An alarming occurence of Esophageal cancer in Balochistan

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Pakistan J. Med. Res.
Vol. 44, No. 2, 2005                                                                              ORIGINAL ARTICLE

          An alarming occurence of Esophageal cancer
                        in Balochistan
                Roohullah, Khursheed MA, Muhammad Ayub Shah, Zainullah Khan, Haider SW,
                                     Burdy GM, Kamran S, Farah Khan
                                   Cenar Quetta, Dental and ENT Departments
                                         Bolan Medical College, Quetta.

    Objective: To evaluate the prevalence, geographical features and disease characteristics of Cancer of Esophagus in
    patients registered at Centre for Nuclear Medicine and Radiotherapy (CENAR).
    Patients and Methods: From January 1991 to Dec 2001 832 cases of esophageal cancer were seen at CENAR Hospital
    Quetta. Only cases confirmed by Histopathology and for whom the esophagus was the primary site of tumor were included
    in the study. The mean age of the patients was 50 + 13year) The geographical background and disease characteristics were
    elaborated, by calculating statistical ratios and percentages of various demographic variables, in different subgroups of
    Results: Cancer of esophagus is 3rd commonest tumor (11.3% of total registered cases) and on average, the annual
    proportion of esophageal cancer constitutes a figure of 11 cases per hundred patients diagnosed at CENAR Hospital. It is
    third common tumor in male and 4th common in female, with Male to female ratio of 1.37. It is about 1.33 times more
    common in Balochistan than in Afghanistan. Naswar and beetle nut chewing (31%), malnutrition (56%) and Alcohol (13
    %) were among the common risk factors present in this study population. About 90% of the cases were of Squamous cell
    variety and 85% of the patients were diagnosed when disease has progressed to stage ¾.and upto 60 % cases involve lower
    third of esophagus. Forty percent of the patients were in 4th decade of life at time of diagnosis.
    Conclusion: The areas that surround CENAR Hospital in Balochistan Province seem to be a high-risk belt for esophageal
    cancer. It is also common in Afghanistan and Peshawar. Naswar and beetle nut chewing along with malnutrition and
    alcohol might be important contributory risk factors.

                 INTRODUCTION                                     Internationally, the male/female rates vary from less than
                                                                  two percent to more than twenty percent4.
                                                                            The geographical distribution of esophageal
C      ancer of the esophagus is the ninth most common
       malignancy worldwide and third amongst the
gastrointestinal malignancies1. Cancer of esophagus is a
                                                                  cancer, which lies on a line extending from China to Iran,
                                                                  along with the unknown etiology of this disease, has
malignancy that is well known for its marked variation by         become an international health problem. Western studies
geographical area, ethnic groups and Sex2.                        indicate the effect of cigarette smoking and alcohol
          The incidence of esophageal carcinoma represents        consumption in the development of this disease1,3 whereas
a 100-fold difference between high- and low-incidence             studies conducted in countries lying on this “Cancer Belt”
region1. An “esophageal cancer belt” extends from                 have failed to determine any specific etiological factor.
northeastern China to the Middle East, including the              Dietary factors, including the consumption of hot tea,
Caspian region of Iran, Hunan Province in northern                leftover food and lack of vegetables or dairy products in
China, and many countries of the former Soviet Union3.            the diet have been considered as etiological factors in
The Transkei area of South Africa also has a high                 esophageal cancer4.
incidence of esophageal carcinoma. Its incidence is                         The majority of esophageal cancers occur as
relatively low in U.S.A, accounting for about 1% of all           Squamous Cell carcinoma. The incidence of this form of
annually diagnosed cancers1,3. However this figure rises          disease has been stable over the past several decades,
to 3% in black males4. Also, annual incidence rates in            however, the incidence of a less common subtype of
males are three times more than in females. Five year is          disease, adenocarcinoma, appears to be rising in the west2.
survival is poor 10% for whites and 6% for blacks.                In fact, among white men, rates of adenocarcinoma of the

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esophagus nearly equal those of Squamous cell tumors. In                 Out of 4343 male patients, cancer of esophagus was
1987, adenocarcinoma accounted for 34% of all esophageal       noted in 481 (11%) patients and found to be 3rd common
cancers in white men, 12 % in white women but only 3 and       tumor. Figure 2.
1 % in black men and women5. Excess of Squamous cell                     Among 3009 female patients, cancer of esophagus
carcinoma in blacks may be partly explained by racial          was 4th common tumor, present in 351(15%) patients. Figure
differences in susceptibility to the carcinogenic effects of   3.
alcohol and tobacco, among blacks and whites. In                         Cancer of esophagus is even not included in 1st ten
developing nations, Squamous variety of the disease still      common malignancies in data obtained at Jamshoro
dominates.                                                     (Hyderabad) from 1992 to 1996 and Inmol (Lahore) from
          Esophageal cancer is a fatal disease, with           1984 to 1995, while it is reported to be third common tumor
mortality matching the incidence rate, and this malignancy     in data collected from Irnum (Peshawar) among16490
is well known for its marked variation by geographical         registered patients from 1990 to 1995.
area, ethnic groups and Sex. Although, incidence in North                Table 1 shows histopathological diagnosis, age,
America and Western Europe is only 5-10/100000, it             stage, site and risk factors noted during this study at
increases to 100/100,000 in Iran and some parts of China.      CENAR.
Balochistan province happens to fall in this “Cancer Belt”
                                                               Table 1: Histopathology, age stage, site and risk factors.
as it shares border with Afghanistan and possibly due to
this reason, the prevalence of cancer is also higher.          Parameter      Subtypes                         N            %
          This study was designed to evaluate prevalence,      Biopsy          Squamous Cell Cancer           747           90
geographic features and patient characteristics of cancer of
                                                                               Adenocarcinoma                 57            7
esophagus in our clinical settings at CENAR Hospital
Quetta.                                                                        Others                         28            3
                                                               Age (years)     0-40                           145           17
          PATIENTS AND METHODS                                                 41-50                          334           40
                                                                               51-60                          257           31
          CENAR is among the regional cancer treatment                         61-Beyond                      96            12
and research centers in Pakistan and provides treatment        Site            Upper                          83            10
facilities to the entire Balochistan province along with                       Middle                         250           30
adjoining territory of Afghanistan. It is 40 bedded cancer                     Lower                          499           60
hospital, attached to Bolan Medical Complex, a 600 bedded      Stage           1&2                            125           15
tertiary care facility.
                                                                               3                              433           52
          This study was conducted from January 1991 to
                                                                               4                              275           33
December 2000. Total 7352 cases reported at this center, of
which 832 new cases of esophageal carcinoma were               Risk factors    Naswar/nut chewing             258           31

registered (mean age 50 ± 13 years). All the suspected                         Malnutrition                   466           56
cases of cancer of the esophagus were referred to primary                      Alcohol                        108           13
medical centre for histo-pathological evidence.
          Only cases confirmed by histopathology, and for               Proportion of esophageal cases was determined
whom the esophagus was the primary site of tumor, were         as number of patients with cancer of esophagus / total
included in the study. Details of age, sex and various         registered cases x 100. The annual proportion of cancer of
demographic variables were collected during the interview.     esophagus and their average for 11 years is shown in
Statistical analysis was done by calculating percentages and   Figure 4.
ratios for each variable.

         Cancer of Esophagus was 3rd most common tumor,
present among 832 (11.3%) of 7352 patients registered at
CENAR from Jan 90 To 31 Dec 2001. Figure 1.
         Among patients having cancer of esophagus, male
to female ratio was 1.37:1 and 476(57 %) patients belonged
to Balochistan and 356(43 %) were referred from

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Figure 1: Ten common tumors at CENAR.

Figure 2: Ten common tumor in male patients.

Figure 3: Common tumors in female patients.

Figure 4: Annual proportion of cancer of esophagus.

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                      DISCUSSION                               of the patients were in 4th decade of their life at the time
                                                               of diagnosis and 85% of patients were diagnosed when
          Our study shows that cancer of esophagus is 3rd      disease had progressed to stage ¾.This data about age and
common tumor (11.3% of total registered cases), and on         stage of disease at the time of presentation may indicate
average, the annual proportion of esophageal cancer            the fact that it is difficult to reach an early diagnosis due
constitutes a figure of 11 cases per hundred patients          to vague symptoms in early stages and lack of standard
diagnosed at CENAR Hospital. It is about 1.33 times            heath care system in this region, developing with slower
more common in Balochistan than in Afghanistan. It is          pace.
also 3rd common tumor at Peshawar (6.9% of registered                    Unfortunately, all above incidence rates and
cases) while it is even not included in first ten tumors in    percentages in this study are based solely on cases that
Jamshoro and Lahore.                                           were histologically confirmed and reported at CENAR.
          Our study shows that prevalence of Esophageal        Most of the outlying rural hospitals do not have resources
cancer varies considerably relative to geographic location.    to do the histological studies and they choose to use
High incidence areas have been identified within Caspian       traditional medical therapies, therefore, they are not
Littoral region of northern Iran, southern republics of the    included in any hospital record. These numbers are,
former Soviet Union and northern China, where the              therefore, clearly an under-representation of actual
incidence exceeds 100 in 100,000 individuals. and over         prevalence.
20% of all deaths are attributable to esophageal cancer6.
The incidence of esophageal cancer ranges from 10 to 50                     ACKNOWLEDGEMENT
in 100,000 in Sri Lanka, India, South Africa, France and
Switzerland7. This disease is less common (average                     Statistical help of Mr Jamil Ahmed of PMRC
incidence less than 10 in 100,000) in most areas within        Research Centre is greatly appreciated
Japan, Great Britain, Europe and Canada8.
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