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Cervical cancer is a growing health concern, especially in resource-limited settings.
The objective of this study was to assess the burden of cervical cancer mortality and disability-adjusted life years (DALYs) in the Eastern Mediterranean Region (EMR) and globally between the years 2000 and 2017 by using a pooled data analysis approach.
We used an ecological approach at the country level. This included extracting data from publicly available databases and linking them together in the following 3 steps: (1) extraction of data from the Global Burden of Disease (GBD) study in the years 2000 and 2017, (2) categorization of EMR countries according to the World Bank gross domestic product per capita, and (3) linking age-specific population data from the Population Statistics Division of the United Nations (20-29 years, 30-49 years, and >50 years) and GBD’s data with gross national income per capita and globally extracted data, including cervical cancer mortality and DALY numbers and rates per country. The cervical cancer mortality rate was provided by the GBD study using the following formula: number of cervical cancer deaths × 100,000/female population in the respective age group.
The absolute number of deaths due to cervical cancer increased from the year 2000 (n=6326) to the year 2017 (n=8537) in the EMR; however, the mortality rate due to this disease decreased from the year 2000 (2.7 per 100,000) to the year 2017 (2.5 per 100,000). According to age-specific data, the age group ≥50 years showed the highest mortality rate in both EMR countries and globally, and the age group of 20-29 years showed the lowest mortality rate both globally and in the EMR countries. Further, the rates of cervical cancer DALYs in the EMR were lower compared to the global rates (2.7 vs 6.8 in 2000 and 2.5 vs 6.8 in 2017 for mortality rate per 100,000; 95.8 vs 222.2 in 2000 and 86.3 vs 211.8 in 2017 for DALY rate per 100,000; respectively). However, the relative difference in the number of DALYs due to cervical cancer between the year 2000 and year 2017 in the EMR was higher than that reported globally (34.9 vs 24.0 for the number of deaths and 23.5 vs 18.1 for the number of DALYs, respectively).
We found an increase in the burden of cervical cancer in the EMR as per the data on the absolute number of deaths and DALYs. Further, we found that the health care system has an increased number of cases to deal with, despite the decrease in the absolute number of deaths and DALYs. Cervical cancer is preventable if human papilloma vaccination is taken and early screening is performed. Therefore, we recommend identifying effective vaccination programs and interventions to reduce the burden of this disease.
Globally, cervical cancer is one of the leading causes of mortality in women [
The Eastern Mediterranean Region (EMR) consists of 22 countries in the Middle East, North Africa, the Horn of Africa, and Central Asia. This region includes some of the greatest social inequalities within countries and between countries in the world [
This study examined the burden of cervical cancer and potential differences within the countries in the EMR in relation to the level of national economic development and age of the patients. The objective of this study was to assess the burden of cervical cancer mortality and disability-adjusted life years (DALYs) as the number of years lost due to disability or early death because of cervical cancer in countries of the EMR and globally. The following research questions were investigated:
What is the pattern of mortality and DALYs due to cervical cancer in the EMR and globally? Further, what changes in this pattern have occurred between the years 2000 and 2017?
Do these rates differ by the level of national economic development and age of the population?
This was an ecological study that was conducted at the country level. Three publicly available databases were linked together in a three-step process. The first step consisted of extracting cervical cancer data at the country level from the Global Burden of Disease (GBD) study in 2000 and 2017 [
The EMR consists of the following 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine (West Bank and Gaza), Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, and the United Arab Emirates [
Cervical cancer mortality rates and DALY rates per 100,000 persons were extracted from the GBD database for people older than 20 years at the country level in the years 2000 and 2017 and then combined for an EMR average (n=22) and global average of EMR plus all other countries (n=122). The mortality rate formula was as follows: cervical cancer deaths (n) × 100,000/female population in the respective age group. The results were then stratified by the 3 income levels (high, middle, low) and 3 age groups (20-29 years, 30-49 years, ≥50 years). The burden of cervical cancer mortality was presented through the compilation of 3 variables: (1) average mortality rates per 100,000 with minimum and maximum values to provide the range as a measure of spread for cervical cancer mortality and mortality from other diseases, (2) DALYs as a measure of total burden, whereby 1 DALY represents 1 healthy year of life lost to cervical cancer; the GBD study did estimate DALYs by summing the fatal burden (years of life lost) and nonfatal burden (years of life with disability) due to cervical cancer [
The rates of cervical cancer mortality and DALYs in the EMR were lower than the global rates; however, the relative difference in the number of deaths and DALYs due to cervical cancer between the years 2000 and 2017 in the EMR was higher than that of the global data. Further, according to age-specific data, the age group of ≥50 years had the highest mortality rates in both EMR countries and globally and the age group of 20-29 years had the lowest mortality rate both globally and in the EMR countries. The EMR average mortality rate due to cervical cancer was lower than the global average for both reference years and all 3 income levels (
Cervical cancer mortality among women older than 20 years in the Eastern Mediterranean Region by country and income level compared to the global average in the years 2000 and 2017.
Group by income level, country | Cervical cancer mortality rate per 100,000 women in year 2000, mean (min-max) | Cervical cancer deaths (n) in year 2000 | Cervical cancer mortality rate per 100,000 women in year 2017, mean (min-max) | Cervical cancer deaths (n) in year 2017 | Relative difference (%) in the number of deaths between years 2000 and 2017a | Absolute difference in the number of deaths between years 2000 and 2017b | |
Low-income countries globally | 12.4 (9.1-16.2) | 26,884 | 10.0 (7.1-13.6) | 33,591 | 24.9 | 6707 | |
|
10.7 (6.3-15.0) | 1448 | 7.9 (4.7-11.5) | 1930 | 33.3 | 482 | |
|
Afghanistan | 5.3 (1.9-7.9) | 468 | 3.9 (1.7-5.7) | 631 | 34.9 | 163 |
|
Somalia | 20.9 (14.7-28.3) | 980 | 15.8 (10.6-22.9) | 1299 | 32.5 | 319 |
Middle-income countries globally | 6.5 (5.7-7.7) | 149,272 | 6.7 (5.4-8.0) | 192,643 | 29.1 | 43,370 | |
|
2.3 (1.9-2.8) | 4755 | 2.2 (1.6-2.8) | 6380 | 34.2 | 1625 | |
|
Djibouti | 16.0 (10.6-22.9) | 48 | 13.8 (8.7-21.8) | 72 | 50.4 | 24 |
|
Egypt | 0.9 (0.8-1.0) | 292 | 1.0 (0.8-1.2) | 449 | 53.6 | 157 |
|
Iran | 1.2 (1.0-1.3) | 397 | 1.8 (1.4-1.9) | 726 | 82.7 | 329 |
|
Iraq | 1.5 (1.0-2.1) | 186 | 0.8 (0.7-0.9) | 168 | –9.4 | –18 |
|
Jordan | 1.5 (1.2-1.9) | 35 | 1.0 (0.8-1.3) | 48 | 37.2 | 13 |
|
Lebanon | 2.4 (2.0-2.8) | 63 | 2.0 (1.7-2.3) | 82 | 31.2 | 20 |
|
Libya | 2.5 (2.0-3.0) | 61 | 3.2 (2.4-4.1) | 106 | 74.4 | 45 |
|
Morocco | 5.5 (4.5-6.4) | 823 | 5.7 (4.1-7.5) | 1011 | 22.8 | 187 |
|
Pakistan | 3.3 (2.8-3.8) | 2213 | 2.8 (2.0-3.8) | 2886 | 30.4 | 673 |
|
Palestine | 1.2 (1.0-1.4) | 18 | 1.2 (0.9-1.4) | 28 | 56.2 | 10 |
|
Syria | 0.9 (0.8-1.1) | 73 | 1.1 (0.8-1.4) | 98 | 34.1 | 25 |
|
Tunisia | 2.4 (2.0-2.9) | 119 | 2.5 (1.8-3.4) | 145 | 22.5 | 27 |
|
Sudan | 1.8 (1.0-2.6) | 242 | 1.4 (0.9-2.0) | 281 | 15.9 | 39 |
|
Yemen | 0.9 (0.8-1.1) | 185 | 1.9 (1.2-2.6) | 279 | 50.8 | 94 |
High-income countries globally | 6.0 (5.8-6.2) | 32,475 | 5.4 (5.0-5.9) | 32,444 | –0.1 | –31 | |
|
1.0 (0.8-1.2) | 123 | 1.0 (0.8-1.4) | 227 | 85.5 | 105 | |
|
Bahrain | 1.9 (1.7-2.3) | 5 | 1.5 (1.2-1.8) | 8 | 51.1 | 3 |
|
Kuwait | 1.1 (1.0-1.1) | 8 | 0.7 (0.6-0.8) | 14 | 59.5 | 5 |
|
Oman | 1.7 (1.2-2.2) | 17 | 1.5 (1.1-1.8) | 23 | 35.9 | 6 |
|
Qatar | 1.4 (1.1-1.8) | 3 | 1.0 (0.7-1.2) | 6 | 122.9 | 4 |
|
Saudi Arabia | 0.7 (0.6-0.9) | 68 | 0.8 (0.6-1.1) | 117 | 71.1 | 49 |
|
United Arab |
2.0 (1.5-2.4) | 21 | 2.3 (1.7-3.1) | 60 | 187.2 | 39 |
Global average (122 countries) | 6.8 (6.4-7.6) | 208,631 | 6.8 (6.3-7.1) | 258,678 | 24.0 | 50,047 | |
EMR average (22 countries) | 2.7 (2.1-3.4) | 6326 | 2.5 (1.8-3.4) | 8537 | 34.9 | 2211 |
aRelative difference (%) in the number of deaths = (absolute difference in the number of deaths/number of cervical cancer deaths in 2000)*100.
bAbsolute difference in the number of deaths = number of cervical cancer deaths in 2017 – number of cervical cancer deaths in 2000.
cEMR: Eastern Mediterranean Region.
DALYs due to cervical cancer by income level globally and in EMR countries have been shown in
Disability-adjusted life years data due to cervical cancer among women older than 20 years in the Eastern Mediterranean Region by country and income level compared to the global average in the years 2000 and 2017.
Group by income level, country | Cervical cancer DALYa rate per 100,000 women in year 2000, mean (min-max) | DALY number in year 2000 | Cervical cancer DALY rate per 100,000 women in year 2017, mean (min-max)c | DALY number in year 2017 | Relative difference (%) in the number of DALYs between years 2000 and 2017b | Absolute difference in the number of DALYs between years 2000 and 2017c | |
Low-income countries globally | 435.3 (312.8-566.6) | 941,128 | 343.9 (239.4-472.8) | 1,157,715 | 23.0 | 216,587 | |
|
388.8 (227.8-553.0) | 52,554 | 287.0 (162.8-424.4) | 69,812 | 32.8 | 17,258 | |
|
Afghanistan | 191.2 (65.2-296.4) | 16,895 | 150.6 (64.5-227.1) | 24,265 | 43.6 | 7371 |
|
Somalia | 761.5 (534.7-1037.1) | 35,659 | 554.5 (355.7-811.5) | 45,546 | 27.7 | 9887 |
Middle-income countries globally | 217.4 (187.6-260.8) | 5,003,701 | 213.0 (167.5-255.4) | 6,086,292 | 21.6 | 1,082,592 | |
|
80.5 (64.7-97.8) | 165,567 | 73.3 (52.9-98.2) | 216,480 | 30.8 | 50,913 | |
|
Djibouti | 585.7 (389.7-840.8) | 1754 | 497.6 (308.6-795.5) | 2598 | 48.1 | 844 |
|
Egypt | 31.2 (27.1-36.3) | 10,191 | 32.3 (25.7-40.2) | 15,065 | 47.8 | 4875 |
|
Iran | 39.5 (33.3-43.3) | 13,058 | 51.8 (41.6-55.6) | 20,993 | 60.8 | 7936 |
|
Iraq | 51.8 (32.5-74.8) | 6619 | 26.8 (22.2-32.4) | 5636 | –14.9 | –983 |
|
Jordan | 52.2 (42.9-64.8) | 1223 | 29.8 (22.9-39.4) | 1482 | 21.2 | 259 |
|
Lebanon | 77.4 (63.4-91.9) | 2043 | 59.3 (49.4-72.1) | 2505 | 22.6 | 461 |
|
Libya | 85.0 (68.0-104.7) | 2092 | 112.2 (81.8-145.0) | 3758 | 79.7 | 1667 |
|
Morocco | 182.7 (147.2-215.1) | 27,265 | 181.1 (131.0-239.0) | 31,984 | 17.3 | 4720 |
|
Pakistan | 118.4 (100.9-139.9) | 80,013 | 100.8 (71.4-141.5) | 105,213 | 31.5 | 25,200 |
|
Palestine | 36.6 (29.3-42.7) | 545 | 34.7 (26.2-41.2) | 825 | 51.5 | 280 |
|
Syria | 32.0 (26.8-39.2) | 2592 | 34.3 (25.1-44.2) | 3051 | 17.7 | 459 |
|
Tunisia | 73.4 (59.7-87.3) | 3604 | 71.0 (50.7-94.7) | 4075 | 13.1 | 471 |
|
Sudan | 60.8 (31.9-90.8) | 8142 | 48.5 (28.6-69.5) | 9644 | 18.5 | 1502 |
|
Yemen | 70.4 (38.8-105.6) | 6426 | 64.1 (39.1-92.6) | 9648 | 50.1 | 3222 |
High-income countries globally | 158.4 (152.4-164.8) | 854,589 | 131.7 (119.7-144.8) | 787,560 | –7.8 | –67,028 | |
|
32.8 (26.7-41.1) | 4193 | 38.0 (28.7-50.3) | 8274 | 97.3 | 4081 | |
|
Bahrain | 65.6 (57.3-78.7) | 183 | 46.8 (39.2-57.1) | 261 | 42.9 | 78 |
|
Kuwait | 39.3 (35.7-43.2) | 315 | 26.5 (22.9-30.5) | 515 | 63.5 | 200 |
|
Oman | 58.9 (42.9-78.7) | 598 | 50.6 (38.1-64.3) | 790 | 32.2 | 193 |
|
Qatar | 47.7 (37.6-61.5) | 99 | 33.8 (25.5-44.0) | 228 | 131.7 | 130 |
|
Saudi Arabia | 24.4 (20.2-30.7) | 2302 | 30.1 (22.8-40.4) | 4348 | 88.9 | 2046 |
|
United Arab Emirates | 65.6 (51.8-82.0) | 697 | 81.9 (58.6-111.6) | 2132 | 205.8 | 1435 |
Global average (122 countries) | 222.2 (206.2-245.9) | 6,799,418 | 211.8 (197.8-220.8) | 8,031,567 | 18.1 | 1,232,149 | |
EMR average (22 countries) | 95.8 (72.1-121.2) | 222,314 | 86.3 (59.2-118.4) | 294,566 | 32.5 | 72,252 |
aDALY: disability-adjusted life year.
bRelative difference (%) in the number of DALYs = (absolute difference in the number of DALYs/number of cervical cancer DALYs in 2000)*100.
cAbsolute difference in the number of DALYs = number of cervical cancer DALYs in 2017 – number of cervical cancer DALYs in 2000.
dEMR: Eastern Mediterranean Region.
The age group of ≥50 years had the highest mortality rate in both EMR countries and globally and the age group of 20-29 years showed the lowest mortality rate both globally and in the EMR countries. Among EMR countries, Somalia and Djibouti showed the highest mortality rate in all the age groups. Kuwait had the lowest mortality rate for the age group of ≥50 years (5.9 per 100,000 in 2000 and 3.3 per 100,000 in 2017) and Qatar had the lowest mortality rate in the age group of 30-49 years (1.5 per 100,000 in 2000 and 0.7 per 100,000 in 2017). Oman had the lowest mortality rate of 0 per 100,000 in 2017 for the age group of 20-29 years (
The relative difference in the number of deaths between 2000 and 2017 in EMR-LICs for age groups 20-29 years and 30-49 years was higher than the global difference (12.8% and 49.6% vs 4.7% and 21.9, respectively), but it was lower for the age group >50 years (25.1% vs 27.3%) (
Cervical cancer mortality rates among women older than 20 years in the Eastern Mediterranean Region by age, country, and income level compared to the global average in the years 2000 and 2017.
Group by income level, country | Average cervical cancer mortality rate per 100,000 women by age range | Relative difference (%) in the number of deaths between years 2000 and 2017a | ||||||||
Year 2000, mean (min-max) | Year 2017, mean (min-max) | |||||||||
20-29 years | 30-49 years | ≥50 years | 20-29 years | 30-49 years | ≥50 years | 20-29 years | 30-49 years | ≥50 years | ||
Low-income countries globally | 2.5 (1.3-4.2) | 53.0 (32.3-79.4) | 94.8 (67.8-127.6) | 1.6 (0.8-2.9) | 38.2 (22.6-59.8) | 77.4 (53.7-107.7) | 4.7 | 21.9 | 27.3 | |
|
2.0 (0.8-3.7) | 57.8 (28.7-96.4) | 72.2 (42.6-101.8) | 1.5 (0.7-2.9) | 34.6 (16.1-59.7) | 72.9 (44.5-106.7) | 12.8 | 49.6 | 25.1 | |
|
Afghanistan | 1.3 (0.4-2.7) | 31.1 (8.6-57.8) | 34.8 (14.4-52.0) | 1.1 (0.4-2.1) | 20.6 (7.0-36.8) | 31.9 (16.2-45.6 | 19.7 | 105.0 | –0.1 |
|
Somalia | 3.3 (1.7-5.7) | 90.8 (53.5-143.2) | 153.2 (108.4-208.4) | 2.4 (1.2-4.5) | 65.6 (36.6-109.1) | 135.3 (90.3-201.5) | 7.1 | 26.1 | 37.5 |
Middle-income countries globally | 1.0 (0.7-1.4) | 16.9 (13.5-21.3) | 31.8 (27.7-38.4) | 0.6 (0.4-0.9) | 13.0 (9.5-16.6) | 26.6 (21.1-32.0) | –24.4 | 4.3 | 43.7 | |
|
0.5 (0.3-0.8) | 7.7 (4.9-11.3) | 15.9 (12.3-19.7) | 0.4 (0.2-0.8) | 5.7 (3.4-8.9) | 13.3 (9.7-17.7) | 13.5 | 27.4 | 39.0 | |
|
Djibouti | 2.1 (1.1-3.7) | 63.2 (37.1-101.8) | 113.9 (75.3-159.5) | 1.3 (0.6-2.4) | 41.8 (23.2-71.6) | 78.7 (50.3-121.1) | 8.1 | 49.1 | 53.1 |
|
Egypt | 0.1 (0.1-0.2) | 2.8 (1.9-4.0) | 6.3 (5.1-7.6) | 0.1 (0.1-0.2) | 2.6 (1.6-3.8) | 6.7 (5.1-8.6) | 34.2 | 35.8 | 64.6 |
|
Iran | 0.2 (0.2-0.3) | 3.3 (2.7-3.8) | 8.5 (7.2-9.5 | 0.2 (0.1-0.2) | 2.5 (2.0-2.8) | 10.2 (7.9-11.1) | –21.4 | 37.3 | 109.0 |
|
Iraq | 0.3 (0.5-0.1) | 6.3 (3.1-10.3) | 11.9 (9.0-16.4) | 0.1 (0.1-0.2) | 2.3 (3.3-1.6) | 5.6 (4.6-6.7) | –23.3 | –24.1 | 0.6 |
|
Jordan | 0.2 (0.1-0.4) | 5.8 (3.9-8.2) | 12.4 (10.0-16.6) | 0.1 (0.0-0.1) | 1.9 (1.2-2.9) | 7.5 (5.7-10.3) | –26.5 | 5.2 | 56.9 |
|
Lebanon | 0.3 (0.2-0.5) | 7.2 (4.7-10.5) | 15.4 (12.3-19.0) | 0.2 (0.1-0.3) | 4.0 (2.6-5.8) | 12.2 (9.6-15.2) | 2.8 | 20.4 | 36.6 |
|
Libya | 0.4 (0.2-0.7) | 8.8 (5.7-12.9) | 16.9 (13.1-22.2) | 0.3 (0.2-0.6) | 7.8 (4.7-11.9) | 15.4 (11.3-20.6) | –0.3 | 97.8 | 65.9 |
|
Morocco | 0.5 (0.3-0.9) | 15.5 (9.9-22.1) | 30.6 (23.5-37.0) | 0.4 (0.2-0.7) | 11.1 (6.6-17.3) | 23.8 (17.3-31.2) | –12.6 | 1.8 | 32.8 |
|
Pakistan | 1.1 (0.6-1.7) | 11.8 (7.8-17.0) | 20.8 (16.5-25.3) | 0.8 (0.4-1.6) | 9.0 (5.3-14.5) | 17.1 (12.5-24.2) | 24.3 | 37.6 | 27.1 |
|
Palestine | 0.2 (0.1-0.2) | 3.8 (2.5-5.4) | 13.8 (11.0-16.5) | 0.1 (0.1-0.2) | 2.6 (1.7-3.8) | 12.1 (8.8-14.7) | 18.0 | 40.8 | 62.6 |
|
Syria | 0.2 (0.1-0.3) | 3.6 (2.5-5.1) | 7.0 (5.8-8.9) | 0.1 (0.1-0.2) | 2.2 (1.4-3.6) | 6.5 (5.0-8.1) | –48.4 | –6.4 | 63.6 |
|
Tunisia | 0.2 (0.1-0.3) | 5.4 (3.5-7.7) | 14.3 (11.6-18.0) | 0.1 (0.1-0.2) | 3.4 (2.0-5.3) | 11.2 (8.0-15.3) | –33.2 | –10.9 | 35.6 |
|
Sudan | 0.4 (0.1-0.7) | 7.2 (2.9-12.5) | 14.6 (9.2-22.2) | 0.2 (0.1-0.4) | 5.2 (2.4-8.7) | 11.3 (7.6-15.9) | –0.9 | 22.1 | 13.5 |
|
Yemen | 0.4 (0.2-0.7) | 9.5 (4.1-16.3) | 18.8 (11.1-28.4) | 0.3 (0.1-0.5) | 7.1 (3.4-11.9) | 15.5 (10.6-22.1) | 30.3 | 49.0 | 52.9 |
High-income countries globally | 0.4 (0.3-0.4) | 8.2 (7.4-9.1) | 19.5 (18.6-20.5) | 0.3 (0.2-0.4) | 5.6 (4.7-6.7) | 14.9 (13.4-16.4) | –16.5 | –26.9 | 6.7 | |
|
0.1 (0.1-0.2) | 2.3 (1.6-3.4) | 8.4 (6.7-10.7) | 0.1 (0.0-0.1) | 1.7 (1.0-2.6) | 7.2 (5.4-9.2) | 25.6 | 110.0 | 74.8 | |
|
Bahrain | 0.2 (0.1-0.4) | 3.3 (2.3-4.7) | 17.4 (14.4-22.6) | 0.1 (0.1-0.2) | 1.2 (0.8-1.7) | 9.6 (7.7-12.3) | –6.8 | 7.2 | 75.5 |
|
Kuwait | 0.1 (0.1-0.2) | 2.5 (1.9-3.3) | 5.9 (5.2-6.6) | 0.1 (0.0-0.1) | 1.5 (1.1-2.0) | 3.3 (2.9-3.8) | –0.5 | 67.4 | 57.5 |
|
Oman | 0.2 (0.1-0.4) | 5.3 (3.3-8.1) | 14.2 (10.9-18.8) | 0.1 (0.0-0.1) | 2.4 (1.5-3.8) | 10.2 (7.6-13.0) | 15.8 | 25.5 | 43.9 |
|
Qatar | 0.1 (0.0-0.1) | 1.5 (0.9-2.3) | 15.2 (19.4-11.8) | 0.0 (0.0-0.1) | 0.7 (0.4-1.1) | 8.0 (6.0-10.4) | 184.6 | 125.6 | 120.7 |
|
Saudi Arabia | 0.1 (0.1-0.1) | 2.0 (1.4-2.8) | 6.3 (5.2-7.8) | 0.1 (0.0-0.1) | 1.7 (1.1-2.6) | 5.3 (4.1-6.6) | 38.5 | 109.5 | 51.2 |
|
United Arab Emirates | 0.1 (0.1-0.2) | 2.5 (1.6-3.8) | 26.6 (19.7-33.7) | 0.1 (0.1-0.2) | 1.7 (1.0-2.7) | 21.2 (15.1-27.8) | 2.3 | 256.5 | 165.6 |
Global average (122 countries) | 1.0 (0.9-1.1) | 16.7 (15.3-18.5) | 29.9 (28.4-32.8) | 0.7 (0.6-0.7) | 13.3 (12.1-14.0) | 24.9 (23.3-25.9) | –19.1 | 3.8 | 35.0 | |
EMR average (22 countries) | 0.6 (0.3-1.0) | 9.2 (5.6-14.0) | 18.9 (13.8-24.2) | 0.4 (0.2-0.8) | 6.7 (3.8-10.7) | 15.6 (11.0-21.1) | 13.5 | 34.5 | 36.6 |
aRelative difference (%) in the number of deaths = ([number of cervical cancer deaths in 2017 – number of cervical cancer deaths in 2000]/number of cervical cancer deaths in 2000)*100.
bEMR: Eastern Mediterranean Region.
Both globally and in the EMR, DALYs declined for all age groups in the period of 2000-2017. The global average of DALYs for the 3 age groups was higher than the EMR average in both the reference years, and the age group of 30-49 years showed the highest number of DALYs (
Disability-adjusted life years data due to cervical cancer among women older than 20 years in the Eastern Mediterranean Region by age, country, and income level compared to the global average in the years 2000 and 2017.
Group by income level, country | Average cervical cancer DALYa rate per 100,000 women by age range | Relative difference (%) in number of DALYs b (2000 vs 2017) | ||||||||
Year 2000, mean (min-max) | Year 2017, mean (min-max) | |||||||||
20-29 years | 30-49 years | ≥50 years | 20-29 years | 30-49 years | ≥50 years | 20-29 years | 30-49 years | ≥50 years | ||
Low-income countries globally | 161.5 (85.5-268.9) | 2473.0 (1496.9-3715.7) | 2062.9 (1466.6-2779.8) | 106.7 (54.8-188.5) | 1783.2 (1051.3-2807.4) | 1641.5 (1128.3-2294.7) | 5.5 | 21.8 | 26.0 | |
|
128.1 (53.6-235.7) | 2637.7 (1294.6-4425.8) | 1689.7 (986.3-2398.2) | 97.3 (43.3-187.5) | 1628.2 (754.6-2815.3) | 1617.3 (972.9-2364.2) | 14.0 | 50.6 | 18.2 | |
|
Afghanistan | 85.8 (25.8-169.6) | 1456.7 (402.8-2719.2) | 783.9 (300.6-1183.2) | 69.9 (25.8-136.6) | 971.6 (331.2-1749.2) | 697.3 (330.0-1001.0) | 21.9 | 95.0 | –1.8 |
|
Somalia | 213.8 (109.5-370.0) | 4186.9 (2458.3-6609.7) | 3555.1 (2483.6-4884.5) | 152.5 (77.2-294.0) | 3022.9 (1679.8-5033.9) | 3006.5 (1978.5-4457.5) | 7.6 | 30.4 | 27.3 |
Middle-income countries globally | 65.6 (47.3-88.9) | 801.3 (638.8-1011.8) | 642.6 (555.4-778.8) | 43.1 (29.8-62.3) | 628.7 (447.7-838.0) | 532.0 (412.6-643.9) | –81.4 | –86.1 | 17.6 | |
|
34.5 (19.7-55.9) | 368.1 (232.7-542.7) | 326.8 (249.3-407.8) | 26.8 (13.7-50.3) | 272.3 (162.1-429.7) | 259.5 (185.7-345.1) | 14.6 | 28.3 | 36.0 | |
|
Djibouti | 135.4 (69.1-237.0) | 2907.3 (1707.0-4709.3) | 2569.5 (1675.6-3674.6) | 82.2 (39.0-155.3) | 1940.6 (1076.8-3330.4) | 1714.6 (1082.4-2677.9) | 8.7 | 50.9 | 49.2 |
|
Egypt | 8.9 (5.1-14.4) | 134.6 (90.5-193.0) | 120.5 (97.7-146.7) | 8.3 (4.4-14.6) | 122.7 (74.6-184.2) | 122.4 (93.5-156.5) | 35.7 | 36.9 | 61.2 |
|
Iran | 16.7 (13.0-20.1) | 158.8 (130.4-182.6) | 163.1 (136.9-181.8) | 10.6 (8.2-12.6) | 121.3 (98.8-138.5) | 176.2 (136.4-190.3) | –20.2 | 37.7 | 98.0 |
|
Iraq | 17.4 (7.4-31.6) | 298.5 (145.6-486.0) | 237.4 (169.3-336.8) | 8.4 (5.0-13.6) | 110.8 (76.2-156.2) | 106.1 (86.5-128.0) | –22.0 | –24.4 | –2.9 |
|
Jordan | 15.2 (8.9-24.0) | 274.6 (185.5-394.6) | 251.4 (200.0-334.0) | 5.5 (3.1-9.3) | 92.1 (59.4-139.5) | 136.0 (102.9-186.6) | –25.2 | 3.5 | 44.5 |
|
Lebanon | 21.5 (12.3-35.3) | 348.6 (225.5-506.7) | 302.1 (239.3-374.7) | 13.8 (7.9-23.6) | 194.7 (124.4-285.3) | 222.5 (174.9-279.2) | 6.0 | 22.0 | 24.9 |
|
Libya | 24.5 (13.0-44.1) | 420.5 (267.5-618.9) | 340.0 (261.3-438.7) | 22.0 (11.6-39.0) | 373.2 (225.4-575.0) | 309.4 (224.1-416.2) | 1.4 | 95.9 | 73.6 |
|
Morocco | 34.5 (18.9-56.0) | 717.9 (458.0-1030.1) | 668.3 (488.1-820.3) | 26.2 (13.1-46.9) | 517.7 (306.5-812.3) | 494.1 (344.1-647.7) | –11.3 | 1.9 | 31.2 |
|
Pakistan | 70.2 (40.3-115.1) | 565.8 (372.8-824.1) | 443.3 (352.6-543.4) | 52.1 (25.5-103.3) | 433.4 (255.2-704.4) | 350.3 (250.5-491.3) | 25.4 | 38.7 | 25.6 |
|
Palestine | 10.7 (6.5-16.3) | 182.8 (119.6-261.9) | 245.2 (194.7-297.8) | 6.9 (3.9-11.4) | 127.2 (83.3-184.1) | 202.4 (153.0-245.4) | 18.9 | 39.1 | 64.0 |
|
Syria | 12.0 (7.1-19.0) | 173.2 (117.2-243.8) | 140.7 (115.5-183.0) | 8.8 (4.4-15.1) | 107.1 (64.6-171.8) | 123.7 (91.8-158.2) | –47.4 | –7.7 | 58.6 |
|
Tunisia | 13.2 (7.6-20.9) | 259.1 (168.2-375.4) | 269.5 (216.5-339.7) | 8.3 (4.2-15.4) | 165.5 (95.9-259.7) | 199.6 (141.2-274.6) | –32.1 | –11.3 | 34.8 |
|
Sudan | 23.7 (9.4-43.9) | 339.9 (134.9-595.9) | 284.8 (173.1-430.4) | 15.1 (7.2-26.8) | 248.1 (113.8-415.3) | 217.8 (140.3-309.9) | 0.1 | 22.5 | 16.7 |
|
Yemen | 25.2 (10.3-45.3) | 448.1 (192.1-769.9) | 381.2 (217.9-575.2) | 17.9 (8.4-30.8) | 335.1 (157.4-561.7) | 311.5 (208.3-450.8) | 31.5 | 51.2 | 51.7 |
High-income countries globally | 24.6 (20.6-29.7) | 399.8 (357.9-445.7) | 339.4 (321.9-357.8) | 20.7 (16.4-26.2) | 275.5 (228.7-331.6) | 249.9 (224.1-278.0) | –15.4 | –26.2 | 3.4 | |
|
7.6 (4.5-12.1) | 112.0 (75.3-162.9) | 154.4 (121.5-199.7) | 5.3 (2.8-9.0) | 76.9 (46.7-121.4) | 124.9 (92.9-161.6) | 28.1 | 111.6 | 90.6 | |
|
Bahrain | 16.1 (8.0-25.3) | 160.0 (109.8-226.1) | 333.0 (271.0-424.9) | 9.7 (4.7-16.3) | 56.5 (37.6-83.6) | 166.5 (132.9-214.7) | –5.5 | 5.7 | 86.7 |
|
Kuwait | 8.6 (5.9-12.1) | 121.8 (90.5-158.9) | 115.5 (100.4-131.5) | 4.8 (3.0-7.3) | 72.0 (52.0-99.3) | 62.6 (52.7-73.8) | 1.1 | 66.3 | 71.4 |
|
Oman | 14.7 (8.1-24.9) | 254.5 (157.3-388.9) | 268.9 (201.6-361.8) | 115.1 (84.6-149.4) | 72.4 (44.4-112.7) | 121.4 (81.0-174.6) | 17.3 | 28.0 | 40.3 |
|
Qatar | 5.4 (3.1-8.9) | 72.0 (45.5-111.6) | 266.4 (202.6-346.4) | 2.2 (1.2-3.6) | 34.7 (21.4-53.7) | 135.6 (100.0-177.5) | 192.8 | 130.9 | 129.8 |
|
Saudi Arabia | 6.1 (3.7-9.6) | 95.8 (66.6-135.4) | 111.4 (89.8-143.0) | 4.4 (2.3-7.6) | 82.0 (50.7-127.8) | 95.0 (72.7-119.9) | 41.8 | 111.9 | 68.5 |
|
United Arab Emirates | 9.1 (5.0-15.6) | 113.7 (72.8-176.0) | 486.3 (356.1-624.4) | 6.9 (12.2-3.7) | 80.4 (46.5-129.8) | 354.4 (250.7-472.1) | 3.7 | 258.9 | 185.6 |
Global average (122 countries) | 65.8 (57.2-73.7) | 795.3 (726.2-874.5) | 596.3 (562.2-655.4) | 44.6 (40.0-49.1) | 631.5 (575.4-669.8) | 491.6 (456.4-512.0) | –18.3 | 3.2 | 35.7 | |
EMR average (22 countries) | 29.9 (21.0-42.1) | 413.6 (340.7-501.7) | 349.1 (317.9-381.6) | 25.2 (16.1-40.1) | 299.1 (218.8-405.3) | 261.2 (223.5-303.5) | –2.0 | –11.8 | 8.0 |
aDALY: disability-adjusted life year.
bRelative difference (%) in the number of DALYs = ([number of cervical cancer DALYs in 2017 – number of cervical cancer DALYs in 2000]/number of cervical cancer DALYs in 2000)*100.
cEMR: Eastern Mediterranean Region.
In this study, we report the results of the data analysis on both mortality and DALYs associated with cervical cancer in 22 countries in the EMR. We found a change in the number of deaths and mortality rates from the year 2000 to the year 2017. Although the number of deaths due to cervical cancer has increased in the year 2017 (n=8537) compared to that in the year 2000 (n=6326) in the EMR, the mortality rate decreased in 2017 (2.5 per 100,000) compared to that in 2000 (2.7 per 100,000). The population expansion in the younger age groups may have contributed to the reduction in the mortality rates. For example, the population size in EMR-LICs in 2017 increased two-fold in comparison to that in the year 2000. According to the causation and nature of cervical cancer, there exists 10-20 years of gap between HPV infection and the development of cervical cancer. Thus, this disease is not seen in the younger generation; therefore, population expansion does not affect the number of deaths whereas mortality rate calculation under its influence decreases, as reported in previous studies [
Our results showed that large differences existed within the EMR in both deaths and DALYs. Considering the stratification by country income level, we found that HICs carried the largest burden of deaths and the number burden of DALYs for the 2 reference years (85.5%) compared to MICs and LICs (34.2% and 33.3%, respectively) and for all the 3 age groups (25.6%, 110%, and 74.8% vs 13.5%, 27.4%, and 39% vs 12.8%, 49.6%, and 25.1%, respectively). The EMR-HICs, unlike the HICs globally, may have higher relative difference even in comparison to LICs. This might have different causes apart from their economic level that are common in countries of the EMR.
In our study, we consider that one cause that may be relevant is the economic development of the Gulf region in the last 3 decades. This development may have improved the access to health care services, education, and changes in lifestyle and nutrition and traditional social and family structures [
The early detection of cancer reduces financial burdens, both on the health care system and economically [
The WHO recommends a comprehensive prevention and control of cervical cancer, which is related to tertiary prevention for women older than 30 years. This includes treating invasive cancer at any age, including ablative surgery, radiotherapy, and chemotherapy palliative care [
The ongoing civil unrest may have affected the quality of the health data in the EMR, as the GBD study uses modelling techniques to generate the estimates based on other available variables or data from countries with a similar health profile in the neighboring region for countries that have insufficient data. In this study, we used data on the numbers of mortality, crude death rate, and DALY rate. Moreover, the incidence of cervical cancer was not examined.
Cervical cancer is becoming a major problem in the EMR, and its burden might increase due to the population growth. There is a need for effective interventions to reduce the burden of cervical cancer. This includes prevention measures such as HPV vaccination, early detection of cervical cancer, and reducing the risk factors associated with cervical cancer.
disability-adjusted life year
Eastern Mediterranean Region
global burden of disease
high-income country
human papillomavirus
low-income country
low- and middle-income countries
middle-income country
visual inspection with acetic acid
World Health Organization
FS, SG, ZEK, and SE conceived the study in the form of a master's thesis project. FS and SG conducted the analysis and wrote the first draft. BR supervised the process of the manuscript writing. All authors reviewed the draft and contributed to the revisions.
None declared.