Review

Prostate Cancer in the Arab World: A View

From the Inside
Lara Hilal,1 Mohammad Shahait,2 Deborah Mukherji,1 Maya Charafeddine,1
Zein Farhat,1 Sally Temraz,1 Raja Khauli,2 Ali Shamseddine1
Abstract
The rates of prostate cancer vary by more than 50-fold across different international populations. The aim of this
review was to explore the differences in epidemiology and risk factors between the Middle Eastern Arab countries and
some of the developed countries in Europe and North America. The age-standardized incidence rate of prostate
cancer in the Arab countries is still lower than that in the Western countries, but is steadily increasing with time. Several
factors come into play to explain this difference. There are health care systems-related factors such as the lack of
good population-based registries, and population-related factors. The latter include the relatively young age structure
in the Arab countries, lower reported androgen and prostate-specific antigen levels in Arab men, the effect of genetic
differences on prostate cancer risk, the metabolic syndrome paradox, and the protective effect of the Mediterranean
diet on a subset of the Arab population. In conclusion, the study of prostate cancer in the Arab world represents a
challenge with the currently available cancer care systems and the increase in the burden of the disease. A multi-
national prospective study to investigate the epidemiology of prostate cancer in the Middle East, with specific
attention to country/geographic variability along with a comparative analysis to that of the Western hemisphere is
needed.

Clinical Genitourinary Cancer, Vol. -, No. -, --- ª 2015 Elsevier Inc. All rights reserved.
Keywords: Epidemiology, Healthcare systems, Incidence, Middle East, Risk factors

Introduction Evidence Acquisition

Prostate cancer is the number one cancer in developed countries
and the second most common cancer among men worldwide.1 The
rates of prostate cancer vary by more than 50-fold between different
international populations.2 This has been associated with variations
in screening practices and the difference in the magnitude of various
prostate cancer risk factors in each population. In this review we focus
on the epidemiology of prostate cancer in the Middle East and
provide an analysis of the possible factors that affect the difference in
incidence of prostate cancer between developed countries such as the
United States of America (US) and the Middle Eastern Arab region.
Lara Hilal and Mohammad Shahait contributed equally to this work.
1
Naef K. Basile Cancer Institute and Department of Internal Medicine
2
Department of Urologic Surgery
American University of Beirut Medical Center, Beirut, Lebanon
Submitted: Apr 17, 2015; Revised: May 25, 2015; Accepted: May 29, 2015
Address for correspondence: Ali Shamseddine, MD, FRCP, Naef K. Basile Cancer
Institute and Department of Internal Medicine, PO Box 11-0236, Riad El Solh 110,
72020 Beirut, Lebanon
Fax: 961-1-370814; e-mail contact: as04@aub.edu.lb
A literature search in English was performed using PubMed and
Google Scholar in January 2015 using the following search terms:
“prostate cancer,” “epidemiology OR risk factors,” and “Middle
East OR Arab.” Relevant articles, from 1984 to 2015, on prostate
cancer in the Arab world were selected. Special attention was given
to studies that investigated the disease epidemiology and risk factors
in the Arab world.
Epidemiology in the Middle East
The incidence of prostate cancer is low in Asia, intermediate in
most of Africa and Eastern Europe, and high in Western Europe
and North America.3 As for the incidence in Middle Eastern Arab
men, the age-standardized incidence rate (ASIR), as low as 3 per
100,000, was recorded in Qatar in 2006,4 compared with an ASIR
of 147.8 per 100,000 in the US,5 according to the Surveillance,
Epidemiology, and End Results (SEER) database.
The low incidence of prostate cancer among men of Middle
Eastern origin is also evident in the first-generation immigrants
in several countries such as Australia,6 Sweden,7 and The
Netherlands,8 and in California.9 However, of note is that this
difference tends to diminish with each generation.6,9 For example,

1558-7673/$ - see frontmatter ª 2015 Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.clgc.2015.05.010 Clinical Genitourinary Cancer Month 2015 -1
 Prostate Cancer in the Arab World
Figure 1 Age-Standardized Incidence Rate of Prostate Cancer in the Middle East and North Africa (MENA) Countries Compared With
the United States (USA)

Abbreviation: UAE ¼ United Arab Emirates.

Data from International Agency for Research on Cancer. World Health Organization. GLOBOCAN 2012: Estimated Incidence, Mortality and Prevalence Worldwide in 2012. All Cancers (Excluding Non-
Melanoma Skin Cancer). Available at: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx.

when Nasseri et al studied cancer incidence in the Middle Eastern Table 1 The ASIR and ASMR of Prostate Cancer in the MENA
Arab population in California, they found that the prostate cancer Countries Compared With European Countries, Japan,
rate was 11-fold higher in the Arab individuals in California than and the United States (USA)
the reported rates from the Middle Eastern countries themselves.9
Country ASIR ASMR
The authors attributed this to several factors including accultura-
Algeria 8.8 4.9
tion to the lifestyle of the host country9 and possible underreporting
Bahrain 13.5 6.5
of good quality data in most of the Middle Eastern countries
Comoros 23.2 21
because of the lack of organized cancer-based registries.10
Djibouti 8.5 8
Figure 1 shows the lower ASIR of prostate cancer in the Middle
Egypt 7.8 5.1
East and North Africa (MENA) countries compared with Western
Iraq 8.7 6.4
countries such as the US based on GLOBOCAN 2012 data.11 In
Jordan 15.9 8.3
2005, during the sixth International Consultation on Prostate
Kuwait 14.5 3
Cancer and Prostatic Diseases, sponsored by the International
Lebanon 37.2 17.1
Union Against Cancer, concerns were raised regarding the future
Libya 15.5 7.5
increase in the incidence of prostate cancer in Asia and the Middle
MENA 19.7 10.2
East. This notion was spurred by the observed trends of prostate
Morocco 18.5 12.9
cancer in the Middle East and Southeast Asia. The meeting synopsis
Oman 10.2 6.3
clearly depicted an alarming increase in the incidence rate in
Qatar 13.2 6
Lebanon, exceeding that of Korea and Japan.
Saudi Arabia 9.5 4.8
Although the incidence and mortality rates for prostate cancer in
Syria 11.9 8
the US and other developed countries are decreasing, the limited
West bank 15.2 e
reports from the Middle East have shown an unexpected increase in
Tunisia 11.3 6
incidence and mortality rates for prostate cancer in our part of the
UAE 10 5.6
world.11 In Lebanon for example, the ASIR increased from 29.9 per
Yemen 2.7 2.3
100,000 in 2003 to 39.2 per 100,000 in 2008.12 As for the
World 31.1 7.8
survival, several studies have used the age-standardized mortality
USA 98.2 9.8
rate (ASMR) to ASIR ratio, known as the mortality rate to inci-
Japan 30.4 5
dence rate ratio (MR:IR), as an indicator of survival.13 Table 1
Southern Europe 58.6 10
shows the ASIR and ASMR of several countries in the MENA
Northern Europe 85 14.5
region compared with European countries, the US, and Japan,
based on the GLOBOCAN 2012 database on prostate cancer.11 The data for MENA region and USA is shown in bold because it’s the data that was used to
show the difference between our MENA region and the USA regarding the MR:IR ratio.
Based on this, Shahait et al used the MR:IR ratio, from the Abbreviations: ASIR ¼ age-standardized incidence rate; ASMR ¼ age-standardized mortality
GLOBOCAN 2012 database on prostate cancer (MR:IR ratio rate; MENA ¼ Middle East and North Africa; UAE ¼ United Arab Emirates.
Data from International Agency for Research on Cancer. World Health Organization. GLOBOCAN
being inversely proportional to the survival), and they found that 2012: Estimated Incidence, Mortality and Prevalence Worldwide in 2012. All Cancers (Excluding Non-
the population-averaged MR:IR ratio was 0.5 in the MENA region Melanoma Skin Cancer). Available at: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx.

2 - Clinical Genitourinary Cancer Month 2015

 Lara Hilal et al
Figure 2 The Mortality Rate to Incidence Rate Ratio of the Middle East and North Africa (MENA) Countries Compared With the United
States (USA)

Abbreviation: UAE ¼ United Arab Emirates.

Data from International Agency for Research on Cancer. World Health Organization. GLOBOCAN 2012: Estimated Incidence, Mortality and Prevalence Worldwide in 2012. All Cancers (Excluding Non-
Melanoma Skin Cancer). Available at: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx.

weighed against 0.09 in the US (Figure 2).14 These data suggest
that mortality from prostate cancer in our part of the world, the
MENA region, is approximately 5.6 times that of the US.
Moreover, the limited data on the stage at presentation of
prostate cancer in the Middle East report a more advanced stage
in our part of the world compared with the US. Osman et al
reported on prostate cancer in Saudi Arabia: of a cohort of 72
patients, 46 (64%) had extraprostatic disease at presentation. Of
the 54 patients who had staging imaging, 27 (50%) had lymph
node metastasis, 12 (22%) had pulmonary metastasis, and 6
(11%) had liver metastasis.15 This is contrary to the lower rate of
extraprostatic disease in the US. According to the SEER database,
out of a sample size of 2,795,592 men, 2,264,430 (81%) prostate
cancer patients present with localized disease, 335,471 (12%)
with regional lymph node metastasis, and only 111,824 (4%)
with distant metastasis.5
According to the available data it is difficult to determine whether
this prediction of a worse stage and survival in the MENA Arab
region compared with the US should be attributed to a different
biology of the tumor or to the health care systems in those Arab
countries or, most probably, to a combination of those different
factors. Underreporting of incidence rates and overreporting of
mortality rates and inaccuracies in mortality reports can lead to
such inconsistencies. The incidence and mortality rates from
prostate cancer are on the rise based on future projection models.
Shamseddine et al published a report on the cancer trends in
Lebanon, and showed that the incidence rate of prostate cancer is
expected to increase from 42 per 100,000 in 2009 to 64 per

Figure 3 Ten-Year Cancer Incidence Projection of the 5 Most Common Cancers in Men (2009-2018)

Reproduced With Permission From Shamseddine et al. Cancer Trends in Lebanon: A Review of Incidence Rates for the Period of 2003-2008 and Projections Until 2018. Popul Health Metr 2014; 12:4.

Clinical Genitourinary Cancer Month 2015 -3

 Prostate Cancer in the Arab World
Figure 4 The Expected Increase in the New Cases of Prostate
Cancer in the Middle East and North Africa Region in
2020
100,000 in 2018 (Figure 3).12 Based on GLOBOCAN 2012
data,11 prostate cancer incidence in the MENA region is expected to
increase from 29,377 new cases in 2012 to 38,562 new prostate
cancer cases in 2020 along with an increase in mortality from
prostate cancer from 15,422 prostate cancer deaths in 2012 to
19,681 deaths in 2020 (Figures 4 and 5).
Hence, the importance of studying the possible factors that affect
the incidence and mortality rates of prostate cancer in our part of
the world. The factors related to treatment and mortality is beyond
the scope of this review. The focus is on the factors that affect the
incidence and current epidemiology of this disease in the Middle
Eastern Arab countries.
Factors That Affect Incidence
Several factors come into play to explain the lower ASIR of
prostate cancer in the Middle Eastern Arab world. They can be
divided into 2 main categories: factors related to the health care
systems in our region and factors related to the different clinical
characteristics of our population.
Factors Related to the Health Care System
The ASIR of prostate cancer reported from the Middle Eastern
countries is affected by the access to health care, the quality of health
services, and by the accuracy of the cancer registries. The lack of a
population-based registry and a prospective oncology database across
the Middle Eastern Arab world represents one of the main obstacles
Figure 5 The Expected Increase in Prostate Cancer Deaths in
the Middle East and North Africa Region in 2020
4 - Clinical Genitourinary Cancer Month 2015
that hamper researchers’ ability to report on temporal trends of
prostate cancer. It also impairs the efforts to translate that into
quantitative evidence to spur governments and health care planners to
implement adequate prostate cancer screening programs. Cultural
awareness of prostate cancer and screening practices in the Middle
East plays a role in affecting the rate of prostate cancer screening. A
study performed by Arafa et al showed that in the 3 studies conducted
in Arab countries: Egypt, Saudi Arabia, and Jordan, participants had
poor knowledge of prostate cancer screening practices.16
Although there have been some recent improvements in
screening and earlier detection of disease in some Arab countries,
such as Qatar, the overall acceptance of screening practices by the
Middle Eastern Arab population is still below expectations.17 This
might be because of the lack of health knowledge and inaccurate
public beliefs in the benefits of screening.17 A survey of 1337
citizens in Saudi Arabia showed that 1,243 people, 92.6% of the
subjects thought a physician’s recommendation is essential for them
to undergo screening.18 However, in another study conducted in
Saudi Arabia it was reported that only 110 out of 204 (54%) of the
physicians practiced prostate cancer counseling and screening with
their patients.19 A survey conducted in Jordan revealed that almost
all believed that cancer screening results in earlier and easier treat-
ment, but only 352 out of 3196, 11% of the participants performed
any form of cancer screening.20 As for the screening practices in
Lebanon, the recent increase in the incidence of prostate cancer has
been partly attributed to better detection rates.21 However, similar
to other Middle Eastern Arab countries, there are not specific na-
tional prostate cancer screening programs. This factor might have
contributed to the lower ASIR detected in this part of the world. As
for the mortality rate from prostate cancer, the data on whether
screening programs decrease mortality is still controversial with
some trials that showed no significant effect of screening on mor-
tality from prostate cancer.22 It should be noted that in some of the
low-income Arab countries like Lebanon and Jordan, with the
limited financial resources, the welfare of patients and the society
should be considered in the analysis of screening decisions.23
However, the lower ASIR of prostate cancer in the Middle
Eastern Arab world is not only because of low screening rates.
Several studies showed that even if the incidence of prostate cancer
is higher in Arab immigrants to the US or Australia than the inci-
dence reported in their native countries, it is still less than the
incidence rates of the non-Arab locals in the host country.6,9
A recent review of the SEER program showed that Arab
American men had a drastically lower incidence rate of prostate
cancer compared with non-Arab white American and Hispanic
men. This finding supports the suggestion that these ethnic
differences cannot be solely explained by differences in the health
care practices and cancer registration.
Population-Related Factors
Age. The age structure of the Middle Eastern population has
changed over the past 20 years with a decrease in the fertility
and mortality rates, yet it is still a relatively young population. A 2010
report from Yemen revealed that three-quarters of its population is
younger than the age of 30 years and 46% younger than the age of 15
years; Yemen has the most youthful age structure in the world outside
of sub-Saharan Africa.24 People in Yemen who are 65 years and older

make up 2.6% of the population. The same applies to other Arab
countries like Saudi Arabia where 3.2% of the population are 65 years
of age and older, in Egypt where 5% of the population is 65 years of
age and older, and finally Lebanon and Morocco, which are
considered to have an older population, with 6.7% and 6.3% older
than or equal to 65 years of age, respectively.25 In contrast, 14.5% of
the population of the US is 65 years of age or older.25
Hormonal Factors. Serum androgen levels in Arab men, including
total testosterone, dehydroepiandrostenedione sulfate, and andro-
stenedione have been reported to be significantly lower compared
with those reported in Caucasian men especially in early adulthood,
the age range of 20 to 29 years.26
In one study performed on serum samples taken from Arab men
mainly from Kuwait and Oman, it was shown that Middle Eastern
Arab men have lower circulating levels of androgens than matched
German (European) individuals and those newly diagnosed with
prostate cancer among the Arab men had higher androgen levels
than their healthy matched counterparts.26
As for the prostate-specific antigen (PSA) values in Arab men, the
mean PSA values for Saudi men were also shown to be low.27
Moreover, although increased serum PSA level is commonly associ-
ated with prostate cancer, subclinical prostatitis is a significant source
of high serum PSA in > 40% of men in Kuwait, which suggests the
need for a locally applicable paradigm to identify prostate cancer.28
Other implicated factors in the development of prostate cancer
are certain growth factors like insulin-like growth factor 1 (IGF-1).
In a study performed in Kuwait, it was shown that there is a strong
association between high IGF-1 levels and prostate cancer risk29 as
has been found in the Chinese population30 and in some studies in
Caucasians from Greece, Sweden, and the US.31-33 They also found
that healthy Arab men have significantly lower serum IGF-1 levels
compared with healthy Caucasian individuals.
Genetics. In Tunisia, in a case control study that enrolled 90 prostate
cancer patients and 131 healthy Tunisians as controls, it was found
that 3 consecutive regions on chromosomes 9, 17, and 22 that
encompass 14 single nucleotide polymorphisms (SNPs) that are highly
associated with prostate cancer. They investigated the presence of any
similarities between Tunisian and Caucasian individuals and found
that 17q21, containing signal transducer and activator of transcription
3 signaling factor, is common so this can be a promising prostate cancer
marker in different ethnic populations. To also investigate whether
these genetic findings in the Tunisian population can be replicated in
other Arab individuals, they studied 155 unrelated prostate cancer
patients and 182 healthy matched control participants from Saudi
Arabia and Qatar. None of the SNPs found in the Tunisian partici-
pants was found in the other Arab individuals who were studied.
The genetic structure difference between North Africa and West
Asia might explain the difficulty of replication of the findings of the
Tunisian genome with genome of other Arab people from Qatar
and Saudi Arabia.34
This finding along with the findings from several other studies
explicitly show that MENA populations are genetically heteroge-
neous. Moreover, several studies point out the presence of genetic
differences between the coastal populations and inland populations
of the same countries.35-38
Lara Hilal et al
Metabolic Syndrome. The metabolic syndrome is pandemic, and
its prevalence among Arab men ranges between 36.3% and
45.5%.39 Intriguingly, the Christian subpopulation of Lebanon has
a high frequency of familial hypercholesterolemia (1 per 85 vs. 1 per
500 worldwide), which can be attributed to the founder effect.40
Diet. The Mediterranean diet, which is rich in antioxidants,
phytoestrogens, polyunsaturated fat, and low fat content, has been
shown to have a plausible effect against prostate cancer develop-
ment.41,42 The dietary pattern in the Middle Eastern region has
changed over the years as a result of urbanization and adoption of a
Western lifestyle. Alas, there is an increase in the consumption of
animal products and refined foods while there is a decrease in fruit
and vegetable intake.43,44
Discussion
The health care- and population-related factors mentioned herein
could contribute to a better understanding of the lower ASIR of
prostate cancer in the Middle Eastern Arab world compared with
the developed countries.
Age is the most well established risk factor in prostate cancer, as is
the case in most of other cancers. The probability of developing
prostate cancer increases from 0.005% among individuals aged
younger than 39 years to 2.2% (1 in 45) for those aged 40 to
59 years and 13.7% (1 in 7) for those aged 60 to 79 years.45 Based
on that and on the previously discussed young age structure in the
Middle Eastern Arab countries, age might be one of the factors that
contribute to the relatively lower ASIR of prostate cancer in our part
of the world, as shown in Table 1, and to the increasing trend of the
disease at the same time.
As for the hormonal factors, the lower androgen levels in Arab men
has been proposed as a protective mechanism against the development
of prostate cancer. In other words, the prolonged duration of exposure
to high androgen levels (ie, starting at an age younger than 30 years) in
African American and Caucasian men compared with Arab and
Chinese men might account for one of the factors that contribute to
the low incidence of prostate cancer in such populations. Moreover,
some studies have shown that IGFs are potent mutagens for a variety
of cancer cells including prostate cancer cells because they stimulate
cancer cell growth and suppress apoptosis.46 Thus, the lower IGF
level in Middle Eastern men might be a possible explanation for the
low incidence of prostate cancer in this group of Arab men.
Another factor that helps to explain the lower incidence in
Middle Eastern Arab men is probably related to prostate cancer
genetics being ethnic-specific as elaborated herein. There is also
compelling evidence in the literature that shows a correlation
between the metabolic syndrome and the risk of prostate cancer;
clinically significant prostate cancer (defined as any Gleason
pattern  4, > 50% involvement of a single biopsy core, or > 1 of
3 total number of cores involved) and intermediate- or high-grade
prostate cancer.47 The high prevalence of the metabolic syndrome
in the Arab world is paradoxical considering the low rates of prostate
cancer in those countries. As for the finding of the metabolic
derangement of hypercholesterolemia in the Lebanese Christian
individuals, this has been used to partially explain the higher inci-
dence of prostate cancer observed in Lebanon compared with other
Arab countries.40
Clinical Genitourinary Cancer Month 2015 -5
 Prostate Cancer in the Arab World
Finally, the Mediterranean diet has been associated with low
androstenedione, testosterone, and free testosterone levels.48 A
systematic review on the effect of diet on prostate cancer risk,
Ma and Chapman recommended a diet low in fats and rich in
vegetables and fruits to decrease the risk of prostate cancer.49
Moreover, the recent shift in diet archetype is probably one of
the culprits behind the increasing incidence of prostate cancer in the
Middle East.
So, those factors combined interplay to affect the incidence of
prostate cancer in the Middle Eastern Arab World that is recently
on the increase. Even though the incidence is relatively still low in
all of the Arab countries partly because of the previously mentioned
causes, there are certain other causative factors that are specific to
each country that necessitate more in-depth epidemiological studies
on prostate cancer in the region.
The main limitations of this review are the following: all the
studies used were retrospective, most had a limited sample size, and
they were conducted in only specific countries from the MENA
region. They might not apply to the whole population of Arab
men. Moreover, the GLOBOCAN database and some of the other
studies relied on either population-based cancer registries or pro-
jections from other countries rather than actual large-scale epide-
miologic studies conducted in each of the countries included in this
review. This results in a lower quality of data.
Accuracy in prostate cancer incidence and mortality rates in the
Arab region is crucial to support more epidemiological studies.
However, this might not be an easy task with the challenges that the
Arab world is currently facing. The protracted war and armed
conflicts that are being witnessed in several Arab countries have
displaced populations and have led to fractured health care sys-
tems.50 In a report by Dewachi et al on this topic, he describes the
importance of addressing what he calls “militarization of health
care”— a process in which health care funds and health care pro-
fessionals have been directed toward the preferential treatment of
soldiers,50 which is similar to the situation in Bahrain,51 Libya,52
and Egypt53 among other Arab countries.
Conclusion
We can infer from the available studies that prostate cancer in the
Arab world represents a challenge to the entire health care system
that goes above and beyond registration issues. It suggests remaining
weaknesses in the cancer care systems in these countries. However,
despite the various challenges, the Arab world with its diverse ge-
netic background provides us an opportunity to explore the effect of
different factors on prostate cancer epidemiology across different
countries. A multinational study to investigate the epidemiology of
prostate cancer in depth in the Middle East, with specific attention
to country and geographic variability and analysis comparative with
that of the western hemisphere is needed. The analysis would
include the study of demographic factors, disease-specific factors,
and possibly serum and tissue markers. Such a study will enable us
to better identify and understand the key risk factors unique to our
region, and potential ways to decrease the increasing burden of
prostate cancer.
Disclosure
The authors have stated that they have no conflicts of interest.
6 - Clinical Genitourinary Cancer Month 2015
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