Preliminary Survey Report of Eye Cancers in Pakistan

By Tayyab Afghani¹, Haroon Awan², Asad Aslam Khan³

Affiliations

1. Department of Ophthalmology, Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan
2. Department of Public Health/Ophthalmology, Avicenna Consultants, Islamabad, Pakistan
3. Department of Ophthalmology, King Edward University and Mayo Hospital, Lahore, Pakistan

doi: 10.29271/jcpsp.2025.06.784

ABSTRACT
Objective: To estimate the magnitude of eye cancer and its annual frequency, extrapolated from major eye care centres of the country.
Study Design: Observational study.
Place and Duration of the Study: Data were obtained from ten dedicated eye care institutions of three provinces of Pakistan, from January to December 2022.
Methodology: This is the report of the first eye cancer survey in Pakistan under the auspices of the National Committee of Eye Health. Eye care institutions, along with major stakeholders involved in the prevention and control of eye cancer, were requested to provide the annual data on tumours of the eye as well as information related to the situation analysis of eye cancer services.
Results: The number of eye tumours reported in one year was 1705; 51% were malignant and 49% were benign. Eight hundred and seventy-seven cases of eye cancers were diagnosed in a year; 38% were eyelid cancers, 31% were intraocular tumours, and 16% were ocular surface tumours, while 15% were cancers of the orbit. KPK had the highest percentage of eyelid cancers (72%), and Sindh had the highest percentage of intraocular cancers (40%).
Conclusion: It is estimated that there are 4 cases of eye cancer per million population of Pakistan and an almost similar number of benign eye tumours. Thus, it is estimated that 8 cases of eye tumours per million population are examined annually. Cost and lack of facilities were found to be major limitations towards eye cancer control.

Key Words: Eye malignancies, Eye surveys, Pakistan, Ophthalmology, Tumours of eye.

INTRODUCTION

There is limited data about eye tumours in Pakistan.  Cancers of the eye and orbit are clinically challenging for ophthalmologists.¹ These patients often present late when options for treatment are minimal.^2-4 The cancers of the eye and orbit are lost in the shadows of major blinding and vision impairing conditions.^5,6 The skilled human resources required for the management of eye cancers are also limited in the country.

According to the International Agency for Research on Cancer, Pakistan has an age-standardised incidence rate of cancer of 110.4 per 100,000 population.⁷ Based on cancer data available, it is estimated that the number of new cases with cancer (all types) in 2020 was 178,000. This number is expected to rise to 319,000 by 2040.
 

According to data available from the WHO cancer country profile, the annual cancer cases (0-14 years) in Pakistan in 2020 were 8,213.⁸ Retinoblastoma accounted for 265 cases out of 8,213 cases. The objective of the study was to estimate the magnitude of eye cancer and its annual frequency, extra- polated from the major eye care centres of the country.

METHODOLOGY

The National Committee for Eye Health (NCEH), Ministry of National Health Services, Regulations and Coordination developed the National Integrated People-Centred Eye Care Plan (IPCEC) 2020 – 2025. One of the objectives of the IPEC Plan was to develop an interim strategy for the prevention and control of eye cancers. As a first step, it was decided to determine the situational status of services and data for cancers of the eye and orbit in Pakistan by conducting a national survey through mapping centres providing subspeciality services for orbit, oculoplastic, and ocular oncology. Consequently, all these centres were approached and requested to provide the annual data for eye tumours, both benign and malignant.

Data were collected from three provinces of Pakistan from 1^st January to 31^st December, 2022. Data from provinces of Baluchistan and Gilgit Baltistan could not be obtained due to their non-availability of a dedicated centre.

The first phase involved a situational survey from various centres in the country. A structured questionnaire was used for this purpose. The institutions covered in this phase included one centre from Khyber Pakhtunkhwa (KPK), three centres from Punjab, and six centres from Sindh.

In the second phase, key informants were interviewed using a semi-structured questionnaire adapted for their specific area of expertise. The key informants included ophthalmologists, medical oncologists, radiation oncologists, public health professionals, cancer genetics researchers, and social support group professionals.

Organisational perspectives in terms of public health and research were obtained from different national and international NGOs, including CBM (Christoffel Blindenmission), Brien Holden Foundation, and Prevention of Blindness Programme, Baluchistan. Quaid-i-Azam University, Islamabad, provided valuable input on cancer genetics research potential in the country.

RESULTS

Information about the magnitude of eye cancer in Pakistan was gathered from major tertiary eye care centres of the country through written requests. It was obtained from three major provinces of Khyber Pakhtunkhwa (KPK), Punjab, and Sindh which comprise over 90% of the country population.

Table I presents the annual frequency and types of eye cancers. The data show that 877 cases of eye cancers were diagnosed in a year. Out of these, 38% were eyelid cancers, 31% were intraocular tumours, and 16 % were ocular surface tumours, while 15% were cancers of the orbit.

KPK region had the highest percentage of eyelid cancers (72%), followed by 14% of ocular surface tumours, 10% of intraocular tumours, and 4% of cancers of the orbit. Sindh province had the highest percentage of intraocular cancers (40%), followed by 31% of eyelid cancers, 19% of cancers of the orbit, and 10% of ocular surface tumours. Similar to KPK, Punjab had the highest proportion of eyelid malignancies (37%), followed by 29% of intraocular cancers, 20% of ocular surface tumours, and 14% of orbital malignancies.

In Sindh, the average frequency of eye tumours based on stakeholders’ answers indicated that out of 730 tumours, benign tumours comprised about 60%, while malignant tumours comprised about 40%. It was, however, the reverse in Punjab (825 tumours) and Khyber Pakhtunkhwa (150 tumours), where malignant tumours comprised 60% of the cancer workload and benign tumours comprised 40%. Based on this information, the annual estimated frequency of benign tumours is calculated and extrapolated along with the overall frequency of eye tumours (Table II).

It is estimated that over 1,700 eye tumours occur per year, out of which around 51% are likely to be malignant and 49% benign. In terms of population, it is estimated that there are 4 cases of eye cancer per million population of Pakistan and an almost similar number of benign eye tumours. Overall, there are roughly 8 cases of eye tumours (both benign and malignant) per million population that are examined annually.

Table I: Annual frequency and types of eye cancer.
 

Provinces	Institutes	Tumours
		Eyelid Tumours	Ocular surface tumours	Intraocular tumours	Orbital tumours	Total
Sindh	Al-Ibrahim (based on 10 years data)	15 2 per year	30 3 per year	151 15 per year	05 01 per year	21
	Civil Hospital Karachi	00	00	15	00	15
	Chandka Medical College	06	04	06	02	18
	JPMC	31	07	13	11	62
	Khairpur	25		12		37
	LRBT Karachi	16	09	50	30	105
	SIOVS Hyderabad	10	06	06	12	34
	Total	90 (31%)	29 (10%)	117 (40%)	56 (19%)	292
KPK	Based on Khyber Teaching Hospital 3.5 years data	65 (72%)	13 (14%)	09 (10%)	03 (4%)	90
Punjab	Al-Shifa Eye Hospital Rawalpindi	60	40	55	25	180
	AFIO Rawalpindi	30	20	25	10	85
	Mayo Hospital Lahore	90	40	65	35	230
	Total	180 (37%)	100 (20%)	145 (29%)	70 (14%)	495
Grand Total		335 (38%)	142 (16%)	271 (31%)	129 (15%)	877

Table II: Estimated frequency of eye cancer per million population.

Regions*	Population	Benign per million	Malignant per million	Total eye tumours per million
Khyber Pakhtunkhwa	40,856,097	1.5	2.25	3.75 / million
Punjab including Islamabad capital territory	130,052,785	2.53	3.80	6.3 / million
Sindh	55,696,147	8	5.30	13.30 / million
Total	226,605,029	3.66	3.88	7.54 / million
*Pakistan Bureau of Statistics -2023 Digital Census.9

The stakeholders’ analysis revealed that there were definite gaps in the provision of medicines and technology. The ophthalmologists indicated the need for surgical equipment, especially for orbital surgery, such as suction machine, diathermy, and bone saw. Ret Cam, an essential diagnostic/ screening/monitoring unit for one of the commonest eye cancers, retinoblastoma, is not available in many tertiary eye care centres. The availability of the facility of MRI/CAT scan is an essential requirement. The lack of proper and prompt repair and maintenance facilities was identified as a restraining factor.

There is an acute shortfall of radiation oncologists and radio-therapy equipment. Pakistan needs 200 linear accelerators. However, currently there are hardly 30 units available. The large workload on these machines also undermines the safety and efficacy of treatment, not to mention the long waiting times.

With regards to chemotherapy facilities in Pakistan, the survey revealed that at present, medical oncology services in the major cities of the country include three in Islamabad, four in Rawalpindi, six in Lahore, three in Multan, one in Faisalabad, five in Karachi, and two in Peshawar. Standard procedures for chemotherapy were not being followed at times due to lack of resources and number of patients. Oncologists informed that the availability of Chemo-Cabinet (a lamellar flow equipment needed to prepare chemo medicines in clean atmosphere) was also an issue. However, the major issue was the cost of the treatment. The current survey reported abandonment of cancer treatment due to financial reasons as a major cause of concern. The patients/parents could not afford even trans-portation charges for repeated visits to the cancer care facilities, which in many cases were located only in a few major cities of the country. Morever, the costs of repeated diagnostic tests such as MRI/CT scans, laboratory tests, ultrasound etc. were not affordable for patients.

Pakistan has made some progress in health financing through allocating and spending an increasing amount of budget to the health sector and social health insurance programmes. In addition, the low-income population also have access to social protection funds (Zakat and Bait-ul-Mal). Bait-ul-Mal is a publicly funded social protection initiative. Healthcare is one of the 6 programmes administered under the Zakat fund. For both Zakat and Bait-ul-Mal, patients need to apply to receive payment for their treatment, which must be provided at selected hospitals.

The private charity sector programmes are playing a very important role. Two hospitals in Lahore and Karachi are providing free treatment for all types of cancer. Al-Shifa Trust Eye Hospital in Rawalpindi is the only facility in the country so far that has set up a dedicated Centre for Eye Cancer that is providing free-of-cost chemotherapy and radiotherapy facilities exclusively for eye cancer patients.

DISCUSSION

This is the first of its kind eye cancer survey in Pakistan sanctioned by the National Committee of Eye Health (NCEH). Although it can be at best termed a conservative estimate of the magnitude and type of eye cancers in Pakistan and available services, it serves as a first step towards planning services for prevention and control of eye cancer in Pakistan.

Eye cancer is relatively rare and makes up approximately 0.15–0.2% of all cancer cases, and less than 0.1% of cancer-related deaths in various regions worldwide.¹⁰ The WHO Pakistan Cancer Country Profile 2020 indicates that there are about 800+ body cancer per million population in Pakistan.⁸ The current survey estimates that over 1,700 eye tumours occur per year, and there are four cases of eye cancer per million population of Pakistan, and almost a similar number of benign eye tumours. Overall, there are an estimated eight cases of eye tumours (both benign and malignant) per million population that are examined annually. This suggests that eye tumours (benign and malignant) comprise about one percent of the total examined annually in the country, while 0.5% of malignancies in Pakistan are eye cancers.

A regional study in Asia based on the year 2013 population estimates shows that 43% (3,452 of 8,099 children) of the global burden of one of the commonest eye cancers – retinoblastoma (RB), lives in 6 countries of Asia-Pacific region: 1,486 children in India, 1,103 children in China, 277 children in Indonesia, 260 children in Pakistan, 184 children in Bangladesh, and 142 children in Philippines.¹¹ The current survey shows that 271 RBs were diagnosed in a year in Pakistan.

Although the survey tends to show national estimates, there are some limitations. Some of the areas had no data available on eye cancers. The survey did not take into account eye cancer-related deaths. Globally, there were approximately 8,202 eye cancer-related deaths in 2020.¹⁰

Despite some of these limitations, the survey gives us a rough estimate for planning. It has identified certain gaps in different areas of eye cancer control, including service delivery, human resources, and technology. The resources for eye cancer control in terms of diagnostic and therapeutic modalities are limited in Pakistan. The developing countries have almost similar limitations in cancer control.¹²

According to the WHO country cancer profile 2020,⁸ there are 17.2 CT scanners and 4.6 MRI scanners per 10,000 cancer patients in Pakistan. As a result, long waiting times as well as breakdowns are some of the issues that delay the start of cancer chemo/radiation.

According to the WHO country profile, the number of radiation oncologists in the country is 1.8 per 10,000 cancer patients.⁸ The survey revealed acute deficiency of radiation machines in the country. Studies elsewhere have also identified under-utilisation of radiotherapy on one hand^13,14 and lack of access on the other as major challenges.¹⁵ A study from India shows that 75% of patients in the public sector do not have access to timely radiotherapy.¹⁵

The cost of treatment is another major limitation. Chemo-therapy involves multiple sessions, and although it is mainly performed on outdoor basis, the cost and non-stop availability of chemotherapeutic agents have been identified as important barriers in the current survey. The average cost of chemo-therapy has been estimated both at the hospital,¹⁶ and global level.¹⁷ The results demonstrate that the cost of administering chemotherapy is approximately $125-150/hour, globally.¹⁷ The current survey has identified only one eye care institution in the country that is not only providing free-of-cost chemotherapy to its eye cancer patients but also bearing the non-medical costs that significantly add to the heavy economic burden in children with eye cancer.¹⁸ This economic burden of cancer treatment is not only quite high for the patient but also for the healthcare provider. Modalities in the form of health insurance coverage need to be established and strengthened to treat these patients.¹⁹

Palliative care for advanced eye cancers is almost non-existent in the country. There is no national palliative care policy in Pakistan. In larger parts of the Middle East, palliative care is still misunderstood among health professionals, cancer patients, and the public at large. It is because the term does not obviously communicate the intent of this clinical discipline, which is lending better quality of life while combating cancer.²⁰

This survey report was shared by the National Committee of Eye Health with the Ministry and recommendations were forwarded to policymakers at national level to fill these gaps. One of the limitations of the study was non-availability of data from Baluchistan and Gilgit Baltistan.

CONCLUSION

The first eye cancer survey in Pakistan estimated that more than 1,700 eye tumours are reported in Pakistan annually, with 51% being malignant. The tumours arise mainly from eyelids, ocular surface, intraocular region, and orbit. Roughly four cases of malignant eye tumours per million population are reported annually. There are barriers in eye cancer care in terms of surgical expertise, deficiency of radiotherapy facilities, cost of chemotherapy, as well as non-medical costs and non-existent palliative care.

COMPETING  INTEREST:
The authors declared no conflict of interest.

AUTHORS’  CONTRIBUTION:
TA: Conception, design, acquisition, and analysis of data.
HA, AAK: Drafting and critical revision.
All authors approved the final version of the manuscript to be published.

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