Bangladesh Journal of Medical Science Vol. 18 No.

02 April’19

Original article
Prevalence of Acute and Chronic Forms of Leukemia in Various Regions of Khyber Pakhtunkhwa,
Pakistan: Needs Much More to be done!
Shujaat Ahmad1, Kifayatullah2, Kiramat Ali Shah3, Haya Hussain4, Anwar Ul Haq5, Abid Ullah6, Asaf
Khan7, Najm Ur Rahman8

Abstract:
Background and objective: Leukemia is one of the fatal diseases and their morbidity and
mortality rates increases day by day all over the world. This piece of research study was designed
in order to find out the prevalence of different types of leukemia in Khyber Pakhtunkhwa,
Pakistan during January 2015 to December 2016. Material and Method: The retrospective
research study was carried out at Institute of Radiotherapy and Nuclear Medicine (IRNUM)
Peshawar. A data of 400 admitted patients of leukemia were evaluated. Result: It was observed
that acute leukemia (80%) was more prevalent than chronic leukemia (20%). Amongst types of
leukemia, Acute Lymphocytic Leukemia (ALL) 49.5% (n=198) was more prevalent than Acute
Myelogenous Leukemia (AML) 31.25% (n=125), Chronic Myelogenous Leukemia (CML)
10% (n=40) and Chronic Lymphocytic Leukemia (CLL) 9.25% (n=37) was less prevalent in
this study. It was also found that leukemia was more prevalent in male patients 64.5% (n=258)
as compared to females 35.5% (n=142) and male to female ratio was 1.8:1. Most of the patients
were under the age of 20 years. Conclusion: Acute leukemia was more prevalent than chronic
leukemia during this study in this part of the country and needs to be address.
Keywords: Leukemia; ALL; AML; CML; CLL; Khyber Pakhtunkhwa

Bangladesh Journal of Medical Science Vol. 18 No. 02 April’19. Page : 222-227

DOI: https://doi.org/10.3329/bjms.v18i2.40689

Introduction: data regarding the prevalence of different types

The word leukemia literally means malignancies of of acute leukemia in northern part of Pakistan5. At
white blood cells; a case rarely developing from red present, there are no cancer registry programs in
blood cells precursors, erythroleukemia, also called Pakistan which can keep a track and notify regarding
Di-Guglielmo’s disease1.ALL is the most common the prevalence and incidence of leukemia, because
malignancy diagnosed in children. It is clinically and Pakistan is an Asian country and canceris becoming
morphologically heterogeneous2. Morphologically, a serious health issue, being the leading cause of
it is classified according to FAB (French, American death in Asia Pacific countries6.The incidence of
and British) criteria into L-1, L-2 and L-3 sub-types, leukemia across the world is 1 per 100,000 per year
which are clinically reproducible3. Bone marrow and contributes to 25% of childhood cancers7. Most
aspiration with trephine biopsy is used as a standard common types of leukemia are; ALL, AML, CML
for diagnosis of leukemia4. Currently, there is limited and CLL. ALL and AML are further characterized

1. Shujaat Ahmad, Email: [email protected]

2. Kifayatullah, Email: [email protected]
3. Kiramat Ali Shah, Email: [email protected]
4. Haya Hussain,
5. Anwar Ul Haq, Email: [email protected]
6. Abid Ullah, Email: [email protected]
7. Asaf Khan, Email: [email protected]
8. Najm Ur Rahman, Email: [email protected]
Department of Pharmacy, Shaheed Benazir Bhutto University, Sheringal Dir (Upper), Pakistan

Correspondence to: Haya Hussain Email: [email protected]

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 Prevalence of Acute and Chronic Forms of Leukemia in Various Regions of Khyber Pakhtunkhwa, Pakistan: Needs Much More to be done!

into subtypes based on French American British

(FAB) classification8.
Acute myeloid leukemia is primarily a cancer of
adults and acute lymphoblastic leukemia is more
prevalent in children under 15 years of age. The
chronic leukemiais distinguished from acute leukemia
by their slower progression9. Acute and chronic adult
leukemia are a heterogeneous group of disorders. They
are also an uncommon form of malignancy affecting
approximately 5 persons per 100,000 in the United
States annually10. Hematological malignancies,
especially leukemia and non-Hodgkin’s lymphoma
are common in South-East Asia than in the U.S.A.
and Europe11. Leukemia is one of the most frequently
occurring cancers in all races or ethnicities with
relative proportion vary between 25-40%12. In 2013,
males have been accounted for more than 57% of the
new cases of leukemia13. High incidence of subtypes
of leukemia in males was due to more exposed to
occupational and environmental carcinogens14. )LJXUH'LIIHUHQWUHJLRQVRI.K\EHU3DNKWXQNKZD
Itfurther states that every 4 minutes, one person in
the United States is diagnosed with a blood cancer15. and patients were classified as suffering from acute or
The second largest contributor to mortality from chronic form of leukemia on the basis of examining
childhood cancer in Britain is leukemia, whereas in peripheral blood and bone marrow aspiration records
India, leukemia continues to be the largest contributor as well as according to percentage of blast cells and
to cancer related mortality in children16.ALL, the premature cells.
most common cancer diagnosed in childhood, with Study design:
higher incidence for white than for black17. Bone Retrospective research study was conducted with in-
marrow aspiration of leukemia patients shows >20% patients.
blast cells18.The mean age for CLL is greater than 50 Study population:
years and the male to female ratio is 2:119. The illness
The record charts of hospitalized patients diagnosed
seems to occur in 0.8 new cases per 100,000 persons
with leukemia as the source of research data.
per year in Brazil. Twice as many men as women are
affected by CLL20. Inclusion criteria:
Due to lack of information and sufficient work in The data collected from those hospitalized patients
this field and its significances to the development who were treated from January 2015 to December
of health of the community and importance to the 2016.
socioeconomic aspect for the development of the Exclusion criteria:
nation, this piece of research project was therefore Patients diagnosed with leukemia who stay less than
designed to investigate the prevalence of different 3 days in the hospital were excluded from this study.
types of leukemia in various residential areas of Data collection:
Khyber Pakhtunkhwa, Pakistan. This data was The data was collected on a special proforma
collected at Institute of Radiotherapy and Nuclear designed by the Department of Pharmacy Shaheed
Medicine (IRNUM) Peshawar which is the only
Benazir Bhutto University Sheringal Dir (Upper),
recognized cancer hospital in this province and
Pakistan, consists of parameters regarding patients’
people frequently visits here for treatment.
Patients and methods: age, gender, date of admission, bed number,
A retrospective study was carried out in IRNUM ward number, address, hospitalization time, chief
Hospital Peshawar and 400 leukemic patients were complaints, medication history, biochemical tests,
treated during 2015-16. In 2015, 175 patients were type of leukemia and address of the patients. FAB
treated and 225 patients were treated in 2016. The classification of acute leukemia was applied for sub-
medical records were taken from the record room typing.
223
 Shujaat Ahmad, Kifayatullah, Kiramat Ali Shah, Haya Hussain, Anwar Ul Haq, Abid Ullah, Asaf Khan, Najm Ur Rahman

Data analysis 3.75% (n=15) in female individuals.ALL has 49.5%

The collected data was analyzed using Microsoft XL (n=198) prevalent which is more common amongst
and Prisms Graph pad. all types of leukemia and 32.5% (n=130) in male and
Ethical Issues: Ethical clearance was obtained 17% (n=68) in females patients. CLL contributed
from UITH Ethical Research Committee. Written 37% (n=9.25) in which male patients suffered 7%
permission was also obtained from Department (n=28) and female 2.25% (n=9) as given in the Table
of Pharmacy, Shaheed Benazir Bhutto University, 2 and Figure 2.
Sheringal Dir (Upper), Pakistan. A signed informed Table 2: Distribution of patients according to
consent was obtained from every participant before Types of Leukemia
being recruited.
Results: Type of
Male n (%) Female n (%) Total n (%)
Leukemia
In this piece of research study 400 leukemia patient’s
data was evaluated containing 64.5% (n=258) and AML 75 (18.7) 50 (12.5) 125 (31.25)
35.5% (n=142). The data has been divided according
to age group and sex (Table 1), most of the patients CML 25 (6.25) 15 (3.75) 40 (10)
were children of age ≤ 10 years 38% (n=152) and
15.5% (n=70) of age group 11-20 years. 15% (n=60) ALL 130 (32.5) 68 (17) 198 (49.5)
patients lye in the age group 21-30 years while the
CLL 28 (7.0) 09 (2.25) 37 (9.25)
others were mostly adults ones as shown in the (Table
1). The male to female ratio is 1.8:1.It is evident from Total 258 (64.5 %) 142 (35.5 %) 400 (100)
the data that leukemia is more prevalent in younger
patients.
Table 1: Distribution of patients according to
Age and Sex

Age
Total n
group in Male Female
(%)
years
0-10 108 44 152 (38)
11-20 45 25 70 (17.5)
21-30 40 20 60 (15)
31-40 20 16 36 (09) )LJXUH'LVWULEXWLRQRISDWLHQWVDFFRUGLQJWRW\SHVRI
41-50 19 15 34 (8.5) OHXNHPLD

51-60 14 03 17 (4.25) According to the relation of leukemia with respect to

age groups, it is evident that 38% (n=152) leukemia
61-70 08 07 15 (3.75)
is prevalent in age group ≤ 10 years comprising AML
71-80 03 08 11 (2.75) 6.75% (n=27), ALL 31.25% (n=125). 17.5% (n=70)
81-90 01 04 05 (1.25) leukemia lye in the age group 11-20 years in which
258 (64.5
AML 6.50% (n=26), CML 1% (n=4) and ALL 10%
Total 142 (35.5 %) 400 (100) (n=40) contributed. It is 15% (n=60) in the age group
%)
The current research study has showed that acute of 21-30 years having AML 6.25% (n=25), CML
leukemia is more prevalent than chronic leukemia 2.5% (n=10) and ALL 6.25% (n=25).In the age group
and more common in male as compared to female 31-40 years AML 4.25% (n=17), ALL 2% (n=8)
patients. AML is prevalent 31.25% (n=125) and their are prevalent. In this piece of research study AML
male to female contribution is 18.7% (n=75) and and ALL are mostly prevalent in young age group
12.5% (n=50) respectively. CML has 10% (n=40) populations while CML and CLL are prevalent in
prevalent and common in male 6.25% (n=25) and adult age group populations as shown in the Table 3.

224
 Prevalence of Acute and Chronic Forms of Leukemia in Various Regions of Khyber Pakhtunkhwa, Pakistan: Needs Much More to be done!

Table 3: Distribution of patients of different types of leukemia in relation to age groups

AML CML ALL CLL Total
Age group in years
n (%) n (%) n (%) n (%) n (%)
0-10 27 (6.75) 00 (0.00) 125 (31.25) 00 (0.00) 152 (38)
11-20 26 (6.50) 04 (1.00) 40 (10.00) 00 (0.00) 70 (17.5)
21-30 25 (6.25) 10 (2.50) 25 (6.25) 00 (0.00) 60 (15)
31-40 17 (4.25) 05 (1.25) 08 (2.00) 06 (1.50) 36 (09)
41-50 20 (5.00) 03 (0.75) 00 (0.00) 11 (2.75) 34 (8.5)
51-60 05 (1.25) 04 (1.00) 00 (0.00) 08 (2.00) 17 (4.25)
61-70 04 (1.00) 06 (1.50) 00 (0.00) 05 (1.25) 15 (3.75)
71-80 01 (0.25) 05 (1.25) 00 (0.00) 05 (1.25) 11 (2.75)
81-90 00 (0.00) 03 (0.75) 00 (0.00) 02 (0.50) 05 (1.25)
Total 125 (31.25) 40 (10) 198 (49.5) 37 (9.25) 400 (100)

Due to the near territories across the border most

of the peoples from Afghanistan visit this hospital
for cancer treatment and during this study 11.25%
(n=45) Afghan peoples have one or more types of
leukemia followed by leukemic patients from Bajaur
Agency 8.75% (n=35), then Mardan and Peshawar
7.50% (n=30), Karak 6.75% (n=27), Kohat 6.25%
(n=25) and 5.75% (n=23) patients from Mohmand
Agency have been diagnosed with leukemia. Other
regions includes Kurram Agency 2.25% (n=9),
)LJXUH3HUFHQWDJHSUHYDOHQFHRI/HXNHPLDLQYDULRXV
Charsada 5% (n=20), Orakzai Agency 1.25% (n=5),
UHJLRQVRI.K\EHU3DNKWXQNKZD
Dir Upper 3.75% (n=15), Dir Lower 3% (n=12), Swat
4.5% (n=18), Shangla 2% (n=8), Malak and 2.5% Discussion:
(n=10), Nowshehra 5% (n=20), North Waziristan Leukemia represents 31% of all cancer cases
5.25% (n=21), Swabi 6.5% (n=26), Khyber Agency occurring among children younger than 15 years of
3% (n=12) and 2.25% (n=9) leukemia patients were age21. Acute leukemia is one of the most common
from Chitral disttrics (Table 4). cancers with about 20,000 cancer diagnoses and
Table 4: Area wise prevalence of leukemia patients over 10,000 annual deaths in the United States22.
treated at IRNUM Hospital The current study showed that acute leukemia is
Area N % more prevalent than chronic leukemia in Khyber
Afghanistan 45 11.25 Pakhtunkhwa province including both sides of tribal
Bajaur agency 35 8.75 areas across Pak Afghan border from January 2015
Mardan 30 7.50 to December 2016.This piece of research study
Peshawar 30 7.50
Karak 27 6.75 revealed that ALL (49.5%, n=198)is more common
Swabi 26 6.50 in children as earlier research studies reported
Kohat 25 6.25 that ALL suffered children more than adults in the
Mohmand Agency 23 5.75 past23.This study also revealed that ALL is more
North Waziristan 21 5.25 common and more prevalent under the age of 10
Nowshehra 20 5.00 years than AML (31.25%, n=125). ALL is the most
Charsada 20 5.00 common pediatric malignancy. It represents 25%
Swat 18 4.50 of all childhood cancers and approximately 75% of
Dir Upper 15 3.75 all cases of childhood leukemia19.There has been a
Khyber Agency 12 3.00 gradual increase in the incidence of ALL in the past
Dir Lower 12 3.00
25 years20. In the current study CLL is more common
Malakand 10 2.50
in adult patients and contributed 9.25% (n=37) of the
Kurram Agency 09 2.25
Chitral 09 2.25 total (n=400) leukemia patients as CLL is consider
Shangla 08 2.00 leukemia of old age population and more prevalent
Orakzai Agency 05 1.25 above 60 years and uncommon below 40 years of
age24.This piece of research study indicated that CML

225
 Shujaat Ahmad, Kifayatullah, Kiramat Ali Shah, Haya Hussain, Anwar Ul Haq, Abid Ullah, Asaf Khan, Najm Ur Rahman

has suffered only 10% (n=40) patients and common leukemia was more prevalent than chronic leukemia
above 20 years of age and found more frequently in in the Khyber Pakhtunkhwa province of Pakistan.
adult patients as median age limit for CML has been ALL was more common and more prevalent in
suggested to be 40-50 years25,26. young age male population of this part of the country
The incidence of leukemia varies with age and gender. followed by AML, CML and CLL. It is suggested
In our present study, the prevalence of leukemia is that a proper policy regarding awareness and
more common in males than females as similar to the treatment of leukemia may be constituted to decrease
findings of Shabbir, 201127. The reason may be linked the incidence as well as decrease the cost of cancer
to the life style, habits like smoking, occupation, therapy throughout the country.
contact with different chemicals and radiations other
Conflict of interest: The authors declare no conflict
than genetic factors. Present study showed male
of interest.
to female ratio 1.8:1, which is similar as reported
Authors’ Contribution:
by Khalil et al 200728.This piece of research study
Data gathering and idea owner of this study: Haya
demonstrated the prevalence of leukemia in various
regions of Khyber Pakhtunkhwa province including Hussain, Shujaat Ahmad, Kifayatullah
in some percentage of peoples from Afghan territories Study design: Kiramat Ali Shah, Haya Hussain,
across the Pak Afghan border (Table 4 and Figure Anwar Ul Haq, Abid Ullah
3).It is essential weather the prevalence of leukemia Data gathering: Haya Hussain, Asaf Khan, Najm Ur
in this study is representative of the whole country, Rahman
if not, then similar study should be conducted to find Writing and submitting manuscript: Shujaat Ahmad,
out the overall prevalence of leukemia in Pakistan. Haya Hussain
Conclusion: Editing and approval of final draft: Haya Hussain,
The outcome of this research project shows that acute Anwar Ul Haq

226
 Prevalence of Acute and Chronic Forms of Leukemia in Various Regions of Khyber Pakhtunkhwa, Pakistan: Needs Much More to be done!

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