POINT PREVALENCE OF COLORECTAL CANCER IN A MEGA CITY OF PAKISTAN, KARACHI – A CROSS SECTIONAL STUDY

*Sheikh Abdul Khaliq1image, Anab Fatima2image, M. Ghias Uddin Siddiqui3image, Mahmood Sheikh4image, 

Ayeshah Zaib-Un-Nisa1image

1Department of Pharmacy Practice, Faculty of Pharmacy, Hamdard University, Karachi – 74600, Pakistan.

2Dow College of Pharmacy, Faculty of Pharmaceutical Sciences, Dow University of Health Sciences, Karachi, Pakistan.

3ATCO Laboratories Ltd., S.I.T.E, Karachi - 75700, Pakistan.

4Researcher, Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Pakistan – 75270.

ABSTRACT 

Background and Objective: Globally, Colorectal Cancers are also third most common cancers and fourth leading cause of death due to carcinoma. Burden of Colorectal Cancers is also high in Pakistan. The main risk factor for Colorectal Cancer is age, however, other risk factors are e.g. family history, irritable bowel disease, sedentary life-style, high visceral adipose tissues, smoking and alcohol. Hence; the main objective of current study was to determine point prevalence of Colorectal Cancers in a mega city of Pakistan, Karachi; a representative population of Pakistan. It is hypothesized that incidences of Colorectal Cancers would be higher in Karachi than rest of the country.   

Materials and Methods: The retrospective cross-sectional study was conducted in Karachi. Duration of study was from January-2015 to October-2019. Data has been collected from two state-owned and four private hospitals of Karachi. Precision analysis technique was used to determine the sample size of study. Study is approved by Board of Advanced Studies & Research, University of Karachi (Reference Number: BASR/01046/Pharm.). Objective of study was explained to patients before initiation the study; informed consent was taken from each patient. S.P.S.S (Statistical-Package-for-Social-Sciences) software version 22 was used to analyze the data.

Results: Among 1,617 patients: male 54.35% (N=879); female 45.64% (N=738). Mean age of diagnosis of colorectal cancer: male 49.51±14.72 years; female 45.28±13.52 years. Significantly higher point prevalence was found in ethnicity speaking Sindhi compared with ethnicity speaking Balochi (p=0.001), Pashto (p=0.0001), Punjabi (p=0.001) and Siraiki (p=0.0001); Urdu speaking compared with Balochi speaking (p=0.0001), Pashto speaking (p=0.0001), Punjabi speaking (p=0.0001) and Siraiki speaking (p=0.0001) in male. In female; Sindhi speaking point prevalence is significantly higher than Siraiki speaking (p=0.028); Urdu speaking point prevalence is significantly higher than patients speaking Balochi (p=0.012), Pashto (p=0.002), Punjabi (p=0.002) and Siraiki (p=0.0001).  

Conclusion: Allocation of resources is required at governmental and non-governmental level for early screening. National cancer registry program should also be initiated to support health policy makers for the development of counter strategies.    

Keywords: Cancer, colorectal, ethnicities, genders, point-prevalence.

 

INTRODUCTION

 

Gastrointestinal Tract (GIT) carcinomas are third leading cancers in a mega city of Pakistan, Karachi1. Alarming situation is that, mean age of diagnosis of any type of cancer in Karachi has shifted from 51.20 years to 45.75 in male; 50 years to 44.07 in female1. Globally, Colorectal Cancers (CRC) is also third most common cancers and fourth leading cause of death due to carcinoma2. Similarly, burden of CRC is also high in Pakistan; according to a meta-analysis conducted in Northern part of Pakistan; prevalence of colorectal cancer in Pakistan is 4-6%3. Although CRC affects both genders; however, its incidences are more observed in male4. Despite such high prevalence; majority of population is unaware about screening of CRC; population have perception that screening procedures are very expensive and facilities are scarce5. Sigmoidoscopy is the preferred technique for the screening purpose in Pakistan6.  

The main risk factor for CRC is age, however, other risk factors e.g. family history, irritable bowel disease (IBD), sedentary life-style, high visceral adipose tissues, smoking and alcohol consumption cannot be overlooked7. Recent evidence suggests that heme-iron in the processed red meat also cause CRC; the proposed mechanism behind such outcome is the production of cytotoxic heme factor, which promotes apoptosis in epithelial cells of colon and compensatory epithelial cells growth8. Heme also causes lipid per-oxidation; hence produce free-radicals, formation of N-nitroso compounds and ultimately initiation of CRC8. Although increase amount of body fat contributes as a risk for CRC; nevertheless, waist circumference is strongly associated risk factor for CRC than Body Mass Index (BMI)9. Crohn’s disease; a type of IBD causes chronic inflammation in the large intestine; hence create microenvironment suitable for the hyperplasia of colonic epithelial cells, which leads to CRC10.

In a clinic-pathological analysis of 348 cases of CRC; increase in tumor infiltrating neutrophils (TIN) are associated with significantly higher grade (p=0.0222) of CRC and advanced TNM (Tumor size; lymph node involvement; metastasis) stage (p=0.0346)11.   Karachi is a mega city of Pakistan and thickly populated12. It is also called mini-Pakistan13 because all ethnic groups of country live here; therefore, population of Karachi is a true representative of country population. Hence; the main objective of current study was to determine point prevalence14 of CRC in a mega city of Pakistan, Karachi; a representative population of Pakistan. It is hypothesized that incidences of CRC would be higher in Karachi than rest of the country.

 

MATERIALS AND METHODS

 

Study Design, Place and Duration: The study design was retrospective cross-sectional; place of study was city of Karachi. Study began on January 2015 and ended on October 2019. 

Sample Size of Study: Precision analysis technique was used to determine the sample size of study15. Although minimum sample size for sufficient power (80%) of study was 299 patients; however, study includes 1617 patients from different centers.

Ethical Approval: Study is approved by Board of Advanced Studies & Research, University of Karachi (Reference Number: BASR/01046/Pharm.). Objective of study was explained to patients before initiation the study; informed consent was taken from each patient. As per Declaration of Helsinki; it was ensured to maintain the confidentiality of patients’ data16. 

Data Collection Method: Data were collected from two state-owned and four private hospitals of Karachi. 

Inclusion criteria: Confirmed diagnosis of CRC by objective findings (Histologically and Cytologically), proven malignancy, age>12 years and no co-morbidities.

Exclusion criteria: Patient is preliminary diagnosed for cancer, objective findings not done, diagnosis is not confirmed, cancer with co-morbidities and children ≤12 years.

Assessment of Data: S.P.S.S (Statistical-Package-for-Social-Sciences) software version 22 was used to analyze the data. Descriptive and inferential (One-Way ANOVA: post-hoc analysis by Scheffe test) statistics were applied.  

 

RESULTS

  

Among total cases; Male are 879 (54.35%) and Female are 738 (45.64%) (Figure 1) Number of cases, point prevalence and descriptive statistics of CRC in male gender. (Table 1) Number of cases, point prevalence and descriptive statistics of CRC in female gender. (Table 2) In a multiple comparison of cases of CRC by one-way ANOVA and post-hoc analysis by Scheffe test reveals significant differences in male (p=0.0001) and female (p=0.0001) genders of ethnic groups. (Table 3 and Table 4).

 

DISCUSSION

 

Incidences of cancers are increasing globally; nevertheless, situation is worst in countries like India, Pakistan, Bangladesh and Sri Lanka17,18. It is also a bleak reality that incidences are rising of Colorectal cancer (CRC) in Karachi, Pakistan. There is no cancer registry program at national level; hence no availability of actual magnitude of CRC. 

Some institutions conducted studies based upon data available in their own medical facility and records. Current study collected the data of CRC from six biggest tertiary care hospitals of a mega city Karachi. Sample size of current study is the largest amongst all studies conducted locally5,19,20. The study reveals that CRC is mostly prevailing in male (54%); however, despite lower number of cases of female (46%), clinically no significant difference observed in both genders. Gender wise distribution of CRC of current study is almost similar to the findings of study conducted by Hassan et al.,5  however, one study demonstrated that CRC incidences are higher in male gender20.

The main objective of current study was to determine point-prevalence of CRC in Karachi. Based upon findings of current study; point prevalnce of CRC is highest in Sindhi (8%) and Urdu speaking (8%) male genders, followed by Balochi (4%), Punjabi (4%) and Pashto (4%) speaking; lowest prevalence found in Siraiki (3%) speaking male. Study conducted by Batool et al.,20  mentioned that CRC is highly prevalent in Urdu speaking population of Karachi. According to findings of current study; mean age of diagnosis of CRC in male gender was 49.51±14.72 years, while in the study of Batool et al.,20; it was 44.43±14.02 years; this fact cannot be overlooked that study of Batool et al.,20 is single centered, while current study is multi-centered. 

In contrast to male gender; among female, highest prevalence was found in Urdu speaking (6%), while lowest in Balochi (3%), Punjabi (3%), Siraiki (3%) and Pashto (3%) speaking. The mean age of diagnosis of CRC in female is found to be 45.28±13.52 years; therefore, it seems that in female CRC occurs at earlier age compare to male. The another study conducted in the province of Punjab reveals that CRC has similar incidences after the age of 45 years in both genders21.

Analysis of current study for male and female genders further revealed the significance and non-significance between the different variables; these variables are ethnicity and point prevalence of CRC. When Sindhi speaking male are compared with other ethnicities male; significantly higher point prevalence was found in patients speaking Sindhi compared with patients speaking Balochi (p=0.001), Pashto (p=0.0001), Punjabi (p=0.001) and Siraiki (p=0.0001). No significant differnce of point prevalence noted with Urdu Speaking (p=0.999). Similarly when Urdu speaking compared with other ethnicities; significantly greater point prevalence noted in Urdu speaking compared with Balochi speaking (p=0.0001), Pashto speaking (p=0.0001), Punjabi speaking (p=0.0001) and Siraiki speaking (p=0.0001). Other comparisons found non-significant differences in the point prevalence. According to International Agency for Research on Cancers (IARC); colorectal, bladder, prostate, lip, oral cavity and larynx are the most prevalent cancers in adult male; while breast, ovary, oral cavity, cervix and uterine cancers are common in adult female of Pakistan22. Similar analysis in female gender found that Sindhi speaking point prevalence is significantly higher than Siraiki speaking (p=0.028), Urdu speaking point prevalence is significantly higher than the patients speaking Balochi (p=0.012), Pashto (p=0.002), Punjabi (p=0.002) and Siraiki (p=0.0001). Other ethnicities comparison found non-significant differences in point prevalence. According to Khaliq et al.,1  in the Sindh province, CRC is third most common cancer in both genders; while Zubair et al.,23 reported it is fifth most common malignancy, while in Punjab it is fifth most prevalent cancer21. The reason of high prevalnce could be urbanization, utilization of fast food, industrial pollution, limited availability of clean drinking water and sedentary life style22.

Limitation of the study

Non availability of a national cancer registry program in Pakistan is a major reason for limited availability of validated data pertaining to incidences and prevalence of cancers; particularly CRC. Results of current study are based upon data collected from six institutions of Sindh province; which cannot be extrapolated for the population of whole country. 

 

CONCLUSION

 

Evaluation of data from six state of the art institutions of Sindh province reveals that CRC is highly prevailing; particularly in the Urdu speaking and Sindhi speaking population. It is more common in male gender. 

 

RECOMMENDATIONS

 

Allocation of resources are required at governmental and non-governmental level for early screening; which may results not only in the reduction of burden of CRC but also significantly decreases the cost burden for the treatment of CRC. National cancer registry program should also be initiated to support health policy makers for the development of counter strategies.    

 

ACKNOWLEDGEMENTS 

 

Authors acknowledge the support of all those state-owned and private institutions of the Sindh province; which provided support for the collection of data.   

 

CONFLICT OF INTERESTS 

 

None of the author has any conflicts of interest.

 

AUTHORS’ CONTRIBUTIONS

 

SAK: Conceived idea, data collection and data analysis; AF: Design the study, final drafting of manuscript and approval of final version; MGS: Literature survey, analysis of data and manuscript review; MS: Manuscript initial drafting and data interpretations; AZ: Literature survey and approval of the final version of manuscript. Final version of manuscript is approved by all authors. 

 

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