University of Nebraska Medical Center DigitalCommons@UNMC Theses & Dissertations Graduate Studies Spring 5-6-2017 Epidemiologic and Clinical Profiles of Uterine Cancer in the Gharbiah Province of Egypt Saad Alshahrani University of Nebraska Medical Center Follow this and additional works at: https://digitalcommons.unmc.edu/etd Part of the Clinical Epidemiology Commons, Community Health and Preventive Medicine Commons, Environmental Public Health Commons, Epidemiology Commons, Public Health Education and Promotion Commons, and the Women's Health Commons Recommended Citation Alshahrani, Saad, "Epidemiologic and Clinical Profiles of Uterine Cancer in the Gharbiah Province of Egypt" (2017). Theses & Dissertations. 188. https://digitalcommons.unmc.edu/etd/188 This Dissertation is brought to you for free and open access by the Graduate Studies at DigitalCommons@UNMC. It has been accepted for inclusion in Theses & Dissertations by an authorized administrator of DigitalCommons@UNMC. For more information, please contact [email protected]. Epidemiologic and Clinical Profiles of Uterine Cancer in the Gharbiah Province of Egypt By Saad Alshahrani A DISSERTATION Presented to the Faculty of the University of Nebraska Graduate College in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Epidemiology Graduate Program Under the Supervision of Professor Amr Soliman University of Nebraska Medical Center Omaha, Nebraska March, 2017 Supervisory Committee: Amr Soliman, MD, Ph.D. Jane Meza, Ph.D. Robert M. Chamberlain, Ph.D. Steven Remmenga, M.D. i Acknowledgements I would like to express my deepest gratitude to my advisor, Professor Amr Soliman for his continuous thoughtful guidance, patience, motivation and providing me with great research skills and immense knowledge. I would like to show my warm thanks to my supervisory committee members, Professor Robert M. Chamberlain, Professor Jane Meza and Professor Steven Remmenga who supported me at every bit and without whom it was impossible to accomplish the end task. Special thanks to Dr. Ahmad Hablas, the director of Gharbiah Cancer Society in Egypt, and his team Dr. Ibrahim A. Seifeldin, Dr. Mohamed Ramadan, Dr. Hoda Gad and Mr. Khalid Dabboos for their help and support during my visit to Gharbiah Cancer Society for data collection. Thanks are also due to faculty, staffs, and students of the epidemiology department at the University of Nebraska Medical Center for their unfailing support and assistance. A very special gratitude goes out to King Fahad Specialist Hospital in Saudi Arabia for helping and granting me the scholarship to pursue my doctoral degree. Finally, I would like to pay special thankfulness, warmth, and appreciation to my family_ my parents, brothers, and sisters_ for their constant supports, prayers, and love. Also, I wish to express my unqualified thanks to my wife Nouf for her unconditional trust, timely encouragement, and endless patience. My sincere thanks extended to my sons Anas and Elias and my daughters Hanin and Hala for giving me happiness during my studies and for their patience with the busy father. They all kept me going, and this ii achievement would not have been possible without them, and I dedicate this milestone to them. iii Abstract: Epidemiologic and Clinical Profiles of Uterine Cancer in the Gharbiah Province of Egypt Saad Alshahrani, Ph.D. University of Nebraska Medical Center, 2017 Supervisor: Amr Soliman, M.D, Ph.D. Background: Uterine cancer is one of the top-ranking cancers of women with wide international variations in incidence rates. Egypt has a lower incidence of uterine cancer than other countries in the Middle East. In addition to the international incidence variation, there are also wide variations in incidence by rural and urban areas within countries. Therefore, this research project focused on the Gharbiah province, north of Cairo in the Nile Delta, with the aims of investigating demographic and clinical characteristics of uterine cancer, assessing rural/urban variation in incidence rates, and evaluating the possible role of hysterectomy in under-estimating the disease incidence in this population. Methods: Uterine cancer data of 660 cases were obtained from the Gharbiah Population- based Cancer Registry in Gharbiah, Egypt during the period 1999-2010. The hysterectomy data of 1040 cases were abstracted from the main pathologic labs over the entire region. The Egypt 2006 data census was used to determine the total population of Gharbiah and the rural and urban subgroups. Crude, age-standardized (ASR), and age- specific rates were calculated and associated with demographic and clinical characteristics of patients. The uterine cancer incidence pre- and post- adjustment for hysterectomy prevalence were compared and 95% confidence intervals (CIs) were calculated. iv Results: The results confirmed the low ASR of uterine cancer in Gharbiah, [4.1 per 100,000 (95% CI: 3.8-4.4)]. The incidence rate significantly increased over the 12-year period. The ASR was 2.5 times higher in urban areas compared to rural areas (6.9 and 2.8 per 100,000), in urban and rural areas, respectively. The prevalence of hysterectomy did not have a significant impact on the uterine cancer incidence rate. Conclusions: The study confirmed the low incidence rate of uterine cancer in the Gharbiah province of Egypt and a statistical significant increase in incidence in recent years. Although, the rate of uterine cancer in this population increased over the past decade, it is still lower than the corresponding global rates. The lack of evidence about the possible role of hysterectomy in lowering of uterine cancer rates adds to the need for research to identify the apparent protective factors for uterine cancer in this population. v Table of Contents Acknowledgements .............................................................................................................. i Abstract: ............................................................................................................................. iii Table of Contents ................................................................................................................ v List of Tables: .................................................................................................................. viii List of Abbreviations ......................................................................................................... ix Chapter 1: ............................................................................................................................ 1 Background ......................................................................................................................... 1 Anatomy and Histology of Uterus: ............................................................................................................. 1 Physiology and Hormonal Changes: ........................................................................................................... 1 Types of Uterine Cancer: .................................................................................................... 2 Pathologic Subtypes and Genomic Classification of Uterine Cancer:................................ 2 Pathogenesis of Uterine Cancer: ......................................................................................... 4 Tumor Staging and Grading System: .................................................................................. 5 Symptoms and Diagnosis of Uterine Cancer: ..................................................................... 8 Treatment of Uterine Cancer: ............................................................................................. 9 Risk Factors ...................................................................................................................... 11 Age: ........................................................................................................................................................... 11 Parity: ........................................................................................................................................................ 11 Family History and Genetic Disorder: ...................................................................................................... 11 Obesity: ..................................................................................................................................................... 12 Diabetes Mellitus:...................................................................................................................................... 13 Hormone Replacement Therapy (HRT): ................................................................................................... 13 Tamoxifen: ................................................................................................................................................ 14 Age of Menarche and Menopause: ............................................................................................................ 14 Protective Factors.............................................................................................................. 15 Contraceptive hormones: ........................................................................................................................... 15 Smoking: ................................................................................................................................................... 15 Physical activity: