Year : 2007 | Volume
: 13 | Issue : 2 | Page : 84--87
Clinico-pathological patterns of colorectal cancer in Saudi Arabia: Younger with an advanced stage presentation
Abdulrahman M Aljebreen
Division of Gastroenterology, King Khalid University Hospital, Riyadh, Saudi Arabia
Abdulrahman M Aljebreen
Gastroenterology Division, King Khalid University Hospital, Riyadh, 11321, PO Box 231494
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.
|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;13:84-87
|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 2020 Jan 17 ];13:84-87
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.  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.  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.  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.  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
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  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.  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. 
According to the latest cancer incidence report from the Saudi National Cancer Registry,  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),  but were comparable to Hispanics in the United States (33%).  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.  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.  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.  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. , Ayyub et al.  and Mansoor et al.  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.  Other Middle-eastern countries (Jordan and Qatar) have reported almost similar findings in terms of disease-stage and location of CRC. ,
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.  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  and worldwide findings.  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.
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