Cancer survival in South Karachi, Pakistan, 1995-1999.

The Karachi cancer registry established in 1995 was the first population-based cancer registry in Pakistan. Cancer registration is done by active methods. The registry contributed data on survival for selected cancers of the head and neck registered during 1995-1999. FoLlow-up has been carried out predominantly by active methods with the median follow-up time ranging between 29-36 months for different cancers. The proportion of histologically verified diagnosis for various cancers ranged between 98-100%; there were no cases as death certificates only (DCOs); 86-93% of total registered cases were included for survival analysis. Five-year followup ranged between 67-76%. The 5-year age-standardized relative survival rates was the highest for cancer of the salivary gland (44%), followed by oral cavity (40%), tongue (39%) and tonsil (3%). Five-year relative survival by age group did not display any pattern or trend and was fluctuating. A majority of cases have been diagnosed with a regional spread of disease: tongue (51%), oral cavity (53%), salivary gland (46%) and tonsil (79%) and survival decreased with increasing extent of disease for these cancers.

Gastrointestinal stromal tumors: a demographic, morphologic and immunohistochemical study.

BACKGROUND AND AIM: There is limited published information on gastrointestinal stromal tumors (GIST) in the South Asian region. This study was conducted to describe the demographic characteristics, organ distribution and frequency of risk categories in cases of GIST referred to a tertiary hospital. METHODS: Data pertaining to 37 cases of gastrointestinal stromal tumors received at the histopathology section of the Aga Khan University Hospital between December 2004 and July 2005 were analyzed. Immunohistochemical stains including vimentin, CD34, CD117 (c-kit), ASMA, desmin and S-100 were performed. RESULTS: Of 37 tumors, 24 (64.9%) were from males. The mean age of the patients was 50.0 years (95% CI 45.3-54.6). Tumors were categorized as high risk (27 cases; 69.2%), intermediate risk (4 cases; 10.3%) and low risk (3 cases; 7.7%). The most common site of involvement was the stomach (29.7%), followed by small bowel (24.3%), mesentery (10.8%), pancreas (8.1%), rectum (2.7%) and retroperitoneum (2.7%). In 21.6% of cases, the site of origin was not specified. The mean age at diagnosis was 50.9 years (95% CI 45.5 - 56.3) in the high risk and 44.8 years (95% CI 28.6 - 60.9) in the intermediate risk category. CONCLUSIONS: Cases of GIST referred to us were more frequently from men, most commonly from stomach or small bowel, mostly in the high risk category, and presented a decade earlier than in other reported series.

Orbital embryonal rhabdomyosarcoma in Karachi (1998-2002).

OBJECTIVE: To study the epidemiology of ocular Rhabdomyosarcoma (ORMS) in Karachi. METHODS: Incident ORMS cases resident of Karachi, registered at Karachi Cancer Registry (KCR) during 1st January 1998 to 31st December 2002 were included in the study. The data were classified using ICD-O2; computerized with Canreg-3, and analyzed using SPSS 10.0. RESULTS: Ten cases of ORMS were reported to KCR during 1998-2002. RMS originated in the orbit in eight cases, conjunctiva in one and eyelid in one. Nine cases presented with proptosis, associated with conjunctivitis in four cases. One case presented with eyelid swelling. The crude annual incidence rate was 0.13/100,000, the age standardized rate was 0.3/100,000. The mean age of childhood cases was 10.4 years (95% CI 4.0; 16.7); and adult cases was 24.8 years (95% CI 12.8; 36.7). At presentation, eight patients were older than 10 years and three were older than 20 years. Five cases were categorized as childhood malignancies. Tumors were a TNM stage III disease at presentation in eight cases; survival at the end of one year was 70%, and at the end of two years 20%. There were no survivors at the end of three years. CONCLUSION: ORMS in Karachi is a disease with a dismal survival. It may reflect a late presentation, or shorter adult ORMS survival or a manifestation of a different genetic pattern, associated with rapid evolution and poor prognosis. Health education for the population, especially parents and health providers is essential for early ORMS diagnosis. Pediatricians, ophthalmologists and health professionals, can play a vital role. Healthcare planning should focus on capacity building for ophthalmologic screening. Cytogenetic studies are advised to determine the genetic pattern.

Cancer esophagus Karachi 1995-2002: epidemiology, risk factors and trends.

OBJECTIVE: To study the trends of cancer esophagus in Karachi South during 1995-2002 and identify risk factors. METHODS: Incident esophageal cancer cases recorded at the Karachi Cancer Registry for Karachi South, during 1st January 1995 to 31st December 2003 were reviewed. For maximum completion of data, incident cases registered from 1st January 1995 to 31st December 2002 were included for final analyses. RESULTS: The Age Standardized Incidence Rates (ASIRs) of cancer esophagus in Karachi South for males were 6.5/100,000 (1995-1997) and 6.4/100,000 (1998-2002). In females the observed rates were 7.0/100,000 (1995-1997) and 8.6/100,000 (1998-2002). CONCLUSION: In the moderately high incidence, cancer esophagus zone of Karachi, the ASIRs in males remained stable during the last decade, but in females, an upward trend was observed suggesting a progressively higher exposure to risk factors in the latter. The potential risk factors in Karachi are use of all forms of tobacco, areca nut, infrequent consumption of raw fruits and vegetables and diet deficiencies. There is a necessity to actively control the proven risk factors and address the existence of other risk factors. The primary recommended strategy for the control of cancer esophagus would therefore be legislation against tobacco and areca nut in Pakistan and public health education. The risk factors of cancer esophagus identified in this article need to be further confirmed.

Male breast cancer.

OBJECTIVE: To review cases of male breast cancer. SETTINGS: Histopathology Section, Department of Pathology, The Aga Khan University, Karachi. METHOD: Fifty one cases of male breast cancer specimens, received during a period of 10 years, routinely processed and stained with Haematoxylin and Eosin were analyzed. Special stains and Immunohistochemistry were used in difficult cases. RESULTS: Male breast cancer affected individuals in the sixth and seventh decades of life with a mean age of 56.2 years. Infiltrating ductal carcinoma (IDC) was the predominant type. Skin involvement was seen in 27.45% of the cases. Breast lump was the most common presenting symptom followed by skin ulceration. At the time of presentation 43.13% patients had a tumour size of more than 3 cm. CONCLUSION: Male breast cancer is a rare disease. Most of our findings correspond to the published local and international data.

Cancer patterns in Karachi division (1998-1999).

OBJECTIVE: A minimal cancer incidence data for Karachi, the largest city of Pakistan, is being presented here, for the years 1998-1999. The city has a population of 9,802,134; males 5,261,712 (52.6%) and females 4,540,422 (47.4%); census 1998. METHODOLOGY: A predominantly mixed (passive and active) registration system has evolved in Karachi, the data sources being the hospitals within the Karachi Division. The reported/retrieved cancer data sets at the Karachi Cancer Registry are checked, coded, computerised in an analytical format and analysed. RESULTS: The incident cancer cases registered in Karachi, during the 2-year period, 1st January 1998 to 31st December 1999 were analysed. The age-standardised incidence rate (ASR) of cancer, all sites was 132.4/100,000 for the males. Cancer of the lung 10.8%; ASR 17.3 was the most frequently recorded malignancy, followed by oral cavity 10.5%; ASR 13.2 and larynx 5.0%; ASR 7.4. The age-standardised incidence rate (ASR) of cancer, all sites was 133.0/100,000 in the females. Cancer of the breast, 32.0%; ASR 40.7 was the most frequently recorded malignancy, followed by oral cavity 8.1%; ASR 11.7 and gall bladder 3.6%; ASR 5.5. CONCLUSION: The present data has been calculated with an estimated 15-20% probable under ascertainment. Tobacco-associated cancers in Karachi were responsible for 38.3% of the tumours diagnosed amongst the males. Two principal cancers, breast and oral cavity were responsible for 40.1% of the cancers in females. A rare finding was the high incidence of gall bladder cancer in the females. At present it is difficult to determine whether this indicates a genuine high risk or a selection bias. A continuous process of cancer registration to study the trends in the incidence and an adequate cancer control program are possible and essential for Pakistan and can be based on the pattern being practiced in Karachi.

Comparability and Quality Control in Cancer Registration; Karachi (data monitoring 1995-2001).

INTRODUCTION: Comparability and Quality Control in Cancer Registration remains an essential component of standardisation of cancer incidence data. The information provided by registries is used as a base-line data for cancer control and cancer research. As such misleading information will encourage fictious cancer patterns with over or under registration of some cancer sites. METHODOLOGY: The registration in Karachi started in 1995 and was confined to a single district of Karachi, the South District. Since 1998 the registration has extended to Karachi Division. For both the data sets, recommendations of the International Agency for Research on Cancer (IARC) and the International Association of Cancer Registries (IACR) have been followed to assure comparability and Quality Control of the results. RESULTS: The 2 data sets from Karachi show well-recorded demographic details of cases. Age was not a true indicator of validity in our case, as we have approximate ages of patients aggregated around quintiles and decades. All the cancer cases were reported from a minimum of 3 sources. Microscopic verifications (MV) were high. Cancers with the highest histological verification (HV) were those located in easily accessible sites e.g. breast, oral cavity and cervix. The age specific incidence rates (ASR) for Karachi South, all sites (1995-1999) was 148.1 males and 175.5 females. The same for Karachi Division (1998-99) was 132.4 males and 133.0 females. CONCLUSION: The cancer data in 1995 during the initial phase of registration was incomplete and suffered from inaccuracies associated with a lack of awareness in early years of registration. By the year 2001, the data (1995-1999) showed improved completion and accuracy. The incidence rates have shown no dramatic changes during the past 2 years. The malignancies also show a stable pattern, despite the possibility of under-registration of clinically diagnosed cases. The microscopic verification is high compared with the world region and similar to those observed in developed countries. This may be due to the widely available diagnostic facilities in Karachi and should therefore be considered an indicator of validity of registered data.

Cancer patterns in Quetta (1998-1999).

INTRODUCTION: Quetta, the capital of Baluchistan, is located at latitude 30.25; longitude 67.00. It has a population of 759,245; 425,474 males (56%) and 333,771 females (44%); Census 1998. The majority of residents are Persian or Baluchi speaking Baluchs. METHODOLOGY: The cancer cases from Quetta reported to the Karachi Cancer Registry were reviewed. The data included cases from the Aga Khan University Hospital (AKUH), Pathology Department (Quetta collection point) and health care facilities in Karachi. The residents of Baluchistan were ascertained and cancer cases residents of Quetta identified with the help of recorded addresses and retraceable telephone numbers. RESULTS: During a 2-year period, 1st January 1998 to 31st December 1999 the Karachi Cancer Registry received 1077 cancer notifications from Quetta. Approximately half the cases were registered from the AKUH Quetta collection point. Others were the referral patterns in Karachi. The age-standardized incidence rate (ASR) of cancer, all sites (1998-99) was 137.0 for males and 92.8/100,000 for females. The commonest cancer in the males and females was cancer of the esophagus (ICD-10 categories C15; males- ASR 25.5, 17.2%; females-ASR 23.4,23.1%). One ofthe highest in the world, for both genders. Incidence of cancer breast in the females (ICD-10 categories C50; ASR 11.8, 13.3%) was low. CONCLUSION: The cancer data from Quetta is quite distinct from the cancer pattern of Karachi. It represents only a part of the cancer burden of Quetta; nonetheless it gives a glimpse into the cancer profile of Baluchistan. The high incidence of esophageal cancer indicates an extension of the geographical limits of the esophageal cancer belt.

Mortality statistics in South Karachi.

OBJECTIVE: To create an awareness amongst the medical profession in Pakistan about the importance of mortality statistics in epidemiological research and its correlation with the cause of death statement. METHODS: The original death registration forms and the statistical information, compiled into a database by the District Municipal Corporation, South Karachi, for the years 1995 to 1998 were evaluated. RESULTS: The total number of deaths reported from the District Municipal Corporation, South Karachi, for the years 1995 to 1998 were 7480. Of these 28% were females and 72% were males. The adult deaths were 99% whereas childhood deaths were 1%. The leading cause of death was cardiovascular disease (33%). However 49% of the deaths were classified as caused by non-specific or ill-defined conditions. CONCLUSION: The maintenance of records and compilation of death registry data by the District Municipal Corporation, South Karachi is satisfactory. The coverage of deaths in the years 1995 to 1998 was reasonable. The degree of precision of the age statement was moderately good as the 'National Identity Card' copy accompanied each adult death notification. As the cause of death statement was non-specific in 49% of the deaths, this data will have limited use in research or health planning. It is therefore essential to emphasize the importance of the death certification process to the medical profession.

Cancer incidence in Karachi, Pakistan: first results from Karachi Cancer Registry.

No cancer incidence data from Pakistan have been published in the 5 decades since independence. Incidence data for the period 1995-1997 from the population of the Karachi South district (1.7 million) are presented here. A total of 4,268 new cancer cases were registered during this period: 2,160 cases in males and 2,108 cases in females. Overall, 95.3% of the incident cases were microscopically verified. The incidence rates for all cancers combined were 80.5 per 100,000 (crude) and 136.7 per 100,000 (age- standardised rates [ASR]) for males and 91.8 (crude) and 163.2 per 100,000 (ASR) for females. In males, lung cancer (ASR 20.3) was the most frequently recorded malignancy followed by oral cavity (ASR 13.8) and larynx cancer (ASR 8.6). In females, breast was the most common site of cancer, accounting for one third of female cancers (ASR 51.7), followed by oral cavity (ASR 14.1) and ovarian cancer (ASR 10.2). Karachi reports the highest incidence of breast cancer for any Asian population, except Jews in Israel. Tobacco smoking is estimated to be responsible for 40% of cancers in males and tobacco chewing for a further substantial proportion of head and neck cancers.

The pattern of malignancies in Karachi (1995 to 1996).

OBJECTIVE: To determine the cancer pattern of the city of Karachi for the years 1995-1996. METHODS: The Karachi Cancer Registry, established in 1995 by the Government of Sindh, in collaboration with the IARC is an active registry. The staff collect the data pertaining to cancer patients and record it on the registry forms. Hospitals in Karachi, district south as well as some of the hospitals in other districts of the city, where patients are likely to go for treatment or diagnosis are visited. People residing in the district for more than six months prior to the onset of the malignancy were considered "residents". All the cases diagnosed on or after 1st January 1995 till 31st December 1996 were considered for analysis. RESULTS: In the years 1995-96, the most common cancer sites among males were cancers of the lung, oral cavity and lymph nodes. For females, breast cancer ranked first, followed by cancer of the oral cavity and ovary. The age standardized rate for all cancers was 96.3 per 100,000 in males and 96.9 per 100,000 in females. At this early stage of registration we assume that the registry has a missing rate of approximately 20-25%. CONCLUSION: The pattern of malignancies in Karachi is similar to the western countries, with lung and breast being the commonest tumors amongst the males and females respectively. The Asian countries have stomach/lung/oral cavity/liver as the commonest tumors amongst the males and cervix/breast amongst the females. Pakistan being a Muslim country, the incidence of cervical cancer showed an expected low figure.

Incidence of carcinoma of the oral cavity in Karachi--district south.

Globally oral cancer is one of the ten common cancers. In some parts of the world, including the Indian sub-continent oral cancer is a major problem. The two year data of the Karachi Cancer Registry, showed oral cancer was the second most common malignancy in the males as well as in the females. The most common malignancy amongst the males being the carcinoma of the lungs and amongst the females, carcinoma of the breast. The annual incidence rate of oral cancer was 4.1 per 100,000 annually for the males and 4.0 per 100,000 annually for the females.