---
title: "Cancer epidemiology in Khyber Pakhtunkhwa, Pakistan (2020–2023): incidence counts and ASIRs"
id: "bmj-open-13-epidemiology-of-cancer-in-khyber-pakhtunkhwa-kp-pakistan-2020-2023-a"
canonical_url: "https://medichelpline.com/clinical-feed/bmj-open-13-epidemiology-of-cancer-in-khyber-pakhtunkhwa-kp-pakistan-2020-2023-a"
content_type: "clinical_feed_article"
specialty: "Oncology"
source_name: "BMJ Open"
source_url: "http://bmjopen.bmj.com/cgi/content/short/16/7/e119877?rss=1"
published_at: "2026-07-22T08:50:16.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Cancer epidemiology in Khyber Pakhtunkhwa, Pakistan (2020–2023): incidence counts and ASIRs
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/bmj-open-13-epidemiology-of-cancer-in-khyber-pakhtunkhwa-kp-pakistan-2020-2023-a
- **Specialty:** [Oncology](https://medichelpline.com/clinical-feed/oncology.md)
- **Primary Source:** BMJ Open
- **Source URL:** [Original Journal Publication](http://bmjopen.bmj.com/cgi/content/short/16/7/e119877?rss=1)
- **Published At:** 2026-07-22T08:50:16.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This retrospective, province-wide, multicentre observational study collected new cancer diagnoses among residents of **Khyber Pakhtunkhwa (KP)** from 1 January 2020 to 31 December 2023 using data aggregated at Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) from multiple centres including PAEC and Chughtai Lab. - A total of 57,852 malignancies were recorded over four years: 51.6% female, 48.4% male. Adults (≥20 years) comprised 90.9% of cases, children (0–14) 6.6%, adolescents (15–19) 2.6%. - Age-standardised incidence rates (**ASIRs**, per 100,000, Segi standard) reported: children—pre-adolescent girls 4.2, boys 6.6; adolescents—females 7.9, males 9.7; adults—females 103.5, males 90.1 (overall ASIRs presented in study tables). - The single most frequent tumour overall and among adult females was **breast cancer** (16.3% of all cases; adult female ASIR 32.6). Among adult males the most frequent were prostate, colorectal/anal, bladder and **non-Hodgkin lymphoma (NHL)**. - In children, haematologic malignancies predominated: lymphoid leukaemia and Hodgkin’s lymphoma had the highest proportions and ASIRs (leukaemia ASIR higher in KP and Lahore than Karachi). In adolescents, bone tumours and ovarian cancer were prominent. - Regional comparisons used published ASIRs from Lahore, Karachi, Kabul (Afghanistan) and Iran. Notable regional differences: Karachi had very high female breast ASIR (177.8) and high bone tumour ASIRs in children; KP’s top male cancers differed from Kabul and Iran where stomach cancer was more common. - Data sources: SKMCH&RC and PAEC contributed 88.9% of KP cases; Chughtai Lab contributed 10.1%. Methods combined active and passive data collection, standard IARC coding and duplication checks; rates calculated using Microsoft Excel 2019. - Limitations reported: uncertain completeness of case capture, limited data on diagnostic basis, stage, treatment and outcomes, and potential bias in interregional comparisons due to methodological differences in registries and study periods. - The study provides baseline incidence counts and ASIRs for KP to inform planning of prevention, diagnostic and cancer-care infrastructure and to support future comparative analyses within and beyond Pakistan.
## Clinical Analysis & Structured Key Points
Skip to main content Intended for healthcare professionals Log In Basket Search for this keyword Advanced search Latest content Archive For authors About Browse by collection You are here Home Archive Volume 16, Issue 7 Email alerts Article Text Article info Citation Tools Share Rapid Responses Article metrics Alerts PDF Epidemiology Original research Epidemiology of cancer in Khyber Pakhtunkhwa (KP), Pakistan, 2020–2023: a retrospective, province-wide, multicentre observational study http://orcid.org/0000-0001-5600-1959Farhana Badar1, Shahid Mahmood1, Mohammad Sohaib2, Omar Rasheed Chughtai3, Alia Ahmad4, Faisal Sultan5, Asif Loya6, Shagufta Nasir Pervez7, Aneel Yousaf1, http://orcid.org/0000-0003-1943-2746Mohammed Aasim Yusuf5 Correspondence to Farhana Badar; farhana@skm.org.pk Abstract Background The province of Khyber Pakhtunkhwa (KP), located in the northwestern region, is the third most populous province in Pakistan, with a population estimated at 41 million. Objectives To determine the cancer counts and age-standardised incidence rates (ASIRs) per 100 000 population over a 4-year period for KP, 2020–2023, and to compare them with those available for two districts of Pakistan and nearby areas. Design A retrospective, province-wide, multicentre observational study. Setting Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, as the collaborating centre, with data reported from leading cancer treatment and diagnostic facilities across the country entered into its hospital information system. Participants New cancer cases diagnosed from 2020 to 2023 among inhabitants of KP. Primary and secondary outcomes Primary measures were cancer counts, proportions and ASIRs per 100 000 population for children (0–14 years), adolescents/young adults (15–19) and adults (≥20 years) in KP. Secondary analyses compared ASIRs across regions. Results A total of 57 852 malignancies were recorded in KP over a 4-year period: 51.6% in females and 48.4% in males. The ASIR per 100 000 persons was as follows: in pre-adolescent girls, 4.2; in pre-adolescent boys, 6.6; in adolescent females, 7.9; in adolescent males, 9.7; in adult females, 103.5; and in adult males, 90.1. Overall, breast cancer accounted for the highest proportion of cases (16.3%). In children, leukaemia had the highest ASIR in KP (1.9 in males, 1.0 in females) and in Lahore (3.3 in males, 2.1 in females), whereas in Karachi, the ASIR was high for bone tumours (8.6 in males and 5.6 in females). In adolescents, the ASIRs for leukaemia (0.8–2.0) were high in all three regions, as were those for ovarian cancer (0.8) in KP. In adults, the ASIRs for breast cancer among females were high in KP (32.6) and Lahore (76.7) but very high in Karachi (177.8). In adult males, the ASIR for prostate cancer was 9.1 in KP and 10.7 in Lahore, while in Karachi, it was 26.0 for colorectal/anal cancer. Overall, breast cancer had the highest ASIR in KP, Kabul in Afghanistan, and Iran among females, but in males, it was bladder cancer and non-Hodgkin lymphoma (NHL) in KP, and in Kabul and Iran, stomach cancer. Conclusion In KP, among children and young adults, haematologic malignancies; in adolescents, bone tumours and ovarian cancers; and in adults, breast and prostate cancers were frequently documented. There were similarities among the three regions (KP, Lahore and Karachi) in incidence rates. Differences were noted in the top three cancers among males in KP versus Kabul and Iran. This report lays the foundation for future comparative analyses and can guide the development of infrastructure for cancer prevention, diagnosis, and management within the province of KP. Data availability statement Data are available upon reasonable request. The datasets generated during the current study are not publicly available because data have been collected from different centres and the collated results are presented after analysis. The data are not available publicly but are provided by the corresponding author upon receiving a reasonable request. https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/. https://doi.org/10.1136/bmjopen-2026-119877 Request Permissions If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways. Request permissions STRENGTHS AND LIMITATIONS OF THIS STUDY A comparison of the incidence rates reported for Khyber Pakhtunkhwa has been made with the incidence rates reported by two registries in Pakistan (Lahore and Karachi) and two nearby regions (Kabul and Iran). It is difficult to assess the level of completion of the reporting. There was insufficient data on the most valid basis of diagnosis, disease stage, treatment outcomes and mortality. There could be a bias related to comparisons with other geographic regions due to methodological differences including registry systems, case-capture method, study years and age-groupings. Introduction Pakistan has a population of over 241 million. Its neighbouring countries are Afghanistan to the west and northwest, Iran to the southwest, India to the east and China to the north, as shown in figure 1.1 The country includes the following provinces and regions: Punjab, Khyber Pakhtunkhwa (KP), Sindh, Balochistan, Azad Jammu and Kashmir (AJK), and Gilgit-Baltistan (GB).1 The regions of KP, AJK and GB are in the northwest part of the country. In 2023, it was estimated that KP had a population of 40 856 097 and was the third most populous province in the country, accounting for 17.3% of the total population.2 KP and Afghanistan have a border in common. Download figure Open in new tab Download powerpoint Figure 1 A map of Pakistan showing the province of Khyber Pakhtunkhwa, along with other regions/provinces, and bordering countries. In Pakistan, cancer registration is a low-priority area due to a lack of awareness regarding its importance, compounded by both the economic crisis and political instability in the country, which delays implementing such initiatives in the area. Globocan has estimated that 185 748 new cancer cases were identified in Pakistan in 2022, while 118 631 deaths were recorded.3 Despite this, cancer registration has failed to receive appropriate attention from policymakers. However, there are a few organisations that have been instrumental in promoting cancer surveillance in the region. These include the Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) and the Pakistan Atomic Energy Commission (PAEC) hospitals.4 5 The Punjab Cancer Registry, sponsored by SKMCH&RC, operates in collaboration with dozens of institutions across the country’s most populous province of Punjab, has been in operation since 2005, and is the country’s largest population-based cancer registry.6 Other than this, there are very few population-based cancer registries operating in the country. The first registry, the Karachi Cancer Registry, presented its first report in 20007 but was then dormant for several years before starting to report cases again in 2017.8 The Punjab Cancer Registry has published papers on cancer in the districts of Lahore, Sheikhupura, Faisalabad and Nankana Sahib.9–11 Authors from SKMCH&RC have also reported 1-year (2020) cancer statistics for KP.12 The current study is a sequel to the previous report but covers a longer period of 4 years, from 2020 to 2023. The racial and ethnic composition of KP’s population differs from that of other provinces of Pakistan. Most people living in KP are Pashtuns, with the rural population accounting for 81% of the population.13 The majority of people living in Punjab are Punjabis, with 40% representing the rural population.14 The population of Sindh is heterogeneous, with 46% accounting for the rural population.15 Close to KP is Afghanistan, with Iran to the south of Afghanistan. Kabul is the capital city of Afghanistan, and Pashtuns (25%) constitute the second largest ethnic group in Kabul.16 In Iran, Persians account for 61% of the population of Iran.17 The aim of the study was to calculate and compare the incidence rates in KP with those available for Lahore in Punjab and Karachi in Sindh to determine variations in the types of cancers most frequently reported in these areas, as well as with regions that are close to Pakistan, such as Kabul in Afghanistan and Iran. These rates can help create a community cancer control programme and provide a benchmark for future assessments. Methods Participating centres We retrospectively collected data on incident cancer cases diagnosed among the residents of KP between 1 January 2020 and 31 December 2023 from leading cancer treatment and diagnostic facilities across the country. The primary contributing facilities were SKMCH&RC and PAEC,4 5 accounting for 88.9% of the cases reported, followed by Chughtai Lab (10.1%).18 A list of all centres contributing data is shown in online supplemental appendix A. Supplemental material [bmjopen-2026-119877supp001.pdf] Shaukat Khanum Memorial Cancer Hospital and Research Centre SKMCH&RC has two hospitals operational in Pakistan—one is in Lahore and the other is in Peshawar.4 The provincial capital of KP is Peshawar. The hospital has a centralised hospital information system. Therefore, regardless of which of the two hospitals the patients visited for management, information on patients belonging to KP can be retrieved readily. SKMCH&RC maintains a network of sample collection facilities (191) across the country of which 23 are in KP. Data on patients with a cancer diagnosis can also be accessed from these facilities, which use the same hospital information system as the two hospitals (SKMCH&RC). The Pakistan Atomic Energy Commission hospitals The PAEC operates 20 atomic energy cancer hospitals in the public sector in Pakistan, five of which are in KP including one in Peshawar.5 From the PAEC data, cancer patients from KP can be identified even if they attended PAEC hospitals outside of KP. Chughtai Lab Similar to SKMCH&RC, Chughtai Lab has multiple collection centres (447) in the country, including 36 in KP. Data collection Data were collected using both active and passive methods. Registry staff conducted official visits to various collaborating centres and instructed their staff on use of paper/electronic means of data provision (online supplemental appendix B). At SKMCH&RC, data were abstracted by the registry staff after reviewing the pathology reports and clinical notes. The information was saved in the cancer registry module of the hospital information system (online supplemental appendices C1 and C2). Supplemental material [bmjopen-2026-119877supp002.pdf] Supplemental material [bmjopen-2026-119877supp003.pdf] Supplemental material [bmjopen-2026-119877supp004.pdf] Variables and edit checks Cancer data were collected using the basic demographic and clinical variables required for population-based cancer registration, as documented by the International Agency for Research on Cancer (IARC).19 As shown in online supplemental appendices B and C, these included a case registration number, patient name, sex, age and/or birth date, date of incidence, tumour site (topography), tumour morphology, behaviour of the tumour and the most valid basis of diagnosis.19 The valid basis of diagnosis was based on the categories defined by IARC (non-microscopic, microscopic, death certificate only and unknown).20 Data were checked for duplication by combining different variables such as the patient’s name, age, father’s name, primary tumour site, telephone number and address.19 If two or more variables matched, records were further checked to determine if it was an actual duplicate or a subsequent primary. Globally accepted coding techniques, the International Classification of Diseases for Oncology, Third Edition, were used to categorise tumours.21 Standard rules for multiple primaries, as recommended by IARC, were followed to identify all cancers in the same individual.22 Population estimates Based on the latest census report, showing an average annual growth rate of 2.38%, the population estimates for KP were determined.2 The average annual population was 39 479 405 (with over 20 million males and 19.46 million females), as displayed in figure 2. Download figure Open in new tab Download powerpoint Figure 2 Population pyramid showing average annual person-years by sex and age group, Khyber Pakhtunkhwa, Pakistan, 2020–2023. Cancer statistics Cancer counts, percentages and age-standardised incidence rates (ASIRs) were computed for three age groups: 0–14 years (children), 15–19 years (adolescents/young adults) and ≥20 years (adults). The ASIRs were calculated per 100 000 population, using the Segi standard.23 The rates were computed using Microsoft Excel 2019, which was also used to generate tables and graphs. Throughout the paper, the ASIRs are presented per 100 000 population. Ethics approval and consent to participate The cancer registry data from the northwestern regions of Pakistan, including the KP, are saved in the centralised cancer registry module of the hospital information system at SKMCH&RC. The cancer registry operates under the same procedures as those established for the Punjab Cancer Registry. These define data contribution, storage and use for surveillance and research purposes. Once the data are submitted to SKMCH&RC by the participating centres, they are curated, managed and maintained centrally within the registry repository. Separate ethical approvals/exemptions were not obtained individually from all contributing institutions because the study involved secondary analysis of centrally pooled data. The link to the Punjab Cancer Registry website displaying the procedures is https://www.punjabcancerregistry.org.pk/reports/PCR_Procedures_2021.pdf.6 The Institutional Review Board (IRB) of the SKMCH&RC waived informed consent requirements as stated in the letter EX-29-11-24-01. This research study did not involve a clinical trial. Individual patient consent was not obtained for this study, as a retrospective review of the records was conducted, and collated and anonymised results were presented. Therefore, it was not deemed appropriate to contact the patients to inform them about the study. The IRB of the SKMCH&RC approved this study after granting it an exemption from full review (EX-29-11-24-01). The IRB is registered with the Office for Human Research Protections (OHRP) as ‘IRB00005898-Shaukat Khanum Mem Cancer Hosp & Rsch Centre IRB #1-SKMCH & RC’. Patient and public involvement None. Comparison of incidence data of KP with that for Kabul and Iran Cancer incidence data sources and analysis Cancer incidence data for Kabul (Afghanistan) and Iran were obtained from previously published studies. Data for Kabul were extracted from the first report on cancer registry-based statistics by Abdullah et al, who calculated the ASIRs using Segi’s World Standard Population.24 Data for Iran were obtained from the national cancer incidence trends study by Roshandel et al, who calculated the ASIRs using the Segi-Doll World Standard.25 Published, aggregate incidence data were extracted and compared with KP’s incidence data. No additional recalculation of incidence rates was performed. Ethics statement Ethical approval was not required for this component of the study because only publicly available, published, aggregate data were used. No identifiable or individual-level patient data were collected or analysed. Results Table 1 presents cancer cases stratified by age group, sex and cancer type or site, in KP. Table 2 shows the ASIRs for the leading malignancies in KP, Lahore and Karachi, by age group and sex.8 9 Online supplemental appendix D displays the ASIRs for the top three cancers in KP, Kabul and Iran, by sex. Supplemental material [bmjopen-2026-119877supp005.pdf] VIEW INLINE VIEW POPUP Table 1 Cancer counts, percentages and age-standardised incidence rates by age group, sex and cancer type or site, KP, Pakistan, 2020–2023 VIEW INLINE VIEW POPUP Table 2 The ASIRs per 100 000 population, by cancer type or site, sex and age group (children, adolescents and adults) in KP, Lahore and Karachi, Pakistan Between 1 January 2020 and 31 December 2023, a total of 57 852 cancer cases were reported in KP. Adults accounted for 90.9% of cases, children for 6.6% and adolescents for 2.6%. Overall, 51.6% of patients were female and 48.4% were male. The mean age at diagnosis was 49.75 years (SD±19.63; range 0.1–120 years). The five most common cancers between 1 January 2020 and 31 December 2023 were breast cancer (16.3%), followed by non-Hodgkin lymphoma (NHL (6.9%), colorectal/anal cancer (6.4%), skin cancer (melanoma and non-melanoma; 5.6%) and urinary bladder cancer (4.6%). Figure 3 displays the ASIRs for children and adolescents, and the ASIRs for adults by sex. Download figure Open in new tab Download powerpoint Figure 3 The ASIRs by cancer type or site in children and young adults, and in adults by sex, Khyber Pakhtunkhwa, Pakistan, 2020–2023. ASIRs, age-standardised incidence rates. Among girls aged 0–14 years, 1403 tumours were registered, with lymphoid leukaemia (18.1%, ASIR 0.76) being the most common, followed by tumours of the nervous system/brain (12.3%, ASIR 0.51), NHL (11.5%, ASIR 0.48), bone tumours (8.8%, ASIR 0.36) and Hodgkin’s lymphoma (8.3%, ASIR 0.33). Among boys (0–14 years), 2402 cases were recorded, with lymphoid leukaemia (20.6%, ASIR 1.4), Hodgkin’s lymphoma (16.4%, ASIR 1.0), NHL (14.6%, ASIR 0.93), nervous system/brain tumours (9.4%, ASIR 0.59) and connective/soft tissue tumours (6.5%, ASIR 0.43) predominating. Among adolescents, the leading tumours in females (n=647) were ovarian (10.0%, ASIR 0.79), bone (9.7%, ASIR 0.77), nervous system/brain (9.3%, ASIR 0.73), connective/soft tissue (9.1%, ASIR 0.72) and NHL (8.3%, ASIR 0.67). In males (n=835), the most common were bone (14.4%, ASIR 1.4), NHL (14.1%, ASIR 1.4), Hodgkin’s lymphoma (11.0%, ASIR 1.1), nervous system/brain (9.3%, ASIR 0.90) and connective/soft tissue tumours (8.9%, ASIR 0.87). Among adults aged ≥20 years, 27 828 tumours were registered in females, with breast cancer being the most common (33.2%, ASIR 32.6), followed by ovarian (6.1%, ASIR 6.4), skin (5.2%, ASIR 6.1), colorectal/anal (5.0%, ASIR 5.1) and NHL (4.4%, ASIR 4.7). In males (n=24 737), prostate (9.2%, ASIR 9.1), colorectal/anal (8.8%, ASIR 7.6), bladder (8.5%, ASIR 8.2), NHL (8.4%, ASIR 7.4) and skin cancers (6.9%, ASIR 6.5) were most frequent. Table 2 compares the most recent reported incidence rates for the Lahore and Karachi districts with those for KP.8 9 In these three regions, the ASIRs for leukaemia per 100 000 population ranged between 1.0 and 3.3 for both males and females, with the highest observed among children in KP and Lahore; however, in Karachi, the ASIRs for bone cancer were recorded as the highest, at 5.6 in females and 8.6 in males. Among adolescents, the incidence rates for bone tumours were the highest in both young females and males (0.8–2.2), while the incidence rate for ovarian cancer was also 0.8. In adults, among females, the leading cancer was that of the breast (ASIR, 32.6 in KP and 76.7 in Lahore), but the ASIR was very high in Karachi (177.8), whereas among adult males, prostate cancer ranked number 1 with an ASI
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