Demographics
Roughly a million square kilometers in size, Egypt is a country that extends from Asia (the Sinai Peninsula) to across northeast Africa. Administratively, it consists of 27 governates.
It is the 14th most populous nation in the World with just over a 102 million people (around 1.3% of the World’s population). 52% of its population is male and the overall life expectancy at birth is 74 years – female life expectancy being about two years more than male.
Per Capita GDP is estimated at about US$ 3,800. Half the population has been estimated to be less than 24 years of age and just 5% above 65.
Egypt has all the characteristics of a developing nation well on the path of development. The country has ample well-trained medical staff and advanced infrastructure compared to other African countries for diagnostics, surgical intervention, therapy (and radiotherapy) and healthcare services. Importantly, in addition to public sector facilities such as university hospitals it has set up General Authority for Health Insurance hospitals, under its Ministry of Health and Population. Private sector hospitals, which are more expensive, are there in significant numbers as well. So are Non-governmental organizations that provide support through their own hospitals and treatment facilities, while also providing emotional support to patients directly.
Factors Unique to Egypt
At the outset of an examination of Cancer in Egypt, it would be important to consider three influences at play there.
Insurance: The health-care system in Egypt was remodeled through the Universal Health Insurance (UHI) law in 2018 which granted universal health coverage for all its citizens. It introduced proper funding through a series of fresh financing instruments. This highly progressive step involves coordinated effort between the Egyptian government and stakeholders, which includes the World Health Organization (WHO). Planned to be fully implemented in 15 years the first of its six phases is ongoing. This means that some level of medical intervention is available to even the poorest and includes treatment for cancer as well. With future phases its benefits will further amplify.
Obesity: Obesity and Type 2 Diabetes go hand in hand and both are associated with increased cancer incidence and mortality. Egypt has the highest obesity rate among the world’s 20 most populous countries, and the prevalence of diabetes in Egyptian adults is around 15.6%.
Schistosomiasis: Also known as bilharzia, this is a condition brought about by parasitic worms. Chronic infection with Schistosoma Mansoni, S. Haematobium, S. Japonicum, S. Mekongi and S. Intercalatum causes this disease. The worst part is that this occurs from contaminated freshwater commonly used in day-to-day life. As a result of the prevalence of schistosomiasis, Egypt has the highest prevalence of hepatitis C virus (HCV) infection in the world. One of reasons for this prevalence was the mass treatment by unsafe intravenous injections in the 1950s and 1960s. The contamination continues to linger on despite great efforts at its eradication.
Schistosoma Haematobium is the prevalent strain in Egypt and its eggs trigger a chronic local inflammatory response in the urinary bladder leading to the formation of “sandy patches.” The chronic wear and tear it imposes triggers the release of many carcinogenic compounds. This leads to a latent period of about 20–30 years between the initiation of infection and the manifestation of SABC. The incidence rate is highest among 40–59 year-old patients (42% of cases), while the schistosomal infection peak is during their 30s.
Cancer numbers
The GLOBOCAN (Global Cancer Observatory) Report released in 2021 reported:
Existing numbers of Cancer Cases in Egypt
Top seven types – All ages – 5 year prevelance
| Rank | Type | Numbers | %age |
| 1 | Breast | 61,160 | 22% |
| 2 | Liver | 28,977 | 10.4% |
| 3 | Bladder | 28,966 | 10.4% |
| 4 | Non-Hodgkinson’s Lymphoma | 19,096 | 6.9% |
| 5 | Leukemia | 14,274 | 5.1% |
| 6 | Brain & Central Nervous System | 11,470 | 4.1% |
| 7 | Prostrate | 10,523 | 3.8% |
| Total – All Cancers | 278,165 | 100% |
Fresh Cancer Cases in Egypt (2020)
| Rank | Type | Numbers | %age |
| 1 | Liver | 29,875 | 20.7% |
| 2 | Breast | 22,038 | 16.4% |
| 3 | Bladder | 10,655 | 7.1% |
| 4 | Non-Hodgkinson’s Lymphoma | 7,305 | 5.4% |
| 5 | Lung | 6,538 | 4.9% |
| Others | 60,201 | 44.7% | |
| Total Fresh Cases | 134,632 |
Fresh Cancer Cases among Males in Egypt (2020)
| Rank | Type | Numbers | %age |
| 1 | Liver | 18,145 | 27.3% |
| 2 | Bladder | 8,410 | 12.6% |
| 3 | Lung | 4,851 | 7.3% |
| 4 | Prostrate | 4,767 | 7.2% |
| 5 | Non-Hodgkinson’s Lymphoma | 3,895 | 5.9% |
| Others | 26,474 | 39.8% | |
| Total Fresh Cases | 66,542 |
Fresh Cancer Cases among Females in Egypt (2020)
| Rank | Type | Numbers | %age |
| 1 | Breast | 22,038 | 34.2% |
| 2 | Liver | 9,750 | 14.3% |
| 3 | Non-Hodgkinson’s Lymphoma | 3,410 | 5% |
| 4 | Ovarian | 2,787 | 4.1% |
| 5 | Collorectum | 2,782 | 4.1% |
| Others | 27,323 | 40.1% | |
| Total Fresh Cases | 68,090 |
Total Population: 102.3 million
Total Mortality (Cancer related): 89,042
Every year, as things stand, one in 750 Egyptians is likely to develop cancer.
Predominant Cancers in Egypt
Breast Cancer: As the tables show, it is the most common malignancy in women, accounting for more than a third of all fresh cases of cancer. Estimates indicate that there could be as many as 46,000 in 2050. Its current mortality rate is around 11%, making it second to liver cancer as a killer.
An interesting comparison has been presented regarding the age and stage of diagnosis of breast cancer in the Egyptian Gharbiah Cancer Registry (GCR) versus the U.S. Surveillance, Epidemiology, and End Results (SEER) Program database (for 2004–2008). This revealed that on average, GCR cases were a full decade younger than SEER cases (mean age = 51 years against 61.4 years in SEER), with nearly 19% of GCR cases aged ≤ 40, compared with only 6% of SEER cases.
Also the stages at diagnosis between the two populations varied widely. GCR cases were diagnosed at more advanced stages, with nearly 5%, 39%, 44%, and 12% diagnosed at stage I, II, III, or IV, respectively, compared to 48%, 34%, 12%, and 5% of SEER cases diagnosed at stage I, II, III, or IV, respectively. This focuses attention on the importance of considering specific disease criteria for planning a breast cancer early detection program.
The most common tumor histology is infiltrating duct carcinoma (83.2%), followed by infiltrating lobular carcinoma (9.1%) and medullary carcinoma (3.2%). The most prevalent type is luminal A subtype (41.2%), followed by triple-negative subtype (28.5%), then Her2-expressing subtype (19.4%), and luminal B subtype (13.9%). This could possibly be due to environmental factors specific to the younger generation, such as:
- Delayed age of marriage leading to delivery of first born at advanced age
- smaller number of offspring
- Delayed age of breastfeeding as more young women are educated and working than ever before
Liver Cancer: Given the prevalence of hepatitis (HCV through schistosomiasis), it is not surprising that liver cancer, mainly hepatocellular carcinoma (HCC, which constitutes about 70.5% of all liver cancers), was the most common cancer among men (33.6%) and was the second-most common cancer among women (13.5%) after breast cancer in the National Cancer Registry Program.
Liver cancer, especially Hepato-Cellular Carcinoma (HCC), is a significant health burden in Egypt, which ranks above the 90th percentile worldwide in liver cancer incidence. There is a strong male predominance of 45.9% versus 22.7% for females; presumably due to higher exposure of males to HCV.
Believing that males were more prone to schistosomiasis, they became primary targets for parenteral anti-schistosomal therapy campaigns, causing iatrogenic transmission of infection.
The global burden of diseases study in 2015, reported the etiological factors for HCC in Egypt as HCV (63%), HBV (13%), alcohol (12%), and other factors (12%) [25]. This significantly high prevalence of viral Hepatitis C among the Egyptian population is linked to HCV. 92.5% of anti-HCV-positive Egyptians are found to be infected with Genotype 4 (Genotype 4a alone constitutes about 63% of Hepatitis C genotypes) and are thus less responsive to interferon therapy [26,27,28,29]. A two-fold increase in HCC incidence rate in the last two decades was reported among chronic liver disease patients in Egypt, accompanied by a significant decline of HBV and a slight increase of HCV as risk factors [26]. HCV is the main risk factor for HCC, as a study reported, anti-HCV antibodies in 71% of HCC cases [27].
The high prevalence of viral Hepatitis B and C has been largely attributed to iatrogenic transmission of infection in mass treatment campaigns of schistosomiasis in the 1960s through 1980s [30]. Environmental factors, especially aflatoxins, have also been linked with the high prevalence of liver cancer in Egypt [31], and have been shown to contaminate more than 20% of silage, due to improper grain storage [32].
Bladder Cancer: Egypt has a very higher prevalence rate of bladder cancer than the global norm. In 1987, Egypt was found to have the highest bladder cancer mortality rate in the world; an age-specific mortality rate of 10.8 per 100,000 in males. Over the next couple of decades however, significant change in the histo-pathological types of bladder cancer in Egypt has been noticed. The relative frequency of Transitional Cell Carcinoma (TCC) increased from 22% in 1980 to 73% of bladder cancers diagnosed in 2005, while Squamous Cell Carcinoma (SCC) decreased from 78% of diagnosed bladder tumors in 1980 to 27% of diagnosed bladder tumors. A significant drop in the relative frequency of bladder cancer at the National Cancer Institute in Cairo was also noted.
Still, bladder cancer remains the second most common cancer among Egyptian males. There is a strong male predominance of the disease with a 4:1 male to female ratio, possibly due to higher rates of schistosomiasis among male farmers who are more exposed to the Nile waters.
Another risk factor for bladder cancer is cigarette smoking. Studies indicate that the risk of bladder urothelial carcinoma in male smokers was 1.8-fold higher than in non-smoking males. 22% of the Egyptian population in 2010, were smokers and it appeared that smoking as a habit was increasing. This is another likely reason for the prevalence of bladder cancer in Egypt.
Steps taken in Egypt for Cancer Detection & Prevention
The Women Health Outreach Program
the Women Health Outreach Program, initiated in October 2007 was Egypt’s first national screening program. Funded by government, it offered free mammograms for Egyptian women aged over 45 using mammography vans, equipped with a full-field digital mammography machine, and a dedicated computer system linked to the National Breast Screening Center. It also conducted tests for diabetes, hypertension and obesity.
Free treatment was offered for cases where breast cancer had been detected. Between October 2007 to February 2009, 20,098 women in three governorates had been screened for breast cancer.
The Egypt National Multi-sectoral Action Plan, 2018–2022
It was recognized that non-communicable diseases are the cause behind 85% of deaths due to disease in Egypt with cancers ranking second in the list for such mortality (14%) after cardiovascular diseases (46%). Accordingly, in 2018, Egypt unveiled this plan for preventing and controlling non-communicable diseases, including cancer.
The Plan’s goals were to reduce premature mortality from non-communicable diseases by 15% by 2022; through:
- Decreasing exposure to risk factors
- Enhancing early detection
- Effective treatment of such disorders
- Setting a target of 70% availability of essential medicines and necessary technologies to treat major non-communicable diseases
- Setting national guidelines for the diagnosis and treatment of patients with cancer with a focus on early detection (a national cancer committee was tasked with this)
- Tweaking the National Cancer Registry Program of Egypt, established in 2007 through enhanced cooperation between the ministries of Communications and Information Technology, Health and Population, and Higher Education and Scientific Research; creating a most accurate public domain cancer database for both researchers and policymakers
Over the years, the Egyptian government has issued many laws and legislation related to carcinogens, such as:
- Discouraging smoking
- Banning asbestos from most industrial applications
- Restricting use of organo-chlorine pesticides
- Restricting air and water pollution.
- Conducting awareness and treatment programs for schistosomiasis using social marketing and mass media
These appear to have contributed dramatically to the primary prevention of bladder cancer in Egypt.
100 Million Healthy Lives Program
In 2018, Egypt embarked on an extensive disease screening and treatment campaign for hepatitis C, hypertension, diabetes, and obesity called the 100 Million Healthy Lives Program. Consequent to this campaign, Egypt now has the most extensive national HCV screening and treatment program in the world.
In July 2019, a nationwide campaign was launched in nine governorates and within two months extended to another eleven governorates and before the end of the year to the remaining seven. The purpose of this campaign is to raise awareness levels about breast cancer and the importance of early diagnosis, and timely treatment of diagnosed cases. Suspected cases are referred for further investigation and treatment at no cost to participants.
Controlling Schistosomiasis
Schistosoma-Associated Bladder Cancer (SABC) is quite different from non-Schistosoma-Associated bladder carcinoma. For a century Egypt has been battling the problem of schistosomiasis and been fairly successful as under:
- Early 1920s – only available treatment: tartar emetic. Brings the disease prevalence down to around 50%.
- Late 1930s – Snail Control program to interrupt life cycle of parasites by destroying their snail host. Marginal impact.
- 1980 – Praziquantel approved – National Schistosomiasis Control Project (NSCP) supplies ten million school-aged children in rural areas and all residents of more than 500 identified high-risk villages. Prevalence of schistosomiasis drops immediately to 20%. By 1999 to 10%; and by 2002 to 3.5% in 2002.
Meanwhile the ratio of SABC to TCC begins to drop. Bladder carcinoma subtype patterns in Egypt start resembling those in developed countries.
Establishing an accurate Data-Base
As part of the 100 Million Healthy Lives Program Egypt’s Ministry of Health set up a nation-wide web-based registry to arrange patient appointments and visits, and to record their patient data using a central database.
More than 49 million individuals from a target population of 62.5 million, or 79.4% of the targeted, spontaneously participated in the screening between October 1, 2018, and April 30, 2019. The results:
- The overall HCV sero-prevalence in them was found to be 4.61%.
- 76.5% of these had viremia; of which 91.8% had started their treatment.
- About half of the patients on treatment, reached the 12-week follow-up after the end of therapy.
- 386,103 of these 465,992 patients (82.9%) had a known treatment outcome
- 381,491 (98.8%) of those with a known outcome had a sustained virologic response.
Anti-HCV and HBV Campaigns
Having identified that hepato-cellular carcinomas were a significant problem, priority was given for controlling HBV and HCV. Accordingly, the Egyptian National Committee for the Control of Viral Hepatitis (NCCVH) began a national treatment program for HCV in 2007, distributing oral Direct-Acting Antivirals (DAAs) – sofosbuvir, pegylated-interferon and ribavirin – at affordable prices.
The cost of HCV testing and treatment component was $207.1 million. The cost of screening came to $85.41 per patient detected, while the cost of curing a patient came to $130.62.
Vaccination
Hepatitis B vaccination has become mandatory for all newborns in Egypt, as the hepatitis B vaccine (HB-Vaccine) with effect from 1992. It is part of the “Expanded Programme on Immunization”, planned to be given in 3 doses for all newborns at 2, 4, and 6 months after birth. Data indicates hepatitis B coverage rate increasing from 91% in 1996 to 97.3% in 2005.
The Egyptian Cancer Research Network was launched on November 5, 2016, as a collective of research professionals, groups, organizations, and institutions involved in Cancer research in Egypt. The goal of the network is to connect oncology researchers in Egypt and to build large-scale multi-centers.
Cancer care in Egypt
Cancer care in Egypt is provided by the Ministry of Health (MoH), university hospitals, Non-Governmental Organizations (NGOs), military and police oncology units, and the private sector.
There are 11 oncology centers supervised by the Ministry of Health, which contain 943 beds. Although the number of all physicians registered in the ministry is 120,606, the number of oncology specialists is a grey area.
University hospitals are a significant section in healthcare; with 24 public and 10 private medical schools, and 109 university hospitals covering most of Egypt. Each medical school has an oncology department with a radiotherapy unit, nuclear medicine, surgical oncology, and chemotherapy unit. Noteworthy institutions include: Cairo University hospitals (Kasr El Ainy), Ain Shams University hospitals (El-Demerdash), Alexandria University hospitals, El-Mansoura University hospitals, and Asyut University hospitals.
The National Cancer Institute (NCI) established in 1969 is an affiliate of Cairo University and located in the heart of Cairo city. Then there is the National Cancer Hospital and Institute: Breast Cancer Hospital (established in 2012) operating in the First Settlement, New Cairo, to address increasing breast cancer incidence in Egypt.
A New National Cancer Institute at Sheikh Zayed City, Giza is expected to open in 2023. It hospital will have 1020 beds for inpatients, 500 beds for day-care, 60 operating theaters, 15 radiotherapy machines, and a research center.
Meanwhile charity hospitals fill the breach for cancer treatment for those in difficulties to bear such costs. The large Shefaa El-Orman Hospital is one such comprehensive center in upper Egypt, with 150 beds for inpatient and 26 beds for Intensive Care. A children’s cancer hospital was established in 2021, with 100 beds for inpatients and 20 beds for Intensive Care.
Some Achievements
The Children’s Cancer Hospital in El-Sayeda Zinab, Cairo reported an average overall survival rate of 72% and handled 3355 cases in 2020. The Baheya Hospital at El-Haram, Giza, screens 3000 women, and provides 3000 chemotherapy sessions and 1000 radiotherapy sessions a year.
Non-Governmental Organizations (NGOs) are quite active players in raising awareness, disseminating information, arranging treatment, financial support, and later, psychological support to breast cancer survivors. Prominent such include the Breast Cancer Foundation of Egypt, the Egyptian Society of Women’s Health, and, CanSurvive.
Other providers are military and police oncology units that treat both military and civilian patients, private cancer centers, and oncology clinics inside private hospitals.
Palliative Care
Although those at the helm of affairs recognize that palliative care is an integral part of cancer treatment, especially in its advanced stages, there are as yet only a limited number of centers in Egypt providing such services. Thus Egypt still needs to:
- Establish many more specialized centers for palliative care
- Train adequate medical personnel for them and for providing home palliative care services
- Ease restrictions on opioid substances such as morphine, for the relief of those in pain
Research and Education
There are 24 public and 10 private medical schools in Egypt generating about 8,000 undergraduate and postgraduate medical personnel every year. Teaching staff are encouraged and mentored to publish quality treatise prolifically; and so to adding value to the medical community. The Theodor Bilharz Research Institute in Warrak, Giza, founded in 1964, as a joint intiative between Federal Republic of Germany and the Egyptian Government is noteworthy for its work on schistosomiasis.
Achievements of Egypt in issues of Cancer
- With an accurate system of data collation in place, Egypt has the ability to formulate effective national healthcare strategies
- With its identification, screening and mass treatment approach, backed by setting realistic targets; Egypt has all but eradicated HCV.
- It is likely to be the first nation to achieve WHO disease elimination targets.
- This will lead to a significant drop in the number of cancer cases, notably HCC among individuals showing a sustained virologic response after antiviral therapy for hepatitis C
- Per the Council of Ministers: 8.5 million women from all over Egypt had been examined for breast cancer by October 20, 2020. The target for the program is 31 million women
- Insurance coverage has been extended to all its citizens
- Given that there is a limitation of funds, Egypt has developed a cost-effective strategy – it costs less overall to reduce causes of many cancers than treatment once cancer has discovered
- Meanwhile there is presence of state-of-art devices and equipment (again given limitations of affordability). There is adequacy of trained operators and medical practitioners are entirely familiar with modes of treatment.
Developing nations around the world should benefit enormously from the Egyptian example.