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Int J Public Health (2018) 63 (Suppl 1):S151–S164 https://doi.org/10.1007/s00038-017-0999-9 O R I G IN AL ARTI CL E Burden of cancer in the Eastern Mediterranean Region, 2005–2015: ﬁndings from the Global Burden of Disease 2015 Study GBD 2015 Eastern Mediterranean Region Cancer Collaborators Received: 1 May 2017 / Revised: 2 June 2017 / Accepted: 13 June 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract and population aging. Breast cancer, lung cancer, and Objectives To estimate incidence, mortality, and disabil- leukemia were the most common cancers, while lung, ity-adjusted life years (DALYs) caused by cancer in the breast, and stomach cancers caused most cancer deaths. Eastern Mediterranean Region (EMR) between 2005 and Conclusions Cancer is responsible for a substantial disease 2015. burden in the EMR, which is increasing. There is an urgent Methods Vital registration system and cancer registry data need to expand cancer prevention, screening, and aware- from the EMR region were analyzed for 29 cancer groups ness programs in EMR countries as well as to improve in 22 EMR countries using the Global Burden of Disease diagnosis, treatment, and palliative care services. Study 2015 methodology. Results In 2015, cancer was responsible for 9.4% of all Keywords Eastern Mediterranean Region Cancer deaths and 5.1% of all DALYs. It accounted for 722,646 Mortality Incidence Disability-adjusted life years new cases, 379,093 deaths, and 11.7 million DALYs. Between 2005 and 2015, incident cases increased by 46%, deaths by 33%, and DALYs by 31%. The increase in Introduction cancer incidence was largely driven by population growth With 8.7 million deaths (16% of all deaths), cancer was globally the second-leading cause of death behind cardio- vascular diseases in 2015 (GBD 2015 Mortality and Causes This article is part of the supplement ‘‘The state of health in the Eastern Mediterranean Region, 1990–2015’’. of Death Collaborators 2016). There were 17.5 million incident cases globally, and cancer accounted for 209 The members of GBD (Global Burden of Disease) 2015 Eastern million DALYs (GBD 2015 DALYs and HALE Collabo- Mediterranean Region Cancer Collaborators are listed at the end of rators 2016; GBD 2015 Disease and Injury Incidence and the article. Christina Fitzmaurice, on behalf of GBD 2015 Eastern Prevalence Collaborators 2016; Global Burden of Disease Mediterranean Region Cancer Collaborators, is the corresponding author. Cancer Collaboration et al. 2016). In many countries, the epidemiological transition has led to a decrease in com- Electronic supplementary material The online version of this municable, neonatal, maternal, and nutritional diseases, at article (doi:10.1007/s00038-017-0999-9) contains supplementary material, which is available to authorized users. the expense of an increase in non-communicable diseases over time (GBD 2015 DALYs and HALE Collaborators & GBD 2015 Eastern Mediterranean Region Cancer 2016). Prior studies examining cancer epidemiology in the Collaborators EMR have either focused on a single year, a single country, email@example.com; http://healthdata.org or a particular component of cancer treatment (Aljurf et al. 2010; Abdel-Razeq et al. 2015; Kulha ´nova ´ et al. 2017). Division of Hematology, Department of Medicine, Institute What has not been analyzed for the EMR is how the epi- for Health Metrics and Evaluation, 2301 5th Avenue, Suite demiological and demographical transition through an 600, UW Campus, Mailbox: 358210, Seattle, WA 98121, aging population, urbanization, industrialization, and USA 123 S152 GBD 2015 Eastern Mediterranean Region Cancer Collaborators lifestyle changes, as well political turmoil has affected the Data were extracted at the most detailed level, by age cancer burden (GBD 2015 DALYs and HALE Collabora- group and sex, and mapped to the GBD cause list. Using a tors 2016). This evidence is essential for comprehensive cause of death ensemble modeling (CODEm) approach cancer control planning. Given the diverse country proﬁles with cause-speciﬁc covariates, we computed mortality in the EMR with large differences in income, age structure, estimates for each individual cause (Foreman et al. 2012). risk factor proﬁle, and political stability, cancer prevention These estimates were scaled to ﬁt into an independently potential and treatment capacity requirements differ sub- modeled all-cause mortality estimate using the algorithm stantially between countries. In this study, we therefore CodCorrect (GBD 2015 Mortality and Causes of Death present the Global Burden of Disease Study 2015 (GBD Collaborators 2016). We transformed the ﬁnal mortality 2015) estimates of incidence, mortality, years of life lost estimates into incidence estimates using modeled MIR. (YLLs), years lived with disability (YLDs), and DALYs Uncertainty from data sources and processing steps was for 29 cancer groups and 22 EMR countries from 2005 to propagated to the incidence estimates. 2015 by age and sex, which to our knowledge is the most Cancer survival was calculated using a MIR-based comprehensive assessment of cancer burden in the EMR scaling factor. We calculated 10-year prevalence of each (GBD 2015 DALYs and HALE Collaborators 2016; GBD cancer and each incidence cohort using these cancer sur- 2015 Disease and Injury Incidence and Prevalence Col- vival estimates. The total prevalence was divided into four laborators 2016; GBD 2015 Mortality and Causes of Death sequelae with variable disability weights: (1) diagnosis and Collaborators 2016; GBD 2015 Risk Factors Collaborators treatment, (2) remission, (3) metastatic, and (4) terminal 2016). This quantitative assessment is especially important phase. We assumed a constant duration for sequelae (1), to guide health policy and to measure progress on the third (3), and (4) for all countries over time. Duration of sequela Sustainable Development Goal (SDG) of reducing prema- (2) was the remaining prevalence after subtracting the ture mortality from non-communicable diseases by one duration of the ﬁxed sequelae. We computed YLLs by third by 2030 (United Nations 2016). multiplying deaths by the normative standard life expec- tancy at each age of death (GBD 2015 Mortality and Causes of Death Collaborators 2016). For each sequela, Methods YLDs were calculated by multiplying the prevalence of each sequela by its disability weight. Finally, DALYs were The GBD 2015 study estimated incidence, prevalence, calculated by summing YLLs and YLDs. deaths, YLLs, YLDs, and DALYs for 195 countries and To analyze the contribution of population aging, popula- territories from 1990 to 2015. In total, 315 causes of dis- tion growth, and changes in age-speciﬁc incidence rates eases and injuries and 79 risk factors were systematically (ASIR) to the absolute change of cancer incidence, we cal- analyzed. Details of the methodology used in GBD 2015 to culated two scenarios. In the ﬁrst, the age structure, sex estimate general disease burden and cancer burden are structure, and age-speciﬁc rates from 2005 were applied to the described in detail elsewhere (GBD 2015 DALYs and 2015 population. The difference between the total number of HALE Collaborators 2016; GBD 2015 Disease and Injury cases in 2005 and the hypothetical scenario were attributed to Incidence and Prevalence Collaborators 2016; GBD 2015 population growth. In the second, the age-speciﬁc rates from Mortality and Causes of Death Collaborators 2016; GBD 2005 were applied to the age structure, sex structure, and 2015 2015 Risk Factors Collaborators 2016; Global Burden of population. The differences between the two scenarios were Disease Cancer Collaboration et al. 2016). attributed to population aging. Differences between the total Brieﬂy, to estimate cancer burden, we mapped all neo- number of cases in 2015 and the second hypothetical scenario plasms as deﬁned by the 10th revision of the International were attributed to changes in the age-speciﬁc rates. Statistical Classiﬁcation of Diseases (ICD-10) to one of the The 22 EMR countries were grouped according to per 29 GBD cancer groups. Input data for cancer mortality capita gross national income (GNI) into low-income estimates came from vital registry mortality and cancer countries (LICs) (Afghanistan, Djibouti, Somalia, and registry incidence data. The latter were transformed to Yemen); middle-income countries (MICs) (Egypt, Iran, mortality estimates using separately modeled mortality-to- Iraq, Jordan, Lebanon, Libya, Morocco, Pakistan, Pales- incidence ratios (MIR) (Global Burden of Disease Cancer tine, Sudan, Syria, and Tunisia); and high-income countries Collaboration et al. 2016). The raw data were processed to (HICs) (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and make them comparable and to account for ‘‘garbage the United Arab Emirates). LICs were deﬁned as those codes’’, which are codes assigned to causes that are not having a per capita GNI of $1045 or less, MICs as those usable from a public health perspective (Naghavi et al. with a per capita GNI between $1046 and $12,735, and 2010). These causes were redistributed to the most likely HICs as countries with per capita GNI of $12,736 or underlying cause of death based on a regression model. greater. 123 Burden of cancer in the Eastern Mediterranean Region, 2005–2015: ﬁndings from the Global… S153 In this publication, all rates are reported per 100,000 standardized DALY rates (ASDR) remained unchanged person-years. We report 95% uncertainty intervals (UIs) between 2005 and 2015: 2663.7 (2486.3–2861.0) in 2005, for all estimates (listed in parentheses after the point and 2605.3 (2404.8–2816.0) in 2015 (eTable 4). estimates). Regional age and sex variations in cancer burden Results Females had higher ASIR in 2015 than males, with 199.6 (175.7–224.5) in females and 163.3 (150.2–178.7) in males Regional burden of cancer (Table 3). Age-standardized mortality rate (ASMR) was higher in males compared to females at 113.8 Between 2005 and 2015 in the EMR region, incident (105.0–124.0) versus 95.8 (85.4–106.7), respectively. In cancer cases increased by 46.1% (34.5–59.4%) from 495 females, breast cancer, leukemia, and cervical cancer were (457–537) thousand in 2005 to 723 (661–790) thousand the most common incident cancers with 177 (149–207) cases in 2015 (Table 1). In 2015, cancer caused 379 thousand, 21 (18–25) thousand, and 20 (15–26) thousand (350–409) thousand deaths (Table 2) and 11.7 million cases, respectively (Table 2). The three cancers responsible (10.8–12.7 million) DALYs, of which 3% were for most cancer deaths in females were breast cancer with attributable to YLDs and 97% to YLLs (eFig. 1). Age- 38 (32–44) thousand deaths, colon and rectal cancer with Table 1 Decomposition Analysis of Cancer Incidence by Country in the Eastern Mediterranean Region, both sexes, 2005–2015 (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 2005–2015) Location Number of Expected number of cases in 2015 Change in incident cases 2005–2015 in % Overall incident cases change in 2005 2015 Given Given population Due to Due to Due to change in population growth and aging population population incidence rates growth alone growth ageing Eastern 494,690 722,646 609,771 670,386 23.3 12.3 10.6 46.1 Mediterranean Region Afghanistan 25,015 36,809 33,400 35,375 33.5 7.9 5.7 47.2 Bahrain 663 1105 1050 1218 58.5 25.3 -17.1 66.7 Djibouti 772 1153 879 1020 13.8 18.3 17.3 49.4 Egypt 62,489 87,853 76,106 80,680 21.8 7.3 11.5 40.6 Iran 67,019 95,011 75,054 88,510 12.0 20.1 9.7 41.8 Iraq 28,593 41,208 38,474 40,354 34.6 6.6 3.0 44.1 Jordan 4016 6188 5677 6504 41.4 20.6 -7.9 54.1 Kuwait 1416 2544 2430 2701 71.5 19.2 -11.1 79.6 Lebanon 7446 13,272 10,867 11,933 45.9 14.3 18.0 78.2 Libya 5205 7646 5638 6762 8.3 21.6 17.0 46.9 Morocco 36,743 53,370 41,475 48,931 12.9 20.3 12.1 45.3 Oman 1127 2524 2016 2240 78.8 19.9 25.2 123.9 Pakistan 175,827 254,242 215,840 233,152 22.8 9.8 12.0 44.6 Palestine 2104 3479 2730 3053 29.8 15.3 20.3 65.4 Qatar 529 1290 1417 1281 167.7 -25.7 1.7 143.7 Saudi Arabia 9384 15,726 11,912 14,359 26.9 26.1 14.6 67.6 Somalia 7207 9862 9193 8974 27.6 -3.0 12.3 36.8 Sudan 20,552 29,740 25,871 27,940 25.9 10.1 8.8 44.7 Syria 7938 10,956 8134 9753 2.5 20.4 15.1 38.0 Tunisia 14,023 19,471 15,592 17,998 11.2 17.2 10.5 38.8 United Arab 3268 9247 6663 8585 103.9 58.8 20.2 182.9 Emirates Yemen 13,352 19,950 17,472 18,375 30.9 6.8 11.8 49.4 123 S154 GBD 2015 Eastern Mediterranean Region Cancer Collaborators Table 2 Incidence, deaths and disability-adjusted life years for all cancers and 29 cancer groups in the Eastern Mediterranean Region, both sexes, 2015 (Global Burden of Disease Study 2015, Eastern Mediterranean Region, 2015) Cause Number of incident cases Number of deaths Number of DALYs (in thousands) Males Females Both Males Females Both Males Females Both All cancers 309,240 413,406 722,646 (660,722–790,102) 198,164 180,929 379,093 5865 5875 11,740 (10,800–12,742) groups (282,640–340,657) (361,086–467,300) (181,894–217,561) (160,360–202,560) (350,252–408,580) (5354–6474) (5191–6608) Lip and oral 14,068 15,358 29,426 (23,752–36,473) 4918 (4009–6069) 4837 (3841–5943) 9755 (8315–11,408) 161 (127–203) 151 (119–187) 312 (263–368) cavity cancer (10,664–18,701) (11,296–21,357) Nasopharynx 3219 (2080–4681) 1836 (1041–2849) 5055 (3606–6940) 1469 (1242–1776) 825 (680–984) 2294 (2006–2681) 52 (43–63) 30 (25–36) 82 (71–97) cancer Other pharynx 4394 (3516–5394) 3593 (2915–4365) 7988 (6914–9273) 1654 (1410–1976) 1391 (1165–1641) 3045 (2679–3457) 46 (40–55) 40 (34–48) 87 (76–99) cancer Esophageal 8795 (7449–10,517) 7992 (6474–9848) 16,788 (14,577–19,253) 9345 (8068–10,879) 8396 (6823–10,239) 17,741 265 (223–317) 251 (203–313) 516 (452–595) cancer (15,743–20,073) Stomach cancer 27,093 17,725 44,818 (40,719–49,095) 17,462 11,847 29,309 441 (394–496) 328 (264–387) 769 (690–851) (24,235–30,565) (14,951–20,558) (15,667–19,460) (9954–13,631) (26,728–31,947) Colon and 18,662 17,150 35,813 (32,240–39,507) 13,268 13,148 26,416 392 (335–450) 373 (321–427) 764 (678–859) rectum cancer (16,276–21,216) (15,090–19,477) (11,666–14,925) (11,498–14,918) (23,736–29,279) Liver cancer 14,660 9908 (7418–11,788) 24,568 (20,618–27,385) 16,617 10,747 27,365 448 (347–513) 292 (211–342) 740 (588–823) (12,042–16,784) (13,869–18,735) (8232–12,290) (23,002–30,174) Gallbladder and 2383 (1983–2803) 4543 (3731–5279) 6926 (5941–7838) 1985 (1673–2312) 3853 (3161–4465) 5839 (4973–6612) 50 (41–59) 98 (79–116) 148 (124–169) biliary tract cancer Pancreatic cancer 6283 (5762–6843) 4885 (4393–5394) 11,168 (10,419–11,995) 7011 (6463–7643) 5480 (4917–6100) 12,491 179 (164–196) 129 (116–144) 308 (285–331) (11,601–13,400) Larynx cancer 11,975 2887 (2458–3493) 14,862 (13,083–17,018) 6477 (5676–7380) 1612 (1345–1917) 8090 (7222–9049) 172 (150–199) 46 (39–54) 218 (193–245) (10,284–14,128) Tracheal, 37,681 11,848 49,530 (44,083–54,564) 39,180 11,831 51,012 1013 317 (277–364) 1330 (1171–1475) bronchial and (32,768–42,292) (10,591–13,321) (34,316–43,815) (10,442–13,380) (45,430–56,191) (879–1144) lung cancer Malignant skin 3021 (2072–3909) 2733 (2326–3212) 5755 (4863–6883) 617 (407–773) 514 (452–591) 1131 (947–1322) 20 (14–27) 16 (14–19) 36 (31–44) melanoma Non-melanoma 9359 (8443–10,285) 4697 (4165–5264) 14,056 (12,711–15,383) 1015 (921–1117) 314 (272–361) 1330 (1223–1449) 27 (24–30) 9 (7–10) 36 (33–39) skin cancer Breast cancer 2058 (1810–2359) 177,389 179,447 (150,924–209,304) 463 (408–530) 38,117 38,581 14 (12–16) 1314 1328 (1115–1561) (148,702–207,371) (32,305–44,251) (32,795–44,698) (1101–1546) Cervical cancer – 19,634 19,634 (14,721–25,505) – 7878 (6158–9928) 7878 (6158–9928) – 251 (192–323) 251 (192–323) (14,721–25,505) Uterine cancer – 14,337 14,337 (11,576–17,621) – 6857 (5641–8076) 6857 (5641–8076) – 193 (157–228) 193 (157–228) (11,576–17,621) Ovarian cancer – 10,946 10,946 (9024–13,395) – 6855 (5953–7833) 6855 (5953–7833) – 235 (201–271) 235 (201–271) (9024–13,395) Prostate cancer 27,533 – 27,533 (20,349–34,378) 13,861 – 13,861 243 (180–297) – 243 (180–297) (20,349–34,378) (10,420–17,187) (10,420–17,187) Testicular cancer 3143 (2315–4266) – 3143 (2315–4266) 1010 (792–1299) – 1010 (792–1299) 52 (40–68) – 52 (40–68) Kidney cancer 5465 (4635–6345) 2856 (2463–3279) 8321 (7364–9305) 3497 (3046–3942) 1741 (1505–2039) 5239 (4699–5834) 110 (96–125) 60 (52–71) 170 (152–190) Burden of cancer in the Eastern Mediterranean Region, 2005–2015: ﬁndings from the Global… S155 13 (11–15) thousand deaths, and stomach cancer with 12 (10–14) thousand deaths. The top three causes of DALYs in females were breast cancer with 1.3 (1.1–1.5) million DALYs, leukemia with 498 (445–557) thousand DALYs, and other neoplasms with 459 (339–546) thousand DALYs (Table 2). The most common incident cancers in males in 2015 were tracheal, bronchus, and lung cancer (TBL) with 38 (33–42) thousand cases, followed by prostate cancer and stomach cancer, with 28 (20–34) thousand and 27 (24–31) thousand cases, respectively. These cancers accounted for 30% of the incidence of all cancers. The most common causes of cancer deaths in males were TBL, stomach cancer, and liver cancer with 39 (34–44) thousand, 17 (16–19) thousand, and 17 (14–19) thousand deaths, respectively. The top three causes of DALYs in males were TBL with 1.0 (0.8–1.1) million DALYs, leukemia with 637 (579–705) thousand DALYs, and other neoplasms with 494 (418–603) thousand DALYs (Table 2). In children aged 0–14 years, the most common cancers were leukemia, other neoplasms, and cancer of the brain and nervous system (Fig. 1). These cancers were also the ones responsible for most childhood cancer deaths (Fig. 2). In adolescents and young adults (ages 15–39 years), the most common cancers were breast cancer, followed by leukemia and other neoplasms. These cancers were also main causes of death in this age group. National cancer incidence, mortality, and burden In 2015, Lebanon had the highest ASIR for all cancers at 261.9 (194.6–336.2), followed by Afghanistan at 258.8 (161.3–411.3), and Iraq at 219.9 (172.2–279.8) (Table 3). ASMRs were highest in Afghanistan at 165.0 (111.5–221.7), followed by Somalia at 148.6 (49.1–319.1), and Djibouti at 142.0 (75.4–256.6). Those three countries also had the highest ASDRs in 2015. Saudi Arabia, Syria, and Oman had the lowest ASIRs in 2015 with 95.6 (82.3–111.5), 103.5 (89.9–117.8), and 115.8 (98.5–131.8), respectively. Those countries also had the lowest ASMR with 54.8 (50.1–60.0), 64.0 (55.0–72.4), and 66.0 (55.2–74.7), respectively. Along with Kuwait, these coun- tries had the lowest ASDRs in 2015 as well. Burden of different cancer groups Excluding the ‘‘other neoplasms’’ group, ﬁve cancers, namely breast cancer, TBL, leukemia, stomach cancer, and colon and rectal cancer ranked highest in terms of incident cases in the region. Breast cancer had the highest ASIR in the EMR in 2015 with 42.3 (35.7–48.9) cases. It also had the second-highest ASMR after TBL in the region with 9.9 (8.5–11.3) deaths (eTable 1). There were 179 (151–209) Table 2 continued Cause Number of incident cases Number of deaths Number of DALYs (in thousands) Males Females Both Males Females Both Males Females Both Bladder cancer 23,449 6404 (5411–7716) 29,853 (26,404–33,966) 9452 (8524–10,545) 3151 (2723–3587) 12,604 217 (194–244) 73 (63–83) 289 (263–320) (20,144–27,360) (11,527–13,821) Brain and 12,805 11,045 23,851 (20,099–27,075) 10,333 8395 (7355–9338) 18,729 427 (321–525) 352 (300–392) 779 (666–881) nervous system (9708–15,710) (9432–12,702) (7909–12,510) (16,185–20,983) Thyroid cancer 3654 (2966–4357) 7536 (6026–9477) 11,191 (9589–13,565) 565 (484–688) 1112 (925–1352) 1678 (1478–2000) 17 (14–20) 32 (26–39) 49 (42–58) Mesothelioma 839 (724–1015) 260 (215–339) 1099 (964–1313) 794 (717–909) 299 (245–360) 1093 (987–1243) 24 (22–28) 10 (8–12) 34 (30–39) Hodgkin 3247 (2539–4383) 2372 (1488–3502) 5619 (4436–7142) 1176 (932–1649) 811 (547–1245) 1987 (1655–2658) 50 (39–70) 36 (23–53) 86 (70–114) lymphoma Non-Hodgkin 16,818 14,549 31,367 (24,638–36,975) 6745 (5684–8121) 5999 (4194–7470) 12,744 251 (209–305) 216 (146–274) 466 (365–553) lymphoma (14,017–20,617) (9501–18,687) (10,225–14,857) Multiple 2693 (2323–3268) 2643 (2205–3157) 5336 (4694–6150) 2318 (2038–2761) 2395 (2028–2834) 4714 (4196–5411) 66 (57–80) 67 (56–80) 132 (116–154) myeloma Leukemia 26,878 20,800 47,679 (42,513–53,365) 14,627 11,206 25,833 637 (579–705) 498 (445–557) 1135 (1053–1232) (23,330–31,115) (17,703–24,679) (13,388–16,013) (10,045–12,467) (24,105–27,809) Other neoplasms 19,054 17,468 36,523 (32,170–42,695) 12,292 11,306 23,599 494 (418–603) 459 (389–546) 953 (840–1103) (15,995–23,621) (14,692–21,110) (10,537–15,191) (9694–13,334) (20,803–27,877) S156 GBD 2015 Eastern Mediterranean Region Cancer Collaborators Table 3 Age-standardized incidence, mortality and DALY rates per 100,000 for the Eastern Mediterranean Region and its 22 countries, both sexes, 2015 (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 2015) Location Age-standardized incidence rate Age-standardized mortality rate Age-standardized DALY rate Males Females Both Males Females Both Males Females Both Eastern 163 (150–179) 200 (176–225) 180 (166–195) 114 (105–124) 96 (85–107) 104 (97–112) 2651 (2435–2915) 2583 (2287–2897) 2605 (2404–2816) Mediterranean Region Afghanistan 178 (127–237) 345 (171–642) 259 (161–411) 156 (109–205) 177 (102–276) 165 (112–222) 3546 (2355–4889) 5066 (2618–8449) 4260 (2634–6153) Bahrain 134 (105–168) 156 (122–196) 138 (117–162) 88 (69–107) 70 (56–85) 77 (66–89) 1752 (1385–2170) 1776 (1395–2221) 1710 (1453–2003) Djibouti 201 (103–409) 221 (105–528) 210 (113–388) 158 (80–311) 129 (61–301) 142 (75–257) 3972 (1896–8438) 3634 (1696–8796) 3783 (1951–7187) Egypt 146 (135–165) 137 (126–149) 139 (131–151) 100 (94–111) 65 (62–71) 81 (77–87) 2437 (2299–2619) 1846 (1740–1973) 2113 (2022–2229) Iran 208 (166–260) 135 (104–175) 173 (146–205) 123 (98–150) 69 (52–89) 97 (81–113) 2650 (2080–3338) 1704 (1286–2243) 2190 (1825–2595) Iraq 185 (129–243) 254 (178–344) 220 (172–280) 138 (95–176) 117 (86–156) 126 (101–155) 3340 (2303–4462) 3329 (2385–4498) 3318 (2625–4180) Jordan 153 (131–179) 145 (115–178) 147 (129–169) 98 (84–114) 64 (53–76) 80 (71–90) 2193 (1888–2580) 1708 (1423–2039) 1939 (1713–2179) Kuwait 139 (118–167) 179 (148–214) 156 (139–176) 71 (60–84) 68 (56–82) 70 (62–79) 1403 (1181–1664) 1523 (1256–1815) 1453 (1292–1644) Lebanon 284 (192–391) 246 (165–341) 262 (195–336) 158 (104–218) 110 (73–146) 133 (99–170) 3302 (2179–4603) 2715 (1771–3746) 2995 (2238–3864) Libya 226 (187–276) 160 (133–194) 189 (166–218) 157 (128–191) 91 (74–110) 121 (104–139) 3326 (2703–4039) 2245 (1815–2752) 2752 (2360–3181) Morocco 180 (126–258) 210 (138–296) 195 (151–252) 140 (98–201) 108 (72–148) 122 (96–159) 3019 (2053–4385) 2690 (1776–3789) 2844 (2205–3728) Oman 121 (97–143) 118 (98–144) 116 (99–132) 74 (58–87) 58 (47–69) 66 (55–75) 1564 (1237–1867) 1397 (1115–1711) 1469 (1220–1688) Pakistan 153 (127–185) 278 (213–350) 214 (180–253) 109 (91–131) 126 (97–155) 117 (100–135) 2878 (2374–3537) 3498 (2678–4319) 3182 (2713–3685) Palestine 149 (115–192) 153 (117–205) 150 (122–182) 116 (87–146) 71 (55–92) 92 (74–110) 2816 (2094–3653) 2015 (1546–2663) 2396 (1925–2898) Qatar 144 (110–189) 180 (136–226) 150 (122–183) 90 (67–118) 79 (59–99) 84 (67–104) 1667 (1251–2170) 1932 (1452–2463) 1700 (1382–2109) Saudi Arabia 104 (85–128) 92 (73–113) 96 (82–111) 67 (60–77) 43 (39–49) 55 (50–60) 1300 (1154–1490) 992 (881–1124) 1134 (1033–1251) Somalia 144 (62–304) 257 (76–608) 202 (69–449) 130 (53–270) 166 (44–382) 149 (49–319) 3267 (1266–7474) 4751 (1262–11,703) 4031 (1274–9504) Sudan 136 (97–185) 163 (97–241) 149 (110–195) 111 (80–157) 85 (54–122) 97 (73–125) 2485 (1719–3601) 2216 (1338–3228) 2338 (1722–3074) Syria 103 (84–124) 105 (86–126) 103 (90–118) 76 (61–92) 54 (44–63) 64 (55–72) 1653 (1343–1972) 1345 (1099–1592) 1487 (1288–1685) Tunisia 224 (169–289) 164 (117–213) 190 (151–231) 163 (122–210) 76 (55–100) 115 (90–141) 3445 (2596–4545) 1878 (1356–2479) 2610 (2057–3170) United Arab Emirates 213 (155–290) 226 (158–310) 207 (157–270) 106 (81–139) 85 (65–115) 97 (76–123) 2191 (1621–2891) 2279 (1694–3069) 2145 (1651–2720) Yemen 131 (85–198) 201 (114–353) 167 (101–268) 109 (72–168) 103 (59–164) 106 (65–164) 2445 (1529–3909) 2753 (1558–4552) 2601 (1527–4180) Burden of cancer in the Eastern Mediterranean Region, 2005–2015: ﬁndings from the Global… S157 100% Lip and oral cavity cancer Nasopharynx cancer Other pharynx cancer 90% Esophageal cancer Stomach cancer Colon and rectum cancer 80% Liver cancer Gallbladder and biliary tract cancer Pancreac cancer 70% Larynx cancer Tracheal, bronchus, and lung cancer 60% Malignant skin melanoma Non-melanoma skin cancer Breast cancer 50% Cervical cancer Uterine cancer Ovarian cancer 40% Prostate cancer Tescular cancer Kidney cancer 30% Bladder cancer Brain and nervous system cancer Thyroid cancer 20% Mesothelioma Hodgkin lymphoma Non-Hodgkin Lymphoma 10% Mulple myeloma Leukemia 0% Other neoplasms <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 ≤ AS All Ages Age group Fig. 1 Age-speciﬁc contribution of cancer groups to total cancer incidence in the Eastern Mediterranean Region, both sexes, 2015 (Global Burden of Disease Study 2015, Eastern Mediterranean Region, 2015) thousand new cases in 2015, 39 (33–45) thousand deaths, Colon and rectum cancer was the sixth most frequent and 1.3 (1.1–1.6) million DALYs caused by breast cancer cancer in the region in 2015 with 36 (32–40) thousand (Table 2). Only 1% (2058 cases) of breast cancer cases incident cases, 26 (24–29) thousand deaths, and 764 occurred in males (Table 2). Nine percent of all DALYs (678–859) thousand DALYs. It was the second most fre- caused by breast cancer came from YLDs (eFigure 1). quent incident cancer in 2015 in Jordan, Kuwait, Lebanon, In 2015, TBL had the second highest ASIR the region Libya, Qatar, and Saudi Arabia. with 13.9 (12.5–15.2). It was the leading cause of cancer deaths and DALYs in the region with 51 (44–55) thousand Drivers of change in cancer incidence incident cases, 51 (45–56) thousand deaths, and 1.3 (1.2–1.5) million DALYs. Seventy-six percent of new Between 2005 and 2015, the overall change in the number cases and deaths occurred in males. Only 1% of DALYs of incident cancer cases ranged between 36.8% in Somalia came from YLDs. and 182.9% in the UAE (Table 1). High-income EMR There were 48 (43–53) thousand new cases of leukemia countries in addition to Lebanon experienced the largest in 2015 in the region and 26 (24–28) thousand deaths, increase in cancer incidence, which was mainly driven by making it the third most common cancer in the region. population growth in all countries. Population aging was Leukemia caused 1.1 (1.1–1.2) million DALYs, with 97% responsible for 12% of the increase in incident cancer cases coming from YLLs. in the region in total, ranging from -25.7% in Qatar to Stomach cancer had the fourth-highest ASIR the region in 58.8% in the UAE. Change in age-speciﬁc incident rates 2015 at 13.2 (12.0–14.4), but ranked ﬁrst in Afghanistan with ranged between -17.1% in Bahrain and 25.2% in Oman 40.5 (26.1–55.0) and second in Iran, Yemen, and Sudan with relative to the overall change in incident cases (Table 1). 29.1 (24.0–35.7), 19.0 (11.6–29.4), and 18.1 (13.2–23.6), respectively (Online Appendix Data). There were 45 (41–49) Discussion thousand cases in 2015, 29 (27–32) thousand deaths, and 769 (690–851) thousand DALYs, of which only 2% came from In 2015, cancer was responsible for 9.4% (8.9–9.9%) of all YLDs. Sixty percent of incident cases, 60% of deaths, and deaths and 5.1% (4.6–5.8%) of all DALYs in the EMR 57% of DALYs occurred in males. countries compared to 15.7% (15.5–15.9%) of deaths and Proporon of all cancer incidence S158 GBD 2015 Eastern Mediterranean Region Cancer Collaborators 100% Lip and oral cavity cancer Nasopharynx cancer Other pharynx cancer 90% Esophageal cancer Stomach cancer 80% Colon and rectum cancer Liver cancer Gallbladder and biliary tract cancer 70% Pancreac cancer Larynx cancer Tracheal, bronchus, and lung cancer 60% Malignant skin melanoma Non-melanoma skin cancer Breast cancer 50% Cervical cancer Uterine cancer Ovarian cancer 40% Prostate cancer Tescular cancer Kidney cancer 30% Bladder cancer Brain and nervous system cancer 20% Thyroid cancer Mesothelioma Hodgkin lymphoma 10% Non-Hodgkin Lymphoma Mulple myeloma Leukemia 0% Other neoplasms <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 ≤ AS All Ages Age group Fig. 2 Age-speciﬁc contribution of cancer groups to total cancer mortality in the Eastern Mediterranean Region, both sexes, 2015. (Global Burden of Disease Study 2015, Eastern Mediterranean Region, 2015) 8.5% (7.8–9.2%) of all DALYs at the global level (GBD provides analyses of all diseases over time, which means 2015 DALYs and HALE Collaborators 2016; GBD 2015 that cancer can be viewed in the context of other health ´ ´ Mortality and Causes of Death Collaborators 2016). This priorities. Kulhanova et al. recently published an analysis puts cancer as the third-leading cause of death and the using GLOBOCAN data to analyze the cancer burden in ´ ´ eighth-leading cause of DALYs in the EMR. In EMR the EMR (Kulhanova et al. 2017). Because of different countries, cancer deaths between 2005 and 2015 have methods to estimate incidence and mortality as well as few increased by 32.9%. Females experienced higher cancer high-quality data sources for cancer incidence and mor- incidence in the EMR but lower cancer deaths compared to tality in the EMR, GBD estimates for incidence differ males, which can be explained by less aggressive cancers between 50% fewer incident cases (for Syria) to 215% (breast, cervical) being among the top cancers in females more incident cases (for the UAE). For mortality, GBD compared to males (lung, stomach). Age-standardized estimates range from 56% fewer deaths in Syria to 153% cancer incidence varied substantially between EMR coun- more deaths in the UAE (eTable 4). Whereas the GLO- tries with infection-related cancers playing a more impor- BOCAN methodology starts with estimating cancer inci- tant role in low- and low-middle income countries (e.g., dence and then for most EMR countries models survival to stomach cancer having the highest ASIR in Afghanistan, estimate mortality (Ferlay et al. 2015), GBD uses cancer Iran, Yemen, and Sudan, and cancers related to low registry incidence-based mortality estimates as well as vital physical activity and cancers with strong lifestyle-related registration data to model mortality and then uses these risk factors such as colorectal cancer being more common mortality estimates as well as modeled MIR to estimate in middle- and high-income EMR countries such as cancer incidence. An advantage of the GBD study is the Lebanon, the UAE, and Libya). ability to compare trends over time, which allows for Given this alarming trend and the substantial contribu- analysis of the effects of the demographical and epidemi- tion of cancer to the disease burden in EMR countries, ological transition, and also the effectiveness of public cancer control has to be among the top health policy pri- health policies. The discrepancies between GLOBOCAN orities. Compared to other studies (Aljurf et al. 2010; and GBD estimates underscore the need for better data to ´ ´ Abdel-Razeq et al. 2015; Kulhanova et al. 2017) analyzing assess cancer burden in the EMR countries. Few high- cancer burden in the EMR countries, the GBD study quality population-based cancer registries exist in the Proporon of all cancer mortality Burden of cancer in the Eastern Mediterranean Region, 2005–2015: ﬁndings from the Global… S159 EMR, with the Global Initiative for Cancer Registry forms of tobacco consumption such as shisha smoking even Development (GICR) actively promoting further develop- rising (Maziak et al. 2015). Secondhand smoking is not ment of cancer registries (International Agency for restricted in most countries in the EMR despite the FCTC Research on Cancer (IARC) 2011). At the same time, recommendations (Heydari et al. 2012). strengthening of vital registration systems and integration Obesity and lack of physical activity are risk factors that of surveillance systems for other non-communicable dis- also follow a dangerous trend, with obesity prevalence eases is needed in the region. Until better data become rising in many EMR countries to concerning levels (Ng available, model-based estimates have to be used to guide et al. 2014). Obesity has been proven to be a risk factor for local policy. esophageal adenocarcinoma, colon, rectal, kidney, and Two signiﬁcant international statements address the pancreas cancer, gallbladder cancer in females, and post- threat of non-communicable diseases and propose inter- menopausal breast, ovarian, and uterine cancers (Lauby- ventions as well as metrics to measure success. The SDGs, Secretan et al. 2016). Physical inactivity has been linked to as the successors of the Millennium Development Goals, an increased risk for cancer, especially colon and breast which shaped public health policy for 15 years, now cancer (American Institute for Cancer Research and World include non-communicable diseases (NCDs) in the third Cancer Research Fund 2007). For both sexes combined, goal, ‘‘by 2030, reduce by one-third premature mortality breast cancer is the most common incident cancer in every from non-communicable diseases through prevention and EMR country, and colorectal cancer is among the top four treatment and promote mental health and well-being’’ most common cancers in all high-income EMR countries (United Nations 2016). Control of NCDs has also been as well as all middle-income EMR countries except for targeted in the WHO Global Action Plan for Prevention Iran, Pakistan, Sudan, Syria, Egypt, Morocco, and Iraq. and Control of NCDs 2013–2020 (World Health Organi- This stresses the importance of health intervention pro- zation 2013). Our study shows that substantial efforts are grams and environmental policies to increase physical required in most EMR countries to meet the SDG targets of activity and healthy dietary habits. reducing cancer mortality. Culprits for the disappointing Other important strategies for primary prevention pace of cancer control to date can be found in all aspects of include vaccination against human papillomavirus (HPV) cancer care, from primary prevention and screening, to for cervical cancer prevention, as well as hepatitis B vac- early diagnosis, access to cancer treatment, tertiary pre- cination and treatment of hepatitis B and C, especially in vention, and palliative care (World Health Organization countries with high hepatitis C prevalence such as Egypt, 2014). where liver cancer is the leading cause of cancer death We have seen exciting advances in our understanding of (Alavian and Haghbin 2016). In the case of liver cancer, screening of high-risk groups has also been recommended cancer and resulting treatment approaches in the last dec- ade. However, the increasing cancer burden due to an aging by the National Comprehensive Cancer Network (NCCN) population and the exploding costs associated with com- as a core intervention in the resources stratiﬁed guidelines plex cancer treatments are leading to unacceptable in- (National Comprehensive Cancer Network 2016). How- creases in health care expenditure, which will be ever, early detection is dependent on a functioning primary impossible to sustain for most countries (Kelly and Smith care system as well as universal access to care, the 2014). For this reason, risk factor reduction has to be a developments of both of which are hampered by frag- priority for any cancer control effort. The top ﬁve risk mented care systems, lack of strategic planning, an factors identiﬁed in GBD as contributing to cancer mor- unregulated private sector, as well as political turmoil in tality in the EMR are tobacco, dietary risks, high body some EMR countries (Regional Committee for the EM/ mass index, occupational risks, and air pollution (GBD RC57/Tech.Disc.1 and Eastern Mediterranean 2010). 2015 Risk Factors Collaborators 2016). With lung cancer An emphasis on addressing cancer once it becomes being the second-leading cause of cancer death in the clinically symptomatic rather than on detecting it early is region, tobacco control has to be the top priority. Health also apparent by the lack of population-wide cancer hazards of cigarette smoking are well established. How- screening programs. Effective screening is currently ever, other forms of tobacco consumption such as chewing available for cervical cancer, colorectal cancer, breast and shisha (waterpipe) smoking also lead to an increased cancer, oral cancer, and stomach cancer (in high-risk risk of death, mainly due to cancer (Etemadi et al. 2016). populations) (Sankaranarayanan 2014). With breast and All countries in the EMR with the exception of Somalia cervical cancer being among the most common cancers in and Palestine have signed the WHO Framework Conven- females in every EMR country, cancer screening should be tion on Tobacco Control (WHO FCTC), and all countries among the prioritized prevention efforts (Goldie et al. except Morocco have ratiﬁed it. However, in many EMR 2005; Yip et al. 2008). For screening programs to be suc- countries, smoking rates have not declined, with certain cessful at the population level, strategic implementation 123 S160 GBD 2015 Eastern Mediterranean Region Cancer Collaborators should be coordinated at the national level and include miscoding of causes of death—as the so-called garbage educational components, as well monitoring and evaluation codes—in vital registration data can inﬂuence both our to ensure success and sustainability. Opportunistic screen- mortality estimates and incidence estimates. Misclassifying ing programs in the past have been hampered by low metastatic sites (e.g., lung, liver, bone) as the primary participation rates due to anxiety, misperception of the cancer site or as second cancers is another potential source screening’s purpose, and a general sense that cancer at any of bias. This is particularly true in countries with low- stage is a death sentence (Al Mulhim et al. 2015; Al-Zal- quality registration and limited diagnostic sources. abani et al. 2016). Civil engagement through education and advocacy is therefore an important pillar of successful and Conclusions sustainable screening programs. Cancer treatment programs depend on multidisciplinary Cancer is among the leading causes of death and DALYs in approaches that are often unavailable in EMR countries. most EMR countries. Prioritization of different aspects of Laboratory services, pathology, radiology, oncology nurs- the cancer control continuum depends on local health ing, surgery, medical and radiation oncology, pharmacol- infrastructure as well as disease epidemiology. Given the ogy, transfusion services, nutritional and psychosocial dramatic increase in cancer cases and deaths over the last support services, as well as palliative care and hospice decade, all stakeholders including health policymakers, services are the core disciplines required to provide cancer care providers, and the general public need to actively care. There is a lack of human capital for many, if not of engage to deﬁne these priorities and work together on all, of these disciplines, which will require continued and implementation of evidence-based cancer control coordinated efforts to train local staff and ensure retention strategies. (World Health Organization 2014). GBD 2015 Eastern Mediterranean Region Cancer Collabora- Another important factor contributing to poor health in tors: Christina Fitzmaurice, MD (corresponding author), Institute for some EMR countries is war, leading to a large number of Health Metrics and Evaluation, University of Washington, Seattle, displaced people, disruption in care structures and supplies, Washington, United States. Ubai Alsharif, MPH, Charite Univer- lack of qualiﬁed healthcare personnel, and ﬁnancial strains sita ¨tsmedizin, Berlin, Germany. Charbel El Bcheraoui, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, on patients and healthcare systems in countries with large Washington, United States. Ibrahim Khalil, MD, Institute for Health refugee populations (Spiegel et al. 2014; Sahloul et al. Metrics and Evaluation, University of Washington, Seattle, Wash- 2016). Innovative solutions to monitor disease burden in ington, United States. Raghid Charara, MD, American University of these most vulnerable populations have been proposed and Beirut, Beirut, Lebanon. Maziar Moradi-Lakeh, MD, Department of Community Medicine, Preventive Medicine and Public Health include web-based cancer registries with linkages between Research Center, Gastrointestinal and Liver Disease Research Center countries (Spiegel et al. 2014). Approaches during (GILDRC), Iran University of Medical Sciences, Tehran, Iran. Ash- humanitarian emergencies to prevent and treat cancer and kan Afshin, MD, Institute for Health Metrics and Evaluation, other diseases requiring complex care systems include University of Washington, Seattle, Washington, United States. Michael Collison, BS, Institute for Health Metrics and Evaluation, clear referral guidelines as provided by the United Nations University of Washington, Seattle, Washington, United States. High Commissioner for Refugees (UNHCR), as well as Adrienne Chew, ND, Institute for Health Metrics and Evaluation, ﬁnancing systems such as health insurance or social secu- University of Washington. Kristopher J. Krohn, BA, Institute for rity (United Nations High Commissioner for Refugees Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. Farah Daoud, BA/BS, Institute for Health 2009, 2012). Metrics and Evaluation, University of Washington, Seattle, Wash- ington, United States. Daniel Dicker, BS, Institute for Health Metrics Limitations and Evaluation, University of Washington, Seattle, Washington, United States. Kyle J. Foreman, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United Our data sources to estimate cancer burden in the EMR are States; Imperial College London, London, United Kingdom. Joseph vital registration and cancer registry data. The GBD study Frostad, MPH, Institute for Health Metrics and Evaluation, University tries to identify and utilize all available data sources in the of Washington, Seattle, Washington, United States. Nicholas J. estimation process. However, data sources in low- and Kassebaum, MD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States; middle-income countries are scarce, and causes of death Department of Anesthesiology & Pain Medicine; Seattle Children’s and cancer registration is not a routine procedure in many Hospital, Seattle, Washington, United States. Michael Kutz, BS, health care systems. Even when civil registration exits, war Institute for Health Metrics and Evaluation, University of Washing- or civil unrest can interrupt routine data collection. In the ton, Seattle, Washington, United States. Haidong Wang, PhD, Insti- tute for Health Metrics and Evaluation, University of Washington, absence of reliable data, our estimates are largely driven by Seattle, Washington, United States. Gebre Yitayih Abyu, MS, regional trends and the selection of model covariates which Mekelle University, Mekelle, Ethiopia, Ethiopia. Isaac Akinkunmi lead consequently to wider uncertainty intervals and time Adedeji, MS, Olabisi Onabanjo University, Ago-Iwoye, Nigeria. trends that are therefore often non-signiﬁcant. Furthermore, Aliasghar Ahmad Kiadaliri, PhD, Department of Clinical Sciences 123 Burden of cancer in the Eastern Mediterranean Region, 2005–2015: ﬁndings from the Global… S161 Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Iran. Maryam S. Farvid, PhD, Department of Nutrition, Harvard T. H. Lund, Sweden. Muktar Beshir Ahmed, MPH, College of Health Chan School of Public Health, Harvard University, Boston, MA, Sciences, Department of Epidemiology, ICT and e-Learning Coor- United States; Harvard/MGH Center on Genomics, Vulnerable Pop- dinator, Jimma University, Jimma, Ethiopia. Ayman Al-Eyadhy, MD, ulations, and Health Disparities, Mongan Institute for Health Policy, King Saud University, Riyadh, Saudi Arabia. Khurshid Alam, PhD, Massachusetts General Hospital, Boston, MA, United States. Seyed- Murdoch Childrens Research Institute, The University of Melbourne, Mohammad Fereshtehnejad, PhD, Department of Neurobiology, Care Parkville, Victoria, Australia; The University of Melbourne, Mel- Sciences and Society (NVS), Karolinska Institutet, Stockholm, Swe- bourne, VIC, Australia; The University of Sydney, Sydney, NSW, den. Florian Fischer, PhD, School of Public Health, Bielefeld Australia. Deena Alasfoor, MSc, Ministry of Health, Al Khuwair, University, Bielefeld, Germany. Tsegaye Tewelde Gebrehiwot, MPH, Oman. Raghib Ali, MSc, University of Oxford, Oxford, United Jimma University, Jimma, Ethiopia. Sameer Vali Gopalani, MPH, Kingdom. Reza Alizadeh-Navaei, PhD, Gastrointestinal Cancer Department of Health and Social Affairs, Government of the Feder- Research Center, Mazandaran University of Medical Sciences, Sari, ated States of Micronesia, Palikir, Federated States of Micronesia. Iran. Rajaa Al-Raddadi, PhD, Joint Program of Family and Com- Nima Hafezi-Nejad, MD, Endocrinology and Metabolism Research munity Medicine, Jeddah, Saudi Arabia. Khalid A. Altirkawi, MD, Center, Tehran University of Medical Sciences, Tehran, Iran. Randah King Saud University, Riyadh, Saudi Arabia. Nelson Alvis-Guzman, Ribhi Hamadeh, DPhil, Arabian Gulf University, Manama, Bahrain. PhD, Universidad de Cartagena, Cartagena de Indias, Colombia. Samer Hamidi, DrPH, Hamdan Bin Mohammed Smart University, Erfan Amini, MD, Uro-Oncology Research Center, Tehran University Dubai, United Arab Emirates. Habtamu Abera Hareri, MS, Addis of Medical Sciences, Tehran, Iran; Non-communicable Diseases Ababa University, Addis Ababa, Ethiopia. Roderick J. Hay, DM, Research Center, Endocrinology and Metabolism Research Institute, International Foundation for Dermatology, London, United Kingdom; Tehran University of Medical Sciences, Tehran, Iran. Nahla Anber, King’s College London, London, United Kingdom. Nobuyuki Horita PhD, Mansoura University, Mansoura, Egypt. Palwasha Anwari, MD, MD, Department of Pulmonology, Yokohama City University Grad- Self-employed, Kabul, Afghanistan. Al Artaman, PhD, University of uate School of Medicine, Yokohama, Kanagawa, Japan. Mohamed Manitoba, Winnipeg, Manitoba, Canada. Solomon Weldegebreal Hsairi, MD, Department of Epidemiology, Salah Azaiz Institute, Asgedom, PhD, Mekelle University, Mekelle, Ethiopia. Tesfay Tunis, Tunisia. Mihajlo B. Jakovljevic, PhD, Faculty of Medical Mehari Atey, MS, Mekelle University, Mekelle, Ethiopia. Ashish Sciences, University of Kragujevac, Kragujevac, Serbia; The Center Awasthi, PhD, Sanjay Gandhi Postgraduate Institute of Medical for Health Trends and Forecasts, Institute for Health Metrics and Sciences, Lucknow, India. Huda Omer Ba Saleem, PhD, Faculty of Evaluation, University of Washington, Seattle, Washington, United Medicine and Health Sciences, Aden University, Aden, Yemen. Umar States. Jost B. Jonas, MD, Department of Ophthalmology, Medical Bacha, PhD, School of Health Sciences, University of Management Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Man- and Technology, Lahore, Pakistan. Aleksandra Barac, PhD, Faculty nheim, Germany. Amir Kasaeian, PhD, Hematology-Oncology and of Medicine, University of Belgrade, Belgrade, Serbia. Neeraj Bedi, Stem Cell Transplantation Research Center, Tehran University of MD, College of Public Health and Tropical Medicine, Jazan, Saudi Medical Sciences, Tehran, Iran; Endocrinology and Metabolism Arabia. Zulﬁqar A. Bhutta, PhD, Centre of Excellence in Women and Population Sciences Institute, Tehran University of Medical Sciences, Child Health, Aga Khan University, Karachi, Pakistan; Centre for Tehran, Iran. Nigussie Assefa Kassaw, MPH, Addis Ababa Univer- Global Child Health, The Hospital for Sick Children, Toronto, ON, sity, Addis Ababa, Ethiopia. Yousef Saleh Khader, ScD, Department Canada. Zahid A. Butt, PhD, Al Shifa Trust Eye Hospital, Raw- of Community Medicine, Public Health and Family Medicine, Jordan alpindi, Pakistan. Carlos A. Castan ˜ eda-Orjuela, MSc, Colombian University of Science and Technology, Irbid, Jordan. Ejaz Ahmad National Health Observatory, Instituto Nacional de Salud, Bogota, Khan, MD, Health Services Academy, Islamabad, Pakistan. Gulfaraz Colombia; Epidemiology and Public Health Evaluation Group, Public Khan, PhD, Department of Microbiology and Immunology, College Health Department, Universidad Nacional de Colombia, Bogota, of Medicine & Health Sciences, United Arab Emirates University, Al Colombia. Abdulaal A. Chitheer, MD, Ministry of Health, Baghdad, Ain, United Arab Emirates. Daniel Kim, DrPH, Department of Health Iraq. Hadi Danawi, PhD, Walden University, Minneapolis, Min- Sciences, Northeastern University, Boston, Massachusetts, United nesota, United States. Jose ´ das Neves, PhD, i3S - Instituto de States. Yohannes Kinfu, PhD, Centre for Research and Action in Investigac ¸a ˜o e Inovac ¸a ˜o em Sau ´ de, University of Porto, Porto, Por- Public Health, University of Canberra, Canberra, Australian Capital tugal; INEB - Instituto de Engenharia Biome ´dica, University of Porto, Territory, Australia. Heidi J. Larson, PhD, Department of Infectious Porto, Portugal. Dragos V. Davitoiu, PhD, University of Medicine and Disease Epidemiology, London School of Hygiene & Tropical Pharmacy Bucharest, Bucharest, Romania. Subhojit Dey, PhD, Indian Medicine, London, United Kingdom; Institute for Health Metrics and Institute of Public Health-Delhi, Public Health Foundation of India, Evaluation, University of Washington, Seattle, Washington, United Gurgaon, India. Samath D. Dharmaratne, MD, Department of Com- States. Asma Abdul Latif, PhD, Department of Zoology, Lahore munity Medicine, Faculty of Medicine, University of Peradeniya, College for Women University, Lahore, Pakistan. Shai Linn MD, Peradeniya, Sri Lanka. Shirin Djalalinia, PhD, Undersecretary for University of Haifa, Israel. Raimundas Lunevicius, PhD, Aintree Research & Technology, Ministry of Health & Medical Education, University Hospital National Health Service Foundation Trust, Tehran, Iran. Huyen Phuc Do, MSc, Institute for Global Health Liverpool, United Kingdom; School of Medicine, University of Innovations, Duy Tan University, Da Nang, Vietnam. Manisha Liverpool, Liverpool, United Kingdom. Hassan Magdy Abd El Dubey, MPhil, International Institute for Population Sciences, Razek, MBBCH, Mansoura Faculty of Medicine, Mansoura, Egypt. Mumbai, India. Hedyeh Ebrahimi, Non-communicable Diseases Mohammed Magdy Abd El Razek, MBBCH, Aswan University Research Center, Tehran University of Medical Sciences, Tehran, Hospital, Aswan Faculty of Medicine, Aswan, Egypt. Azeem Majeed, Iran; Liver and Pancreaticobiliary Diseases Research Center, Diges- MD, Department of Primary Care & Public Health, Imperial College tive Disease Research Institute, Shariati Hospital, Tehran University London, London, England, United Kingdom. Reza Malekzadeh, MD, of Medical Sciences, Tehran, Iran. Donatus U. Ekwueme, PhD, Digestive Diseases Research Institute, Tehran University of Medical Centers for Disease Control and Prevention, Atlanta, Georgia, United Sciences, Tehran, Iran; Digestive Diseases Research Institute, Tehran States. Aman Yesuf Endries, MPH, Arba Minch University, Arba University of Medical Sciences, Tehran, Iran. Deborah Carvalho Minch, Ethiopia. Babak Eshrati, PhD, Ministry of Health and Medical Malta, PhD, Universidade Federal de Minas Gerais, Belo Horizonte, Education, Tehran, Iran; Arak University of Medical Sciences, Arak, Brazil. Desalegn Markos, MS, Madda Walabu University, Robe, Iran. Alireza Esteghamati, MD, Endocrinology and Metabolism Ethiopia. Peter Memiah, PhD, University of West Florida, Pensacola, Research Center, Tehran University of Medical Sciences, Tehran, FL, United States. Ziad A. Memish, MD, Saudi Ministry of Health, 123 S162 GBD 2015 Eastern Mediterranean Region Cancer Collaborators Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, KwaZulu-Natal, Durban, South Africa; UKZN Gastrointestinal Can- Riyadh, Saudi Arabia. Walter Mendoza, MD, United Nations Popu- cer Research Centre, South African Medical Research Council lation Fund, Lima, Peru. Tuomo J. Meretoja, PhD, Comprehensive (SAMRC), Durban, South Africa. Sadaf G. Sepanlou, PhD, Digestive Cancer Center, Breast Surgery Unit, Helsinki University Hospital, Diseases Research Institute, Tehran University of Medical Sciences, Helsinki, Finland; University of Helsinki, Helsinki, Finland. Ted R. Tehran, Iran. Masood Ali Shaikh, MD, Independent Consultant, Miller, PhD, Paciﬁc Institute for Research & Evaluation, Calverton, Karachi, Pakistan. Mark G. Shrime, MD, Harvard Medical School, MD, United States; Centre for Population Health, Curtin University, Boston, Massachusetts, United States. 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Lancet 388:1545–1602. doi:10.1016/ Informed consent The study did not involve human participants and/ S0140-6736(16)31678-6 or animals; therefore, no informed consent was needed. GBD 2015 Mortality and Causes of Death Collaborators (2016) Global, regional, and national life expectancy, all-cause mortal- Funding The funding source played no role in the design of the ity, and cause-speciﬁc mortality for 249 causes of death, study, the analysis and interpretation of data, and the writing of the 1980–2015: a systematic analysis for the Global Burden of paper. GBD 2015 is funded by Bill & Melinda Gates Foundation. Disease Study 2015. Lancet 388:1459–1544. doi:10.1016/ S0140-6736(16)31012-1 Open Access This article is distributed under the terms of the Creative GBD 2015 Risk Factors Collaborators (2016) Global, regional, and Commons Attribution 4.0 International License (http://creative national comparative risk assessment of 79 behavioural, envi- commons.org/licenses/by/4.0/), which permits unrestricted use, distri- ronmental and occupational, and metabolic risks or clusters of bution, and reproduction in any medium, provided you give appropriate risks, 1990–2015: a systematic analysis for the Global Burden of credit to the original author(s) and the source, provide a link to the Disease Study 2015. Lancet 388:1659–1724. doi:10.1016/ Creative Commons license, and indicate if changes were made. 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International Journal of Public Health – Springer Journals
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