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LUNG CARCINOMA TYPES GENDER AND ITS CHANGING TREND IN THE PUNJAB 2008-2012.

Byline: Rubab .Z. Kahlon Ibtisam Butt Samina .T. Azeemi and Naveed Akbar

ABSTRACT: Lung carcinoma is the foremost cause of both morbidity and mortality in the world with an expected growth rate of 1.67 million each year. Purpose of the present study was to observe the prevalence of different lung cancer types in both genders and to observe their varying trends with time. It is a retrospective analytical study from 2008 to 2012. Total 1498 patients were analyzed for this research. Cases only from the Punjab province were included in the present study. Data was analyzed in SPSS version 15.0 and the tests applied for analysis were Paired Samples T- Test and One Samples T- Test. Squamous Cell was found in 26.08% of cases. The overall male to female ratio was 34.33:7. Squamous Cell Carcinoma prevalence increased from17.57- 27% while the Adenocarcinoma increased from 10-15.3%. Non- Small Cell type showed decrease from 28-11.3%. Increased in the prevalence of Squamous Cell Carcinoma was found in both male and females.

While as the changes in the prevalence of Large Cell Carcinoma were found only in male. In our region Squamous cell carcinoma was the most widespread variant of lung cancer followed by the small cell carcinoma. Male to female ratio across the various histological patterns did not show important variation. Increase prevalence in squamous cell carcinoma was statistically significant in both genders but in the case of adenocarcinoma change in its prevalence was only significant in females.

Keywords: Lung cancer Histopathology Gender prevalence Chromotherapy Punjab.

INTRODUCTION:

Lung cancer has been considered as one of the deadliest form of non-communicable disease to mankind. Western culture influences and dietary way of life have to be resulted in lung cancer (1). Lung cancer is now estimated as one of the most common cancer in world. It is also the most common reason of morbidity and mortality worldwide in both male and females with 1.67 million cases and 1.38 million deaths (18.2% of the total deaths). Majority of cases are now occurring in the developing countries as compared to developed countries (2). Uncontrolled growths of abnormal cells cause a disease that is known as cancer. Lung cancer begins to develop when normal cells start to damage. Primary lung cancer symptoms include cough chest pain coughing up blood and shortness of breath (3).

Global trends indicate that there has been a shift in the distribution of histological types of lung cancer since the decade of the 1980s with adenocarcinoma now being the most commonly diagnosed histological subtype of lung cancer in most locales. This contrasts with squamous cell carcinoma being the most predominant morphologic pattern documented in most cancer registries up until the 1980s (4). Changing trends in histological patterns of lung cancer has observed during different time periods and it is due to change in different risk factor like smoking. Besides smoking other factors of lung cancer expansion are tobacco chewing dietary habits occupational exposure and as well as indoor and outdoor pollution. Though the survival rate for all types of lung cancer is poor and the prognosis is not more than 5 years (5). Non-small cell lung (NSCL) cancer constitutes 80% of all cases of lung cancer and 30-40% of that is Squamous cell carcinoma (6).

In developing countries like Pakistan lung cancer incidence is rising at an alarming rate in current years especially in male lung cancer which is now on top the list. Approximately 3 million lung cancer patients in Pakistan annually registered. Out of which 1 62000 were from the Punjab (7). Diagnosis of lung carcinoma at an earlier stage is palpable but high cost of diagnosis make it difficult to acknowledge at an early stage. A lot of patients in developing countries like Pakistan die because of lack of awareness high cost of treatment and failure to attend treatment centers at earliest.

The study was conducted to see the prevalence of different lung cancer types in both gender and to observe their varying trends with time.

MATERIALS AND METHODS:

A retrospective study was conducted. Data for the present study was collected from 11 lung cancer dealing hospitals. Data of some hospitals were taken directly by visiting concerned hospitals. While the data of some hospitals were taken from Pakistan Society of Clinical Oncology a Government organization was formed on 21st November 1999 that retains data on the epidemiological and clinic- pathologic feature of cancers and then formulates a central registry. Society collects data of all cancer's type affecting people in the Punjab through local hospitals and registers it in digital database. Data analyzed for the study was over the period of 2008-2012. Patients from all districts of the Punjab province were included in the present study. Only lung carcinoma patients with gender and histological findings were included while the patients of other carcinomas were excluded.

Data was arranged and tabulated in MS Excel 2010 and analyzed in SPSS (version 15) by using Paired-Samples T Test and One-Samples T Test. Results were considered significant when the pless than 0.05.

RESULTS:

Total 1498 Cases of lung cancer were analyzed. Overall patient's population was ranged from young to old age. Out of the total 1498 cases Squamous cell carcinoma was found to be the most prevailing with 388 cases (26.08%) followed by Small cell carcinoma (19.08%) Adenocarcinoma (18.48%) Non- small cell carcinoma (16.73%) Carcinoid carcinoma (11.56%) undifferentiated carcinoma (4.23%) and large cell carcinoma (3.83%) as shown in Figure.1. There were 1236 males and 252 females in the total with overall male to female ratio of 34.3:7. This ratio was the highest in Squamous cell carcinoma patients (6.5:1) followed by the Small cell carcinoma (5.6:1) Carcinoid (4.9:1) Non-small cell (4.2:1) and Adenocarcinoma (4:1).

Throughout the study period the prevalence of Squamous Cell Carcinoma was increased from 17.57- 27% (p=0.035). Similarly Adenocarcinoma showed an increase of 10.0- 15.3 % (p=0.072) and carcinoid carcinoma also showed an increase of 12.1- 16.4 %( p=0.026) but on the other hand Non- small cell showed a decrease from 28.0-11.3% (p=0.021) and in Small cell carcinoma decrease was also seen from 22.5- 18.9% (p= 0.0348) Undifferentiated type also showed the decrease of 7.5-6.5% (p= 0.031) which is obvious from Table 1. Overall in both genders the squamous cell cancer was found to be the most prevalent in males (26.94%) and females (21.8%) as shown in Table-2. However in both genders a statistically significance increase in the prevalence of Squamous cell carcinoma had been shown across the study period (male: p= 0.020 females: p=0.021).

DISCUSSION: Major findings that have emerged from our analyses are as follows:

First of all it has been noticed from the data collected from all the cancer registries of the Punjab that there was persistence increase of Squamous cell carcinoma in both male and female. Prevalence of the Squamous cell carcinoma may be an attribute of the smoking behavior which was thought to be more strongly connected with Squamous cell carcinoma than

Adenocarcinoma. One cause would be the switching from the non-filtered cigarettes to the filtered cigarettes. Early cigarettes were primarily high tar products unfiltered and the smoke from these products was considered to be irksome to the central bronchi where the squamous cell carcinomas mainly arise (4).

Some studies showed the Adenocarcinoma the most common type in both genders with relative prevalence ranging between 38.3-52.5% (8 9). Though a momentous number of studies have reported Squamous cell carcinoma to be the most widespread histological type with frequency ranging from 42.7% (5 10 and 11). These results were in good agreement with our study which showed Squamous cell carcinoma to be the most prevalent type 26.08% (table 3). The ratio male to female in the present study was 34.3:7 which was not compatible in other Asian countries 2.67:1 (5). In our study the ratio was the highest in Squamous cell carcinoma (6.5:1) which was much similar to the results shown by other researches (5 8). During the five years study period a significant increases was seen in the prevalence of Squamous cell carcinoma (p=0.021). Although small cell carcinoma was the second most prevalent type in our study but it failed to show a significant change in its prevalence over time (p=0.035).

Some studies have shown an increase in the prevalence of Squamous cell carcinoma which are in good agreement with our study (5). However this was in dissimilarity to obtain literature which has shown Adenocarcinoma the second most prevalent type (5). Increase in the prevalence of Squamous cell carcinoma was noteworthy in both genders (male= 0.020 females=0.021). While as far as Adenocarcinoma is concerned major change in its incidence was only noted in females (0.024). This was not in contrast to some studies which have shown an increase in the prevalence of squamous cell carcinoma in both genders with time (5

Table 1: Histological Patterns of various lung carcinomas during the year 2008-2012

###Lung Cancer Type###2008###2009###2010###2011###2012###Total###P

###Small Cell###54(22.59)###36(21.42)###47(18.00)###95(17.39)###52(18.97)###284###0.035

###Non Small Cell###67(28.03)###27(16.07)###50(19.15)###74(13.53)###31(11.31)###249###0.021

###Adenocarcinoma###24(10.04)###36(21.42)###41(15.70)###132(24.17)###42(15.32)###275###0.072

###Squamous Cell###42(17.57)###38(22.61)###81(31.03)###153(28.02)###74(27.00)###388###0.021

###Large Cell###5(2.092)###3(1.785)###14(5.363)###23(4.212)###12(4.37)###57###0.106

###Undifferentiated###18(7.531)###12(7.142)###4(1.532)###11(2.014)###18(6.56)###63###0.031

###Carcinoid###29(12.13)###16(9.523)###24(9.195)###58(10.62)###45(16.42)###172###0.026

###Total Cases (N)###239###168###261###546###274###1488

Table 2: Gender-Wise Histological Patterns of Lung Cancer from 2008-2012

###Lung Cancer Type###2008###2009###2010###2011###2012###Total###P

###Small Cell###M###40(21.3)###29(22.4)###41(19.1)###92(19)###39(17.4)###241###0.012

###F###14(27)###7(18)###6(2.80)###3(4.76)###13(25.4)###43###0.015

###Non-Small Cell###M###47(25.1)###22(17.0)###40(18.6)###68(14)###24(10.7)###201###0.009

###F###20(38.5)###5(12.8)###10(21.2)###6(9.52)###7(13.7)###48###0.025

###Adenocarcinoma###M###18(9.62)###25(19.37)###34(15.8)###109(22.5)###34(15.2)###220###0.056

###F###6(11.8)###11(28.2)###7(14.8)###23(36.5)###8(15.6)###55###0.024

###Squamous Cell###M###37(19.7)###30(23.2)###69(32.2)###131(27.1)###66(29.5)###333###0.020

###F###5(9.61)###8(20.5)###12(25.5)###22(34.9)###8(15.6)###55###0.021

###Large Cell###M###5(2.67)###2(1.55)###9(4.20)###21(4.34)###8(3.58)###45###0.050

###F###-###1(2.56)###5(10.6)###2(3.17)###4(7.84)###12###0.061

###Undifferentiated###M###16(8.55)###9(6.97)###2(0.93)###10(2.07)###16(7.17)###53###0.015

###F###2(3.84)###3(7.69)###2(4.25)###1(1.58)###2(3.92)###10###0.003

###Carcinoid###M###24(12.8)###12(9.30)###19(8.87)###52(10.7)###36(16.1)###143###0.15

###F###5(9.61)###4(10.2)###5(10.6)###6(9.52)###9(17.6)###29###0.003

###Total Cases (N)###M###187###129###214###483###223###1236

###F###52###39###47###63###51###252

Table 3: Histological Patterns of Lung Cancer in various Studies

###Author###Year###Region###Squamous###Cell###Adenocarcinom(%)###Small###Cell

###Carcinoma (%)###Carcinoma (%)

###Present Study###2014###Punjab Pakistan###26.08###18.48###19.08

###Siddiqui###2010###Khyber###42.7###20.3###16.4

###Pakhtunkhwa

###Menon###1979###Finland###34###25###12

###Perng###1996###Taiwan###37.1###38.3###12.2

###Sntoz- Martine###2005###Malaysia###33###30###-

###Lee###2000###Korea###44.7###27.9###-

In the present study it has also been found that the rate of lung carcinoma incidence among male population peaked throughout the study period as compared to the female population. Both statistical and clinical researches established an optimistic relationship between exposure to the tobacco smoke and the incidence of lung cancer (4). It is expected that around 90% of lung cancers in male and 79% in female are directly attribute to smoking exposure (4). Besides smoking habits it may be because of the air pollution and occupational exposures. Men spend more time outside so that they are more prone to air pollution radon and asbestos.

Even though available data clearly demonstrates differing trends in lung cancer incidence the rates for squamous cell Non- small cell Small cell undifferentiated and Carcinoid carcinoma among men peaked in 2008 but decreased in the year 2009. Trends in the incidence rates among men for small cell non-small cell adenocarcinoma squamous cell large cell carcinoma increased during the year 2010 and 2011 but in 2012 the incidence of all major histological type showed a dramatic decrease as compared to the last two years as shown in figure 2. On the contrary in females the incidence rate for small cell non- small cell and carcinoid were peaking in the 2008 but in 2009 a decrease was seen in these carcinoma types and an increase was noticed in the incidence rate of adenocarcinoma squamous cell and undifferentiated carcinoma than 2008. In 2010 rise in the incidence of squamous non- small large cell and carcinoid carcinoma was also observed among women.

However during 2011 except adenocarcinoma and squamous cell carcinoma decrease was seen in the incidence of all carcinoma types among females. In 2012 incidence rate of all types were increased expect adenocarcinoma and squamous cell carcinoma. It was also noticed that overall number of females were reduced in 2012 than the year 2011 as shown in figure 3.

It is also interesting to note that overall fluctuations in lung carcinoma incidence from 2008-2012 was seen. This may be because of so many reasons:- In years ( 2008 2010 2011) when high incidence were reported reasons can be improved registry system modification in the definition of new biopsy techniques which have greatly improved the diagnosis. But on the other hand in years (2009 2012) when low incidence rate was reported. It may be because of low awareness among people about lung cancer poor registry system and financial condition of the people and high inflation could have also effected reporting.

One major point that arise from our study is a large gap was seen in number of cases from 2011-2012.

SUGGESTIONS

Our findings suggested that due to illiteracy and unawareness most of the patients do not get registered in hospitals so a proper data registry system is required not only at district level but also at tehsil level. It is also suggested that people should be given awareness about the importance of routine medical checkup for early detection and availability of cancer treatments. As per study it was concluded that people are also very interested in taking first line treatment at home. Previously Chromotherapy (treatment with visible range electromagnetic radiations colors) has shown remarkable effect on antioxidant enzyme superoxide dismutase (13). Chromotherapy has also been suggested as a low cost safe yet an effective treatment for lung cancer (14 15). It is also suggested that Cancer awareness campaigns are required especially for rural population and print and electronic media (newspaper radio TV) cancer hospitals and cancer research centers can play a main role in this context.

In addition working and environmental factors responsible for higher cancer in male should be reduced and such chemicals should be strictly banned e.g. tobacco alcohol smoke. Factories waste having carcinogens and asbestos should be properly wasted to make sure that it is harmless for public. These are the some measures which can be taken to reduce cancer. In addition such studies should be conducted on larger scale and at regular intervals.

ACKNOWLEDGEMENTS

The authors would like to acknowledge Dr. Shaharyar President of Pakistan Society of Clinical Oncology and all the hospitals' Oncology Department heads for their cooperation in data collection and abstraction.

REFERENCES

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15. Azeemi Shamsuddin Rang-o-Roshni sey Elaj" Al- Kitab Publications Karachi
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Date:Feb 28, 2015
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