Trends in the Incidence and Mortality of the Most Common Cancers in Iraq (Iraqi Cancer Registry 1999-2019).

Cancer is the second leading cause of death in Iraq following heart and cerebrovascular diseases. Assessment of incidence and mortality trends is essential for prioritizing cancer control in the national health policies and plans. AIM: To determine the patterns and trends in the incidence and mortality of the leading types of cancers affecting the Iraqi population during the last two decades. MATERIAL AND METHODS: This is a descriptive retrospective study based on the available data of the Iraqi Cancer Registry for the years (1999 - 2019). The analyzed information included the annual total number of new cancer cases and cancer deaths during the assigned period categorized by site, age, gender and morphology of each cancer. The data was coded according to Cancer Registry Program 4 (Can Reg4) and the International Classification of Diseases for Oncology (ICD-O). The estimated total annual number of Iraqi populations for the same period was retrieved from the Iraqi Ministry of Planning. The incidence and mortality rates were calculated per 100,000 Iraqi population and classified by ICD-O, site of the tumor, gender and age group. RESULTS: The overall cancer incidence rate (IR) in 2019 was 91.66/100,000 population (78.14 and 105.46/100,000 in males and females, respectively). The age standardized rate (ASR) was 155.60/100,000. The top five cancers in terms of IR were those of the breast (18.17/100,000; ASR:29.93/100,000), lung (7.24/100,000; ASR:14.81 /100,000), colorectum (5.95/100,000; ASR:10.77 /100,000), brain/CNS (5.83/100,000, ASR:8.39/100,000) and leukemia (5.05/100,000; ASR:6.83/100,000). The peak IR was observed among patients of both genders in the eighth decade of life (1127.37/100,000). The trend of IR for all cancers has significantly increased from 43.95/100,000 in 1999 to 91.66/100,000 in 2019 (more than 100%, p < 0.0001). The highest increase was demonstrated in cancers of the colorectum (from 1.2 to 5.90, p< 0.001), breast (from 6.6 to 18.2, p< 0.001) and brain (from 2.0 to 5.80, p=0.032). On the other hand, the mortality rate (MR) was 28/100,000 population in 2019 (28.45 and 27.55/100,000 in males and females, respectively). The highest MR was observed in cancers of the lung (4.48/100,000), breast (3.16/100,000) and leukemia (2.42/100,000). Whereas a non-significant increase in the mortality trends of leukemia, colorectum, breast and lung cancers were noted, our data revealed a decline in the trend of brain/CNS cancer mortality (from 3.2 to 2.3/100,000). CONCLUSIONS: The top leading cancers in Iraq are steadily increasing in upward trends though they remain lower than the global rates. The underestimated IRs and MRs are possibly attributed to suboptimum registration and missing data due to the lack of a national surveillance system. Efforts should be directed to prioritize the adoption of the national cancer control plan focusing on strengthening the population-based cancer registry. KEY WORDS: Trends, incidence; mortality, Iraq; common cancers.

Impact of COVID-19 on Affected Individuals in Iraq Focusing on Deceased Cancer Patients.

PURPOSE: Mortality because of COVID-19 infections is continuously increasing among the high-risk groups, namely, elderly patients and those with underlying comorbidities including cardiovascular diseases, diabetes, respiratory problems, and cancer. The study aimed to assess the impact of COVID-19 on affected individuals in Iraq, focusing on the characteristics of COVID-19 deceased cases, with special emphasis on cancer as the associated comorbidity. PATIENTS AND METHODS: This is a retrospective review of the data collected from 15,852 case investigation records of deceased patients with COVID-19, from all over Iraq, between March 20, 2020, and December 20, 2021. The analyzed variables included patients' age, sex, duration of stay in hospital, use of mechanical ventilation, and associated morbidities. Comparisons of having comorbidities and cancer with the characteristics were carried out using the chi-square test of independence. The chi-square test of goodness of fit was used to describe the distribution of the characteristics of the deceased COVID-19 patients; P values < .05 were considered statistically significant. RESULTS: Overall, 62% were ≥ 60 years with a predominance of male (63.2%). Patients with cancer were significantly younger (41.5% were ≥ 60) with no difference concerning sex distribution. Almost 70% of patients who died from COVID-19 infection had associated comorbidities. Cardiovascular diseases, diabetes, chronic obstructive pulmonary diseases, and cancer constituted 49.7%, 39.3%, 2.9%, and 1.1%, respectively. Patients with a history of cancer had a significantly longer duration of stay in hospital with no statistical association regarding the use of ventilation. CONCLUSION: In Iraq, patients with cancer infected with COVID-19 were younger and spent longer durations in the hospital before they died than patients with other comorbidities. The pandemic has revealed significant gaps in the health information and surveillance systems that demand prompt strengthening as part of the emergency preparedness.

Memory and CAR-NK cell-based novel approaches for HIV vaccination and eradication.

Human immunodeficiency virus (HIV) is one of the critical infectious agents with thousands of newly infected people worldwide. High mutational capability and rapid diversification, inhibition of humoral and cellular immune responses, and thus inability for recognition of an immunogenic region in the viral envelope by the immune system are major challenges. Natural killer (NK) cells are multifunctional, playing a key role in the identification and elimination of HIV-infected cells. These cells identify and eliminate virus-infected cells in a multilateral manner, such as ligand stress, antibody-dependent cell cytotoxicity (ADCC), T follicular helper (Tfh), and the activation of most of the stimulatory receptors. Moreover, these cells release cytokines leading to the activation of cytotoxic lymphocytes (CTLs) and dendritic cells (DCs), contributing to efficient viral elimination. Some subsets of NK cells exhibit putatively enhanced effector functions against viruses following vaccination easily expanded and identified by NK cell lines culture. Furthermore, NK cells promote the elimination of HIV-infected cells which reduce the expression of major histocompatibility complex (MHC) molecules. Memory NK cells have higher functionality and renewable potential. A pioneering strategy to establish an efficacious HIV vaccine would include stimulation of the accumulation and long-term maintenance of these HIV-reactive NK cells. CAR-NK (chimeric antigen receptor-natural killer) cells-based antiviral therapies have emerged as novel approaches with the ability of antigen recognition and more advantages than CAR-T (chimeric antigen receptor-T) cells. Recent development of induced pluripotent stem cell (iPSC)-derived NK cells with enhanced activity and efficiency conferred a promising insight into CAR-NK cell-based therapies. Therefore, memory and CAR-NK cells-based approaches can emerge as novel strategies providing implications for HIV vaccine design and therapy.

Correlation between Breast Self-Examination Practices and Demographic Characteristics, Risk Factors and Clinical Stage of Breast Cancer among Iraqi Patients.

BACKGROUND: Breast Cancer (BC) is the most common cancer and the leading cause of cancer death among women globally. The disease can be cured with limited resources if detected early. Breast self-examination (BSE) is considered a cost-effective feasible approach for early detection of that cancer in developing countries. AIM: To determine the correlation between BSE performance and demographic characteristics, risk factors and clinical stage of BC among Iraqi patients. METHODS: This retrospective study included a total of 409 female patients diagnosed with BC at the Referral Training Center for Early Detection of Breast Cancer and the National Cancer Research Center in Baghdad. The studied variables included the age of the patient, occupation, marital and educational status, parity, history of lactation, contraceptive pill intake, family history of cancer and the clinical stage of the disease. RESULTS: Our findings revealed that the most important predictors for practicing BSE was family history of BC or any other cancers (OR = 3.87, P = 0.018) followed by being a governmental employee (OR = 1.87, P = 0.024), history of contraceptive use (OR = 1.80, P = 0.011) and the high level of education (OR = 1.73, P = 0.004). On the other hand, there was no significant correlation between the practice of BSE and the BC stage at the time of presentation. CONCLUSION: There is a relatively poor practice of BSE among Iraqi patients diagnosed with BC. It is mandatory to foster the national cancer control strategies that focus on raising the level of awareness among the community through public education as a major approach to the early detection of cancer in Iraq.

Comparison of Clinico-Pathological Presentations of Triple-Negative versus Triple-Positive and HER2 Iraqi Breast Cancer Patients.

BACKGROUND: Breast cancer remains the most common malignancy among the Iraqi population. Affected patients exhibit different clinical behaviours according to the molecular subtypes of the tumour. AIM: To identify the clinical and pathological presentations of the Iraqi breast cancer subtypes identified by Estrogen receptors (ER), Progesterone receptors (PR) and HER2 expressions. PATIENTS AND METHODS: The present study comprised 486 Iraqi female patients diagnosed with breast cancer. ER, PR and HER2 contents of the primary tumours were assessed through immunohistochemical staining; classifying the patients into five different groups: Triple Negative (ER/PR negative/HER2 negative), Triple Positive (ER/PR positive/HER2 positive), Luminal A (ER/PR positive/HER2 negative), HER2 enriched ((ER/PR negative/HER2 positive) and all other subtypes. RESULTS: The major registered subtype was the Luminal A which was encountered in 230 patients (47.3%), followed by the Triple Negative (14.6%), Triple Positive (13.6%) and HER2 Enriched (11.5%). Patients exhibiting the Triple Negative subtype were significantly younger than the rest of the groups and presented with larger size tumours. A significant difference in the distribution of the breast cancer stages was displayed (p < 0.05); the most advanced were noted among those with HER2 enriched tumours who exhibited the highest frequency of poorly differentiated carcinomas and lymph node involvement. CONCLUSION: The most significant variations in the clinicopathological presentations were observed in the age and clinical stage of the patients at diagnosis. Adoption of breast cancer molecular subtype classification in countries with limited resources could serve as a valuable prognostic marker in the management of aggressive forms of the disease.

Clinical and Pathological Characteristics of Triple Positive Breast Cancer among Iraqi Patients.

BACKGROUND: Breast cancer is the most common malignancy affecting the Iraqi population and the leading cause of cancer related mortality among Iraqi women. It has been well documented that prognosis of patients depends largely upon the hormone receptor contents and HER-2 over expression of their neoplasm. Recent studies suggest that Triple Positive (TP) tumors, bearing the three markers, tend to exhibit a relatively favorable clinical behavior in which overtreatment is not recommended. AIM: To document the different frequencies of ER/PR/HER2 breast cancer molecular subtypes focusing on the Triple Positive pattern; correlating those with the corresponding clinico-pathological characteristics among a sample of Iraqi patients diagnosed with the disease. PATIENTS AND METHODS: This retrospective study involved 570 female patients diagnosed with breast cancer who visited the Main Referral Center for Early Detection of Breast Cancer and the National Cancer Research Center. The requested data was mainly extracted from an established information system database, developed by the principal author over a 4-years period from 2012 to 2016. The registered information comprised data related to clinical presentation, diagnostic and pathologic findings. ER, PR and HER2 status were analyzed immunohistochemically and the detected profiles were correlated with the corresponding clinico-pathological characteristics. RESULTS: The rates of ER (+), PR (+) and HER-2 (+) tumors were 66.8%, 64% and 29.3% respectively. The tumor marker expression status was documented in eight subtypes; 83 cases (14.6%) of the examined breast carcinomas were categorized as ER+/PR+/HER2+ (Triple Positive/Luminal B), 89 cases (15.6%) were ER-/PR-/HER2- (Triple Negative), 241 (42.2%) were ER+/PR-/HER2- (Luminal A) while 67 (11.8%) showed ER-/PR-/HER2+ expression (HER-2 variant). No significant variations were noted when comparing age, menopausal status and tumor grade of Luminal B pattern to Luminal A and the rest of the studied subtypes. Although our data revealed a statistical difference with respect to the distribution of tumor types; where infiltrative ductal carcinoma constituted the major histology among patients with Triple Positive/Luminal B subtype (86.7% as compared to 67.6% in Luminal A), nevertheless, more than two third of those patients (67.4%) were diagnosed at earlier stages (I and II) compared to 55.2% of those in the remaining groups. CONCLUSIONS AND RECOMMENDATIONS: Our findings support the hypothesis that the Triple Positive subtype might be driven primarily by the hormone receptor status. Further comprehensive surveys are recommended to focus on the intrinsic interactions and tumor cell heterogeneity of that pattern to avoid overtreatment and predict accurate response to therapy.