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Cancer Pathology Registry

2003-2004

And Time Trend Analysis

Nadia Mokhtar

Chairman & Professor of Pathology

National Cancer Institute

Cairo University

Iman Gouda Iman Adel

Lecturer of Pathology Lecturer of Pathology

National Cancer Institute National Cancer Institute

Cairo University Cairo University

Department of Pathology, NCI

2007

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Preface

Histopathological data are important and mandatory to accurate cancer registration. Cancer Pathology Registry was originally developed by the Department of Pathology at the National Cancer Institute (NCI) since 1985. NCI of Cairo University is a large referral center draining the Cairo Metropolitan area as well as other parts of the country. The hospital receives a big number of patients, of which about 80% are presented to the Department of Pathology for tissue diagnoses. This material includes tissue biopsies, surgical specimens and referred slides and constructs the basis of this registry. Thus, such data have the advantage of establishing a model for hospital-based cancer registry founded on confirmed tissue diagnoses with detailed tumor typing, grading and pathologic staging.

Our data included all cases presented to the Department of Pathology, Surgical Pathology Unit during the years 2003-2004 with active participation of all the team members of this Unit. Their scientific experience and professional accurate diagnoses shaped the keystone of this work. The unified extended use of the International Histological Classification of Tumors by the WHO, and the ICD-O coding system applied in this registry may help towards a great degree of standardization and hence better comparability with other international registries. The implication of both coded and descriptive database computer system proved to be both practical and efficient. Leukemia data were kindly supplied by the Department of Clinical Pathology at NCI, headed by Professor Azza Kamel.

The material of this book could be of help to oncologists, post-graduate students and researchers in the field of cancer in general and cancer pathology in particular. Comparison with our previous Cancer Pathology Registry issued in 1991, provides a model for time trend analysis in cancer profile at large. This book also presents comparative features with other cancer registries from Egypt, namely a hospital-based cancer registry issued by the Department of Statistics and Cancer Epidemiology at NCI and the Gharbia population-based Cancer Registry issued by the Ministry of Health & Population.

The computer-aided database system was provided by the Department of Statistics & Cancer Epidemiology at NCI under supervision of Professor Inas El-Attar, chairman of the Department. She thankfully offered data from the NCI registry. Special thanks are due to Professor Amal Sami Ibrahim, Professor of Statistics and Cancer Epidemiology at NCI for granting data from the Gharbia Cancer Registry.

Professor Mohamed Hussein, Professor of Community Medicine at Faculty of Medicine Cairo University, enriched this registry book with a Chapter on epidemiology describing important comparative data and offering possible justifications for time trend changes. He provided expert suggestions for data presentation.

Dr. Atef Badran, the clinical data manager at NCI, gratefully compiled this book. He demonstrated skilled table and graphic designs. His effort, dedication and dexterity are greatly appreciated.

The editors wish to express gratitude to Professor Hussein Khaled, Dean of NCI and Professor of Medical Oncology for his enthusiasm and helpful ideas. His full support aided in launching this registry book.

This publication was funded by the National Cancer Institute and Sanofi Aventis. It is distributed free of charge.

The Editors

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Preface

Cancer is a global problem. It comes next to cardiovascular diseases as the cause of mortality of mankind. In Egypt, cancer morbidity and mortality are becoming increasingly important health problems. However, a national cancer registry is not available although many efforts are on the way to create such an essential development. An example is the Gharbia Governorate cancer registry headed by Prof. Amal Sami Ibrahim.

The National Cancer Institute, which is the largest comprehensive cancer center in the region, has been a pivotal corner in such efforts since the early 1970s starting with the cancer profile of Cairo Metropolitan Area. In addition to this, the hospital based cancer registry of our institute is being updated every year, and the latest for 2002 – 2003 is to be available soon.

Over the last 20 years, great efforts within the Department of Pathology have also been conducted by professor Nadia Mokhtar and colleagues, not only to evaluate the profile of cancer cases coming to be managed at the NCI, but also to study in depth the different clinicopathologic criteria of such cases. The previous Cancer Pathology Registry was one of the pioneer works in that field.

In this latest edition of the Cancer Pathology Registry, you will observe how cancer frequencies and patterns are changing over the years. I feel deeply indebted and thankful to Professor Nadia Mokhtar, Dr. Iman Gouda and Dr. Iman Adel from the Department of Pathology for their professional and detailed informative work. Now this book is a part of the oncology data base that is greatly needed for every oncologist in Egypt, the region and the rest of the world.

Professor Hussein Khaled

Dean of NCI

and Professor of Medical Oncology

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Members of the Department of Pathology

Surgical Pathology Unit

National Cancer Institute

Cairo University

Professor Hassan Nabil Tawfik

Professor Nabil El-Bolkainy

Professor Saad Eissa

Professor Nadia Mokhtar

Professor Nader Dahaba

Professor Nayera Anwar

Professor Magda Murad

Professor Sumaya El-Huseiny

Professor Hala Taha

Professor Mustafa El-Kabany

Professor Amani El-Deeb

Dr. Akram Nouh

Dr. Hoda Ismail

Dr. Amani Abdel Hamid

Dr. Mona Sakr

Dr. Wael Tharwat

Dr. Iman Gouda

Dr. Iman Adel

Dr. Tarek El-Bolkainy

Dr. Asmaa Salama

Dr. Iman Loay

Dr. Dina Salah

Dr. Nevine Fayez

Dr. Safinaz Talaat

Dr. Mohab Eissa

Dr. Ghada Abdel Salam

Dr. Iman Naguib

Dr. Hanaa Ebrahim

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No matter how good you may seem,

You’re always better in a team.

Nadia Mokhtar

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Table of Contents

	Chapter
1	General Features Of Total Pathology Series
2	Epidemiology
3	Malignant Urinary System Tumors
4	Breast Cancer
5	Lympho-Hematopoietic System Tumors
6	Malignant Digestive System Tumors
7	Malignant Respiratory System Tumors
8	Malignant Female Genital System Tumors
9	Malignant Skin Tumors
10	Soft Tissue Sarcomas
11	Malignant Bone Tumors
12	Malignant Endocrine System Tumors
13	Malignant Male Genital System Tumors
14	Malignant Central Nervous System Tumors
15	Malignant Eye And Ear Tumors
16	Multiple Malignant Tumors
17	Locally Recurrent Tumors
18	Metastatic Tumors At Initial Presentation With Unknown Primary
19	Metastatic Recurring Tumors
20	Tumors Of Border-Line Malignancy

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Chapter 1

General features of total Pathology series

Introduction

The Department of Pathology at NCI is built up of three units: 1. Surgical Pathology Unit, concerned with histopathologic diagnosis of cases presented to the NCI using recent tools and research facilities; 2. Cytology Unit, concerned with cytology diagnosis of cases; 3. Tissue Culture and Cytogenetics Unit, concerned mainly with advanced research activities. The material of this book represents all cases received by the Surgical Pathology Unit during the two-year period 2003-2004. Such material represents about 80% of the cases presented to the NCI during the same period of time (Table 1.1).

Time trend data compares the present series with our previous Cancer Pathology Registry including data of the 80’s and issued in 1991. Demographic data compares age and sex distribution of this recent series with our previous registry. Comparison with other hospital-based and population-based registries from Egypt is also presented.

Table 1.1: Percentage of New cancer cases who visited NCI, 2003-04

	2003 %	2004 %	2003-04 %
Histopathology diagnosis	79.6%	79.7%	79.6%
Non-histopathology diagnosis	20.4%	20.3%	20.4%

Figure 1.1: New cancer cases who visited NCI, 2003-04

Material of study

During the years 2003-2004, the Surgical Pathology Unit has received a total number of 20081 cases distributed as follows: biopsies 9113 cases (45.38%), surgical specimens 6378 cases (31.76%), and referred slides 4590 cases (22.86%). A total of 2638 cases were cancelled because of double registration due to biopsy or slide revision and specimen material. For double registered cases, only information from specimens' material was considered (Table 1.2). The rest of material (17443 cases) formed the core of data presented (Table 1.3). Non-malignant cases were presented only as main categories. Primary malignant solid tumors formed more than half of all categories (8437 cases). This group of new cancer cases, included cases of carcinoma in-situ, invasive cancer, and multiple tumors in the same site and in different sites, tumors with direct spread from an adjacent site, tumors not certain whether primary or secondary, as well as metastases at initial presentation with unknown primary.

A total of 1371 new leukemia cases were received by the Department of Clinical Pathology during the same period of time 2003-04. The leukemia cases summed to the primary malignant solid tumors formed a total of 9808 cases. This combined group formed the database to represent the relative frequency data of the Cancer Pathology Registry. A total of 805 recurrent and relapsing tumors and 218 tumors of borderline malignancy were presented separately.

Table 1.2: Total material received

	No.	%
Material included	17443	86.86
Double registered (cancelled)	2638	13.14
Total received	20081	100.00

The information was coded for computer data entry using the ICD-O coding system, while the topographic code was recorded using a coding system originally designed by Professor Nabil El-Bolkainy, Professor of Pathology and former Dean of NCI. Coded data were retrieved from the Surgical Pathology computer network and included the following items: hospital number, age, sex, pathology number, nature of specimen, type of operation, site or topography, morphologic diagnosis, grade, stage, surgical margin, lymph node status, etiology, secondary site, and category. Data concerning leukemia cases were retrieved from the Biostatistics and Cancer Epidemiology Department based on the records of the Department of Clinical Pathology.

The presented profile concerning the changing pattern of cancer and time trend analysis was performed by comparing the data base coded and descriptive parameters with similar parameters from the prior Cancer Pathology Registry issued by us in 1991. Time interval between both registries was about 15 years.

General Features of Total Series

The frequency distribution of all documented categories including the non-malignant cases showed a high predominance of malignant tumors constituting a majority of 53.16% (Table 1.3, Figures 1.2 and 1.3). This high figure is expected in cancer hospitals. The NCI receives referred cases from various regions of the country.

Table 1.3: Percent distribution of categories – 17443 cases

Category	%
I. Malignant tumors	53.16
Malignant primary site	48.38
Local recurrence	3.00
Metastatic recurrence and relapse	1.53
Uncertain primary or secondary	0.25
II. Borderline malignancy	1.25
III. Benign tumors	7.23
IV. Tumors of unpredictable biological potential	0.45
V. Premalignant lesions	2.37
Dysplasia	1.40
Atypical lesion	0.97
VI. Non neoplastic lesions and other conditions	35.54
Inflammatory	9.88
Non-neoplastic (NOS)*	6.19
Hyperplasia	6.13
Inadequate sample	4.88
For further data	2.85
Normal appearance	1.70
No definite diagnosis	1.64
Degenerative	1.03
Developmental malformation	0.40
Dysfunctional	0.30
Metaplasia	0.28
Immunologic disorder	0.26

*NOS: not otherwise specified

Figure 1.2: Percent distribution of categories – 17443 cases

Figure 1.3: Percent distribution of categories of malignant tumors

Table 1.4: Ranking of some important malignant tumors

Site	Rank	Number	Percent
Breast	1	1718	17.50
Leukemia	2	1371	13.95
Bladder	3	1201	12.22
Lymphoma	4	1146	11.66
Colon and rectum	5	427	4.34
Oral cavity and oropharynx	6	282	2.87
Lungs and pleura	7	233	2.37
Stomach	8	208	2.12
Liver and biliary tract	9	178	1.81
Larynx	10	174	1.77
Cervix	11	169	1.72
Esophagus	12	141	1.43
Ovaries	13	135	1.37
Corpus uteri	14	108	1.10
Prostate	15	47	0.48
Pancreas	16	41	0.42

Lymphoid tumors of different organs were incorporated in the lymphoma chapter

Figure 1.4: Ranking of malignant tumors

The ranking of 16 important malignant tumors internationally identified is shown in table 1.4 and figure 1.4. Breast cancer constituted 17.5% ranking as No. 1, followed by leukemia, bladder cancer and lymphoma as ranks 2, 3 and 4 respectively. This is different from WHO reports showing that lung, colorectal, and stomach cancers are the most common cancers in both industrialized and developing countries. Lung and pleura cancer in our series ranked as number 7 and colorectal cancer as number 5 while stomach ranked as number 8. Among men, prostate cancer is largely seen in developed countries. But in our series prostate cancer is low and bladder cancer is high. For women, the most common cancers worldwide are breast and cervical cancer, although cervical cancer is primarily seen in less developed countries. In our series breast cancer is the most common tumor, keeping in accordance with worldwide figures, however, cervical cancer is low. The unique feature of our series is the high prevalence of bladder cancer, breast and lympho-hematopoietic malignancies.

Table 1.5: Sex distribution of malignant primary tumors

in different systems-9808 cases

Site	Male		Female		Total
	No.	%	No.	%	No.	%
Lympho-hematopoietic system	1641	65.20	876	34.80	2517	25.67
Breast	26	1.50	1692	98.50	1718	17.50
Urinary system	991	74.85	333	25.15	1324	13.50
Digestive system	721	54.62	599	45.38	1320	13.45
Respiratory system	422	73.00	156	27.00	578	5.90
Female genital system	0	0.00	461	100.00	461	4.70
Skin	224	61.20	142	38.80	366	3.74
Soft tissue	161	60.07	107	39.93	268	2.74
Endocrine system	102	46.58	117	53.42	219	2.23
Bone	120	63.83	68	36.17	188	1.92
Male genital system	95	100.00	0	0.00	95	0.97
Central nervous system	38	50.00	38	50.00	76	0.77
Special senses	8	50.00	8	50.00	16	0.16
NOS	320	48.34	342	51.66	662	6.75
Total	4869	49.65	4939	50.35	9808	100.00

Figure 1.5: Sex distribution of malignant solid tumors

Table 1.6: Age distribution of malignant primary tumors

in different systems-9808 cases

Site	Adults		Pediatrics		Total
	No.	%	No.	%	No.	%
Breast	1718	100.00	0	0.00	1718	17.50
Lympho-hematopoietic system	1691	67.18	826	32.82	2517	25.67
Urinary system	1273	96.15	51	3.85	1324	13.50
Digestive system	1275	96.59	45	3.41	1320	13.45
Respiratory system	570	98.62	8	1.38	578	5.90
Female genital system	450	97.61	11	2.39	461	4.70
Skin	348	95.08	18	4.92	366	3.74
Soft tissue	193	72.00	75	28.00	268	2.74
Endocrine system	146	66.66	73	33.44	219	2.23
Bone	85	45.20	103	54.80	188	1.92
Male genital system	90	94.74	5	5.26	95	0.97
Central nervous system	41	54.44	35	45.56	76	0.77
Special senses	12	75.00	4	25.00	16	0.16
NOS	608	91.84	54	8.16	662	6.75
Total	8500	86.66	1308	13.34	9808	100.00

Figure 1.6: Age distribution of malignant primary tumors (number of cases)

Table1.5 and figure 1.5 represent the relative frequency of malignant tumors of the different systems with sex distribution, while table 1.6 and figure 1.6 show age distribution. They show high incidence of lympho-hematopoietic, breast, digestive, urinary, and respiratory systems as the 5 most common systems.

Sex distribution; The male to female ratio in the whole series was 1:1.01 reflecting the large bulk of female breast cancer. In males, the lympho-hematopoietic system represented the highest figure of 33.70%, followed by the urinary system 20.35% and the digestive system 14.80% as seen in table 1.8. In females, however, the highest figure was that of the breast 34.26%, followed by the lympho-hematopoietic system 17.74%, the digestive system 12.13%, and the female genital system 9.33%. Table 1.9 shows the ranking of female malignancies in different systems. Comparative ranking between male and female malignancies is demonstrated in figure 1.5.

Table 1.8: Ranking of male malignant tumors- 4869 cases

Site	Rank	Number	Percent
Lympho-hematopoietic system	1	1641	33.70
Urinary system	2	991	20.35
Digestive system	3	721	14.80
Respiratory system	4	422	8.67
Skin	5	224	4.63
Soft tissue	6	161	3.30
Bone	7	120	2.46
Endocrine system	8	102	2.10
Male genital system	9	95	1.95
Central nervous system	10	38	0.78
Breast	11	26	0.53
Special senses	12	8	0.16
NOS		320	6.57

Figure 1.8: Ranking of male malignant tumors

Table 1.9: Ranking of female malignant tumors- 4939 cases

Site	Rank	Number	Percent
Breast	1	1692	34.26
Lympho-hematopoietic system	2	876	17.74
Digestive system	3	599	12.13
Female genital system	4	461	9.33
Urinary system	5	333	6.74
Respiratory system	6	156	3.16
Skin	7	142	2.90
Endocrine system	8	117	2.36
Soft tissue	9	107	2.16
Bone	10	68	1.37
Central nervous system	11	38	0.77
Special senses	12	8	0.16
NOS		342	6.92

Figure 1.9: Ranking of female malignant tumors

Age distribution; The total primary malignant tumors were divided into 2 groups; namely adults and pediatrics. The adult group constituted a majority of 86.66% of cases. In this group, breast cancer represented alone 20.20%. The lympho-hematopoietic system, digestive system, and urinary system came next in frequency being 19.90%, 15.00%, and 14.98% respectively. The pediatric group formed a minority of 13.34%, 63.15% of which were in the lympho-hematopoietic system. Bone and soft tissue tumors constituted 7.87% and 5.73% respectively. Tables 1.10, 1.11 and corresponding figures show the ranking of adult and pediatric tumors in different systems respectively.

Table 1.10: Ranking of adult malignant tumors-8500 cases

Site

Rank

Number

Percent

Breast	1	1718	20.21
Lympho-hematopoietic system	2	1691	19.90
Digestive system	3	1275	15.00
Urinary system	4	1273	14.98
Respiratory system	5	570	6.71
Female genital system	6	450	5.29
Skin	7	348	4.10
Soft tissue	8	193	2.27
Endocrine system	9	146	1.72
Male genital system	10	90	1.06
Bone	11	85	1.00
Central nervous system	12	41	0.48
Special senses	13	12	0.14
NOS		608	7.14

Figure 1.10: Ranking of adult malignant tumors

Table 1.11: Ranking of pediatric malignant tumors-1308 cases

Site	Rank	Number	Percent
Lympho-hematopoietic system	1	826	63.15
Bone	2	103	7.87
Soft tissue	3	75	5.73
Endocrine system	4	73	5.58
Urinary system	5	51	3.90
Digestive system	6	45	3.44
Central nervous system	7	35	2.68
Skin	8	18	1.38
Female genital system	9	11	0.84
Respiratory system	10	8	0.61
Male genital system	11	5	0.38
Special senses	12	4	0.31
NOS		54	4.13

Figure 1.11: Ranking of pediatric malignant tumors

Table 1.12 and figure 1.12 compare two Cancer Pathology Registries. There is increased relative frequency of breast and lung cancers and decreased relative frequency of bladder cancer in the present series.

Table 1.12: Time trend of cancer pathology registries

Site	CPR 2003/2004		CPR 1985-1989
	%	Rank	%	Rank
Breast	17.50	1	11.34	3
Leukemia	13.95	2	6.79	5
Bladder	12.22	3	26.39	1
Lymphoma	11.66	4	12.23	2
Colon and rectum	4.34	5	5.05	6
Oral cavity and pharynx	2.87	6	7.62	4
Lungs and pleura	2.37	7	0.58	13
Stomach	2.12	8	3.06	8
Liver and biliary tract	1.81	9	2.63	9
Larynx	1.77	10	1.04	11
Cervix	1.72	11	3.58	7
Esophagus	1.43	12	1.83	10
Ovaries	1.37	13	0.80	12
Corpus uteri	1.10	14	0.53	14
Prostate	0.48	15	0.32	15
Pancreas	0.42	16	0.13	16

Figure 1.12: Time trend of Cancer Pathology Registries

Table 1.13 and figure 1.13 compare the present registry series with 2 other registry series, from the Department of Biostatistics & Cancer Epidemiology at NCI and from the population-based Gharbia Governorate Cancer Registry. The 3 Egyptian registries, in spite of some differences, all agreed on frequent cancers. The minor differences among the three registries can be justified by the nature of the material collected, geographical differences, and the followed protocols of management.

Table 1.13: Relative frequency of common sites of cancer in different registries

Site	CPR 2003/2004	NCIR 2003/2004	GCR 1999
Breast	17.5%	18.9%	18.6%
Bladder	12.2%	10.1%	9.5%
Lymphoma	11.6%	8.1%	9.5%
Colon and rectum	4.3%	4.4%	3.8%

CPR: Cancer Pathology Registry, NCIR: National Cancer Institute Registry (Department of Biostatistics & Cancer Epidemiology), GCR: Gharbia Cancer Registry.

Figure 1.13: Relative frequency of common sites of cancer

in different registries

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Chapter 2

Epidemiology

Epidemiologic Implications of the NCI Cancer Pathology Registries Between 1985-89 and 2003-04

By comparing the two period's pathology registries, it was noticed that the yearly pathologically examined cases dropped by 9% during this 15-year interval. This drop was due to the appreciable decrease in number of male pathological specimens. On the other hand female pathological specimens showed slight increase during the 15-year interval (Table 2.1).

Table 2.1: Average number of solid malignant tumors per year

Sex	1985-89	2003-04
Males	2647	2026
Females	1976	2182
Total	4623	4208

Before investigating the reasons for this noticeable drop in pathologically examined cases with the accompanying different sex behavior, it is important to consider the other important factors that changed over the same time interval. Despite NCI being the main cancer treating center in Egypt, yet since the mid 1990's other cancer management centers were established by other Universities as well as Ministry of Health and Population in many geographical areas of the country. Also, mix of cases and protocols of management including other non-histologic tests for diagnosis has changed over the years. These two factors may explain some of the appreciable drop in the number of pathologically confirmed cases at the Department of Pathology at NCI. Table 2.2 shows that not only the absolute number of pathologically examined cases had dropped, but also the drop was more in relation to the increased population size during the 15- year interval. The overall estimate of yearly incidence index for males was 107.8 cases, diagnosed by pathology at the NCI per million Egyptians during the 1980's period. The yearly incidence estimate halved to 51.9 male malignancies per million male populations during 2003-04.

Table 2.2: Pathologically examined cases in relation to Egyptian population

	Population size		Cases / million population
Sex	1986 census 1985-1989	2003 estimation 2003-2004	1985-1989	2003-2004
Males	24 710 000	34 444 000	107.8	51.9
Females	23 545 000	32 869 000	84.3	62.6

If the Department of Pathology at NCI was the only place for malignancy diagnosis then this would represent true drop in incidence of malignant tumors for both sexes. However, these proportions shown in Table 2.2 could not be taken as true incidence rates or even an approximation. It is used as indicators of changes of confirmed cases in relation to population size, to correct for increasing population.

Figure 2.1: Pathologically examined male cases in relation to Egyptian male population (annual incidence rate)

There was a drop in the population related rates of pathologically diagnosed male cases in most systems as seen in Figure 2.1. The most appreciable rate of decrease was noticed for cancer of the urinary system. This dramatic drop in urinary system malignancy rate was mostly due to drop in average number of yearly diagnosed bladder cancer cases. This could be a real decrease in Egyptian bladder cancer cases. The pathology details that are shown later in the Chapter on urinary system may give some clue to the probable decrease of the schistosoma related type.

It is important to note that the general ranking of the systems was the same for the two periods. In other words, the urinary system malignancies are the most common among males, and the brain malignancies showed the lowest occurrence. Every male pathological specimens by site in relation to male population showed that the rate for 2003–04 was almost half the rate for 1985-89. This rate drop was most noticeable in the urinary system malignancy where it dropped to one third.

The estimated age specific incidence rates, as seen in figure 2.2, showed continuous increase starting after the age of 25 years, which is more noticeable after the age of 45 years. In the recent period 2003-04, the rates continued to increase after the age of 60 years which was not noticed during the 1980's data. This last finding may be due to longevity of the population (increased life span) which leads to more old age males who are at higher risk of malignancy. However, this old age increase of incidence may also be due to more awareness of the public towards their health status and improved health care seeking behavior.

Figure 2.2:Annual age specific estimate of incidence rate for male malignancies

Figure 2.3: Pathologically examined female cases in relation to Egyptian female population (annual incidence rate)

Female malignant cases in relation to Egyptian female population showed appreciable increase in the recent time period for breast cancer. In contrast to males, the relative distribution of system malignancies was different in recent than old time period, e.g. digestive system stepped up from the third to the second position, while female genital system stepped down from rank 2 to rank 3.

Female estimated overall yearly malignancy incidence index dropped from 84.3 to 62.6 cases per one million Egyptian female population between 1985-89 and 2003-04.

The estimate of incidence rates of the ages between 20 years and 50 years showed an exponential increase for both time periods. During the early period of the 1980's estimates of incidence rates before the age of 60 were higher then those of the 2003-04 time period. After the age of 60, female annual incidence rates showed increase during recent time period, as compared to the 1980's period (Figure 2.4). This may explain changing of health care seeking behavior among females in older ages. However, the cohort of living Egyptian women who are older than 70 years seemed to still keep the tradition of negligence of seeking health care.

Detailed and careful analysis of site-specific rates should be done to understand whether this changing pattern is true or apparent due to changes in female health seeking care attitudes.

Figure 2.4: Annual age specific estimate of incidence rate for

female malignancies

Epidemiologic Aspects of Urinary Bladder Cancer

The annual urinary bladder pathologically recorded cases dropped in recent years as compared to earlier ones, from 862 cases per year in 1985-89 to 600 cases in 2003-04. However, this drop in cases was similar for males and females as shown by the stable slightly changed sex ratio. This Male to Female ratio showed that male urinary bladder pathological cases were more than three times those among females (Table 2.3).

Table 2.3: M:F ratios in bladder cancer

Period	M:F case ratio	M:F incidence ratio
1985-89	3.8	3.7
2003-04	3.5	3.3

The majority of cases in both sexes showed that squamous cell carcinoma and transitional cell carcinoma together constituted around 90% of all pathological types. The squamous carcinoma was the highest in 1985-89 then it gave way to the transitional carcinoma in the recent time period (Figures 2.5 and 2.6).

Figure 2.5: Relative frequency of histopathologic types of urinary bladder cancer in male patients

Figure 2.6: Relative frequency of histopathologic types of urinary bladder cancer in female patients

It is noticed that females showed less relative frequency (proportion to all cases) drop for squamous type than males between the two time periods. Females dropped by one third while males dropped by one half. Many Egyptian studies incriminate schistosomiasis as a high risk for development of urinary bladder malignancy especially the squamous type. Accordingly, it is tempting to suggest that female reluctance to seek early diagnosis and treatment of schistosomiasis increases the chances of pathological sequels including squamous bladder malignancy.

As seen in figures 2.7 the age distribution of bladder cancer cases in males is very similar to that of the overall malignancy that was shown in figure 2.2. Figure 2.8 illustrates the previously mentioned low health care seeking behavior of the old aged women.

More than three quarters of the transitional cell carcinoma were above the age of 50 years (79%). In contrast, the squamous cell carcinoma shows lower proportion of cases occurring above the age of 50 years, only 57%.

Figure 2.7: Annual age specific estimate of incidence rate of urinary bladder cancer in male patients

Figure 2.8: Annual age specific estimate of incidence rate of urinary bladder cancer in female patients

Epidemiologic Aspects of Breast cancer

Figure 2.9 shows that female breast cancer incidence was similar for the two periods until the age of 45 years. Starting from the age of 50 years and above, the pathologically registered cases for the later period 2003-04 showed markedly higher rates.

This pattern of age incidence may suggest age misreporting during the earlier period 1985-89 especially around the ages of 30-39 years and older than 50 years. However, more in depth epidemiologic studies need to be done for this seemingly increasing type of malignancy. These studies should include hormonal, environmental and maybe genetic epidemiology. For example; the drop in incidence after menopause could be in line with the hormonal etiology hypothesis.

The female to male ratio of breast cancer has shown a 3-fold increase from 23.7 in 1985-89 to 72.8 in 2003-04.

Figure 2.9: Annual age specific estimate of incidence rate of breast cancer in female patients

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Chapter 3

malignant Urinary system tumors

The urinary system malignancies represented a high incidence of 13.50% of total malignant tumors. The main bulk was dominated by the urinary bladder cancer, 12.22%. The rest of the urinary system malignancies constituted a minority of only 1.27%. Table 3.1 and figure 3.1 show the relative frequency of malignant tumors of the urinary system.

Table 3.1: Urinary system malignancies – 1324 cases

Site	No.	%	%Total
Urinary bladder	1201	90.71	12.22
Kidney	118	8.91	1.22
Ureter	4	0.30	0.05
Urethra	1	0.08	0.01
Total	1324	100.00	13.50

Figure 3.1: Percent distribution of urinary system malignancies – 1324 cases

Urinary bladder

The total number of bladder cancer cases was 1201. The material received at the Department of Pathology for cases of bladder cancer was distributed as follows: surgical specimens, TUR and biopsies constituted 86.1%, while referred slides constituted 13.9%. After excluding referred cases (13.9%), the nature of the surgical material received at the Department of Pathology was as follows: radical operations done for bladder cancer at NCI, whether radical cystectomy or anterior pelvic excentration represented 44.29% of the bladder cancer surgical material. Cystectomy whether subtotal or not otherwise specified (NOS) represented 1.55%. TUR procedure was mostly performed for transitional cell carcinomas, and represented 17.12%. Biopsies were 37.04%. Table 3.2 and figure 3.2 show the nature of material for bladder cancer submitted from the Department of Surgery at NCI, excluding cases with referred slides only.

Table 3.2: Surgical material for bladder cancer at NCI- 1034 cases

Nature	Transitional		Squamous		Adeno.		Undifferent.		Total
	No.	%	No.	%	No.	%	No.	%	No.	%
Radical specimens	229	34.18	196	65.55	22	53.66	11	45.83	458	44.29
Cystectomy (Subtotal or NOS)	9	1.34	5	1.67	2	4.88	0	0	16	1.55
TUR	156	23.28	17	5.69	2	4.88