The Gharbiah Population-based Cancer Registry (GPCR)

The idea of establishing a population-based cancer registry in Gharbiah is not a recent one. In the early eighties, the late Calum Muir of IARC wrote a report after a visit to evaluate future prospects of cancer registration in Egypt. By that time, the Cancer Registry for the Metropolitan Cairo Area (CRMCA) was fully developed. He recommended Gharbiah to be an ideal site for a population-based cancer registry that corrects the limitations and difficulties encountered by the CRMCA. Lack of appropriate funding was the problem facing registry establishment in Gharbiah.

With the initiation of MECC, the joint cancer registration project was considered the cornerstone of the infrastructure of cancer management in the region. In Egypt, Gharbiah was considered an optimum site to develop a population-based cancer registry in Egypt. This decision marked the first step in development of the first population-based cancer registry in Egypt, with an eye on an eventual National Cancer Registry of Egypt. The decision was based on previous studies hoping to make use of all previous attempts to initiate cancer registration in Egypt.

The registry is affiliated with the Ministry of Health and Population of Egypt and is located in Tanta, capital of the Gharbiah Governorate. The headquarters are in Tanta Cancer Center. The Principal Investigator is Prof. Amal Samy Ibrahim, Professor of Epidemiology in the National Cancer Institute, Cairo University. The executive Director of the project is the Director of the Cancer Center in Tanta, currently Prof. Hany Hussein, Professor of Pediatric Oncology in the National Cancer Institute, Cairo University. The co-investigators are Drs. Kadry Ismail and Ahmed Hablas, Consultants of Surgical Oncology and previous Directors of Tanta Cancer Center. The data supervisors are Drs. Ibrahim Abdel Bar and Mohammad Ramadan.

The Gharbiah Governorate:

The Gharbiah Governorate is located in the middle of the Nile delta, about 90km north to Cairo and 120km south east to Alexandria. Its surface area is 1,943 km2 (0.2% of national area). The population size is 3.406 million (5.7% of the total population of Egypt). Population density is 1752/km2. The male : female ratio is 1.02:1.

Gharbiah Governorate is considered an urban-rural Governorate by the Central Agency for Public Mobilization and Statistics (CAPMAS). Tanta is the capital of the Governorate. The Governorate is divided into 8 districts (markaz). Each district has a main city and a number of villages. The total number of villages in the Governorate is 316 villages. Gharbiah is mainly an agricultural governorate. However, one of its divisions (Elmehalla Elkobra) is the main textile region of the country.

Main Objectives of GPCR:

1- To define the size of cancer problem and pattern of cancer incidence rates.

2- To calculate cancer incidence rates for use by researchers, professionals, health planners and policy-makers to achieve better cancer prevention, control and management in a cost effective manner.

Results Overview:

The total number of cases first diagnosed in 1999 amounted to 3427 non-duplicate cases including 1735 males and 1692 females. If skin cancer other than melanoma (C44) is excluded, the number drops to 3337 cases; equally distributed between males and females.

The main sources of data were Tanta Cancer Center followed by Private Pathology and Hematology Laboratories then Gharbiah Cancer Society. The 3 sources together accounted for about 2/3 of registered cases.

Death certificate only (DCO) cases represented about 10% of registered cases. This number is relatively high compared to what could be accepted for this source for data. However, this number should be evaluated taking into consideration that it was based on data of the first year of registry activity. In absence of other data, the date of diagnosis is considered the same as date of death (1999).

This frequency of DCO cases is expected to decrease in following years. Nevertheless, experience of this first year of registration points to the importance of this source of data. Although record linkage cannot be done by the computer, still manual checks proved not to be tedious. This source should not be neglected especially with the improvement in quality of death registration in Egypt. Use of the unique national identification number will greatly simplify this matching process to detect duplicate cases.

The Basis of Diagnosis in the large majority of cases (80%) was microscopic evidence of the disease, whether by pathological or cytological examination. Radiological diagnosis was reported in about 6% of cases. Apart from death certificate only (10%), the other bases of diagnosis had low frequency. The results point to the importance of pathology laboratories data as a source for case finding. Collaboration of the pathology laboratories, all of them are private, should be commended. The only incentive for these laboratories was scientific interest, and their collaboration was mainly based on personal efforts of registry staff. In fact there is no law in Egypt that forces those private laboratories to report or give access to their data.

Based on 1999 findings, the relative frequency of different sites of cancer was calculated. The relative frequency, based on population data, proved the clinical impression that were based on different hospital-based statistics mainly those of NCI-Cairo.

In males, the most frequent site of cancer is the urinary bladder. This has always been related to Schistosomiasis, a parasitic disease that affects the bladder leading to hematuria, urothelial damage, fibrosis and calcification with marked lower urinary tract obstruction. The disease has been known since the time of ancient Egyptians. A Schistosoma hematobium ovum had been detected in one of the Egyptian mummies several years ago. Engravings on the walls suggest that hematuria was known to be an important symptom of the disease. They recognized that it is due to urinary tract infection and in one of the papyri; wearing a penile sheath was recommended for primary prevention preventing the causative agent from entering to the urinary system through the urethera. Despite the recent active control of the disease and its eradication in certain areas, bladder cancer is still the most frequent type of cancer in males. Next in frequency was liver cancer. Lung cancer; a disease intimately related to the spreading smoking epidemic in Egypt, occupies the fourth rank after Non-Hodgkin lymphoma.

In females, breast cancer is by far the commonest type of cancer, again in accordance with previous statistics and clinical impressions. Non-Hodgkin Lymphoma followed this. The fourth rank was that of liver cancer; again stressing the importance of this type of cancer in Egypt.

An important observation is the very low frequency of cancer of the cervix uteri (not shown among the frequent types of cancer) unlike cancer of the ovary that occupied the sixth rank.

Lung cancer is a potential threat. It is expected to be on the rise in review of the increasing frequency of female smokers at a relatively young age.