Epidemiological trends and screening patterns of breast cancer in Saudi Arabia: A 17-year secondary data analysis (2001-2017)

Study design

This was a retrospective secondary data analysis utilizing publicly available aggregate data from multiple authoritative sources. This methodological approach was selected to synthesize existing national surveillance data and provide comprehensive epidemiological insights without requiring primary data collection.

Data sources

Variables analyzed

The primary outcome variable was age-standardized breast cancer incidence rate per 100,000 females, calculated using the Segi world standard population. Secondary outcomes included: crude incidence rates; total case counts; median age at diagnosis; regional incidence rates across all 13 administrative regions of Saudi Arabia; age-specific incidence rates by 5-year age groups; histological subtype distribution; stage at diagnosis (from national registry data); mammography screening rates; and temporal trends.

Statistical analysis

APC was calculated using joinpoint regression analysis to identify statistically significant trends in incidence rates over time.³ The APC was computed using the formula: APC = (exp(β) − 1) × 100, where β is the slope coefficient from the regression of log-transformed rates against calendar year. Confidence intervals (95% CI) for APC were derived using the logarithmic transformation method. Statistical significance was assessed at p <0.05 (two-tailed).

For regional comparisons, ASRs were compared using rate ratios with 95% CI. Trend analysis utilized Chi-square tests for trend to evaluate temporal changes in stage distribution.

All statistical analyses were performed using the Joinpoint Regression Program version 4.9 (National Cancer Institute, USA) and Microsoft Excel 2019 for secondary calculations.

Screening age group rationale

Mammography screening rates were calculated for females aged 50-74 years, as this represents the age group with the strongest evidence for screening benefit and cost-effectiveness according to international guidelines and the World Health Organization recommendations. While some Saudi and GCC guidelines recommend screening from age 40 years, the 50-74 age group was selected as the primary denominator to align with evidence-based international standards and enable comparability with global benchmarks. This age range balances sensitivity to detect clinically significant cancers against minimizing false positives and overdiagnosis, which are more common in younger age groups.

Ethical considerations

Ethical approval was not required as this study utilized publicly available, de-identified aggregate data from national registries and published reports. No individual-level data were accessed or analyzed. The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies.¹²

Temporal trends in breast cancer incidence

Analysis of SCR data revealed a marked increase in breast cancer cases over the 17-year study period.³ Total cases increased from 545 in 2001 to 2,463 in 2017, representing a 351.9% absolute increase [Table 1]. The crude incidence rate rose from 6.8 to 24.6/100,000 females, a 261.8% increase.

The ASR derived from SCR data increased from 11.8/100,000 in 2001 to 29.7/100,000 in 2017, representing a 151.7% increase [Figure 1].³ Joinpoint regression analysis demonstrated a significant upward trend with an APC of 5.13% (95% CI: 4.0-6.3, p <0.001).³ This steady increase was consistent throughout the study period without significant joinpoints indicating trend changes.

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Figure 1: Temporal trends in age-standardized breast cancer incidence rates in Saudi. Line graph showing the temporal trend in age-standardized breast cancer incidence rates (ASR)/ 100,000 females in Saudi Arabia from 2001 to 2017. The graph demonstrates a consistent upward trend with an annual percent change (APC) of 5.13% (95% CI: 4.0-6.3, p <0.001). Each data point represents biennial measurements from the Saudi Cancer Registry. The steady increase without joinpoints indicates a consistent trend throughout the study period. Source: Saudi Cancer Registry data. ASR: Age-Standardized rate, CI: Confidence interval

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For contextual comparison, GLOBOCAN 2022 model-based estimates indicated 25.3/100,000 for females in 2022, with 3,777 new cases diagnosed that year.¹ GBD 2021 model-based estimates demonstrated a longer-term trend from 15.4/100,000 (95% UI: 11.2-21.0) in 1990 to 46.0/100,000 (95% UI: 34.5-61.5) in 2021.⁷

Age-specific patterns

Based on SCR data, median age at diagnosis increased from 48 years in 2001 to 51 years in 2017, indicating a gradual aging of the breast cancer population.³ Peak incidence was observed in women aged 45-49 years, followed by the 40-44, 50-54, and 35-39 year age groups [Table 2].

Age-specific trend analysis from SCR data revealed that the highest APC occurred among older women.³ The 70-74 year age group demonstrated an APC of 10.2% (95% CI: 7.2-13.4), followed by women aged 75 years and older with an APC of 7.2% (95% CI: 6.0-8.5).³ The 55-59 and 50-54 year age groups showed APCs of 6.9% (95% CI: 5.1-8.7) and 6.8% (95% CI: 5.7-8.0), respectively.³ Younger age groups demonstrated more modest increases, with the 45-49 year group showing an APC of 4.1% (95% CI: 2.6-5.7).³

Regional variations

Substantial heterogeneity in breast cancer incidence was observed across Saudi Arabia’s 13 administrative regions based on SCR data [Table 3, Figure 2].³ The Eastern Region exhibited the highest ASR at 52.2/100,000 in 2017, followed by Riyadh (38.5/100,000) and Makkah (35.2/100,000) Regions, which collectively account for ∼60% of the national population.³

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Figure 2: Regional variation in breast cancer age-standardized incidence rates across Saudi Arabia’s 13 administrative regions, 2017. Displaying regional variation in age-standardized breast cancer incidence rates per 100,000 females across Saudi Arabia’s 13 administrative regions in 2017. The Eastern Region exhibits the highest rate (52.2/100,000), while the Al-Baha Region shows the lowest (9.1/100,000), representing a six-fold difference. This heterogeneity likely reflects differences in urbanization, healthcare access, diagnostic capacity, cancer registration completeness, and potentially true epidemiological variation. Source: Saudi Cancer Registry data.

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The southern regions demonstrated lower incidence rates. Al-Baha Region had the lowest ASR at 9.1/100,000, followed by Najran (10.6/100,000) and Jazan (10.9/100,000).³ These differences may reflect true epidemiological variation, differential healthcare access, varying diagnostic capacity, or differences in cancer registration completeness.

Regional trend analysis from SCR data revealed varying APCs.³ Al-Jouf Region demonstrated the highest APC at 8.8% (95% CI: 3.7-14.2, p = 0.008), followed by Hail at 8.7% (95% CI: 6.2-11.3, p <0.001) and Northern borders at 8.6% (95% CI: 3.0-14.6, p = 0.012).³ The Makkah Region showed the lowest significant APC at 4.0% (95% CI: 2.4-5.6, p <0.001), while Tabuk demonstrated a non-significant trend (APC: 2.0%, 95% CI: −0.4-4.4, p = 0.096).³

Histological characteristics

Based on SCR data, invasive ductal carcinoma (IDC) was the predominant histological subtype, accounting for a mean of 77.8% of all breast cancers (range: 72.4-80.5%) throughout the study period.³ Invasive lobular carcinoma represented 5.8% of cases, while mixed subtypes accounted for 2.6%.³

Stage at diagnosis

Mortality burden

For contextual comparison, GLOBOCAN 2022 model-based estimates indicated 1,046 breast cancer deaths in Saudi Arabia in 2022, with an age-standardized mortality rate of 7.6/100,000 females.¹ GBD 2021 model-based estimates indicated that deaths increased from 201 in 1990 to 1,190 in 2021, with the mortality rate rising from 6.73 (95% UI: 6.73-9.03) to 9.77 (95% UI: 7.63-13.00)/100,000.⁷

Interpretation of temporal trends

This comprehensive analysis reveals that breast cancer incidence in Saudi Arabia increased by 151.7% over the 17-year study period (2001-2017), with an APC of 5.13% based on SCR data.³ This substantial increase likely reflects multiple concurrent factors that must be carefully distinguished.

First, improved cancer registration completeness and diagnostic capabilities have enhanced case ascertainment over time.³ The SCR has progressively expanded coverage and data quality since its establishment in 1994. The consistent APC throughout the study period, without significant joinpoints, suggests that both true epidemiological changes and improved detection contribute to the observed trend. The particularly high APCs in previously underserved regions (Al-Jouf: 8.8%, Hail: 8.7%, Northern Borders: 8.6%) support a catch-up phenomenon as registration and diagnostic access improve.³

Second, a true epidemiological transition associated with rapid socioeconomic development has likely modified exposure to established risk factors.² These include changing reproductive patterns (later age at first birth, reduced parity, shortened breastfeeding duration), increased obesity prevalence (∼40% among Saudi women), reduced physical activity, and dietary changes.^2,19,20 The gradual increase in median age at diagnosis from 48 to 51 years and the particularly high APCs among older women (70-74 years: 10.2%) may reflect both improved survival to older ages and age-related accumulation of risk factors.³

The challenge of disentangling true incidence increase from detection artifacts is a common limitation in cancer surveillance. While we cannot definitively quantify the relative contributions of improved registration versus true epidemiological rise, the consistency of trends across regions with varying healthcare infrastructure and the concordance with broader GCC regional patterns suggest that genuine epidemiological changes are occurring alongside detection improvements.^2,10,11

Regional disparities and healthcare access

The sixfold difference in ASR between the Eastern Region (52.2/100,000) and the Al-Baha Region (9.1/100,000) warrants careful interpretation.³ Multiple factors likely contribute to this heterogeneity.

Higher rates in the Eastern Region may reflect: (1) greater urbanization and higher socioeconomic status associated with petroleum industry development; (2) more comprehensive diagnostic infrastructure and cancer registration systems; (3) higher healthcare utilization rates; and (4) potential differential exposure to risk factors.³

Lower rates in southern regions (Al-Baha, Najran, Jazan) likely reflect a combination of: (1) genuine lower disease burden associated with different risk factor profiles; (2) under-ascertainment due to limited healthcare access in mountainous and rural areas; (3) incomplete cancer registration coverage; and (4) potential differences in healthcare-seeking behavior.³

The finding that northern regions (Al-Jouf, Hail, Northern Borders) demonstrate the highest APCs suggests ongoing improvements in case ascertainment as healthcare infrastructure expands into previously underserved areas.³ This catch-up phenomenon indicates that national incidence rates may continue rising as registration completeness improves, independent of true epidemiological trends.

Addressing these regional disparities requires both strengthening cancer registration systems to capture true disease burden and expanding screening and diagnostic services to underserved areas. Mobile mammography units and telemedicine consultations may be particularly valuable for reaching rural populations in southern and northern regions.

Screening uptake and stage at diagnosis

The critically low mammography screening uptake of 6.7-8.0% among women aged 50-74 years represents a major barrier to achieving Vision 2030 health targets.^6,16 The National Cancer Control Plan target of 75% mammography coverage by 2025 appears unlikely to be met without substantial intensification of efforts.⁴

Published systematic reviews have identified multifaceted barriers to screening in Saudi Arabia, including: (1) fear of cancer diagnosis and treatment; (2) lack of awareness about screening benefits and recommendations; (3) cultural factors including modesty concerns and preference for female healthcare providers; (4) limited healthcare access in rural and remote areas; (5) absence of organized invitation and recall systems; and (6) limited family physician recommendations.¹⁷

The evidence from published studies showing stage migration, with increased localized-stage diagnoses and reduced regional/unknown-stage cases following screening implementation, provides encouraging proof of concept that screening is beneficial when utilized.^14,15 The Eastern Province pilot program’s achievement of detecting 70.2% of cancers at small sizes demonstrates the potential for downstaging with organized screening.¹⁵ However, these benefits remain unrealized at the population level due to poor uptake.

The higher detection rate observed in the BCED Project (6.93/1,000 screened) compared to international screening programs (3-5/1,000) likely reflects the prevalence screening effect and accumulation of undetected cases in a previously unscreened population.¹⁸ As screening coverage expands, detection rates should normalize to international levels.

The national stage distribution showing 55% of cases diagnosed at advanced (regional or distant) stages contrasts sharply with high-income countries, where 60-70% of cases are diagnosed at localized stages.¹² This late-stage diagnosis pattern directly impacts survival outcomes and treatment costs. Hospital-based data from tertiary referral centers showing even higher proportions of advanced-stage disease should be interpreted cautiously due to referral bias, as these facilities preferentially receive complex cases.¹³

International and regional context

Saudi Arabia’s ASR of 29.7/100,000 (2017 SCR data) remains substantially lower than rates in high-income Western countries (typically exceeding 80/100,000).^1,3 For contextual comparison, GLOBOCAN 2020 model-based estimates indicate that within the GCC region, the UAE (58.5/100,000) and Kuwait (50.3/100,000) have higher rates than Saudi Arabia (28.8/100,000).¹⁰ These differences may reflect varying screening activity levels, differential case ascertainment, demographic differences, or genuine variation in risk factor prevalence.^10,11

All GCC countries share similar sociocultural contexts and have experienced comparable rapid socioeconomic transitions over recent decades, yet demonstrate heterogeneous cancer profiles.^2,11 Further research examining risk factor prevalence, screening practices, and registration completeness across GCC countries would provide valuable insights into these variations.

Implications for vision 2030 and policy recommendations

These findings have direct relevance to Saudi Arabia’s Health Sector Transformation Program under Vision 2030.⁵ The continued rise in breast cancer incidence, combined with population aging and growth, projects a substantial increase in cancer burden. Model-based projections suggest a potential doubling of cancer cases by 2040 if current trends continue.¹¹

Key policy recommendations emerging from this analysis include:

• 1.

  Expansion of screening infrastructure: Deployment of mobile mammography units to reach rural and underserved populations, particularly in southern and northern regions.

• 2.

  Culturally-appropriate awareness campaigns: Development of targeted health communication strategies addressing fear, stigma, and misconceptions about breast cancer and screening, with involvement of religious and community leaders.¹⁷

• 3.

  Integration with primary healthcare: Incorporation of breast cancer screening into routine primary care with automated invitation and recall systems modeled on successful international programs.⁴

• 4.

  Training female healthcare workforce: Addressing modesty concerns by expanding training for female radiologists, mammography technicians, and breast health nurses.¹⁷

• 5.

  Strengthening cancer registry infrastructure: Continued investment in improving data quality, timeliness, and completeness across all regions, with particular focus on southern areas.³

• 6.

  Targeted interventions in high-incidence regions: Resource allocation prioritizing the Eastern, Riyadh, and Makkah regions while ensuring equitable access nationwide.³

• 7.

  Research on barriers and enablers: Implementation research examining effective strategies to overcome sociocultural barriers and improve screening uptake in the Saudi context.¹⁷

Future research directions

Several priority areas for future research emerge from this analysis:

Strengths and limitations

Strengths of this study include: (1) utilization of comprehensive national cancer registry data spanning 17 years;³ (2) incorporation of multiple authoritative data sources for triangulation and contextual comparison;^1,7,10,11 (3) comprehensive analysis of temporal, regional, and age-specific patterns; (4) clear separation of primary registry-based analysis from secondary contextual sources; and (5) policy-relevant findings aligned with Vision 2030 health transformation goals.⁵

Limitations must be acknowledged. First, as a retrospective secondary data analysis, we were constrained by data available in published sources and could not access individual-level records for more detailed analyses of risk factors, molecular subtypes, or treatment patterns.¹² Second, variations in cancer registration completeness across regions and time periods complicate the interpretation of trends.³ We cannot definitively quantify the extent to which observed increases reflect true epidemiological rise versus improved case ascertainment. Third, screening data from 2013-2015 may not reflect current practices, although more recent published reports suggest screening rates remain low.^6,16 Fourth, mortality data have greater uncertainty than incidence data due to challenges in cause-of-death attribution.^1,7 Fifth, the most recent SCR data publicly available extend only to 2017, limiting contemporary relevance.³ Sixth, hospital-based stage data are subject to referral bias and cannot be extrapolated to the national population.⁹ Seventh, the lack of individual-level data prevents adjustment for potential confounders or examination of interactions between risk factors.