Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-047049 on 19 August 2021. Downloaded from Cancer in Lahore, Pakistan, 2010–2019: an incidence study Farhana Badar ,1 Shahid Mahmood2 To cite: Badar F, Mahmood S. ABSTRACT Strengths and limitations of this study Cancer in Lahore, Objectives To study the cancer incidence rates over 10 Pakistan, 2010–2019: an years (2010–2019), in Lahore, Pakistan. ► As part of cancer surveillance, this is the first time incidence study. BMJ Open Design An incidence study. 2021;11:e047049. doi:10.1136/ that the age-standardised incidence rates have Setting The population- based Punjab Cancer Registry bmjopen-2020-047049 been presented for any region of Pakistan, over an was established in 2005 in Lahore, which is the provincial extended 10- year period. ► Prepublication history and metropolis of the province of Punjab (five rivers), and ► The age- specific incidence rates have been com- additional supplemental material is located in the northeast region of Pakistan. The puted for cancers commonly diagnosed among fe- for this paper are available coordinating office of the Registry is located within males and males, in the district of Lahore, Pakistan. online. To view these files, Shaukat Khanum Memorial Cancer Hospital and Research please visit the journal online ► Mortality statistics could not be generated because Center. Both the active and passive forms of data (http:// dx. doi. org/ 10. 1136/ of the ongoing follow- up issues and the absence of collection are used. bmjopen- 2020- 047049). a central death registry. Participants Residents of the district of Lahore diagnosed Received 17 November 2020 with cancer. The average annual population of Lahore was Accepted 09 August 2021 estimated at 11.1 million. Outcome measures Cancer counts and incidence rates The latest version of Cancer Incidence in Five per 100 000 population, by age- group, sex and cancer site/ Continents, Volume XI (CI5 XI), published type, over 10 years. by the International Agency for Research Results In Lahore, from 2010 to 2019, 58 394 incident on Cancer (IARC), shares information from cases were reported, with the majority seen in females (57.1%). Adults accounted for 92.2%, adolescents 343 population-based cancer registries in 65 2.2% and children 5.6% of the total cases. Per 100 000 countries on cancers diagnosed from 2008 2 population, the age- standardised incidence rate was to 2012. Of these 65 countries, 17 are in 103.4 for females and 65.6 for males. Among females, the Asia. However, Pakistan is not listed in these highest incidence rates were recorded for breast cancer countries. Population- based results from http://bmjopen.bmj.com/ (76.7) in adults, bone tumour (1.2) in adolescents and Pakistan were last included in CI5 Volumes lymphoid leukaemia (1.6) in children, and among males, VIII and IX, with the latter being released prostate cancer (10.7) in adults, bone tumour (2.2) in in 2007.3 The statistics were based on new young adults and lymphoid leukaemia (2.4) in children. cancer diagnoses within the geographically The age- specific incidence rates peaked in the 60–70 year demarcated Karachi South district of the group, reaching a high of 420 per 100 000 in women and province of Sindh, representing a population 330 per 1 00 000 men. 3 Conclusions In Lahore, the incidence rates for cancers of 1.7 million during 1998–2002. Karachi is on September 25, 2021 by guest. Protected copyright. of the breast, prostate, lymphoid leukaemia and bone a coastal town located in the southernmost © Author(s) (or their were among the highest documented. More cases were part of the country, adjacent to the Arabian employer(s)) 2021. Re- use recorded in females than in males. The results reported sea, at a distance of nearly 1200 km from permitted under CC BY-NC. No could be used as a reference point for assessing the Lahore.3 The Karachi Registry stopped func- commercial re- use. See rights effectiveness of future interventions. and permissions. Published by tioning when Dr Yasmin Bhurgri, who had BMJ. established the Registry, passed away in 2012. 1Cancer Registry and Clinical However, this Registry is now being revived. Data Management, Shaukat BACKGROUND A recent report on cancer incidence in the Khanum Memorial Cancer In 2020, Pakistan, categorised as a lower- Karachi division for 2017–2019 has shown Hospital and Research Centre, middle- income country in South Asia, had a that the data were collected from eight Lahore, Punjab, Pakistan 2 population of nearly 220 million with a Gross centres of Karachi, which has a population Cancer Registry and Clinical 1 Data Management, Shaukat Domestic Product of US$263 billion. In such of nearly 16 million, and that tobacco- related Khanum Memorial Cancer a heavily populated country, cancer registra- malignancies and breast cancer were the most Hospital and Research Centre, tion should be a requirement for programme common diagnoses.4 However, this report Lahore, Pakistan planning and evaluation to alleviate its does not mention any problems related to Correspondence to morbidity and mortality. In reality, it is not the functioning of the Registry. Further, two Dr Farhana Badar; so. Cancer surveillance is a challenging task reports representing the time periods 2010– farhana@ skm. org. pk in most developing countries of the world. 2019 and 2010–2015 from a hospital-based Badar F, Mahmood S. BMJ Open 2021;11:e047049. doi:10.1136/bmjopen-2020-047049 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-047049 on 19 August 2021. Downloaded from cancer registry of Dow University in Karachi indicate the Union Council.18 This has been problematic in esti- that the importance of cancer registration has been mating patient survival in the region. recognised, and this could pave the way for promoting population- based cancer registration in the region.5 6 Structure of the registry Moreover, an institutional cancer registry has also been The administrative centre of the Registry is the Cancer established by the Pakistan Atomic Energy Commission Registry and Clinical Data Management unit of Shaukat that collates data from 17 cancer hospitals of the Commis- Khanum Memorial Cancer Hospital and Research Center sion.7 Other than this, the Shaukat Khanum Cancer (SKMCH&RC), Lahore, Pakistan. The focal persons Registry, a hospital- based registry, has been in existence involved in this project are an epidemiologist/biostatisti- for more than 25 years and it collates and reports its data cian, medical coders and cancer registry officers, 10–13 in regularly.8 Additionally, efforts are being made to estab- number. Over 40 members in 22 hospitals and laboratories lish a National Cancer Registry in Pakistan though it is in the private and government sectors report their cases to still in its initial stage.9 the central office (online supplemental appendix 1). This Cancer registration has been ongoing in Lahore for is through a mutual agreement between these centres. over a decade and the incidence rates have been reported The representatives from these centres serve on the in three different studies, with the last one covering a Governing Council of the Registry and assist in decision- period of 6 years (2010–2015).10–12 Even though the inci- making about the Registry. The Registry is sponsored by dence rates have been computed, both patient follow-up the Shaukat Khanum Memorial Trust, registered under and collection of mortality data have been problem- the Societies Registration Act of Pakistan, and is a member atic throughout.10–12 Nevertheless, the study now being of the International Association of Cancer Registries. reported was conducted to determine the population- Data collection based cancer incidence rates in Lahore, by sex, age- The surveillance system uses both the active and passive group and cancer site/type, over 10 years. This is the forms of data collection from various hospitals and labo- first time that cancer statistics over a 10- year period are ratories, thereby collecting detailed data on new cancer being reported for any region of Pakistan. It is hoped that diagnoses among the residents of a geographically the data provided will assist policymakers ascertain how defined area of the district of Lahore, included in the healthcare delivery needs should be met most effectively catchment area of the Registry.17 Data sources include the through the allocation of existing and anticipated future medical records from inpatient admissions, outpatient/ resources. emergency assessment visits, hospital death certificates, pathology/operative reports, chemotherapy/radio- therapy logs, radiology/nuclear medicine reports and METHODS triage clinics. The information on the demographics and http://bmjopen.bmj.com/ Study setting diagnostic findings is collected on a prescribed form with Pakistan and the catchment area uniform data standards and definitions (online supple- There are five regions in Pakistan, and Punjab accounts mental appendix 2). The information is entered into the for nearly 50% of the population of the country. Lahore Registry database within the electronic Hospital Informa- is the capital and one of the 36 districts of Punjab.13 14 It tion System of SKMCH&RC, developed in Oracle by the is located in the northeast of the country, west of India.15 Information Technology staff. The total land area of the district is 1772 sq km. with the Incidence date population density being 6300 per sq km.16 Nearly 95% on September 25, 2021 by guest. Protected copyright. The incidence date on the data capture form is defined of the residents of Lahore are Muslims, whereas only 5% as the date of cytological/histological confirmation of constitute the minority.15 16 malignancy on a pathology report; the date of consul- tation at an outpatient clinic/walk- in clinic (without a Punjab Cancer Registry clinical investigation or a tissue diagnosis); the date of History clinical investigation(s) as imaging or tumour markers In 2005, the Registry was established in Lahore, within a confirming the diagnosis; the date of admission to the 17 densely inhabited Punjab.