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National Cancer Registry Past, Present and Future Presented by: Ali Shamseddine, MD. Professor, Head Hematology Oncology AUB VP /NCR

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History of Cancer Registration The first systematic collection of information on cancer was in 1728 in the general census of cancer in London. The first systematic collection of information on cancer was in 1728 in the general census of cancer in London. The first reliable cancer statistics appeared in mortality figures for the city of Verona in 1842. The first reliable cancer statistics appeared in mortality figures for the city of Verona in 1842. The International Association of Cancer Registries (IACR) was formed in 1966. The International Association of Cancer Registries (IACR) was formed in 1966.

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Population-based cancer registries world-wide Country Establishment year Notification Germany (Hamburg) USA (NY) USA (Connecticut) Denmark Canada (Saskatchewan) England & Wales (SW region) England & Wales (Liverpool) New Zealand Canada (Manitoba) Slovenia Canada (Alberta) USA (EL Paso) HungaryNorway Former USSR Former German Democratic Republic FinlandIceland192919401941194219441945194819481950195019511951195219521953195319531954VoluntaryCompulsoryCompulsoryCompulsoryCompulsoryVoluntaryVoluntaryCompulsoryVoluntaryCompulsoryCompulsoryVoluntaryCompulsoryCompulsoryCompulsoryCompulsoryCompulsoryVoluntary

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Cancer registry (CR) Aim: Aim: Systematic collection, storage, analysis, interpretation, and reporting of data on subjects with cancer Systematic collection, storage, analysis, interpretation, and reporting of data on subjects with cancer Types: Types: Hospital-based CR Population-based CR

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Hospital-based CR Record information on new cancer patients seen in a particular hospital Record information on new cancer patients seen in a particular hospital Objective: Objective: To contribute to patient care by providing readily accessible information on the subjects with cancer, the treatment they received & the results To contribute to patient care by providing readily accessible information on the subjects with cancer, the treatment they received & the results

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Population-based CR Seek to collect data on all new cases occurring in a well defined population. Seek to collect data on all new cases occurring in a well defined population. Objective: Objective: -Produce statistics on the occurrence of cancer in a defined population (Incidence, prevalence, CFR) -Provide a framework for assessing and controlling the impact of cancer in the community

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The Lebanese National Cancer Registry The Past (before 1998)

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The idea of establishing a National Cancer Registry started in the 1970 The idea of establishing a National Cancer Registry started in the 1970 Other registries in the Arab world at that time: Kuwait, Egypt, Iraq Other registries in the Arab world at that time: Kuwait, Egypt, Iraq Meanwhile efforts started to establish hospital-based cancer registries Meanwhile efforts started to establish hospital-based cancer registries

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National Based Studies The only national-based study was that of Abou Daoud The only national-based study was that of Abou Daoud in 1966. in 1966. Pathology Reports of 8 Medical Institutions in Lebanon (1 Pathology Reports of 8 Medical Institutions in Lebanon (1 year from 01/08/1964-31/07/1965): Sample Size: 1,950 cases (1,507 Lebanese, 443 Non-Lebanese) Sample Size: 1,950 cases (1,507 Lebanese, 443 Non-Lebanese) Results: Results: Males: Skin (17.0%), Bladder (9.1%), Lung (7.1%), Larynx (5.7%) Males: Skin (17.0%), Bladder (9.1%), Lung (7.1%), Larynx (5.7%) Females: Breast (16.4%), Cervix and Uterine (14.1%), Skin (10.7%) Females: Breast (16.4%), Cervix and Uterine (14.1%), Skin (10.7%) Cancer Incidence Rates: Cancer Incidence Rates: 74.9 per 100,000 for males 74.9 per 100,000 for males 75.6 per 100,000 for females 75.6 per 100,000 for females Adjusted Crude Incidence Rates: Adjusted Crude Incidence Rates: 102.8 per 100,000 for males 102.8 per 100,000 for males 104.1 per 100,000 for females 104.1 per 100,000 for females Abou Daoud KT; Cancer; 19: 1293-1300, 1966.

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Lebanese Hospital-based CR AUBMC 1970: Founded (Drs. Kamal Bikhazi and Elizabeth Morton) 1971: Dr. Philip Salem appointed as first AUBMC tumor registry head. 1983: Reactivated (Dr. Ghaleb Saab) 1984: HDF (Drs. Najib Taleb and Edgard Gedeon) HDF (Drs. Najib Taleb and Edgard Gedeon)

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Hospital Based Studies Publication Sample Size HospitalResultsMaleResultsFemale Saab G, Int. J Epidemiol 1985 1,256 AUB -MC Lung Bladder (12.7%) Lymphoma (11.7%) Bladder (low incidence) Geahchan N, ARC, Paris Oct. 1986 2,355 10 Pathology Centers other than AUB Bladder (16.3%) Lung (14%) Leukemia-Lymphoma (13.1%) Breast (27.2%) Lymphoma-Leukemia (10.7%) Cervix (7%) Ghosn M Leb Med J 1992541 Htel-Dieu de France- Beirut Lung (19%) Bladder (16.7%) Prostate (11.6%) Breast (36.1%) Uterine(15.2%) Digestive Tract (12.3%) Taleb N Leb Med J 1994 (Review) Bladder (18%) Lung (14%) Prostate (11%), Breast (30%) Uterus (12%) Colorectal (6%), Saghir N Leb Med J 199810,220 AUB - MC Lung (17%), Bladder (9.8%), Larynx (8.6%), Breast (35.5%) Cervix Uteri (10.4%) Colorectal (4.9%) Adib SM Ann Epidemiol 1998 9364 AUB- MC Lung(17.8%), Bladder(10%), Larynx (8.9%) Breast(35.2%), Cervix uteri(10.6%), Lymphoma(5.2%)

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Mir Amin Meeting, 1994--- special committee was set up to create a NCR under the auspices of MOPH a NCR under the auspices of MOPH This committee met for about 5 years without any practical results.

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The Lebanese National Cancer Registry The Present (1998-2008)

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1998 : The establishment of the LCEG 1998 : The establishment of the LCEG 2001: The Italian Cooperation signed an agreement with the Ministry of Public Health (MOPH) of Lebanon to fund in 2002 activities leading to a National Cancer Registry in Lebanon. 2001: The Italian Cooperation signed an agreement with the Ministry of Public Health (MOPH) of Lebanon to fund in 2002 activities leading to a National Cancer Registry in Lebanon. Report 2002: The report 2002 was supported by the NCDP and MOPH Report 2002: The report 2002 was supported by the NCDP and MOPH Report 2003: Funded and supported by LSMO and the Italian Cooperation under the umbrella of MOPH. Report 2003: Funded and supported by LSMO and the Italian Cooperation under the umbrella of MOPH. 2005: NCR oversight committee. 2005: NCR oversight committee. 2008: Reports 2003(Revised) and 2004,collection of 2005,2006 and 2007 data. 2008: Reports 2003(Revised) and 2004,collection of 2005,2006 and 2007 data. Overview

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The Lebanese Cancer Epidemiology Group (LCEG) Founded in 1998 Founded in 1998 A network of all hospitals with oncology specialists and all pathology laboratories. A network of all hospitals with oncology specialists and all pathology laboratories. To study cancer caseload and to estimate incidence rates at the national level. To study cancer caseload and to estimate incidence rates at the national level. All cases diagnosed in the year 1993, and for each 5-year interval thereafter, are registered. All cases diagnosed in the year 1993, and for each 5-year interval thereafter, are registered.

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The Lebanese Cancer Epidemiology Group Fifteen Hospitals: Fifteen Hospitals: American University of Beirut-Medical Center American University of Beirut-Medical Center Hotel-Dieu de France University Hospital Hotel-Dieu de France University Hospital St George University Hospital St George University Hospital Hammoud Hospital Hammoud Hospital Hopital Libanais Hopital Libanais Hopital Notred-Same des Secours Hopital Notred-Same des Secours Khoury General Hospital Khoury General Hospital Makassed Hoapital Makassed Hoapital Middle-East Hospiatl Middle-East Hospiatl Rizk Hospital Rizk Hospital Sacre-Coeur Hospital Sacre-Coeur Hospital St Geaorge Hospital St Geaorge Hospital Sahel Hospital Sahel Hospital Zahraa Hospital Zahraa Hospital Barbir Hospital Barbir Hospital Pathology Laboratories : Dr. Albert Aoun Dr. Fady Assi Dr. Akram El-Ahadab Dr. Mouin Soussi

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Cancer incidence in postwar Lebanon: The first population-based estimates, 1993 and 1998. Shamseddine et al. Annals of Epidemiology, 2004 (1998 data) The Lebanese Cancer Epidemiology Group

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Findings were based on 2856 and 4388 incident cases reported and registered in Lebanon in the year 1998 and 1993 respectively. Crude and age-standardized rates (ASRs) per 100,000 population were calculated and results were contrasted with estimates from developed and developing countries in the region. 19981993 141.491.7Males 126.8584.4Females Crude Incidence Rates (1993-1998)

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Crude incidence and age-specific incidence Males

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Cancer incidence 1993 and 1998 Possible causes for the increase in crude incidence rates Improvement in detection rate Improvement in detection rate Reporting and data gathering of various cancers due to the marked rise in the number of diagnostic facilities Reporting and data gathering of various cancers due to the marked rise in the number of diagnostic facilities After 1991, a proliferation in the number health-care institutions as well as a significant upsurge in modern diagnostic technologies, equipment and services: After 1991, a proliferation in the number health-care institutions as well as a significant upsurge in modern diagnostic technologies, equipment and services: MRIs (n = 12) MRIs (n = 12) CT Scans (n = 54) CT Scans (n = 54) Colonoscopy and gastroscopies (over 30 suites) Colonoscopy and gastroscopies (over 30 suites) mammograms, cytology and pathology labs. Ammar W et al. Leb Med J 1998;46:149-155. Soweid A et al Gastrointest Endosc 2001;54:279-281. mammograms, cytology and pathology labs. Ammar W et al. Leb Med J 1998;46:149-155. Soweid A et al Gastrointest Endosc 2001;54:279-281. During the past decade alone, the number of oncology specialists in the country has risen from 20 to around 80 physicians (Lebanese Cancer Society). During the past decade alone, the number of oncology specialists in the country has risen from 20 to around 80 physicians (Lebanese Cancer Society). Several risk factor awareness campaigns and screening programs became part of national public policies with wide advertisement and coverage. Several risk factor awareness campaigns and screening programs became part of national public policies with wide advertisement and coverage.

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Cancer incidence 1993 and 1998 Breast Cancer Breast cancer was the most frequent malignancy in females in Lebanon (Over one third of all female cancers). Breast cancer was the most frequent malignancy in females in Lebanon (Over one third of all female cancers). Same rates observed in all earlier hospital-based studies in the country. Azar HA. Cancer in Lebanon and the near east. Cancer January-February 1962;15:66-74. Ghosn M et al. The cancer registry at the Hotel Dieu de France Hospital. Leb Med J 1992;40:4-10. El-Saghir NS et al. Cancer in Lebanon: analysis of 10220 cases from the American University of Beirut Medical Center. Leb Med J 1998;46:4-10. Same rates observed in all earlier hospital-based studies in the country. Azar HA. Cancer in Lebanon and the near east. Cancer January-February 1962;15:66-74. Ghosn M et al. The cancer registry at the Hotel Dieu de France Hospital. Leb Med J 1992;40:4-10. El-Saghir NS et al. Cancer in Lebanon: analysis of 10220 cases from the American University of Beirut Medical Center. Leb Med J 1998;46:4-10. ASR (38.9 per 100,000, 1998) ASR (38.9 per 100,000, 1998) Lower than that observed for the US (90.7), UK (68.8), France (78.8) or Israel (77.4) Lower than that observed for the US (90.7), UK (68.8), France (78.8) or Israel (77.4) Much higher than other developing countries of the region such as Algeria Much higher than other developing countries of the region such as Algeria

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Breast Cancer The age pattern at diagnosis is typical of that in low-risk countries The age pattern at diagnosis is typical of that in low-risk countries Increase in the rate up to the 5 th decade, around menopause, and a decrease thereafter. Rodriguez-Cuevas Et al. Breast carcinoma presents a decade earlier in Mexican women than in women in the United States or European countries. Cancer 2001;91:863-868 Increase in the rate up to the 5 th decade, around menopause, and a decrease thereafter. Rodriguez-Cuevas Et al. Breast carcinoma presents a decade earlier in Mexican women than in women in the United States or European countries. Cancer 2001;91:863-868 Median age at diagnosis was 52 years (range 22-92) Median age at diagnosis was 52 years (range 22-92) Around 43% of cases presenting before the age 50 compared to median age of 63 years for developed countries such as the US. Bosch X. Early development of breast cancer in Mexican women. The Lancet Oncology 2001;2:194 Around 43% of cases presenting before the age 50 compared to median age of 63 years for developed countries such as the US. Bosch X. Early development of breast cancer in Mexican women. The Lancet Oncology 2001;2:194

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Public Health Implications Breast Cancer In Lebanon; causes for the rise: Breast Cancer In Lebanon; causes for the rise: Screening programs are widely adopted by most academic and health centers Screening programs are widely adopted by most academic and health centers Changes in certain reproductive factors: Changes in certain reproductive factors: Mean age at marriage of women has increased from 23.2 years in 1970 to 27.5 in 1996 Mean age at marriage of women has increased from 23.2 years in 1970 to 27.5 in 1996 Total fertility rate has steadily declined from 4.4 to 2.5 Total fertility rate has steadily declined from 4.4 to 2.5 United Nations. Health and reproduction. In: The female and male in Lebanon: a statistical profile. The Lebanese Republic, 2000 pp.57-65

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Should we screen for breast cancer among younger age groups (below 40 years) and what type of screening should we adopt? Should we screen for breast cancer among younger age groups (below 40 years) and what type of screening should we adopt? Screening of high-risk groups (MRI). Screening of high-risk groups (MRI). Unification of the screening programs and training of the radiology technicians. Unification of the screening programs and training of the radiology technicians.

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Tobacco Associated Cancers Bladder Cancer Bladder Cancer Lung Cancer Lung Cancer

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Public Health Implications Bladder Cancer Incidence rates in Lebanon are high, in particular among males. Incidence rates in Lebanon are high, in particular among males. Incidence rates parallel those observed in developed countries such France, the USA, UK and Israel. Incidence rates parallel those observed in developed countries such France, the USA, UK and Israel. Rates have always been this high in national and hospital based studies in the country. Abou-Daoud KT. Morbidity from cancer in Lebanon. Cancer 1966;19:1293-300. Azar HA. Cancer in Lebanon and the near east. Cancer January- February 1962;15:66-74. Ghosn M et al. The cancer registry at the Hotel Dieu de France Hospital. Leb Med J 1992;40:4-10. El-Saghir NS et al. Cancer in Lebanon: analysis of 10220 cases from the American University of Beirut Medical Center. Leb Med J 1998;46:4-10. Rates have always been this high in national and hospital based studies in the country. Abou-Daoud KT. Morbidity from cancer in Lebanon. Cancer 1966;19:1293-300. Azar HA. Cancer in Lebanon and the near east. Cancer January- February 1962;15:66-74. Ghosn M et al. The cancer registry at the Hotel Dieu de France Hospital. Leb Med J 1992;40:4-10. El-Saghir NS et al. Cancer in Lebanon: analysis of 10220 cases from the American University of Beirut Medical Center. Leb Med J 1998;46:4-10. Tobacco smoking was identified as a major risk factor for bladder cancer. Abou- Daoud KT. Cancer of the bladder and cigarette smoking, coffee and alcohol drinking in Lebanon. Leb Med J 1980;3:251-257. Tobacco smoking was identified as a major risk factor for bladder cancer. Abou- Daoud KT. Cancer of the bladder and cigarette smoking, coffee and alcohol drinking in Lebanon. Leb Med J 1980;3:251-257.

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Bladder Cancer Internationally, a stronger relationship between smoking and bladder cancer is reported in women than in men. Brennan P et al. The contribution of cigarette smoking to bladder cancer in women pooled European data. Cancer Causes Control 2001;12:411-7 Internationally, a stronger relationship between smoking and bladder cancer is reported in women than in men. Brennan P et al. The contribution of cigarette smoking to bladder cancer in women pooled European data. Cancer Causes Control 2001;12:411-7 A small proportion of bladder cancer can be attributed to coffee drinking especially in nonsmokers. Sala M et al. Coffee consumption and bladder cancer in non-smokers: a pooled analysis of case-control studies in European countries. Cancer Causes Control 2001;11:925-31 A small proportion of bladder cancer can be attributed to coffee drinking especially in nonsmokers. Sala M et al. Coffee consumption and bladder cancer in non-smokers: a pooled analysis of case-control studies in European countries. Cancer Causes Control 2001;11:925-31 Other causative agents: Other causative agents: Bilharsia (Egypt, Iraq) Bilharsia (Egypt, Iraq) Exposures to paint components, polycyclic aromatic hydrocarbons, diesel exhausts, and aromatic amines Zeegers Mpet al. Occupational risk factors for male bladder cancer: results from a population based case cohort study in the Netherlands. Occcup Envoron Med 2001;58:590-6 Exposures to paint components, polycyclic aromatic hydrocarbons, diesel exhausts, and aromatic amines Zeegers Mpet al. Occupational risk factors for male bladder cancer: results from a population based case cohort study in the Netherlands. Occcup Envoron Med 2001;58:590-6

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Role of HPV in bladder cancer!! Role of HPV in bladder cancer!! Two of the HPVs (16 and 18) are known to be high risk for the incidence of bladder cancer. The association between bladder cancer and HPVs was found to be ranging between 2.5-81%. Soulitzis N et al. p53 Codon 72 Polymorphism and its Association with Bladder Cancer. Cancer Letters, 2002. Lopez-Batran A et al. Human Papillomavirus and Bladder Cancer. Biomed and Pharmacother, 1997. Two of the HPVs (16 and 18) are known to be high risk for the incidence of bladder cancer. The association between bladder cancer and HPVs was found to be ranging between 2.5-81%. Soulitzis N et al. p53 Codon 72 Polymorphism and its Association with Bladder Cancer. Cancer Letters, 2002. Lopez-Batran A et al. Human Papillomavirus and Bladder Cancer. Biomed and Pharmacother, 1997. The role of HPV among Bladder Cancer should be investigated. The role of HPV among Bladder Cancer should be investigated. Should we design a retrospective cohort study on bladder cancer patients? Should we design a retrospective cohort study on bladder cancer patients? Public Health Implications Bladder Cancer

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Public Health Implications Lung Cancer Lung cancer has long been closely linked to tobacco smoking. Doll R, Peto R. The cause of cancer. Oxford: Oxford University Press, 1981 Lung cancer has long been closely linked to tobacco smoking. Doll R, Peto R. The cause of cancer. Oxford: Oxford University Press, 1981 In countries with prolonged smoking history, about 90% of cases of lung cancer in men are related to tobacco. Parkin DM. Global cancer statistics in the year 2000. The Lancet Oncology 2001;2:533-542 In countries with prolonged smoking history, about 90% of cases of lung cancer in men are related to tobacco. Parkin DM. Global cancer statistics in the year 2000. The Lancet Oncology 2001;2:533-542 In various countries, national trends in lung cancer incidence and mortality reflect the maturity of the smoking epidemic. Gilliland FD, Samet JM. Lung cancer. Cancer Surv 1994;19-20:175-95 In various countries, national trends in lung cancer incidence and mortality reflect the maturity of the smoking epidemic. Gilliland FD, Samet JM. Lung cancer. Cancer Surv 1994;19-20:175-95

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Lebanon may have reached this maturity in men, the trend in women is certainly still increasing. Lebanon may have reached this maturity in men, the trend in women is certainly still increasing. Smoking prevalence rates among men have long been in the range of 50-60%. Khogali M et al. Dar el fatwa, Aisha Bakar, CVD Project. Spring-Summer 1999 Smoking prevalence rates among men have long been in the range of 50-60%. Khogali M et al. Dar el fatwa, Aisha Bakar, CVD Project. Spring-Summer 1999 In women, smoking prevalence have considerably increased: In women, smoking prevalence have considerably increased: 1960s: 28% Abou- Daoud KT. Cancer of the bladder and cigarette smoking, coffee and alcohol drinking in Lebanon. Leb Med J 1980;3:251-257 1960s: 28% Abou- Daoud KT. Cancer of the bladder and cigarette smoking, coffee and alcohol drinking in Lebanon. Leb Med J 1980;3:251-257 1992: 35% Nuwayhid I et al. In: Deeb M, ed. Beirut: a health profile 1984-1994. Beirut, AUB, 1997 1992: 35% Nuwayhid I et al. In: Deeb M, ed. Beirut: a health profile 1984-1994. Beirut, AUB, 1997 1999: 47% & 57% Khogali M et al. Dar el fatwa, Aisha Bakar, CVD Project. Spring-Summer 1999. Chidiac C. The profile of the Lebanese smoker: prevalence, characteristics and risk factors. USJ 1998 (unpublished paper) 1999: 47% & 57% Khogali M et al. Dar el fatwa, Aisha Bakar, CVD Project. Spring-Summer 1999. Chidiac C. The profile of the Lebanese smoker: prevalence, characteristics and risk factors. USJ 1998 (unpublished paper) Public Health Implications Lung Cancer

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Lung cancer rate among women doubled during recent years and this can be expected to continue its rise as smoking is increasingly seen in successive birth cohorts with prevalence rates: Lung cancer rate among women doubled during recent years and this can be expected to continue its rise as smoking is increasingly seen in successive birth cohorts with prevalence rates: 30-39 years: 54% 30-39 years: 54% Over 60 years: 16% Over 60 years: 16% Nuwayhid I et al. Morbidity, mortality and risk factors. In: Deeb M, ed. Beirut: a health profile 1984-1994. Beirut, AUB, 1997 Public Health Implications Lung Cancer

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Primary Prevention Lung Cancer Effective anti-smoking programmes should be implemented to prevent future rise. School children and women should be particularly targeted. Effective anti-smoking programmes should be implemented to prevent future rise. School children and women should be particularly targeted. Distribution channels should include mass media, MOPH institutions, Ministry of Social Affairs institutions, schools, NGOs and places of work. Distribution channels should include mass media, MOPH institutions, Ministry of Social Affairs institutions, schools, NGOs and places of work.

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Public Health Implications Prostate Cancer Significant increase in the crude incidence of prostate cancer from 1993 to 1998 (9.1 and 17.6 per 100,000 respectively). Significant increase in the crude incidence of prostate cancer from 1993 to 1998 (9.1 and 17.6 per 100,000 respectively). The second most common type of malignancy in men. The second most common type of malignancy in men. Surveillance and detection bias Surveillance and detection bias National awareness campaigns promoting screening for prostate cancer in 1994 National awareness campaigns promoting screening for prostate cancer in 1994

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Age specific incidence rates Males 1993

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Distribution of the 5 most common Male cancers diagnosed and or treated at AUBMC during 1983-2000 (N=4220)

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Age specific incidence rates Males 1998

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Public Health Implications Colorectal Cancer Rise of colon cancer in females from 2.8 per 100,000 in 1993 to 6.7 in 1998. Rise of colon cancer in females from 2.8 per 100,000 in 1993 to 6.7 in 1998. ASRs were lower than in the USA, France, and Israel and higher than in Kuwait and Algeria. ASRs were lower than in the USA, France, and Israel and higher than in Kuwait and Algeria. The major influences on colon cancer: The major influences on colon cancer: Environmental exposures Environmental exposures Sedentary lifestyle Sedentary lifestyle Alcohol Alcohol Dietary habits: high fat consumption and low fruit, vegetable, and fiber intake Dietary habits: high fat consumption and low fruit, vegetable, and fiber intake The risk may be decreased among recent post-menopausal HRT users. Nanda K et al. Hormone replacement therapy and the risk of colonrectal cancer: a meta-analysis. Obstet Gynecol 1999;93:880-8 The risk may be decreased among recent post-menopausal HRT users. Nanda K et al. Hormone replacement therapy and the risk of colonrectal cancer: a meta-analysis. Obstet Gynecol 1999;93:880-8

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Colorectal Cancer Large increase in the number of endoscopy suites (from less than 10 in 1990 to over 30 in 2001). Large increase in the number of endoscopy suites (from less than 10 in 1990 to over 30 in 2001). Over 30,000 gastroscopies and colonoscopies done yearly. Soweid A et al. GI endoscopy in Lebanon: past, present and future. Gastrointest Endosc 2001;54:279-281 Over 30,000 gastroscopies and colonoscopies done yearly. Soweid A et al. GI endoscopy in Lebanon: past, present and future. Gastrointest Endosc 2001;54:279-281 Recent increase in the use of HRT in Lebanon, promoted as a preventive measure against osteoporosis. Recent increase in the use of HRT in Lebanon, promoted as a preventive measure against osteoporosis.

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Public Health Implications Brain Cancer Significant increase in Brain cancer among females between 1993-1998. Significant increase in Brain cancer among females between 1993-1998. Cellular phones effects!!! Cellular phones effects!!! Radio-frequency radiation emitted by cell phones and brain tumors?? Some studies show increased risk of brain tumors with an OR of 2.4 for ipsilateral use of cell phones ( Hardell L. et al Ionizing radiation, cellular telephones and the risk for brain tumours. European Journal of Cancer Prevention, 2001). While other studies do not show that the hand-held cellular telephones causes brain tumors, they admit that their data are not sufficient to evaluate the risks among long-term, heavy users. Inskip P et al. Cellular-Telephone Use and Brain Tumors. The New England Journal of Medicine 2001, Johanssen C et al. Cellular telephone and cancer- a nationwide cohort study in Denmark. J Natl Cancer Inst, 2001. Radio-frequency radiation emitted by cell phones and brain tumors?? Some studies show increased risk of brain tumors with an OR of 2.4 for ipsilateral use of cell phones ( Hardell L. et al Ionizing radiation, cellular telephones and the risk for brain tumours. European Journal of Cancer Prevention, 2001). While other studies do not show that the hand-held cellular telephones causes brain tumors, they admit that their data are not sufficient to evaluate the risks among long-term, heavy users. Inskip P et al. Cellular-Telephone Use and Brain Tumors. The New England Journal of Medicine 2001, Johanssen C et al. Cellular telephone and cancer- a nationwide cohort study in Denmark. J Natl Cancer Inst, 2001. Researchers conclude that even small risks would be of considerable public health importance. Inskip P. Researchers conclude that even small risks would be of considerable public health importance. Inskip P.

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The major objectives of the registry were: To establish and maintain a cancer incidence reporting system. To establish and maintain a cancer incidence reporting system. To be an informational resource for the investigation of cancer and its causes To be an informational resource for the investigation of cancer and its causes To provide information to assist public health officials and agencies in the planning and evaluation of cancer prevention and cancer control programs. To provide information to assist public health officials and agencies in the planning and evaluation of cancer prevention and cancer control programs. To provide a primary source of unbiased population-based cases for investigators seeking to conduct case-control or cohort studies, clinical trials and survival analysis. To provide a primary source of unbiased population-based cases for investigators seeking to conduct case-control or cohort studies, clinical trials and survival analysis. NCR Objectives - 2001

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NCR obtained its data in 2002 from only one source, that of the MOPH Drug Dispensing Center (DDC). NCR presented its 2002 report, admitting that it had covered no more than 40% of all cases. NCR obtained its data in 2002 from only one source, that of the MOPH Drug Dispensing Center (DDC). NCR presented its 2002 report, admitting that it had covered no more than 40% of all cases. Salim Adib, 2004 Salim Adib, 2004 NCR Report 2002

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Limitations 1.Incompleteness of data: only 40% of the cases were captured in the 2002 report 2.Epidemiological measures: only relative frequencies no incident measures 3.Incompleteness of cancer-specific data specifically for cancer pathology 4.Data retrieval: there is a need for a unified and systematic process for cancer data retrieval

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Data Collection 2003 In 2003, LSMO in cooperation with LCEG decided to continue their support of the 2003 data collection (5 years from the 1998 data). At the same time, the NCDP and MOPH continued their efforts to gather the 2003 data. In 2003, LSMO in cooperation with LCEG decided to continue their support of the 2003 data collection (5 years from the 1998 data). At the same time, the NCDP and MOPH continued their efforts to gather the 2003 data. Funds provided by the Italian Cooperation in Lebanon and LSMO. Funds provided by the Italian Cooperation in Lebanon and LSMO. These efforts led to a better data collection for the year 2003. These efforts led to a better data collection for the year 2003.

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NCR Committee In May 2005 the decree 230/1 was issued from the HE Dr. Mohammad Jawad Khalifeh, Minister of Public Health, creating an oversight Committee for the National Cancer Registry in Lebanon. In May 2005 the decree 230/1 was issued from the HE Dr. Mohammad Jawad Khalifeh, Minister of Public Health, creating an oversight Committee for the National Cancer Registry in Lebanon.

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The Lebanese National Cancer Registry The Future

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The Lebanese National Cancer Registry (NTR) Function Define the size of the cancer problem Define the size of the cancer problem Determine patterns of occurrence of various cancers Determine patterns of occurrence of various cancers Monitor cancer trends over time. Monitor cancer trends over time. Guide planning and evaluation of cancer control programs: Guide planning and evaluation of cancer control programs: Prevention Prevention Screening Screening Treatment Treatment Help set priorities for allocating health resources. Help set priorities for allocating health resources. Advance clinical, epidemiologic and health services research. Advance clinical, epidemiologic and health services research.

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Confidentiality Ownership Mode of Collection

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Data Collection A consistent system for data collection must be defined. A consistent system for data collection must be defined. Issue a ministerial decree or a mandate law that categorizes cancer as a mandatory notifiable disease. Issue a ministerial decree or a mandate law that categorizes cancer as a mandatory notifiable disease. The NCR must have full access to cancer data from: The NCR must have full access to cancer data from: All governmental and private hospitals All governmental and private hospitals Clinics Clinics Pathology and hematology laboratories. Pathology and hematology laboratories. The registry must The registry must Provide a unified software package Provide a unified software package Set-up and training to these centers Set-up and training to these centers

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Data Collection Clinical data are coded by a trained tumor registrar by means of the International Classification of Disease (ICD-O3) Clinical data are coded by a trained tumor registrar by means of the International Classification of Disease (ICD-O3) The registrar will check for missing information on abstracts collected from different health sources (avoid duplication). The registrar will check for missing information on abstracts collected from different health sources (avoid duplication). Data entry and analysis using the CANREG-4 cancer registration computer software developed by International Agency for Research on Cancer (IARC) Data entry and analysis using the CANREG-4 cancer registration computer software developed by International Agency for Research on Cancer (IARC)

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National Cancer Registry Confidentiality and Consent Data Ownership and Publication Rights Data Quality Legal and Ethical Aspects of Cancer Data To be discussed in the afternoon workshop To be discussed in the afternoon workshop

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Patients Follow-Up Follow up of cancer patients is the systematic process of obtaining accurate information at least annually, on the patient's health, vital status, and progression of disease. Follow up of cancer patients is the systematic process of obtaining accurate information at least annually, on the patient's health, vital status, and progression of disease.

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An adequate staff and budget must be provided to handle follow-up volume. The staff must be trained and qualified to represent the institution in this process. An adequate staff and budget must be provided to handle follow-up volume. The staff must be trained and qualified to represent the institution in this process.

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NCR Annual Caseload

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Figure1. Cancer Cases in Lebanon (1990-2010)

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Crude Incidence Rate of All Cancers in Lebanon 1990-2010

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NCR Staff Requirements for 2006 Registry Manager: Registry Manager: Manages Manages Supervises Supervises Coordinates the activities of the registry Coordinates the activities of the registry Tumor Registrar Tumor Registrar Data collection/cross checking Data collection/cross checking Data coding Data coding Data mainteinance Data mainteinance Administrative Assistant Administrative Assistant Data collection Data collection Data entry Data entry General assistance General assistance Driver or office boy ? Driver or office boy ? Research assistants as needed. Research assistants as needed.

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Marketing NCR Information and Services The registry must develop customer bases and create a demand for registry services.

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Potential markets for cancer data services are numerous and include national organizations, private agencies, hospitals, physicians, pharmaceutical companies as well as the general public. Increasing the usage of cancer data is a matter of exposing the registry's potential customers to the services it offers. Potential markets for cancer data services are numerous and include national organizations, private agencies, hospitals, physicians, pharmaceutical companies as well as the general public. Increasing the usage of cancer data is a matter of exposing the registry's potential customers to the services it offers.

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The NCR can only continue if it is reinforced by a major contribution that is independent from financial uncertainties, bureaucratic inconsistencies and poor managerial decisions. Only a firm and written commitment from the MOPH to provide continuous support can make the NCR a success. The NCR can only continue if it is reinforced by a major contribution that is independent from financial uncertainties, bureaucratic inconsistencies and poor managerial decisions. Only a firm and written commitment from the MOPH to provide continuous support can make the NCR a success.

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NATIONAL CANCER REGISTRY CANCER IN LEBANON 2003 & 2004

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49.9% 50.1% Men Women GENDER (2003) DEMOGRAPHIC CHARACTERISTICS OF INCIDENT CANCER CASES IN LEBANON 2003 & 2004 N = 7142 cases N = 7197 cases GENDER (2004)

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DEMOGRAPHIC CHARACTERISTICS OF INCIDENT CANCER CASES IN LEBANON 2003-2004 N=7197 N=7142

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MEAN AGE IN YEARS BY SEX CANCER CASES 2003-2004

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DIFFERENCES IN AGES BY GENDER FOR SELECTED CANCER TYPES Lung

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DIFFERENCES IN AGES BY GENDER FOR SELECTED CANCER TYPES Colorectal

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DIFFERENCES IN AGES BY GENDER FOR SELECTED CANCER TYPES Leukemia

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DIFFERENCES IN AGES BY GENDER FOR SELECTED CANCER TYPES 2003 Lymphoma 0 5 10 15 20 25 30 35 40 45 MaleFemale

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DIFFERENCES IN AGES BY GENDER FOR SELECTED CANCER TYPES 2004 Non-Hodgkin Lymphoma

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DIFFERENCES IN AGES BY GENDER FOR SELECTED CANCER TYPES 2004 Hodgkin Lymphoma

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0 5 10 15 20 25 30 35 40 45 BEIRUT MOUNT-LEBANON NORTH-LEBANON SOUTH-LEBANON NABATIEH BEKAA INCIDENT CANCER CASES BY AREA OF RESIDENCE, LEBANON 2003 40,9 18,8 15 10.5 15.4 Metn Baabda others 6.5 10.3 Tripoli Others 16,8 10,5 6,37,9 5.5 5 Saida Others

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INCIDENT CANCER CASES BY AREA OF RESIDENCE, LEBANON 2004

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5.8 5.2 2.2 1.8 16 4.5 0.7 42.3 17.6 15.2 3.5 5 4.1 3.2 2 1.4 0.9 0.4 0.2 0 5 10 15 20 25 30 35 40 45 ColonRectumLung Breast Prostate NHL L LeukemiaBladderM LeukemiaOther leukemia Males Females RELATIVE FREQUENCY OF CANCER SITES BY GENDER 2003 2004

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0 5 10 15 20 25 30 35 34.5 13.9 8.8 5.9 5.5 3.4 2.9 2.5 16.8 Leukemia Meninges and brain Bone and cartilage Kidney Non-Hodgkin's lymphoma Soft/connective tissue Eye Testis Hodgkin's lymphoma Lung and trachea Others SITES OF PEDIATRIC CANCERS, LEBANON 2003 2004

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PRIMARY SITES N AGE-SPECIFIC RATES per 100,000 CRUDE RATES ASR UN0-1415-2425-3435-4445-5455-6465-7475+ Oro-pharynx72120.180.550.701.499.6217.4711.3317.004.03 3.79 Stomach114120.180.550.704.488.2519.0636.2656.656.39 6.17 Colon-rectum281260.550.284.559.9623.3743.6987.25147.3015.74 15.43 Liver3330.180.280.350.502.063.1817.0011.331.85 1.77 Pancreas5840.000.000.001.498.259.5323.8017.003.25 3.38 Larynx103110.000.000.352.499.6215.8935.1359.495.77 5.62 Lung546510.920.281.4013.4555.67112.00175.63280.4431.6 31.62 Skin melanoma 5550.181.100.003.496.195.5612.4631.163.08 3.04 Prostate587790.000.000.350.5014.4381.02264.01424.9132.8929.88 Testis7921.483.318.759.965.502.80.002.834.43 4.29 Kidney6750.740.280.702.496.8713.5019.2617.003.75 3.81 Bladder569800,180.002.8011.4632.99101.67193.76311.6031.88 29.51 CANCER INCIDENCE RATES AMONG MALES IN LEBANON 2003

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PRIMARY SITESN AGE-SPECIFIC RATES per 100,000 CRUDE RATES ASR UN0-1415-2425-3435-4445-5455-6465-7475+ Meninges & brain10232.962.484.98.479.6214.307.9311.335.87 H lymphoma7830.923.598.402.996.193.977.9317.004.374.17 NH lymphoma17082.031.933.1514.9413.0623.0339.6662.329.529.70 Multiple myeloma3910.00 6.198.7415.8611.332.182.40 Leukemias170117.953.862.8010.9610.3114.3026.0645.329.529.31 All cancers356538022.3625.1247.61109.5263.9545.71078.71682.6199.71191.29 ASR:Age-standardized rates CANCER INCIDENCE RATES AMONG MALES IN LEBANON 2003

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PRIMARY SITESN AGE-SPECIFIC RATES per 100,000 CRUDE RATES ASR UN0-1415-2425-3435-4445-5455-6465-7475+ Oro-pharynx95280.80.50.92.75.613.81.52.34.9 4.75 Stomach149310.00.80.67.314.415.32.38.17.6 7.45 Colon-rectum309780.00.51.37.317.037.29.113.615.8 15.45 Liver57100.50.00.31.45.65.81.71.82.9 2.85 Pancreas5930.0 0.32.36.310.21.53.13.0 2.95 Larynx104170.0 0.96.924.03.12.95.3 5.20 Lung5631040.80.03.88.645.292.516.018.528.8 28.15 Skin melanoma2470.00.80.02.71.90.00.20.81.2 1.20 Prostate5521131.50.30.00.510.166.319.435.228.227.6 Testis72100.72.57.37.71.90.70.00.33.7 3.60 Kidney61110.70.00.31.85.610.21.51.03.1 3.05 Bladder5611590.70.31.05.427.670.614.925.528.7 28.05 CANCER INCIDENCE RATES AMONG MALES IN LEBANON 2004

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PRIMARY SITESN AGE-SPECIFIC RATES per 100,000 CRUDE RATES ASR UN0-1415-2425-3435-4445-5455-6465-7475+ Meninges & brain10772.21.34.59.55.618.91.10.35.55.35 H lymphoma8261.74.05.15.98.83.60.00.54.24.10 NH lymphoma273232.71.54.516.828.233.55.38.913.913.65 Multiple myeloma5340.30.00.30.55.69.51.42.62.72.65 Leukemias164105.73.54.15.911.911.72.74.98.48.20 All cancers358667521.520.339.199.36234.7455.286.78 137. 9183.2179.30 ASR:Age-standardized rates CANCER INCIDENCE RATES AMONG MALES IN LEBANON 2004

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AGE-ADJUSTED CANCER RATES PER 100,000 IN SELECTED COUNTRIES (1997-2002) 0 50 100 150 200 250 300 350 400 450 AlgiersSao Paolo CanadaBeijingLebanonKuwaitBas-RhinSaar ASR/Males

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PRIMARY SITESN AGE-SPECIFIC RATES PER 100,000 CRUDE RATES ASR UN0-1415-2425-3435-4445-5455-6465-7475+ Oro-pharynx4620.591.440.633.521.967.599.9316.552.542.59 Stomach88100.000.580.946.179.8214.4123.1738.624.855.13 Colon-rectum151240.200.862.517.9325.5239.4481.65154.48.3214.65 Liver2640.00 0.442.622.8214.3413.791.43 1.53 Pancreas5000.000.310.005.246.0724.2730.342.76 2.93 Lung & bronchus224130.000.637.4919.6349.3070.62121.3712.3413.3513.17 Bone3221.730.000.443.931.522.210.001.76 1.92 Skin melanoma2660.000.631.765.242.286.628.281.43 1.55 Breast13021370.5817.26134.82 244.0 9 203.2 8221.78262.0571.7471.76 78.26 Cervix uteri8140.290.314.4116.3613.6924.2711.034.46 4.95 Corpus uteri88100.290.633.0814.4016.6925.3830.344.85 5.30 Ovary1680.00 5.893.792.210.000.88 1.06 Kidney3870.290.312.202.624,5511.038.282.09 2.21 Bladder106210.000.312.2010.4721.2433.1071.715.84 6.25 CANCER INCIDENCE RATES AMONG FEMALES IN LEBANON 2003

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PRIMARY SITESN AGE-SPECIFIC RATES PER 100,000 CRUDE RATES ASR UN0-1415-2425-3435-4445-5455-6465-7475+ Meninges & brain6051.443.774.415.892.289.935.523.31 3.35 Thyroid73160.862.519.2512.436.077.7216.554.02 4.24 H lymphoma4550.393.463.453.523.933.791.100.002.482.41 NH lymphoma133120.793.173.775.739.1621.2429.7966.207.337.52 Multiple myeloma2700.00 1.321.965.318.8316.551.491.57 Leukemia10254.322.022.515.737.2013.6516.5544.135.626.32 All cancers357734718.4720.1849.58233.82456.12497.58723.83 1078.5 3197.14190.70 CANCER INCIDENCE RATES AMONG FEMALES IN LEBANON 2003

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PRIMARY SITESN AGE-SPECIFIC RATES PER 100,000 CRUDE RATES ASR UN0-1415-2425-3435-4445-5455-6465-7475+ Oro-pharynx3150.5 0.32.02.41.40.51.01.61.55 Stomach134300.50.30.64.89.013.93.25.16.76.70 Colon-rectum283650.40.01.71.023.434.25.214.014.2 Liver42100.00.30.01.63.63.50.91.82.12.10 Pancreas5780.0 2.44.27.71.52.52.92.85 Lung & bronchus215380.20.00.63.622.234.25.56.410.810.75 Bone3961.81.61.72.41.20.70.30.52.01.95 Skin melanoma2330.0 2.41.22.10.60.81.21.15 Breast13832670.21.311.196.9194.2183.316.919.369.569.15 Cervix uteri94200.0 0.96.011.412.51.31.54.74.70 Corpus uteri125290.0 3.618.020.21.72.86.36.25 Ovary166350.31.01.68.223.414.63.1 8.38.30 Kidney3760.90.30.60.43.63.50.61.31.91.85 Bladder110370.40.50.31.26.612.51.65.15.55.50 CANCER INCIDENCE RATES AMONG FEMALES IN LEBANON 2004

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PRIMARY SITESN AGE-SPECIFIC RATES PER 100,000 CRUDE RATES ASR UN0-1415-2425-3435-4445-5455-6465-7475+ Meninges & brain8021.82.42.03.68.49.81.30.54.04.00 Thyroid111240.21.84.98.49.09.11.00.85.65.55 H lymphoma5640.44.22.92.46.03.50.10.52.82.80 NH lymphoma212220.71.34.35.621.619.56.36.410.710.60 Multiple myeloma3520.0 4.26.31.01.8 1.75 Leukemia10615.02.92.62.04.211.82.41.55.3 All cancers360665215.421.337.1170.4405.8432.160.185.2181.3180.30 CANCER INCIDENCE RATES AMONG FEMALES IN LEBANON 2004

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AGE-ADJUSTED CANCER RATES PER 100,000 IN SELECTED COUNTRIES (1997-2002) 0 50 100 150 200 250 300 AlgiersSao Paolo CanadaBeijingLebanonKuwaitBas- Rhin Saar ASR/Females

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AGE DISTRIBUTION (%) OF INCIDENT CANCER CASES IN LEBANON 2004 (N=7197) AGE DISTRIBUTION (%) OF INCIDENT CANCER CASES IN LEBANON 2004 (N=7197)

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CHANGES IN INCIDENCE RATES (partially valid because of uncertain denominators) ASR196619982004 Males102.8154.2179.3 Females104.1134.8180.3

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Acknowledgements Ministry of Public Health Ministry of Public Health Lebanese Cancer Epidemiology Group Lebanese Cancer Epidemiology Group AUB Registry Staff AUB Registry Staff NCDP Staff NCDP Staff NCR Committee and Staff NCR Committee and Staff Italian Cooperation Group Italian Cooperation Group Lebanese Society of Medical Oncology Lebanese Society of Medical Oncology Lebanese Cancer Society Lebanese Cancer Society Lebanese Society of Pathology Lebanese Society of Pathology Lebanese Society of Hematology Lebanese Society of Hematology

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THANK YOU www.public-health.gov.lb/en/prev --> epidemiological surveillance unit cancer www.public-health.gov.lb/en/prev