases in region : .

(3) Total incident cases in the 3 regions : where –3.

(4) Incident cases in total Egypt :

(5) Calculation of national age specific incidence rates for the 3 regions.

Step 2 (calculation of regional and national incident cases for a given year/sex). The same procedure was followed applying calculated above to the population of the year under study.

Step 3 (future projections). For estimation of incident cancer in a specific year till 2050, the national age specific incidence rates by sex were applied to the corresponding population structure [41]. This estimated number would be due to population growth and demographic change with aging of the population. The fraction due to population growth could be calculated using corresponding population sizes. The remainder of increase in number would be due mainly to demographic change.

List of Abbreviations

ASIR: | Age specific incidence rate
ASR: | Age standardized rate
DCO: | Death certificate only
HCV: | Hepatitis C virus
IARC: | International Agency for Research on Cancer
ICD-10: | International Statistical Classification of Diseases and related health problems, 10th revision
NCRP: | National Cancer Registry Program of Egypt
NHL: | Non-Hodgkin Lymphoma
SEER: | Surveillance, Epidemiology, and End Results Program.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

Acknowledgments

The authors acknowledge the important role played by staff of the Ministry of Communication and Information technology specially Dr. Hesham El Deeb engineers El-Sayed Abdelwahid and Mohamed Hamid who were actively behind success of the registry. The dedication of data managers who supervised peripheral registries’ activities during the initial phase of registration, namely, Drs. Amir Bishara (Aswan), Hassan Afifi (Minya), Tarek Heikal (Damietta), and Professor Nelly Alieldin (National Cancer Institute, Cairo University) is also acknowledged. Furthermore, this work would have not been accomplished without the remarkable effort of abstractors, coders, and supporting staff in participating registries.

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