Saudi Journal of Gastroenterology
Home About us Instructions Submission Subscribe Advertise Contact Login    Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
Users Online: 1075 


 
ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 13  |  Issue : 2  |  Page : 84-87
Clinico-pathological patterns of colorectal cancer in Saudi Arabia: Younger with an advanced stage presentation


Division of Gastroenterology, King Khalid University Hospital, Riyadh, Saudi Arabia

Click here for correspondence address and email
 

   Abstract 

Aim: Colorectal cancer (CRC) is the third most common cancer in the world. The aim of this study was to identify the clinical and pathological features of CRC in a tertiary care hospital in Saudi Arabia. Materials and Methods: This is a retrospective study of all patients diagnosed to have CRC at King Khalid University Hospital in Riyadh, Saudi Arabia over a 10 year period (1995-2005). The data collected from medical files, endoscopy and imaging reports included age, gender, clinical presentation, smoking, relevant past or family history, site and size of the tumor, stage, carcinoembryonic antigen level and tumor grade. Results: A total of 113 patients were included over the 10 year period. The average age at diagnosis was 55 years (S.D.=15), 58% of the patients were males and 42% were females. Thirty-seven percent of the patients were 50 years of age or younger. The most common clinical presentation was abdominal pain (68%) followed by rectal bleeding (62%) and weight loss (55%). Left-sided lesions and rectal cancer constituted 76% and 48% of all CRC tumors respectively. Sixty-eight percent of lesions were stage C and above. Forty-five percent of patients presented with complete large bowel obstruction. Conclusion: In this analysis, we found that Saudi patients were more likely to present with colorectal cancer at a more advanced stage of the disease and at younger ages compared to Western populations. This data suggests the need for a mass screening program to be implemented for this common and preventable cancer in Saudi Arabia.

Keywords: Colon cancer, rectal cancer, Saudi Arabia, stage.

How to cite this article:
Aljebreen AM. Clinico-pathological patterns of colorectal cancer in Saudi Arabia: Younger with an advanced stage presentation. Saudi J Gastroenterol 2007;13:84-7

How to cite this URL:
Aljebreen AM. Clinico-pathological patterns of colorectal cancer in Saudi Arabia: Younger with an advanced stage presentation. Saudi J Gastroenterol [serial online] 2007 [cited 2019 Sep 19];13:84-7. Available from: http://www.saudijgastro.com/text.asp?2007/13/2/84/32183


Colorectal cancer (CRC) is the third most common cancer in the world and the second leading cause of cancer-related deaths in the United States. [1] Globally, the incidence of CRC varies widely with higher incidence rates in North America, Australia and northern and western Europe. Developing countries have lower rates, particularly Africa and Asia. [2] Age is a major risk factor for sporadic CRC. It is a rare diagnosis before the age of 40 with the incidence beginning to increase significantly between the ages of 40 and 50 years and age-specific incidence rates increasing in each succeeding decade thereafter. [3] Large differences exist in survival rates and are generally related to the stage of the disease at diagnosis. It is estimated that 394,000 deaths still occur worldwide annually in the European Union due to colorectal cancer. [4] Data relating to CRC from the Middle-eastern region is still scarce and the aim of this study was to identify the clinical and pathological features of this disease in a tertiary care hospital in Riyadh, Saudi Arabia.


   Materials and Methods Top


This is a retrospective study of all patients diagnosed to have CRC at King Khalid University Hospital in Riyadh, Saudi Arabia over a 10 year period (1995-2005). It was approved by the departmental Ethics Committee. We first searched for colorectal cancer cases in our endoscopy reports and then reviewed the medical files, laboratory data and imaging reports of all of these cases. Variables like age, sex, nationality, history of smoking or alcohol consumption, relevant past or family history, tumor location, disease stage (Duke's classification), mode of presentation, carcinoembryonic antigen (CEA) levels and pathology reports were assessed.

The location of the tumor was categorized as right colon and left colon. Right colon tumors were of the appendix extending to the hepatic flexure and transverse colon whereas left colon tumors were of the splenic flexure extending to the sigmoid colon and rectum. CEA levels were considered high when the levels were more than 5 ng/ml. Subgroup analyses of clinico-pathological features of patients under 50 years of age were compared with those above 50 years of age using Chi-square and Fishers exact tests. P value of < 0.05 was considered significant.


   Results Top


A total of 118 patients were diagnosed as having CRC over the 10 year period from1995-2005. Five patients were excluded because of incomplete data, so we only included 113 patients for this analysis. The average age at diagnosis was 55 years (S.D.=15); 58% of the patients were males and 42% were females. Forty-two patients (37%) were 50 years of age or younger. One hundred patients (89%) were Saudi nationals. The most common clinical presentation was abdominal pain (n=77, 68%) followed by bleeding per rectum (62%), weight loss (55%), constipation (50%), melena (14%), fever and anemia (6%) [Table - 1]. Two patients (2%) had a family history of colon cancer (familial adenomatous polyposis). Two more patients (2%) had a history of inflammatory bowel disease (ulcerative colitis).

The tumor was located in the rectum in 54 patients (48%), in the sigmoid or descending colon in 28%, in the transverse colon in 3.5%, and 22% had right-sided lesions (ascending colon or cecum). Left-sided lesions constituted 76% of all tumors. Twenty-five percent and 27% of patients were found to have synchronous tumor and adenomas respectively. Sixty-eight percent of lesions were stage C and above, i.e., involvement of the local lymph nodes and distant metastases (stage A (2%), stage B (20%), stage C (32%) and 36% presented with liver metastasis) [Table - 2]. Fifty-one patients (45%) presented with complete large bowel obstruction. Histopathology showed that 56% of tumors were moderately differentiated, 24% were well-differentiated and 10% were poorly differentiated adenocarcinomas whereas 9% had only dysplasia (including carcinoma in situ). CEA levels were available for 44 patients and were elevated in 14 of them (32%) with a mean level of 4.3 ng/ml.

When we compared patients who were above 50 years of age to those who were under 50 years of age, we found no significant statistical difference between the 2 groups in terms of sex, symptomotology, associated risk factors, site of the primary tumor, stage of disease at diagnosis and histological grading [Table - 3].


   Discussion Top


Colorectal cancer is considered the second most frequent cause of death in most Western countries just after cancer of the lung in men and breast and lung cancer in women. Approximately 55,100 deaths were supposed to have occurred in United States in the year 2006. [5] How many actually occurrred that we are in 2007 if you say "predicted"? Worldwide, colorectal cancer represents 9.4% of all incidental cancers in men and 10.1% in women. [4] The risk of developing CRC increases with age. Incidence rates decreased by 1.8% per year during 1998-2002 in the United States, this partly reflects increased screening and polyp removal, which prevents progression of polyps to cancer. [6]

According to the latest cancer incidence report from the Saudi National Cancer Registry, [7] in 2001, there were 753 cases of CRC accounting for 6.6% of all newly diagnosed cancers. CRC was ranked fourth among all cancers in both males and females in Saudi Arabia with an overall age-standardized rate (ASR) of 4.9/100,000 population. In our study, we found that only 22% of CRC cases were localized, while 36% presented with distant metastasis and 45% presented with large bowel obstruction. Total=103% These findings were far greater than the figures reported from Western communities (35-40% of CRC cases were localized, only 18% presented with distant metastasis and only 8% presented with obstruction), [8] but were comparable to Hispanics in the United States (33%). [9] These findings in our community could be related partly to the absence of screening programs in the country.

Another important finding in our study was that 37% of our patients were 50 years of age or younger, the incidence being higher than that reported from Western populations. However, this observation is comparable to findings reported by other investigators from Saudi Arabia and regional countries. This suggests a possible hidden familial risk for colon cancer and identifies the need for a mass screening program for CRC, preferably for individuals aged 40 years and above. However, this aspect could be better studied and prospectively validated in a controlled study.

Mansoor et al. [10] reported that 39% of their patients were below 50 years of age which is consistent with our findings. From 2000-2003, the median age for cancer of the colon and rectum was 71 years of age in the American population. [6] Evidently, none were diagnosed under the age of 20 years; 0.9% between 20 and 34 years of age; 3.5% between 35 and 44 years; 10.9% between 45 and 54 years; 17.6% between 55 and 64 years; 25.9% between 65 and 74 years; 28.8% between 75 and 84 years; and 12.3% were above 85 years of age. [6] Based on the current recommendations for colorectal cancer screening at 50 years of age, 39% of the Saudi population with colorectal cancer would not be diagnosed at the time of screening.

Seventy-six of our CRC cases were left-sided, which is somewhat higher than the number in the United States (60%). This finding was consistent with other findings previously reported by other investigators from Saudi Arabia. [10],[11] Ayyub et al. [11] and Mansoor et al. [10] reported that left-sided lesions constituted about 68% of all CRC cases. Ayyub et al. found that 60% of patients had stage C or D CRC whereas only 23% had distant metastasis. [11] Other Middle-eastern countries (Jordan and Qatar) have reported almost similar findings in terms of disease-stage and location of CRC. [12],[13]

We did not find any differences in either the clinical or the pathological features among patients who were above 50 years of age and those who were under 50 years of age. Al-Jaberi et al. [12] reported their findings in Jordanian patients where 68% of their patients who were younger than 40 years already had an advanced stage (C or D) of CRC compared to only 40% of those who were above 40 years of age. Fifty-six percent of tumors in our study were moderately differentiated adenocarcinoma, which is comparable to both local [10] and worldwide findings. [8] In conclusion, in this analysis we found that Saudi patients present with colorectal cancer at a more advanced stage of the disease at younger ages compared to Western populations. We believe this data supports the case for a general population-based screening program in Saudi Arabia for this common and preventable cancer. Additional studies are required to determine the appropriate age for screening.

 
   References Top

1.Howe HL, Wu X, Ries LA, Cokkinides V, Ahmed F, Jemal A, et al . Annual report to the nation on the status of cancer, 1975-2003, featuring cancer among U.S. Hispanic/Latino populations. Cancer 2006;107:1711-42.  Back to cited text no. 1    
2.Parkin DM, Pisani P, Ferlay J. Global cancer statistics. CA Cancer J Clin 1999;49:33-64,1.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Eddy DM. Screening for colorectal cancer. Ann Intern Med 1990;113:373-84.  Back to cited text no. 3  [PUBMED]  
4.Boyle P, Langman JS. ABC of colorectal cancer: Epidemiology. BMJ 2000;321:805-8.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Jemal A, Siegel R, Ward E, Murray T, Xu J, Smigal C, et al . Cancer statistics, 2006. CA Cancer J Clin 2006;56:106-30.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Jemal A, Clegg LX, Ward E, Ries LA, Wu X, Jamison PM, et al . Annual report to the nation on the status of cancer, 1975-2001, with a special feature regarding survival. Cancer 2004;101:3-27.   Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.National Cancer Registry. Cancer Incidence Report, Saudi Arabia 1994-2001. Ministry of Health: Riyadh (KSA); 2001. p. 48-9.  Back to cited text no. 7    
8.Ries LA, Wingo PA, Miller DS, Howe HL, Weir HK, Rosenberg HM, et al . The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer. Cancer 2000;88:2398-424.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Stefanidis D, Pollock BH, Miranda J, Wong A, Sharkey FE, Rousseau DL, et al . Colorectal cancer in Hispanics: A population at risk for earlier onset, advanced disease and decreased survival. Am J Clin Oncol 2006;29:123-6.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Mansoor I, Zahrani IH, Abdul Aziz S. Colorectal cancers in Saudi Arabia. Saudi Med J 2002;23:322-7.  Back to cited text no. 10  [PUBMED]  
11.Ayyub MI, Al Radi AO, Khazeindar AM, Nagi AH, Maniyar IA. Clinicopathological trends in colorectal cancer in a tertiary care hospital. Saudi Med J 2002;23:160-3.  Back to cited text no. 11    
12.Al Jaberi TM, Ammari F, Gharieybeh K, Khammash M, Yaghan RJ, Heis H, et al . Colorectal adenocarcinoma in a defined Jordanian population from 1990 to 1995. Dis Colon Rectum 1997;40:1089-94.  Back to cited text no. 12    
13.Rasul KI, Awidi AS, Mubarak AA, Al Homsi UM. Study of colorectal cancer in qatar. Saudi Med J 2001;22:705-7.  Back to cited text no. 13    

Top
Correspondence Address:
Abdulrahman M Aljebreen
Gastroenterology Division, King Khalid University Hospital, Riyadh, 11321, PO Box 231494
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.32183

Rights and Permissions



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3]

This article has been cited by
1 Higher prevalence of KRAS mutations in colorectal cancer in Saudi Arabia: Propensity for lung metastasis
Talha Bader,Abdelsalam Ismail
Alexandria Journal of Medicine. 2014;
[Pubmed] | [DOI]
2 Clinico-Pathological Patterns and Survival Outcome of Colorectal Cancer in Young Patients: Western Saudi Arabia Experience
Shereef Ahmed Elsamany,Abdullah Saeed Alzahrani,Mervat Mahrous Mohamed,Soha Ali Elmorsy,Jamal Eddin Zekri,Ahmed Saleh Al-Shehri,Rasha Mostafa Haggag,Ahmed Abdel-Reheem Alnagar,Hani Abdalla El Taani
Asian Pacific Journal of Cancer Prevention. 2014; 15(13): 5239
[Pubmed] | [DOI]
3 Knowledge, Attitude, Practice, and Perceived Barriers of Colorectal Cancer Screening among Family Physicians in National Guard Health Affairs, Riyadh
Eyad Demyati
International Journal of Family Medicine. 2014; 2014: 1
[Pubmed] | [DOI]
4 First national survival data for colorectal cancer among Saudis between 1994 and 2004: what’s next?
Mahmoud S Al-Ahwal,Yasmin H Shafik,Hazem M Al-Ahwal
BMC Public Health. 2013; 13(1): 73
[Pubmed] | [DOI]
5 Clinicopathological correlation and prognostic significance of VEGF-A, VEGF-C, VEGFR-2 and VEGFR-3 expression in Colorectal cancer
Martins, S.F. and Garcia, E.A. and Luz, M.A.M. and Pardal, F. and Rodrigues, M. and Filho, A.L.
Cancer Genomics and Proteomics. 2013; 10(2): 55-68
[Pubmed]
6 First national survival data for colorectal cancer among Saudis between 1994 and 2004: Whatæs next?
Al-Ahwal, M.S. and Shafik, Y.H. and Al-Ahwal, H.M.
BMC Public Health. 2013; 13(1)
[Pubmed]
7 Histopathologic characteristics and short-term outcomes of colorectal cancer in young tunisian patients: One centeræs experience
Bouassida, M. and Feidi, B. and Mroua, B. and Chtourou, M.F. and Sassi, S. and Chebbi, F. and Bouchtili, S. and Mighri, M.M. and Touinsi, H. and Azzouz, M.M. and Sassi, S.
Pan African Medical Journal. 2012; 12(1)
[Pubmed]
8 Status of mismatch repair genes hMSH2 and hMSH6 in colorectal cancer in Saudi patients: An immunohistochemical analysis [Statut des gènes dæappariement et de réparation hMSH2 et hMSH6 chez des patients saoudiens atteints dæun cancer colorectal: Analyse immunohistochimique]
Alkhalidi, H. and Kfoury, H.
Eastern Mediterranean Health Journal. 2012; 18(11): 1114-1117
[Pubmed]
9 The adiponectin gene, ADIPOQ, and genetic susceptibility to colon cancer
Al-Harithy, R.N. and Al-Zahrani, M.H.
Oncology Letters. 2012; 3(1): 176-180
[Pubmed]
10 Patientsæ Profile, Clinical Presentations and Histopathological Features of Colo-rectal Cancer in Al Hassa Region, Saudi Arabia
Tarek Tawfik Amin, Waseem Suleman, Abdul Aziz Al Taissan, Abdul Latif Al Joher, Othman Al Mulhim, Abdul Hameed Al Yousef
Asian Pacific Journal of Cancer Prevention. 2012; 13(1): 211
[VIEW] | [DOI]
11 Use of the single cell gel electrophoresis (comet assay) for comparing apoptotic effect of conventional antibodies versus nanobodies
Ghada H. Shaker, Nahla A. Melake
Saudi Pharmaceutical Journal. 2011;
[VIEW] | [DOI]
12 Evaluation of quality parameters of rectal cancer surgery at the Coloproctology Unit of Hospital de Braga
de Castro, M.A.P. and Martins, S.F.F.
Journal of Coloproctology. 2011; 31(4): 362-371
[Pubmed]
13 Cytokeratin 20 and vascular endothelial growth factor as molecular markers in Egyptian patients with colorectal cancer
Auf, F.A. and El-Eibdy, G.K. and Mosaad, Y.M. and El-Ghannam, D.M. and El-Masry, E.E.
Journal of Oncology Pharmacy Practice. 2011; 17(3): 160-167
[Pubmed]
14 Clinicopathological patterns of colorectal cancer in Tunisia
Missaoui, N. and Jaidaine, L. and Abdelkader, A.B. and Beizig, N. and Anjorin, A. and Yaacoubi, M.T. and Hmissa, S.
Asian Pacific Journal of Cancer Prevention. 2010; 11(6): 1719-1722
[Pubmed]
15 Role ofNigella sativaand a number of its antioxidant constituents towards azoxymethane-induced genotoxic effects and colon cancer in rats
Dalal Al-Johar,Neptune Shinwari,Jamal Arif,Nasser Al-Sanea,Alaa Abdul Jabbar,Raæafat El-Sayed,Abdullah Mashhour,Grisellhi Billedo,Inaam El-Doush,Iman Al-Saleh
Phytotherapy Research. 2008; 22(10): 1311
[Pubmed] | [DOI]
16 Role of Nigella sativa and a number of its antioxidant constituents towards azoxymethane-induced genotoxic effects and colon cancer in rats
Al-Johar, D., Shinwari, N., Arif, J., Al-Sanea, N., Jabbar, A.A., El-Sayed, R., Mashhour, A., (...), Al-Saleh, I.
Phytotherapy Research. 2008; 22(10): 1311-1323
[Pubmed]
17 Multiple primary cancers of the colon, rectum, and the thyroid gland
Zubaidi, A.
Saudi Journal of Gastroenterology. 2008; 14(4): 202-205
[Pubmed]



 

Top
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Materials and Me...
    Results
    Discussion
    References
    Article Tables

 Article Access Statistics
    Viewed7620    
    Printed209    
    Emailed6    
    PDF Downloaded1009    
    Comments [Add]    
    Cited by others 17    

Recommend this journal