Background and aims: Thyroid cancer is the most common endocrine malignant and papillary cancer and three times more prevalent in women than men. The aim of this study was to evaluate the incidence rate and trend of thyroid cancer in Iranian population. Methods: National incidence was rated by Iran National Cancer Registry data derived from Iran’s annual national cancer registration reported from 2003 to 2009. The crude rate and age standardized rate were used to express the incidence of thyroid cancer. Results: The results indicated that, the incidence of thyroid cancer increased from 2003 to 2009. The age standardized rate for women and men increased from 2.02 and 0.82 to 4.2 and 1.36 per 100,000, respectively. Conclusion: This study indicated remarkable increasing trends in thyroid cancer incidence. So, attention to high risk groups and public programs is necessary to reduce the incidence of this cancer in future

Baghestani, Ahmad Reza.

Hajizadeh, Nastaran.

Pourhoseingholi, Mohamad Amin.

shahrekord university of medical scinces

International Journal of Epidemiologic Research, 2015; 2(1): 12-17.*Corresponding author: Mohamad Amin Pourhoseingholi, Biostatistics Dept., Shahid BeheshtiUniversity of Medical Sciences, Tehran, I.R. Iran; Tel: 00982122432515; E-mail: amin_phg@yahoo.com.12ijer.skums.ac.irINTRODUCTIONCancer is a major cause of morbidityand mortality worldwide and its burden isglobally increasing. Although endocrinecancers are relatively uncommon, they maybe one the most important and potentiallytreatable cancers. In fact, thyroid cancer isthe most prevalent form of endocrine cancer,accounting for 1% of all new cancers (0.5%of cancers in men and 1.5% of cancers inwomen).1-3 The worldwide incidence rate ofthyroid cancer (TC) is generally lower than3 per 100,000 in men and 5 per 100,000 inwomen.4-8 TC is indeed one of 10 (theeighth) leading common cancers amongwomen in the world.9TC has four main histological types;papillary (PTC) accounts for 80%, follicular(FTC) 10-15%, medullary (MTC) 5-7%, andanaplastic (ATC) 1-2% of all thyroid cancertypes. In addition, PTC is the most prevalenttype, and it is three times more common inwomen than men.5,8,10 Five-year survivalrate for PTC is higher than 90%, for FTChigher than 90%, for MTC 30-80%, and forATC 1-17%.11 TC is mostly diagnosedamong people aged from 45-54 years withmedian age of diagnosis of 50 years. Thepercentage of mortality from TC is highestamong people aged 75-84 with median ageof 73 years at death.12Incidence rate of thyroid cancer in Iranian population, trendanalysis from 2003 to 2009Nastaran Hajizadeh1, Mohamad Amin Pourhoseingholi2*, Ahmad Reza Baghestani11Biostatistics Dept., Shahid Beheshti University of Medical Sciences, Tehran, I.R. Iran;2Gastroenterology and Liver diseases Research Center, Shahid Beheshti University ofMedical Sciences, Tehran, I.R. Iran.Received: 16/Oct/2014 Accepted: 30/Nov/2014ABSTRACTBackground and aims: Thyroid cancer is the most common endocrine malignant andpapillary cancer and three times more prevalent in women than men. The aim of thisstudy was to evaluate the incidence rate and trend of thyroid cancer in Iranian population.Methods: National incidence was rated by Iran National Cancer Registry data derivedfrom Iran’s annual national cancer registration reported from 2003 to 2009. The cruderate and age standardized rate were used to express the incidence of thyroid cancer.Results: The results indicated that, the incidence of thyroid cancer increased from 2003to 2009. The age standardized rate for women and men increased from 2.02 and 0.82 to4.2 and 1.36 per 100,000, respectively.Conclusion: This study indicated remarkable increasing trends in thyroid cancerincidence. So, attention to high risk groups and public programs is necessary to reducethe incidence of this cancer in future.Keywords: Thyroid cancer; Incidence; Trend analysis; Iran.Original articleHajizadeh N, et al. Incidence of thyroid cancer in Iran13In a survey conducted by the IranianCancer Institute, 1.8% of all cancers and76.1% of all endocrine cancers constitutedby the neoplasm of thyroid gland; forexample, in a study in Iran, mean age ofIranian patients was 42.8 years (95% CI:41.9-43.7) with markedly older malepatients.8,13 Also, the female to male ratiowas about 1.8, while this ratio was 1.3 foranaplastic carcinoma due to the higherproportion of the affected men.8,14 The aimof this study was to determine the trends ofTC incidence in Iranian general populationfrom 2003 to 2009.METHODSThe data were extracted from IranNational Cancer Registry data derived fromIran’s annual national cancer registrationreported from 2003 to 2009 (IslamicRepublic of Iran Ministry of Health andMedical Education, Center for DiseaseControl and Prevention, NoncommunicableDeputy Cancer Office, 2009).15 The IranMinistry of Health and Medical Educationregisters all the new cancer cases, accordingto pathology reports, in all provinces and thedata are publicized after revision.Age standardized rate (ASR) and crudedeath rate (CDR) of TC (ICD-9: 193) formen and women from 2003 to 2009 wereexpressed per 100,000 as the annualincidence, overall and for all provinces.Then, the trend of ASR, CDR, and five mostcommon morphologies of TC in Iran weredrawn.RESULTSAll incidence records of TC from 2003to 2009 were included in the analysis. TheASR of TC dramatically increased duringthese years from 1.42 to 2.78 per 100,000for both men and women. In women, thisrate varied from 2.02 to 4.2 per 100,000 andin men from 0.82 to 1.36 per 100,000. TheCDR of TC increased from 1.24 to 2.57 per100,000 for both men and women. Inwomen, it varied from 1.75 to 3.96 per100,000 and in men from 0.74 to 1.17 per100,000 (Table 1 and Figure 1). The highestASR of TC was derived in Isfahan provincefor all years under study. For someprovinces, no data reported (Table 2).Table 1: Crude rate (CR) and agestandardized rate (ASR; per 100,000) forthyroid cancer incidence in IranYears ASR CRfemales males females Males2003 2.02 0.82 1.75 0.742004 2.8 1.06 2.42 0.92005 3.47 1.16 2.93 0.982006 3.76 1.3 3.32 1.122007 3.4 1.11 2.98 0.952008 4.47 1.51 3.85 1.312009 4.2 1.36 3.96 1.17Figure 1: Age standardized rate (ASR) andcrude rate (CR) of thyroid cancer for femaleand male in Iran (2003-2009)International Journal of Epidemiologic Research, 2015; 2(1): 12-17.14Table 2: The age standardized rate (ASR) for thyroid cancer incidence (per 100,000) from all provinces in IranProvince 2004 2005 2006 2007 2008ASRFASRMASRtotalASRFASRMASRtotalASRFASRMASRtotalASRFASRMASRtotalASRFASRMASRtotalEast Azarbaijan 2.89 1.24 2.065 1.14 0.4 0.77 0.35 0.48 0.415 4.46 1.67 3.065 7.09 2.44 4.765West Azarbaijan 1.47 0.43 0.95 1.5 0.45 0.975 3.21 0.84 2.025 2.82 1.34 2.08 2.74 1.2 1.97Ardebil 4.25 0.95 2.6 0.27 0.19 0.23 3.76 1.3 2.53 2.49 0.2 1.345 3.03 1.8 2.415Esfahan 4.01 2.09 3.05 5.48 1.3 3.39 5.85 1.54 3.695 5.62 1.48 3.55 8.17 2 5.085Ilam 3.28 2.2 2.74 1.03 2.2 0.84 1.52 0.24 0.89 0.565 2.38 0.66 1.52Bushehr 1.36 0.67 1.015 2.18 2.02 2.1 2.21 0.83 1.52 3.36 0.63 1.995 2.93 0.62 1.775Tehran 2.76 0.64 1.7 3.57 1.14 2.355 3.59 1.22 2.405 2.8 0.93 1.865 5.29 1.74 3.515Chaharmahalbakhtiari 2.93 2.89 2.91 8.19 1.8 4.995 7.99 1.02 4.505 5.12 0.78 2.95 5.52 2.53 4.025South Khorasan 0.86 0.32 0.59 0.37 0.43 0.4 0.76 2.08 1.52 1.8KhorasanRazavi 1.98 1.24 1.61 1.9 0.78 1.34 3.66 1.19 2.425 2.43 0.86 1.645 3.01 0.99 2North Khorasan 1.97 0.74 1.355 0.69 0.33 0.51 1.45 0.56 1.005 2.11 2.56 2.335Khozestan 2.47 1.06 1.765 2.08 0.47 1.275 2.84 0.56 1.7 1.99 0.64 1.315 4.1 0.87 2.485Zanjan 1.85 0.67 1.26 2.71 0.17 1.44 2.23 0.9 1.565 1.78 0.56 1.17 2.11 0.43 1.27Semnan 2.34 1.53 1.935 1.7 1.13 1.415 3.9 1.15 2.525 1.2 0.97 1.085 1.68 0.64 1.16Sistanbalochestan 1.25 0.32 0.785 0.79 1.03 0.91 1.26 0.57 0.915 0.88 0.64 0.76 1.53 0.72 1.125Fars 2.2 0.82 1.51 3.54 1.3 2.42 3.34 1.36 2.35 5.61 1.59 3.6 6.25 1.87 4.06Ghazvin 4.04 0.62 2.33 3.83 1 2.415 3.9 0.97 2.435 3.51 1.05 2.28 2.92 1.56 2.24Qom 1.63 1.28 1.455 2.37 0.35 1.36 2.74 0.93 1.835 2.9 0.47 1.685 1.18 0.48 0.83Kordestan 1.61 0.33 0.97 1.18 0.36 0.77 2.16 0.59 1.375 2.16 1.06 1.61 2.71 1.22 1.965Kerman 2.89 2.16 2.525 3.28 0.37 1.825 3.61 1.15 2.38 3.77 1.47 2.62 4.61 1.1 2.855Kermanshah 1.42 1.05 1.235 2.83 1.36 2.095 3.44 0.43 1.935 3.05 1.46 2.255 4.26 1.46 2.86Kohgiloyeboyerahmad 4.76 1.24 3 1.39 1.25 1.32 1.86 1.61 1.735 5.85 0.36 3.105 4.39 0.93 2.66Golestan 2.65 0.75 1.7 1.78 0.64 1.21 3.42 1.36 2.39 2.26 0.51 1.385 2.93 1.41 2.17Gilan 1.99 0.54 1.265 2.29 0.67 1.48 2.49 1.2 1.845 1.72 1.33 1.525 5.77 1.61 3.69Lorestan 1.91 0.35 1.13 1.63 0.28 0.955 2.32 1.31 1.815 2.28 0.81 1.545 2.82 1.95 2.385Mazandaran 2.8 0.78 1.79 3.28 1.33 2.305 4.3 0.85 2.575 3.51 0.86 2.185 3.9 1.69 2.795Markazi 1.46 0.66 1.06 3.42 0.36 1.89 3.78 1.28 2.53 2.5 0.63 1.565Hormozgan 2.04 0.19 1.115 1.66 0.55 1.105 1.47 0.45 0.96 1.58 0.13 0.855Hamedan 1.95 0.89 1.42 3.02 0.6 1.81 3.2 1.47 2.335 1.92 0.62 1.27Yazd 5.01 0.22 2.615 4.26 0.99 2.625 3.62 2.38 3 4.63 0.9 2.765M: Male, F: FemaleThe trend of five most commonmorphologies of TC in Iran from 2003 to2008 was also assessed; the papillaryadenocarcinoma was the most commonthyroid tumor followed by papillarycarcinoma follicular variant, follicularadenocarcinoma, medullary carcinoma, andanaplastic carcinoma (Table 3).Table 3: The number of cases according to five most common morphologies of thyroid cancer in IranYears a b c d eF M Both F M Both F M Both F M Both F M Both2003 414 180 594 50 18 68 47 12 59 27 23 50 9 8 172004 568 204 772 78 22 100 44 21 65 25 26 51 16 7 232005 695 260 956 78 19 97 64 16 80 48 30 78 16 9 252006 824 270 1094 91 25 116 55 14 69 43 29 72 18 10 282007 757 233 990 112 32 144 13 4 17 38 27 65 11 14 252008 960 322 1282 90 21 111 66 11 77 48 43 91 14 9 23a) Papillary Adenocarcinoma, NOS; b) Papillary Carcinoma, Follicular Variant; c) Follicular Adenocarcinoma;d) Medullary Carcinoma, NOS; e) Carcinoma, Anaplastic, NOS; M: Male, F: Female.Hajizadeh N, et al. Incidence of thyroid cancer in Iran15Estimated TC incidence, mortality,and 5-year prevalence, based onGLOBOCAN2012, for the whole world,more developed regions, less developedregions, ASIA, Islamic Republic of Iran,WHO Americas region (PAHO), andWHO Europe region (EURO), arepresented in Table 4.Table 4: Estimated thyroid cancer incidence, mortality, and 5-year prevalence according toGLOBOCAN 2012Varieties Gender Incidence Mortality 5-year prevalenceNumber % *ASR (W) Number % *ASR (W) Number % Prop.World Men 68179 0.9 1.9 12627 0.3 0.3 271270 1.8 10.4Women 229923 3.5 6.1 27142 0.8 0.6 934805 5.6 36.0Both sexes 298102 2.1 4.0 39769 0.5 0.5 1206075 3.7 23.2More DevelopedRegionsMen 29672 0.9 3.6 3651 0.2 0.3 121600 1.4 24.3Women 93104 3.3 11.1 6740 0.5 0.4 392196 4.7 72.7Both sexes 122776 2.0 7.4 10391 0.4 0.4 513796 3.0 49.4Less DevelopedRegionsMen 38507 0.9 1.4 8976 0.3 0.4 149670 2.2 7.1Women 136819 3.6 4.7 20402 0.9 0.7 542609 6.1 26.4Both sexes 175326 2.2 3.0 29378 0.6 0.6 692279 4.4 16.7ASIA Men 32858 0.9 1.5 7127 0.3 0.3 129384 2.1 0.8Women 111621 3.6 5.0 15286 0.8 0.7 451739 6.3 28.9Both sexes 144479 2.1 3.2 22413 0.5 0.5 581123 4.4 18.3Islamic Republicof IranMen 513 1.1 1.4 181 0.6 0.5 1885 2.4 6.4Women 1512 3.8 4.0 429 1.8 1.4 5772 6.4 20.0Both sexes 2025 2.4 2.7 610 1.1 0.9 7657 4.5 13.1WHO AmericasRegion (PAHO)Men 19401 1.3 3.7 1879 0.3 0.3 81176 2.1 23.0Women 66065 4.6 12.1 3372 0.5 0.5 280246 6.8 76.0Both sexes 85466 3.0 8.0 5251 0.4 0.4 361422 4.5 50.1WHO EuropeRegion (EURO)Men 14036 0.7 2.5 2379 0.2 0.3 54900 1.1 15.4Women 48775 2.8 8.1 5088 0.6 0.5 192534 3.9 49.5Both sexes 62811 1.7 5.4 7467 0.4 0.4 247434 2.5 33.2*ASR: age standardized rateDISCUSSIONThis study, indicated a remarkableincreasing trend in TC incidence, based onthe national registry data from 2003 to 2009.This trend was different for men andwomen. Enhanced detection couldcontribute to the increased TC incidence inthe past decades, but cannot fully explain theincrease, suggesting that maybe a trueincrease exists.16 In addition, when the mainreason is the increasing detection, theimprovement in small and early-stagetumors should be accompanied by aprogressive decline of larger and moreadvanced tumors. The TC increases, whilemost prominent for small tumors and acrossall tumor sizes and stages, suggesting thatincreasing of detection is not the onlyreason.17-19 The remarkable increase inincidence of TC in advanced stages, usuallyclinically apparent, is too difficult to beexplained by increased detection. Moreover,the TC increase has been almost exclusivelyobserved for papillary tumors, whileimproved detection must affect allhistotypes.17 Finally, when increasing ofdetection is the only reason, it is expectedthat the cancer increase to be observed in allage and gender categories. Indeed, the age-adjusted incidence rates of TC haveincreased in women more than in men(158% vs. 106%) with a clear birth cohortpattern, possibly reflecting changes in riskInternational Journal of Epidemiologic Research, 2015; 2(1): 12-17.16factors and the birth cohort contributionwhich suggest that the increasing ofdetection is not the only reason of theincreased incidence of TC.17, 20Furthermore, by the report ofGLOBOCAN 2012, annually 298102 newcases of TC occurred around the world.9 In theUnited States, TC is the ninth leading cancerand it is estimated that new cases wouldregister 62,980 in 2014. Five-year survival wasabout 97.8% in 2004-2010. Using statisticalmodels of analysis, rates of new TC cases havebeen rising on average by 5.5% per year overthe last 10 years.12 In the United Kingdom2,727 people were diagnosed with TC in 2011.Around 75.0% of adult TC patients (74.2% ofmen and 78.9% of women) in England andWales survived five years or longer during1996-1999.21 TC represents 2.1% of all newcancer cases in the world, 3.0% in WHOAmericas region, 2.4% in Iran, 2.2% in lessdeveloped regions, 2.1% in Asia, 2% in moredeveloped regions, and 1.7% in WHO Europeregion.9Study of potential etiologic and riskfactors of TC showed that radiation exposure,genetic factors, pre-existing thyroid disease,hormonal and reproductive factors (as thecancer is more frequent in women),  anddietary factors (specially iodine) could play themain roles in pathogenesis of TC.22,23The limitation of this study was theincomplete data which were collected fromall provinces before 2004 and no publishedinformation for provinces after 2008. Inaddition, from 2003 to 2009, the coverage ofregistered new cancer cases was increasing.So, for the early years under the study, thecollected data could suffer fromunderestimation.CONCLUSIONThis study indicated an increasingincidence of TC in Iranian population. Sincemany cases of TC could be treatedsuccessfully, it is expected to diagnose TC atearly stages. Therefore, the development ofa guideline can be helpful to diagnose TC atearly stages. Moreover, attention to high riskgroups and setting awareness programsshould be focused to reduce the incidence ofthis cancer in the future.CONFLICT OF INTERESTThe authors declare that they have noconflict of interests.ACKNOWLEDGMENTWe gratefully thank all workers assistedus in conducting this research.REFERENCES1. Deandrea M, Gallone G, Veglio M,Balsamo A, Grassi A, Sapelli S, et al. Thyroidcancer histotype changes as observed in amajor general hospital in a 21-year period. JEndocrinol Invest. 1997; 20(2): 52-8.2. De Jong SA. 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Incidence rate of thyroid cancer in Iranian population, trend analysis from 2003 to 2009

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