Types and distribution of cancer patients attending in a tertiary care hospital of Bangladesh

of of a national cancer a gap in the regarding the presentation of cancer statistics of country. The objective of this study was to assess the types and distribution of the cancer patients attending a tertiary center hospital in A cross-sectional study was conducted among all the confirmed cancer patients attending the in-patient and out-patient, and daycare facilities in University in October, 2019. A validated questionnaire, recommended by for the Registry was used to collect data. Written informed consent was obtained from every respondent. This study had received its ethical clearance from Institutional Review Board of BSMMU. Among the 1656 respondents, 78.8% were adult and 25.2% were from paediatric age groups. Leading cancer for adult males were lung cancer (9.6%), leukaemia (9.4%) and lymphoma (9.0%); and breast cancer (28.1%), thyroid cancer (16.1%), and cervical cancer (12.2%) for females. Leukaemia was the most frequent cancer in the paediatric group for both males (71.5%) and females (66.5%). Establishing a hospital-based cancer registry with high quality data in an academic medical center setting is feasible and can set the stage for establishing nationwide hospital-based as well as establishing a popula-tion-based cancer registry in Bangladesh, which is necessary to identify and tackle the rising burden of cancer in this country.


Introduction
The estimated global cancer burden accounts for 18.1 million new cases and 9.6 million deaths, in 2018 1 , where for the same year in Bangladesh, the number of new cases and deaths were 150,781 and 108,137, respectively. 2 Population-based cancer registries (PBCRs) are the gold standard for obtaining authentic cancer incidence, but is more resource intensive compared to hospital-based cancer registries (HBCRs). 3 In the absence of PBCRs, HBCRs can be utilized to retrieve data on the frequent cancers and improve the cancer care delivery systems in low-and middle-income countries. 3 Bangladesh, similar to other countries is experiencing an increased burden of cancer. Absence of a national cancer registry has created a gap in the information regarding the presentation of cancer statistics of the country. The objective of this study was to assess the types and distribution of the cancer patients attending a tertiary academic medical center hospital in Bangladesh. A cross-sectional study was conducted among all the confirmed cancer patients attending the in-patient and out-patient, and daycare facilities in Bangabandhu Sheikh Mujib Medical University in October, 2019. A validated questionnaire, recommended by International Agency for the Cancer Registry was used to collect data. Written informed consent was obtained from every respondent. This study had received its ethical clearance from Institutional Review Board of BSMMU. Among the 1656 respondents, 78.8% were adult and 25.2% were from paediatric age groups. Leading cancer for adult males were lung cancer (9.6%), leukaemia (9.4%) and lymphoma (9.0%); and breast cancer (28.1%), thyroid cancer (16.1%), and cervical cancer (12.2%) for females. Leukaemia was the most frequent cancer in the paediatric group for both males (71.5%) and females (66.5%). Establishing a hospital-based cancer registry with high quality data in an academic medical center setting is feasible and can set the stage for establishing nationwide hospital-based as well as establishing a population-based cancer registry in Bangladesh, which is necessary to identify and tackle the rising burden of cancer in this country. University (BSMMU) is the only premiere post graduate university hospital in Bangladesh, where a large number of cancer patients from every region of the country come for quality cancer care, has only an ongoing pathology-based cancer registry. Due to paucity of the data of the cancer burden and cancer care tended by this hospital, as well as demonstrating the feasibility of establishing a HBCR in BSMMU, a cross-sectional study was conducted to assess the types and distributions of the attending cancer patients.

Methods
The present cross-sectional study was conducted in BSMMU, for the month of

Results
Data of 1656 respondents were collected from the outdoor, indoor, daycare, pathology, and radiology departments of BSMMU. Among them, the highest proportion (35%) of the patients were interviewed in the OPD, 26% in the indoor department, 20% from pathology and radiology departments, and 19% from daycare centers (data not shown).    When the cancers were stratified according to age and sex ( Table-IV), leukemia was found to be the most prevalent cancer in both sexes of 0-18 years, and also for 40-59 years adult male. Female of age groups 40-59 and ≥ 60 years were found to suffer more from breast cancer (32.8%, 21.7% respectively) and cervical cancer (11.3%, 14.7% respectively).
Lung cancer was predominant (13.9%) among males of the age group ≥60 years. Among the cancer patients, majority (53.3%) of them received chemotherapy and the second most common treatment modality was a combination of surgery and chemotherapy (20.7%). Other common treatments modalities observed were surgery (10.5%), a combination of surgery and radiotherapy (9.0%), and radiotherapy (2.7%).

Discussion
This present study was conducted to explore the types and distribution of cancer patients attending BSMMU. The mean age of the adult patients in this study was 48.6 ±14.6 years. Majority (70.7%) of them belonged to the age group of ≥40 years. The reason behind this large proportion of cancer patients may be due to the high prevalence of multiple cancer risk factors at this age, where incidence rates begin to rise for many types of cancer. 7 Various studies done in tertiary hospitals of Dhaka also revealed that the largest age group of cancer patients attending the hospital were above the age of 40. 7,8 In the current study, the male-female ratio in the adult age group was 1:1.2. Higher ratio of females suffering from cancer was also reported by another study conducted in another hospital in Dhaka. 8 On the contrary, the national cancer institute of Bangladesh reported the male-female ratio to be 1.2:1. 9 This discrepancy in the male-female ratio, is possibly due to the increasing number of breast cancer cases and cancers of women of reproductive age over the past few years, 10 early cancer detection programs for breast and cervix 8 , and introduction of dedicated female cancer management centers in BSMMU.
The leading cancer identified in the adult male was lung cancer (9.6%), which corresponds to the proportion of lung cancer (11.1%) observed in Globocan 2018-Bangladesh. 2 Breast cancer (28.1%) ranked the highest among all cancers in the females, and is aligned with the national statistics, where it is the most common cancer (19.0%). 11 The burden of these two cancers were also ascertained by the worldwide incidence data of 2018, where lung cancer in male contributed to 14.5% and breast cancer in female contributed to 24.2% of the new cases diagnosed. 2 Similarly, during the same period, lung cancer (11.2%) and breast cancer (26.4%) ranked highest among males and females of all ages, respectively in the South-East Asia region. 13 An important finding of this study revealed the gravity of female cancers, where the reproductive organ cancers contributed to almost half (49.6%) of all cancers in females. Breast cancer (28.1%) topped the list and other cancers were 21.5% (cervical cancer 12.2% and ovarian cancer 6.9%). The magnitude of the reproductive organ cancers has also been shown in Globocan 2018, where, breast cancer was identified as the most common cancer in 154 of the 185 countries included in Globocan 2018 1 and cervical cancer in 39 countries, all of which are low-middle income countries. 14 Pediatric patients attending BSMMU had a mean age of 7.4±4.2 years and the proportion of cancers observed was much higher in males than females (male-female ratio 1.7:1), which was also reported in other studies done in Bangladesh. 9,15 Leukemia was identified as the most common (69.6%) cancer in this study, where, male preponderance was observed (65.1% were male and 34.9% female). This finding is concurrent with global data where, leukemias are the most common group of childhood cancers 16,17 in India and 26% in Pakistan. Nearly half (49.1%) of the leukemia patients suffered from ALL, where the proportion was higher in male than female (63.6%, 36.4%, respectively), which is accordant with other studies. 15,[18][19][20] With regards to the preponderance in male, it may be due to differences in disease biology which could be hormonal or genetic. 18 Also, gender bias in seeking health care might play a role 20 , and there are reports about under reporting of childhood cancers among girls. 21 A population-based study has shown that nearly 15-35 % of ALL cases go unreported. 21 Cancer patients in BSMMU received different modalities of treatment depending on the type of cancers and stages presented in. Chemotherapy was the commonest (53.3%) treatment received by the patients followed by the combination of surgery and chemotherapy (20.7%). Possible reason behind the higher proportion of patients receiving chemotherapy might be due to the higher number of patients attending the indoor and daycare centers of the hospital. Another reason might be the large number of leukemia patients attending where chemotherapy is the first line of treatment. 12 Similar scenario was also observed in another hospital of Bangladesh, where most of the patients were treated with chemotherapy 7 and then with a combination of surgery and chemotherapy.
A study conducted by Parveen et al. (2015) mentioned that the highest proportion (24.3%) of the cancer patients received a combination of surgery, chemotherapy and teletherapy. In contrast to this, in BSMMU, only 1.9% of the cancer patients received the above-mentioned combination therapy. This difference can be explained by the nature of the institution where the afore mentioned hospital was a specialized cancer center.
This study revealed a few challenges, where, absence of automation for data management, and lack of organized structure for storage and access of medical records, was a hurdle for data collection. In many cases, patients and their family members as respondents were hesitant to share information, due to their disconcerted mood in the hospital.

Conclusions
To conclude, lung cancer and breast cancer were the leading cancers among adult male and female, respectively. Leukemia was the commonest cancer for both sexes in the pediatric age group. By ensuring high quality data in academic medical centers, it is feasible to develop a nationwide hospital-based cancer registry as a first stage to establish a population-based cancer registry in Bangladesh, which is necessary to identify and tackle the rising burden of cancer in this country.