DOI:http://dx.doi.org/10.7314/APJCP.2015.16.17.

7759 ​Leukemia in Iran: Epidemiology and Morphology Trends

RESEARCH ARTICLE
Leukemia in Iran: Epidemiology and Morphology Trends
Fatemeh Koohi​1​, Hamid salehiniya​1,2, ​Reza Shamlou​3​, Soheyla Eslami​3​,
Ziyaeddin Mahery Ghojogh​4​, Yones Kor​4​, Hosein Rafiemanesh​1​* ​Abstract

Background: Leukemia accounts for 8% of total cancer cases and involves all age groups with different
prevalence and incidence rates in Iran and the entire world and causes a significant death toll and heavy
expenses for diagnosis and treatment processes. This study was done to evaluate epidemiology and
morphology of blood cancer during 2003-2008. Materials and Methods: This cross- sectional study was
carried out based on re- analysis of the Cancer Registry Center report of the Health Deputy in Iran during a
6-year period (2003 - 2008). Statistical analysis for incidence time trends and morphology change percentage
was performed with joinpoint regression analysis using the software Joinpoint Regression Program. Results:
During the studied years a total of 18,353 hematopoietic and reticuloendothelial system cancers were
recorded. Chi square test showed significant difference between sex and morphological types of blood cancer
(P-value<0.001). Joinpoint analysis showed a significant increasing trend for the adjusted standard incidence
rate (ASIR) for both sexes (P-value<0.05). Annual percent changes (APC) for women and men were 18.7 and
19.9, respectively. The most common morphological blood cancers were ALL, ALM, MM and CLL which
accounted for 60% of total hematopoietic system cancers. Joinpoint analyze showed a significant decreasing
trend for ALM in both sexes (P-value<0.05). Conclusions: Hematopoietic system cancers in Iran demonstrate
an increasing trend for incidence rate and decreasing trend for ALL, ALM and CLL morphology.
Keywords: ​Epidemiology - trend - leukemia - hematopoietic system - Iran
Asian Pac J Cancer Prev, 1​ 6 (17)​, 7759-7763
Introduction
Although overall incidence is rare, leukemia is the most common type of childhood cancer. It accounts for 30% of
Cancer is set to become a major cause of morbidity
all cancers diagnosed in children younger than 15 years and mortality in the coming decades in every region of
(Belson et al., 2007), but it is not limited to children and the world (Bray et al., 2012). Today, Cancer is the leading
has higher incidence among adults with more complicated cause of death in economically developed countries and
treatment process (Tahmasebi et al., 2006). the second leading cause of death in developing countries
Leukemia is classified to main four categories with (Jemal et al., 2011). Malignant disorders in hematopoietic
different clinical symptoms: AML or acute myeloid system include different conditions which some of them
leukemia which mostly involves adults and consists are related to bone marrow and other may be related to
about 30% of total adults’ leukemia cases, ALL or acute lymphatic system. Three main types of blood cancer are
lymphatic leukemia which is the most common type of leukemia, lymphoma myeloma and plasma cell disorders
disease among children and almost 80% of leukemia (Rodriguez-Abreu et al., 2007).
cases among children is attributed to this type and finally, Leukemia is a metastatic and malignant disease for
CML or chronic myeloid leukemia which usually is seen blood-making organs which is resulted due to incomplete
among adults and CLL or chronic lymphatic leukemia evolution and problematic proliferation of white blood
the most common type of leukemia in adults which 90% cells (WBCs) and its substrates in blood and bone marrow
of this type cases happens after 50 years old (Rodriguez- (Howlader N NA, , based on November 2013 SEER data
Abreu et al., 2007). Also multiple myeloma or plasma cell submission, posted to the SEER web site, April 2014).
myeloma is a malignant blood disease in which plasma Leukemia is responsible for 8% of total cancer cases (Zand
cells (which produce anti body) involve by cancer (Raab et al., 2010) and involves all age groups with different
et al.). Multiple myeloma consists less than 1% of total prevalence and incidence rate in Iran and whole the world
cancer cases and less than 10% of total cancer cases and and causes significant death toll and heavy expenses for
10% of total blood malignancies and mostly involves old diagnosis and treatment process (Tahmasebi et al., 2006).
ones between 65-70 years old (Rodriguez-Abreu et al.,
1​ ​
Department of Epidemiology and Biostatistics, School of Public Health, ​3Department of Elder Nursing, School of Nursing and
2​ ​
Midwifery, Tehran University of Medical Sciences, ​ Minimally Invasive Surgery Research Center, 4​ Department of Elder Nursing,
School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran. *​ For correspondence:
Rafiemanesh.hosein@ gmail.com
Asian Pacific Journal of Cancer Prevention, Vol 16, 2015 ​7759
Fatemeh Koohi ​et al ​2007). Regarding increasing number of old age groups during past decades, multiple myeloma
incidences have been increased (Rodriguez-Abreu et al., 2007).
According to United state statistics, leukemia incidence rate has been increased during 2002-2011 (Howlader N NA,
based on November 2013 SEER data submission, posted to the SEER web site, April 2014). Also an incidence
increase has been observed in a twenty years period in Netherlands among women between 50-64 years old (Van
den Broek et al., 2012) and for Denmark between 1943-2003 (Thygesen et al., 2009).
In Iran, based on performed studies, blood malignancies have been surged during 1997-2003 for both sexes
(Tahmasebi et al., 2006). Studies around the world show that blood malignancy incidence is increased by age
(Coebergh et al., 2006; Sant et al., 2010; Dores et al., 2012; Novak et al., 2012). Performed studies in Iran confirm
increasing trend of blood cancer incidence by age increase so that age groups higher than 70 years old has the most
incidence rate (Tahmasebi et al., 2006). Studies in Iran and other countries have shown that blood malignancies
incidence is higher among men than women (Tahmasebi et al., 2006; Sant et al., 2010; Zand et al., 2010; Dores et
al., 2012; Novak et al., 2012; Howlader N NA, based on November 2013 SEER data submission, posted to the
SEER web site, April 2014).
Although the etiology of leukemia is unknown, but some environmental factors such as ionizing radiations, chemical
materials such as benzene, pesticides, chemotherapy, smoking, genetic disorders, family history about CLL,
infection with HTLV-1, financial and social level have been recognized as the risk factors for blood cancer (Novak
et al., 2012).
Some studies have confirmed changes in the Epidemiology and morphology trends of the cancers in some countries
and Iran (Keyghobadi et al., 2014; Razi et al., 2014; Almasi et al., 2015; Mirzaei et al., 2015; Rafiemanesh et al.,
2015). Considering different incidence rate around the world, so performed studies abroad the country cannot
determine the cancer situation in Iran and also there has not been yet any study about epidemiology, morphology
and trend of this important disease during recent years in Iran and on the other hand, epidemiological studies are
necessary for successful planning, therefore this study was done to evaluate epidemiology and morphology of blood
cancer during 2003-2008.
Materials and Methods
Data source
This is analytic cross-sectional study, carried out based on re-analysis national registry of cancer (NCR), and
Disease Control and Prevention (CDC) report of ministry of Health and Medical Education in Iran. Deputy for
health of each university is responsible for health issues of the population and all health activities are managed by
these deputies. All deputies for health have been included in the NCR. Registrar would apply the national
registration software which was developed by CDC. For pathologic centers, without software, the cancer records
were gathered manually. The Cancer Office of CDC should ​7760
Asian Pacific Journal of Cancer Prevention, Vol 16, 2015
provide techniques and funding supports. The data are transmitted every 3 months, by electronic file and also hard
copy of ‘Cancer Registry Data Collection Form’; this form is comprised of three parts: part I, regarding patient’s
identity characteristics in addition to the name of biopsy-taker physician, name of hospital, location of which the
biopsy is taken, clinical diagnosis and date of biopsy sent to histological laboratory and demographic information of
the patients includes race and residence. Part II includes the most important findings of patient’s clinical history.
 Part III includes preclinical findings. The information includes primary location of tumor, date of cancer diagnosis,
morphology and histology and its behavior and diagnosis method. Physicians fill the form of clinical data and the
official personnel fill the identity and demographic information. Quality control has been coordinated in five main
areas by Cancer Office of CDC: Regarding completeness of coverage; ​ii) c​ ompleteness of details; ​iii) a​ ccuracy of
data; ​iv) ​accuracy of reports; ​v) a​ ccuracy of interpretation and ​vi) ​repeated cases are deleted from national data.
Surveillance of pathology is based on the cancer record in several selected provinces to compare it with the present
pathology cancer record for a general and complete evaluation and also for the accuracy of the collected data. IARC
software provides a way to identify inaccuracies in data coding. Data were collected retrospectively reviewing all
new hematopoietic and reticuloendothelial systems cancer patients in Cancer Registry Center report of health deputy
for Iran during a 6-year period (2003 - 2008) (Bray et al., 2012). Accordance of The International Classification of
Diseases for Oncology (ICD-OC: topography with ICD- OM: morphology) Hematopoietic and reticuloendothelial
systems cancer was defined as ICD-O C42(Fritz, 2000). This study investigated all cases of the morphology of
Acute Myeloid Leukemia (AML)(9861/3), Acute Lymphoblastic Leukemia, NOS (ALL)(9821/3), Chronic
Lymphocytic Leukemia (CLL)(9823/3) and Multiple Myeloma(MM) (9732/3).
Statistical analysis
We calculated crude incidence rate (CIR) and the Age-standardized incidence rate (ASIR) per 100,000 persons. We
used direct standardized method using world standard population(Santos, 1999). To describe incidence time trends,
we carried out joinpoint regression analysis using the software Joinpoint Regression Program, Version 4.1.1.1
October 2014. As well to evaluate the morphological changes, were obtained the percentage allocated for kind of
morphological types. So to analysis morphology change percentage trends for six year, we carried out joinpoint
regression analysis using the software Joinpoint Regression Program. The analysis included logarithmic
transformation of the rates, maximum number of one joinpoints, and minimum of six years between zero joinpoints.
All other program parameters were set to default values. The test of significance uses a Monte Carlo Permutation
method (i.e., it finds “the best fit” line). joinpoint regression analysis involves fitting a series of joined straight lines
on a log scale to the trends. The aim of the approach is to identify possible joinpoints where
DOI:http://dx.doi.org/10.7314/APJCP.2015.16.17.7759 ​Leukemia in Iran: Epidemiology and Morphology Trends ​a significant
change in the trend occurs. In this study 0 joinpiont (Full model) was a significant model. The final model selected
was the most parsimonious of these, with the estimated annual percent change (APC) based on the trend within each
segment. In describing trends, the terms “significant increase” or “significant decrease” signify that the slope of the
trend was statistically significant (P < 0.05). All statistical tests were two sided.
Results
During studied years (2003-2008) totally 18353 cancer for hematopoietic and reticuloendothelial systems were
recorded which 37.76% (6930 cases) related to women and 62.24% (11423 cases) were related to men. Sex ratio
(male to female) is equal to 1.65 (table 1).
Morphological diversity for blood cancer cells is higher in men than women. Chi square test showed significant
difference between sex and morphological type of blood cancer (P-Value<0.001).
Epidemiologic trend
Joinpoint analyze showed a significant increasing trend for adjusted standard incidence rate (ASIR) for both sexes.
Annual percent change (APC) for women was 18.7 (CI: 13.4 - 24.3) and for men equal to 19.9 (CI: 14.1 - 25.9)
which can be seen in Figure1.
Morphological trend
The most common morphological blood cancer are Acute Lymphoblastic Leukemia (ALL), Acute Myeloid
Leukemia (AML), Multiple Myeloma (MM) and Chronic Lymphocytic Leukemia (CLL) which include 22.19%,
15.66%, 11.39% and 10.09% of total hematopoietic system for women, respectively. These values for men are
21.14%, 12.24%, 13.11% and 14.36% for men, respectively.
It means that these 4 morphological types consist 60% and 60.84% of total hematopoietic system for women and
men, respectively. (Table 2)
Joinpoint analyze shows a decreasing trend for ALL,
Table 1. Frequency, Crude and age Standardized Incidence of Hematopoietic Systems Cancer by Sex, During
the years 2003 to 2008
Female Male
N. CIR ASIR N. CIR ASIR
2003 677 2.09 2.43 1057 3.1 3.39 2004 946 2.87 3.26 1550 4.47 4.85 2005 1068 3.11 3.68 1728 4.78 5.36 2006 1263 3.7 4.44
2148 5.97 6.8 2007 1283 3.76 4.65 2240 6.22 7.36 2008 1693 4.96 6.29 2700 7.5 8.94
CIR: crude incidence rate (per 100,000 persons); ASIR: Age-standardized incidence rate (per 100,000 persons)
Table 2. Frequency and percent Change in the percentage allocated to the four morphology data for
hematopoietic systems cancer (2008-2003)
2003 2004 2005 2006 2007 2008
N%N%N%N%N%N%
Female ALL* 157 23.19 216 22.83 235 22 295 23.36 301 23.46 334 19.73 AML 165 24.37 250 26.43 141 13.2 162 12.83 186
14.5 181 10.69 MM 54 7.98 107 11.31 130 12.17 162 12.83 127 9.9 209 12.34 CLL 75 11.08 103 10.89 121 11.33 122 9.66 106
8.26 172 10.16 Male ALL 220 20.81 418 26.97 347 20.08 500 23.28 459 20.49 471 17.44 AML 209 19.77 270 17.42 191 11.05
206 9.59 270 12.05 252 9.33 MM 97 9.18 200 12.9 223 13.31 271 12.99 291 14.6 287 13.48 CLL 156 14.76 223 14.39 271 15.68
291 13.55 287 12.81 412 15.26
Acute Lymphoblastic Leukemia (ALL), Acute Myeloid Leukemia (AML), Multiple Myeloma (MM) and Chronic Lymphocytic Leukemia (CLL)
Table 3. ​Joinpoint Analyses of Cancers Percentage Allocated to the four Morphology Data for Hematopoietic
Systems Cancer (2008-2003)
Female Male
APC 95% CI APC 95% CI
Acute Lymphoblastic Leukemia -1.9 -5.9 to 2.3 -4.4 -12.6 to 4.7 Acute Myeloid Leukemia -15.6^ -26.8 to -3.3 -13.3^ -23.2 to
-2.1 Multiple Myeloma 5.4 -5.8 to 17.9 6.7 -1.5 to 15.5 Chronic Lymphocytic Leukemia -4 -10.2 to 2.7 -0.9 -6.2 to 4.6
^APC is significantly different from zero at alpha = 0.05
for ASIR by sex group between 2003-​-2008
Figure 1. ​Hematopoietic systems cancer change trend for ASIR by sex group between 2003-2008
Asian Pacific Journal of Cancer Prevention, Vol 16, 2015 ​7761
Fatemeh Koohi ​et al ​AML and CLL types among both sex groups. Decreasing trends for ALM type with significant
annual percent of change (APC) were equal to -15.63 and -13.32 for women and men, respectively (P-Value<0.05)
(Table 3).
Discussion
According to obtained results, blood cancer in Iran has an increasing trend. During a study which was done by
Tahmasebi et al. in Mazandaran province during 1996- 2003, an increasing trend for 8 years period was observed,
with non-Hutchkin lymphoma as the highest incidence rate and myeloma leukemia has the lowest incidence rate
(Tahmasebi et al., 2006). Farahmand et al. found during their study that standard incidence rate for blood cancer
among children during a 8 years’ time period i.e. 2000- 2008 has been increased significantly for both sex groups
and the highest incidence rate was related to ALL type (Farahmand et al., 2011).
Hejazi conducted a research in western Azerbaijan province in Iran for children less than 15 years old during
2003-2008 showed that acute blood cancer incidence has not a regular decreasing or increasing trend during studied
years (Hejazi et al., 2010). In a study which was done by Rajabli et al. from 2004-2009 in Golestan province,
standardized incidence rate for leukemia among men and women were respectively 10.4 and 7.8 (per 100000
population), respectively. Similar age standardized incidence rate for multiple myeloma among men and women
were obtained equal to 2.1 and 2 (per 100000 populations) which is higher than country and whole world (Rajabli et
al., 2013).
Based on last data released by United States, leukemia incidence rate has been increased annually 0.2% from 2002
to 2011 and attributed death toll has been decreased on average 1% from 2001 to 2010 (Howlader N NA, , based on
November 2013 SEER data submission, posted to the SEER web site, April 2014). During a research which
conducted in Korea from 1999-2008, blood cancer incidence has been raised from 10.2 to 13.7 and lymphatic
myeloma and multiple myeloma were the most common types of malignant blood diseases (Park et al., 2012).
During a research which was done in Kazakhstan from 2003-2012, blood cancer incidence has been decreased from
4.3 to 3.2 (Igissinov et al., 2014) and one study in Hong Kong showed a stable trend for blood cancer from 1990-
2008 (Xie et al., 2012).
Also performed study in Croatia showed a significant ALL stable trend for ALL incidence rate from 1988- 2009,
meanwhile AML incidence has been decreased and CML incidence showed decrease for female but it has been
stable among male group. Also this study showed a stable incidence rate for ALL which is similar to England, USA
and New Zealand. An increased incidence rate for CLL in Croatia is similar to Denmark and Netherlands (Novak et
al., 2012).
Similar studies in USA concerning blood cancer in Europe and USA in 2005 showed that overall incidences for
hematopoietic malignancies have been raised along western countries and AML incidence had slow decrease or
stable trend in the most European countries but it has ​7762
Asian Pacific Journal of Cancer Prevention, Vol 16, 2015
been surged in Wales and England about 70% from 1971 for both sexes (Rodriguez-Abreu et al., 2007).
Also researches have shown that different blood cancer incidence are higher among men (than women) which is
comparable in the countries including Iran, Kazakhstan, Croatia, European union and United states (Coebergh et al.,
2006; Tahmasebi et al., 2006; Rodriguez-Abreu et al., 2007; Hejazi et al., 2010; Sant et al., 2010; Dastgiri et al.,
2011; Farahmand et al., 2011; Modak et al., 2011; Smith et al., 2011; Dores et al., 2012; Novak et al., 2012; Rajabli
et al., 2013) and higher incidence among men may be attributed to genetically or environmental factors (Rajabli et
al., 2013; Igissinov et al., 2014).
Also this study showed that blood cancer incidence in Iran is being increased although some part of this increase
may be attributed to improvements on cancer registry system, but there is the possibility for blood cancer increase
due to increasing related risk factors and regarding the fact that etiology of disease is not known completely, so
identification of risk factors for this disease around different parts of the country is essential for preventing and
diagnosis at initial stages for better control over this disease.
Conclusion: It can conclude that the incidence of leukemia cancer is increasing in Iran. Therefore, the plan for the
control and prevention of this disease must be a high priority for health policy makers. Our findings was obtained
from the descriptive study on the incidence trend of the disease in recent years and it is recommended that analytical
studies should be conducted to obtain a causal relationship and solve problems related to the disease.
Limitations:It should be stated that the cancer registry system in Iran is still not fully and equally in all area and
sometimes the differences in the quality and coverage of data is observed and in some cases there is Undercount and
misclassification.
Acknowledgements
The authors are thankful for contributions of those who helped them to carry out this study.
References
Almasi Z, Rafiemanesh H, Salehiniya H (2015). Epidemiology characteristics and trends of
incidence and morphology of stomach cancer in iran. Asian Pac J Cancer Prev, 16, 2757.
Belson M, Kingsley B, Holmes A (2007). Risk factors for acute leukemia in children: a review.
Environmental Health Perspectives, 138-45. Bray F, Jemal A, Grey N, et al (2012). Global
cancer transitions according to the Human Development Index (2008-2030): a population-based
study. Lancet Oncol, 13, 790-801. Coebergh J, Reedijk A, De Vries E, et al (2006). Leukaemia
incidence and survival in children and adolescents in Europe during 1978-1997. Report from the
Automated Childhood Cancer Information System project. Eur J Cancer, 42, 2019-36. Dastgiri
S, Fozounkhah S, Shokrgozar S, et al (2011). Incidence of Leukemia in the Northwest of Iran.
Health Promot Perspect, 1, 50. Dores GM, Devesa SS, Curtis RE, et al (2012). Acute leukemia
incidence and patient survival among children and adults in
DOI:http://dx.doi.org/10.7314/APJCP.2015.16.17.7759 ​Leukemia in Iran: Epidemiology and Morphology Trends t​ he United
States, 2001-2007. ​Blood​, ​119​, 34-43. Farahmand M, Almasi Hashiani A, Mohammad BA, et al (2011). The epidemiology of
childhood hematopoietic and reticuloendothelial cancer based on Fars province cancer registry data system from 2001 to 2008.
Daneshvar Medicine.​ Fritz AG 2000. International classification of diseases for
oncology: ICD-O, World Health Organization. Hejazi S, Gholami A, Salarilak S, et al (2010). Incidence rate of acute leukemia in
west azarbaijan during 2003-2008. The Journal Of Urmia University Of Medical Scinces. Howlader N NA KM, Garshell J,
Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). ,
based on November 2013 SEER data submission, posted to the SEER web site, April 2014. SEER Cancer Statistics Review,
1975-2011, National Cancer Institute. [Online]. Igissinov N, Kulmirzayeva D, Moore MA, et al (2014). Epidemiological
Assessment of Leukemia in Kazakhstan, 2003. ​Asian Pac J Cancer Prev,​ ​15​, 6969-72. Jemal A, Bray F, Center MM, et al
(2011). Global cancer
statistics. ​Ca Cancer J Clin,​ ​61​, 69-90. Keyghobadi N, Rafiemanesh H, Mohammadian-Hafshejani A, et al (2014). Epidemiology
and trend of cancers in the province of kerman: southeast of iran. ​Asian Pac J Cancer Prev,​ ​16​, 1409-13. Mirzaei M, Hosseini
SA, Ghoncheh M, et al (2015). Epidemiology and Trend of Head and Neck Cancers in Iran. ​Global J Health Science,​ ​8​, 189.
Modak H, Kulkarni SS, Kadakol G, et al (2011). Prevalence and risk of leukemia in the multi-ethnic population of North
Karnataka. ​Asian Pac J Cancer Prev,​ ​12​, 671-5. Novak I, Jakšić O, Kuliš T, et al (2012). Incidence and mortality trends of
leukemia and lymphoma in Croatia, 1988-2009. ​Croatian Med J,​ ​53​, 115-23. Park HJ, Park EH, Jung KW, et al (2012). Statistics
of hematologic malignancies in Korea: incidence, prevalence and survival rates from 1999 to 2008. ​Korean J Hematol,​ ​47​, 28-38.
Raab MS, Podar K, Breitkreutz I, et al (????). Multiple Myeloma.
Lancet,​ ​374​, 324-39. Rafiemanesh H, Rajaei-Behbahani N, Khani Y, et al (2015). Incidence trend and epidemiology of common
cancers in the center of Iran. ​Global J Health Sci,​ ​8​, 146. Rajabli N, Naeimi-Tabeie M, Jahangirrad A, et al (2013). Epidemiology
of leukemia and multiple myeloma in Golestan, Iran. ​Asian Pac J Cancer Prev​, ​14​, 2333-6. Razi S, Rafiemanesh H, Ghoncheh
M, et al (2014). Changing Trends of Types of Skin Cancer in Iran. ​Asian Pac J Cancer Prev​, ​16​, 4955-8. Rodriguez-Abreu D,
Bordoni A, Zucca E (2007). Epidemiology
of hematological malignancies. ​Ann Oncol,​ ​18​, 3. Sant M, Allemani C, Tereanu C, et al (2010). Incidence of hematological
malignancies in Europe by morphological subtype: results of the HAEMACARE project. ​Blood,​ blood-2010-05-282632. Santos
SI (1999). Cancer epidemiology, principles and methods.
Cancer epidemiology, principles and methods. Smith A, Howell D, Patmore R, et al (2011). Incidence of haematological
malignancy by sub-type: a report from the Haematological Malignancy Research Network. ​British J Cancer,​ ​105​, 1684-92.
Tahmasebi B, Mahmoudi M, YAHYAPOUR Y, et al (2006). Determination and comparison of incidence rate and trend of
morbidity of leukemia and lymphoma in Mazandaran province (1376-1382). Journal of Mazandaran University of Medical
Sciences.
Thygesen LC, Nielsen OJ, Johansen C (2009). Trends in adult leukemia incidence and survival in Denmark, 1943-2003. ​Cancer
Causes Control​, ​20​, 1671-80. Van den Broek E, Kater A, van de Schans S, et al (2012). Chronic lymphocytic leukaemia in the
Netherlands: trends in incidence, treatment and survival, 1989-2008. ​Eur J Cancer​, ​48​, 889-95. Xie WC, Chan MH, Mak KC, et
al (2012). Trends in the Incidence of 15 Common Cancers in Hong Kong. ​Asian Pac J Cancer Prev,​ ​13​, 3911-6. Zand A, Imani
S, Saadati M, et al (2010). Effect of age, gender and blood group on blood cancer types. ​Kowsar Medical J,​ ​15​, 111-4.
Asian Pacific Journal of Cancer Prevention, Vol 16, 2015 ​7763