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April 1997, Volume 47, Issue 4

Original Article

Cancer in North West Pakistan and Afghan Refugees

Sher Mohammad Khan  ( Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, Pakistan. )
Jawad Gillani  ( Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, Pakistan. )
Shagufta Nasreen  ( Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, Pakistan. )
Salar Zai  ( Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, Pakistan. )


The medical records of all patients attending the Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar during 1990 to 1994 were analysed to determine the frequency of most common cancers. There were 13,359 adults with biopsy proven cancers of these 10,371 belonged to the North West Frontier province (NWFP) and remaining 2988 were Afghan refugees. In NWFP there were 55% males and 45% females, while in Afghan refugees there were 59% males and 41% females. Patients whose his­topathology was doubtful or not available were excluded from the study. The most common male tumours were skin, lymphoma, oral cancer, urinary bladder, lung, oesophagus, soft tissue, prostate, brain and myeloid leukemia. Among male Afghan refugees the most common cancers were oesophagus, skin, lymphoma, oral cancer, soft tissue, myeloid leukemia, stomach, urinary bladder, testis and colorectal cancer. Breast cancer was the most common cancer in women (JPMA 47:122, 1997).


There are geographic variations in the incidence of cancer. Some tumours are more common in certain regions of the world, while other neoplastic diseases are uniformly distributed throughout the world. In developing countries, the pattern of occurrence of cancer remains to be clearly established1 because clues to the aetiology of tumours may be provided by geographical distribution2. Earlier reports3-5 on cancer pattern from this area has shown variable results and the reliability of this data has been questioned. The aim of the present study was to analyse all patients referred to IRNUM and establish the occurrence of cancer in the North West of Pakistan (N.W.F.P.) and Afghan refugees.

Materials and Methods

The Institute is located in Peshawar, a town bordering Afghanistan. It is the only hospital in the province where radiation and nuclear medicine facilities are available under •one roof. Majority of cancer patients are referred to this hospital for treatment. Accurate and reliable data regarding name, age, sex, the site and nature of cancer were collected, analysed and coded according to WHO6 before entry into computer. Only biopsy proven cancer cases were included in the study. Leukemia was diagnosed using blood tests and biopsy of the bone marrow. The most common cancers in men and women were determined on the basis of their percentage. All cases with inadequate information were excluded.


A total of 13,359 patients were included in this study; of these 10,371 were adults from NWFP, while 2988 were Afghan refugees. Males and females of NWFP were 5707 and 4664 respectively while amongst Afghan refugees, 1755 were males and 1233 females. In NWFP cases skin cancer was the commonest cancer in males (8.9%) followed by lymphoma (8%), oral cancer (7.1%), bladder (5.4%), lung (4.9%), oesophagus (4.6%) (Table I). In male refugees oesophagus was the commonest cancer (16.6%) followed by skin(13.3%), lymphoma (8.7%), oral cancer (4.4%), soft tissue (4.0%), myeloid leukemia (3.6%) (Table I).

In females breast cancer was the commonest (20.8%) in NWFP, followed by skin, ovary, oral carcinoma, oesophagus and cervix (Table II). In femala refugees breast cancer was the most common cancer (20.8%), followed by oesophagus, skin, cervix, lymphoma ovary (Table II).


Skin cancer is the leading cancer in males of NWFP, while it ranks second in women. It is the second common cancer in male and the third in female Afghans. In Rawalpindi7, it is the second common cancer in women but fourthamong men. The frequency of this cancer reported from South8 is not high. The higher frequency of skin cancer in the North and lower in the South of the country points to the possible North South gradient8. The skin colour of the people in this region as well as Afghanistan is lighter. Majority of the people also live at higher altitude are outdoor workers. Skin cancer is reported to be the most common tumour in Afghanistan9 and Iran10,11. Skin cancer is not included in the registries of some countries because it is detected early and is cured. Basal cell carcinomas and squamous cell carcinomas in this region present late and therefore, measures have to be takento prevent and detect it early. Breast cancer is the leading female malignancy in Pakistan4,5. including NWFP. It is the most common cancer in Afghan women also. More than 30% of the women in their fourth decade of life are reported to be suffering from breast cancer in Rawalpindi12. The probability of an average Pakistani woman to seek treatment for breast cancer by the age of 65 years is one to two percent13. Ethnically, majority of the people in the North West of Pakistan and Afghanistan ate the same. Breast cancer is less common in the developing countries, but in this study the pattern of occurrence is the same as in some Western countries14. In India it is the second common cancer in women15. Lymphoma is the second common cancer in men and seventh in women of NWFP. It is the seventh female malignancy among women in India also15. The increased incidence compared to some countries is not clear and further studies are needed..
Oesophageal carcinoma is the sixth commonest cancer in men in local population, while it is the leading one in the Afghans. Both, NWFP and Afghanistan come in the oesophageal cancer belt area which stretches from Caspian Sea to the North of China. It is not clear whether it is due to dietary factors or other environmental factors16. Oesophageal cancer is almost always in the adult Afghans and the exposure to the cancer pmducing agents is probably during childhood.
Oesophageal cancer is however, rare in Southern province of Pakistan. It will be interesting to know the frequency of cancer in the Afghan refugees who are born in Pakistan and who return to their own country. In India it is the second common cancer in males and the third in females15. In Shanghai’7 it is the fourth common cancer in men and the seventh in females. In Japan carcinoma of stomach is more common than that of oesophagus18. Oral cancer is the third common cancer in men and fourth in women of this province. It is a tobacco related cancer. Men and some women use “Naswar"19 which is tobacco mixed with ash and is kept in the buccal cavity between lips and alveolus. Oral cancer is more common in the South7. In Karachi, for example, it is the third common cancer in males (21.3%) and the second in females (18.7%). The frequency of this cancer in the South has decreased over the years in both the sexes20. Oral cancer is one of the ten most common cancers worldwide. In developing countries, it is the third most common cancer. In Sri Lanka, India, Pakistan and Bangladesh oral cancer out numbers others. In parts of India oral cancer represents over 50% of all cancers21. In the developed world it ranks eighth, although the ranking varies between countries. In France, for example, it is the third most common male malignancy22. Patients in Pakistan present in late stages, therefore measures have to be taken to prevent it and detect it early. This study is in sharp contrast to the early repoited4 study fmm this area where the frequency of bone cancer inNorth West of Pakistanwas showntobe highenough to be included among the ten most common cancers. Bone
cancer ranked fifteenth among males and nineteenth among females in the present study. Proper hospital based or population based registries are not available in Pakistan, but very useful information on cancer pattem can be denved from hospital based studies which are the only referral centres in the country.


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