Cardiovascular disease risk factors in Pakistani population with newly diagnosed Type 2 diabetes mellitus: A cross-sectional study of selected family practitioner clinics in four provinces of Pakistan (CardiP Study).

OBJECTIVE: To explore cardiovascular risk factors in people with newly-diagnosed type 2 diabetes mellitus. METHODS: The cross-sectional, prospective, multicentre, study was conducted from June 2014 till July 2015 at family practice clinics in 27 cities across Pakistan, and comprised individuals aged 30-50 years diagnosed with type 2 diabetes mellitus within the preceding six months. Laboratory investigations were conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, and Aga Khan University Hospital, Karachi. The 10-year absolute risk of fatal or non-fatal coronary heart disease and stroke was calculated using the United Kingdom Prospective Diabetes Study Risk Engine version 2.0. Data were analysed using SPSS 19. RESULTS: Out of 888 subjects, 362(40.8%) were women and 526(59.2%) were men. The overall mean presenting age was 42.4}5.8 years. After stratification by age, those ≥40 years were significantly associated with higher glycated haemoglobin (p=0.02) and those ≤39 years were associated with higher levels of very low density lipoprotein (p=0.001) and triglyceride (p=0.006). The mean risk estimate for CHD was 9.7% (95% Confidence Interval (CI) 9.0- 10.1)), for fatal CHD 4.4% (95% CI 4.0-4.6), for stroke 1.5% (95% CI 1.2-1.7), and for fatal stroke 0.25% (95% CI 0.24- 0.26). CONCLUSIONS: There is a need for screening cardiovascular risk factors even in younger age groups of newlydiagnosed diabetes.

Carcinoma of the urinary bladder in a tertiary care setting in a developing country.

BACKGROUND: Men have greater incidence and mortality rates than women for bladder cancer. Most bladder cancers are transitional cell carcinomas. OBJECTIVES: To determine the epidemiologic features of urinary bladder cancer cases presenting at a cancer hospital, from Dec. 1994 through Dec. 2004. METHODS: Six-hundred and seven medical records were evaluated retrospectively at the Shaukat Khanum Memorial Cancer Hospital. Gender, age, histologic types, grade, stage, symptoms, risk factors, and patient follow-up were studied. Staging was done through the American Joint Commission on Cancer's criteria. Class of Case was established using the Facility Oncology Registry Data Standards, 2004. RESULTS: Mean age: 55.5 years; men: 83%. Transitional cell- in 86%, squamous cell- in 4%, adeno- in 3%, and undifferentiated carcinoma in 7% of the cases. Stage: II in 18.3%, I in 17.3%, III in 14.2%, IV in 26%, 0 in 6.3%, and not evaluable in 17.8% of the cases. Grades: G3 in 37.9%, G2 in 25.2%, G1 in 9.7%, G4 in 2.8%, and undetermined in 24.4% of the subjects. Commonest presenting symptom: hematuria in 54.7% men and 52.9% women; risk factor: positive smoking history in nearly 35% males and 2% females. Average interval between diagnosis and last contact: 26.5 months; for analytic cases, 34.9 months. CONCLUSION: Urinary bladder cancer was seen primarily in males; transitional cell type was dominant. The majority of the patients were symptomatic; smoking history was recorded mostly in men. Further, improving in staging could be useful in addressing the concerns about data reproducibility over time and use for surveillance purposes.

Survival from hepatocellular carcinoma at a cancer hospital in Pakistan.

OBJECTIVES: To determine the tumour and general characteristics, especially survival, of patients presenting with hepatocellular carcinoma at our tertiary care cancer hospital. PATIENTS AND METHODS: We retrospectively studied 584 charts of patients consecutively registered between 1995 and 2004 at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, in Lahore, Pakistan. Descriptive statistics were obtained for gender, age, tumour size and morphology, alpha fetoprotein level, means of diagnosis, Child-Pugh status, risk factors, treatment given and follow-up. Survival analysis was conducted using the Kaplan-Meier method. RESULTS: Mean age at presentation was 56 years. Four hundred and forty four (76%) were male. Average tumour diameter evaluable in 412 patients was 8 cm. HCC was unifocal in 194 (33%), multifocal in 303 (52%) and unevaluable in 106. Mean AFP was 4,198 u/ml (range 1 - 278,560). Methods of diagnosis were FNA in 71, biopsy in 26, imaging/AFP > 200 in 70, lipiodol angiogram in 42, combinations of two of these in 365 and biphasic CT scans in 10. Initial Child-Pugh available for 400/584 was A in 216, B in 147 and C in 37. Evidence of prior hepatitis B infection was found in 114, and for hepatitis C in 254. Other than the four patients who had TACE followed by surgical resection, treatment was offered to 79/584 patients: among the 48 who had TACE, 26 experienced cancer progression whereas 11 had stable disease ranging from 6 - 20 months; another 11 were lost to follow-up. Of the 14 patients who underwent local resection, 2 were lost to follow-up, 7 developed recurrences but 5 remained disease free for a mean of 33 months. Following ethanol ablation in 17 patients, disease progressed in 5 but remained stable in 2 for a mean of 13 months; 10 were lost to follow-up. At the time of writing, 56 patients are alive (mean follow-up 20 months), 210 are known to have died (mean follow-up 9 months), and 318 were lost to follow-up within 3 months. Median overall survival was 10.5 months, death being the point of interest for survival analysis. Child-Pugh class stratified analysis (400/584) revealed median survival of 12 months for class A, 7.7 months for class B and 4 months for class C (p < 0.001). CONCLUSIONS: Most patients present with large, multifocal tumours, with poor liver function. Sixty one percent had evidence of prior infection with hepatitis B or C. The advanced stage at presentation, poor background liver function in many and the absence of a national liver transplantation program limit treatment options. Only 14% of patients were considered suitable for definitive treatment. Survival correlated with Child-Pugh status at presentation. Overall prognosis remains bleak. There is an urgent need to educate the public about the risks of hepatitis B and C and health professionals about early diagnosis and treatment, including possible development of a sustainable national liver transplant program.

Cervical carcinoma in a Muslim community.

OBJECTIVES: The aim of the research was to review the distributions of age, stage at presentation, and morphology of patients presenting with carcinoma of the cervix in a predominantly Muslim population. STUDY DESIGN: This retrospective study was conducted at a comprehensive cancer diagnostic and treatment facility situated in Lahore, Pakistan, reviewing the medical records of the patients. PATIENTS AND METHODS: Four-hundred and nineteen cervical cancer patients were registered at the hospital during a nine-and a half year time period extending from December 1994 to June 2004. Histology was confirmed by exfoliative cervical cytology typically by means of Papanicolaou smear. The International Federation of Gynecology and Obstetrics classification was used to stage the disease. Univariate analysis on factors as age, stage at presentation, and morphology was conducted. RESULTS: 1) The age distribution of the 419 patient cohort was recorded to be as follows: mean 49.2 years (SD 11.7, range 11-85 years) and mode 50 years (37 patients). Only one patient was less than 18 years. 2) Of these 419 patients, 73.5% (308/419) had squamous cell carcinoma (SCC), 7.9% (33/419) had adenocarcinoma, and 0.7% (3/419) had adenosquamous carcinoma; of the remainder, 1.4% (6/419) had rare types (3 each of sarcoma and small cell carcinoma) and 16.5% (69/419) had unspecified carcinoma. 3) Only two patients (0.5%) were identified as being in stage 0, 49/419 (11.7%) in stage I, 140/419 (33.4%) in stage II, 90/419 (21.5%) in stage III, 52/419 (12.4%) in stage IV, and 86/419 (20.5%) as not being evaluable. CONCLUSIONS: A large proportion of patients (67%) presented in stages II to IV and only 12% presented early at stages 0 or I. This emphasizes the need for early detection of this tumor in our population. Accordingly, the importance of detection of the pre-clinical stage of the disease by considering the possibility of initiating a cost-effective screening measures needs to be emphasized in our setting.

Characteristics of lung cancer patients--the Shaukat Khanum Memorial experience.

OBJECTIVES: The aims of this descriptive study were to characterize lung cancer patients by age at diagnosis, smoking status, and histology and, also to explore the histologic sub-type according to cigarette smoking, in a tertiary care setting. PATIENTS AND METHODS: A retrospective review of 830 patients for whom smoking status was available in the records was carried out at a comprehensive cancer care facility, the Shaukat Khanum Memorial Cancer Hospital and Research Center, situated in Lahore, Pakistan. RESULTS: The mean age at presentation of the 830 evaluable cases was 59.8 years (standard deviation 11.8, range 18-90). Stratifying by gender, statistically significant differences were found in the average age at diagnosis between males (60.1 years) and females (57.5 years) and, in the distributions of non-smokers, current smokers, and ex-smokers, but none for histology. CONCLUSIONS: Similar to other populations, the age of disease onset amongst females was lower than that seen in males. The proportion of smokers was higher amongst males versus females. The reversal of smoker to non-smoker ratio when stratified by gender, may highlight the importance of exploring alternate pathways implicated in the etiology of lung cancer in our population.