\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[greek,english]{babel}



\usepackage{float}








\begin{document}

\title{Epidemiology of Gastric Cancer in Saudi Arabia}



\author[1]{IBRAHIM ALGHAMDI}%
\affil[1]{Al Baha University Faculty of Applied Medical Sciences}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objectives: This study examines the epidemiological trend of gastric
cancer (GC) in all Saudi Arabian administrative areas. It examines the
incidence of diagnosed cases, the age-specific incidence rate (AIR), the
crude incidence rate (CIR), and the age-standardized incidence rate
(ASIR) stratified by age group, year of diagnosis, and region. Methods:
From 2004 to 2017, a retrospective descriptive epidemiological study of
all GC cases recorded in the Saudi Cancer Registry (SCR) was conducted.
The data were analysed with descriptive statistics, the t-test, the
Kruskal-Wallis test, and the sex ratio using version 20.0 of the
Statistical Package for the Social Sciences (SPSS). Results: Between
January 2004 and December 2017, a total of 4,066 GC cases were reported
in the SCR. Riyadh, Najran, and Eastern Region had the highest overall
ASIR of GC among males and females in Saudi Arabia (Males: 4.0, 3.8, and
3.8; Females: 2.6, 2.3 and 2.2 per 100,000 people). In contrast, Jazan
had the lowest overall ASIR of GC among Saudi males and females (1.5 and
0.5 per 100,000 people, respectively). However, the overall ASIR of GC
was statistically higher in men than in women (P-value 0.05), with a
male-to-female ratio of 2.8 per 100,000 in Saudi Arabia. Conclusion:
There was a small decline in the CIRs and ASIRs of GC in Saudi Arabia
Between 2004 and 2017. Riyadh, Najran, and the Eastern Region had the
greatest prevalence of GC among males and females in Saudi Arabia. Men
and women in Jazan, Saudi Arabia, were shown to be the least impacted by
GC. In Saudi Arabia, the rates of GC were substantially greater among
males than among females.%
\end{abstract}%



\sloppy


\textbf{Epidemiology of Gastric Cancer in Saudi Arabia}

\textbf{Authors} : Ibrahim G. Alghamdi

\textbf{Institutions} :

University of Al-Baha, College of Applied Medical Sciences, Public
Health Department, Saudi Arabia\textbf{Corresponding Autho}r: Dr.
Ibrahim Alghamidi University of AL-Baha College of Applied Medical
Sciences Public Health Department Prince Mohammad Bin Saud, Al-Baha,
65527 E-mail / bio-stat@hotmail.com Mobile number / 00966553777925

\textbf{Abstract} :

\textbf{Objectives:} This research examines the pattern of gastric
cancer (GC) in all Saudi Arabian administrative areas. It examines the
incidence of diagnosed cases, the incidence rate (age-specific), the
incidence rate (Crude - CIR), and the incidence rate (age-standardized -
ASIR) adjusted by age, year, and region.

\textbf{Methods:} All GC cases recorded into the Saudi Cancer Registry
(SCR) between 2004 and 2017 were the subject of a retrospective
descriptive epidemiological analysis. Using SPSS version 20.0, we
performed a descriptive analysis, a t test, a Kruskal-Wallis test, and a
sex ratio on the collected data.

\textbf{Results:}Between January 2004 and December 2017, a total of
4,066 GC cases were reported in the SCR. Men and women in Saudi Arabia
had the highest overall ASIR of GC in Riyadh, Najran, and Eastern Region
(Men: 4.0, 3.8, and 3.8; Women: 2.6, 2.3 and 2.2 per 100,000 people). In
contrast, both men and women in Jazan, Saudi Arabia, had the lowest
overall ASIR of GC (1.5 and 0.5 per 100,000 people, respectively).
However, men had a statistically greater overall ASIR of GC than women
(P-value \textless{} 0.05), with a ratio of 2.8 per 100,000 people.

\textbf{Conclusion:} CIRs and ASIRs of GC in Saudi Arabia decreased
slightly between 2004 and 2017. Riyadh, Najran, and the Eastern Region
had the greatest prevalence of GC among males and females in Saudi
Arabia. The region of Jazan were shown to be the least impacted by GC.
In Saudi Arabia, the rates of GC were substantially greater among males
than among females.

Keywords: Cancer; epidemiology; gastric cancer; Saudi Cancer Registry;
oncology; crude Incidence rate.

\textbf{Introduction}

Gastric cancer (GC) is one of the most frequent diseases in both men and
women globally, with around 990,000 new cases identified each
year.\textsuperscript{1-2} It is the third or fourth biggest cause of
mortality in the globe, accounting for around 738,000 fatalities per
year.\textsuperscript{1-3} Incidence rates of GC differ between men and
women, as well as between countries. Males are three times as likely
than females to have GC disease.\textsuperscript{1-2} More than fifty
percent of new cases of GC are predicted to occur in developing nations,
with the greatest rates in Central and South America, Eastern Europe,
and East Asia (China and Japan), and the lowest rates in Australia and
New Zealand, Southern Asia, North and East Africa, North America, and
Canada.\textsuperscript{1\&4}

The incidence rates of GC have declined in the majority of the world
over the past few decades.\textsuperscript{5} The incidence of sporadic
intestinal GC has declined, but the incidence of diffuse GC has
increased.\textsuperscript{6-7} However, the risk of acquiring GC is
significantly affected by several factors, such as genetics, nutrition,
alcohol intake, smoking, Helicobacter pylori infection, and Epstein-Barr
virus (EBV) infection.\textsuperscript{1}

In the US, GC accounts for around 1.5\% of newly diagnosed cancer cases
each year. According to the American Cancer Society, 26,380 new cases of
GC will be detected in 2022 (15,900 in men and 10,480 in women), while
11,010 fatalities will be attributed to the disease (6,690 men and 4,400
women).\textsuperscript{8}

It was predicted by the International Agency for Research on Cancer
(IARC) that in 2020, the age-standardized incidence rate (ASIR) of GC in
Saudi Arabia would be 2.7 per 100,000 people across all age groups and
sexes (ranking 15), while the age-standardized mortality rate (ASMR)
would be 2.1 per 100,000 people (Ranking 12).\textsuperscript{9} In
addition, the ASIR of GC was much lower in Saudi Arabia and Kuwait
compared to the rest of the Arabian Gulf. In 2020, the reported ASIR for
all sexes and all ages was higher in Oman, Qatar, Bahrain, and the
United Arab Emirates than in Saudi Arabia, at 8.0, 5.2, 4.8, and 4.4,
respectively.

This study's primary objectives were to investigate the prevalence of GC
in the Saudi population. To achieve this, we focused in on CIR and ASIR,
which were then categorized according to the year of diagnosis,
geographical region, and age group. As a result, we plan to carry out
observational descriptive epidemiological research of the GC, taking
into consideration the regional and temporal distribution of cases that
have been documented in the SCR between the years 2004 and 2017.

\textbf{Materials and methods}

The purpose of this research was to conduct a retrospective
observational descriptive epidemiological analysis on all instances of
GC that were identified in Saudi Arabia across all regions between
January 2004 and December 2017. Because the information on the GC
incidence in Saudi Arabia is readily available to the scientific
researchers and can be obtained through the SCR reports with little
effort, the observational descriptive epidemiological study that was
conducted did not require any kind of ethical approval. The Saudi
Ministry of Health established a population-based cancer registry in
1992, and its records provided the basis for this investigation.
Furthermore, the first cancer report in Saudi Arabia was issued in 2001,
and the most precise cancer reports in Saudi Arabia were published at
the beginning of 2004. In addition, the most recent information
accessible from the SCR was collected in 2017.

SCR has been issuing reports on the pattern of cancer in Saudi Arabia
since 2001, with the primary purpose of describing the epidemiological
spread of the disease. On the basis of this data, we have access to
in-depth reports for 13 administrative regions, covering the years
2004-2017, that detail the CIR and ASIR, adjusted by province in Saudi
Arabia, patient gender, and year of diagnosis. However, for this study,
all of the information from the SCR was used to collect important data.

Data was analysed using SPSS, the Statistical Package for the Social
Sciences, version 20.0. The descriptive statistics of the
epidemiological data involved computing the overall of percentage, CIR,
and ASIR adjusted by gender, geographical region, and year of diagnosis.
Comparisons of CIR and ASIR of GC between male and female Saudis were
analysed using t-test for independent samples.

Version 20.0 of the Statistical Package for the Social Sciences (SPSS)
was employed in the study of data. The descriptive analysis of the
epidemiological data involved computing the overall percentage, the
age-specific incidence rate (ASR), the CIR, and the ASIR stratified by
gender, geographical region, and year of diagnosis. The independent
sample t-test was performed to compare male and female Saudis' CIR and
ASIR of GC. In addition, both the CIR and ASIR of GC were analysed
across regions of Saudi Arabia using the Kruskal-Wallis test. However,
the sex ratio for GC was computed from the age-specific incidence rate,
the CIR, and the ASIR in this study.

\textbf{Results}

\textbf{Gastric cancer among Saudi men}

A total of 2477 GC cases were reported by the SCR throughout the time
span commencing in January 2004 and ending in December 2017
respectively. This represents a small rise in the number of GC cases.
According to Figure 1a, there were 141 GC cases in 2004 (5.7\%). This
number raised to 201 in 2009, showing a 2.4\% increase. From 2010 to
2017, the number of GC cases fluctuated between 165 and 208 every year,
suggesting a percentage range of 6.5\% to 8.4\% per year. However, from
2004 to 2017, the overall number and percentage of GC cases among Saudi
males was 175 (7.1\%) every year.

Using data from the SCR, the average number and percentage of GC cases
diagnosed in male Saudis by age group between 2004 and 2017 were
computed. The class width for age groups ranging from 0 to 4 years, 5 to
9 years, 10 to 14 years, 15 to 19 years, 20 to 24 years, and above 75
years of age was 5 years. From 2004 to 2017, GC was most commonly
diagnosed in Saudi males aged 75 years and older, then those aged 70--74
years, with 27.4\% (48 overall cases annually) and 14.8\% (26 overall
cases annually), respectively. However, the overall percentage of men in
Saudi Arabia aged 50 or older who were diagnosed with GC reached 83.3\%
between the years 2004 and 2017. In contrast, younger Saudi male age
groups (0-49 years) had the lowest cases of GC, with an annual average
percentage of 16.7\% (Figure 1a). Furthermore, the overall age specific
incidence rate of GC among Saudi males was high from 2004 to 2017, with
the age groups 75 years and older, 70-74, 65-69, and 60-64 at (37.6,
27.2, 17.2, and 10.9 per 100,000 people). However, the male-to-female
ratio of the age-specific incidence rate of GC was three times greater
among Saudi males aged 55 to 75 and older, whereas there was no
significant difference in the age-specific incidence sex ratio for the 0
to 54 age group (Figure 2).

According to Figure 3, the CIRs of GC cases among Saudi males show a
little increase from 2004 to 2009, a slight decline from 2010 to 2011,
and then a constant trend from 2012 to 2017. The estimated CIR for 2004
was 1.7 per 100,000 people, and the highest CIR reported by the SCR was
2.2 per 100,000 people in 2009. In addition, the overall CIR of GC among
Saudi males between 2004 and 2017 was 1.6 (95\% CI: 1.3 to 1.8) per
100,000 people. The t-test for two independent samples revealed that the
CIR of GC in male Saudis was considerably higher than in females (t(23)
= 3.823, P 0.001). However, the overall CIR male-to-female ratio from
2004 to 2017 per 100,000 people was 1.5. Among Saudi men in Asir,
Makkah, and Riyadh, the overall CIRs for GC were the highest at 2,3,
2,1, and 2,0 per 100,000 people, respectively. Statistically, these
districts of Saudi Arabia are distinct from the rest of the country, as
shown by the Kruskal-Wallis test (2(12,N=181) =52,298;
P\textless{}0.001).In contrast, the smallest overall CIR of GC was
reported in both Jazan and Jouf regions, at 1.1 per 100,000 people
(Figure 4).

The ASIR of GC cases among male Saudis, adjusted by year of diagnosis
from 2004 to 2017 per 100,000 people, was observed using the SCR (Figure
5). Similarly, there was a small increase from 2004 to 2009, then steady
decrease from 2010 to 2017. In 2006 and 2009, the ASIR of GC was the
highest at 3.9 per 100,000 people, but in 2014 the rate was the lowest
at 2.4 per 100,000 people. However, from 2004 to 2017, the overall ASIR
of GC among Saudi males per 100,000 persons was 2.8 (95\% CI, 2.2 to
3.2). The t-test for two independent samples revealed that the Saudi
male ASIR of GC was noticeably higher than that of Saudi females t(20) =
8.823, P\textless{}0.001) However, from 2004 to 2017, the overall
male-to-female ratio of ASIR per 100,000 males was 1.5. According to
Figure 6, Riyadh, Najran and the Eastern region of Saudi Arabia, had the
highest overall ASIR for GC at 4.0 and 3.8 per 100,000 people. the
Kruskal-Wallis test showed that these areas were significantly~different
from other regions of Saudi Arabia (2(12,N=180) =59.556,
P\textless{}0.001). In contrast, Jazan, Hail, and Baha had the smallest
overall ASIR of GC at 1.6, 1.5, and 1.5, respectively.

\textbf{Gastric cancer among Saudis women}

From 2004 to 2017, the SCR recorded a total of 1589 cases of GC among
Saudi women. According to Figure 1b, there were 70 GC cases in 2004
(4.4\%). This number raised to 133 in 2011, showing a 4.0\% increase.
From 2012 to 2017, the number of GC cases fluctuated between 186 and 208
every year, suggesting a percentage range of 7.5\% to 8.4\% per year.
However, from 2004 to 2017, the overall number of confirmed cases of GC
among Saudi women were 110 (7.1\%) per year. GC was diagnosed most
commonly in Saudi women aged 75 and older, followed by those aged 70--74
years, who accounted for 20.4\% (23 overall cases annually) and 11.1\%
(13 overall cases annually), respectively. However, the overall
percentage of women in Saudi Arabia aged 50 or older who were diagnosed
with GC reached 70.9\% between the years 2004 and 2017. In contrast,
younger Saudi women aged (0-49 years) had the smallest overall number of
GC cases, with an average of 16.7\% per year (Figure 1b). In addition,
the overall age specific incidence rate of GC from 2004 to 2017, was
high among Saudi women with the age groups 75 years and over, 70-74,
65-69, 60-64 at (18.3, 14.3, 9.8, and 6.5 per 100,000 people) (Figure
2).

According to Figure 3, the CIRs of GC cases among females in Saudi
Arabia, adjusted by year of diagnosis from 2004 to 2017, per 100,000
people show a modest increase from 2004 to 2007, a small reduction from
2008 to 2012, and a steady trend from 2013 to 2017. The estimated CIR
for 2004 was 0.8 per 100,000 people, and the highest CIR reported by the
SCR was 1.7 per 100,000 people in 2007. Furthermore, the overall CIR of
GC among Saudi women between 2004 and 2017 was 1.1 (95\% CI: 0.9 to 1.2)
per 100,000 people. The regions of Asir, Riyadh, and the Eastern region
had the highest overall CIRs for GC among Saudi women, at 1,4, 1,3, and
1,3, respectively, per 100,000 people. The Kruskal-Wallis test revealed
significant differences between these locations and other regions of
Saudi Arabia \selectlanguage{greek}χ\selectlanguage{english}\textsuperscript{2}(12,N=181) =39.689, P \textless{}
0.001). In contrast, the region of Jazan had the lowest overall CIR of
GC, at 0.4 per 100,000 people (Figure 4).

The ASIR of GC cases among Saudi women, adjusted by year of diagnosis
from 2004 to 2017, was documented using the SCR (Figure 5). From 2004 to
2006, there was a modest rise, followed by a constant trend from 2007 to
2017. In 2006, the ASIR of GC was the highest at 2.7 per 100,000 people,
but in 2012 and 2016, it was the lowest at 1.5 per 100,000 people.
However, the overall ASIR of GC among Saudi women from 2004 to 2017 per
100,000 people was 1.8 (95\% CI, 1.2 to 2.2). Furthermore, the overall
ASIR of GC stratified by Saudi Arabian region from 2004 to 2017 per
100,000 people show that Riyadh, Najran, and the Eastern region of Saudi
Arabia had the highest overall ASIR for GC at 2.6, 2.3, and 2.2 per
100,000 people, respectively. In contrast, the Jazan region had the
lowest overall ASIR of GC at 0.5 per 100,000 people (Figure 6).

\textbf{Discussion}

The CIRs and ASIRs of GC cases among the Saudi population must be
tracked and kept current for all Saudi regions. The purpose of this
study was to investigate the CIR and ASIR patterns of GC in Saudi Arabia
from 2004 to 2017. According to the PubMed database, this is the first
descriptive epidemiological research on the spatial/temporal
distribution of GC among men and women in different regions of Saudi
Arabia. It explores the actual state of the GC trend and the relevance
of the disease in the population of Saudi Arabia.

From 2004 to 2017, the overall number of GC cases among Saudi men and
women was 175 and 110 (7.1\%), respectively. In addition, the overall
number of confirmed cases of GC between 2004 and 2017 by age group of
Saudi males and females were recorded, as the disease occurred in a
significant percentage among those aged 50 years and older (Male:
83.3\%, Female: 70.9\%), whereas the age group younger than or equal to
49 years was less affected by GC (Male: 16.7\%, Female: 29.0\%). These
findings are similar with those of other studies indicating that the
median age of diagnosis for GC is 72 years old and that roughly 10\% of
gastric carcinomas are diagnosed in patients 45 years of age or
younger.\textsuperscript{10-12}

In this study, the incidence of GC was observed to be higher in males
than in females. From 2004 to 2017, the CIR and ASIR of GC were twofold
greater in Saudi men than in women. Globally, the incidence of GC varies
by sex and geographical location. It is more prevalent in men than in
women, and the risk of developing it rises with
age.\textsuperscript{13}In the United States, the recent studies
indicates that the most major risk factor for the development of GC is
male gender, with a ratio 2:1 male to female
predominance.\textsuperscript{14} As well as, in the developed
countries, men are 2,2 times more likely than women to be diagnosed with
GC.\textsuperscript{15} Therefore, other studies indicate that male
gender is a significant predictor of GC. In addition, Yang et
al.\textsuperscript{16} found in their research of the survival rates of
patients with metastatic GC that male patients had poorer survival rates
than female patients.

In Saudi Arabia, the ASIR trend of GC among Saudi men and women has
dropped steadily from 2004 to 2017. Similarly, over the past several
decades, the incidence rates of GC have decreased gradually throughout
the majority of the world including the United States (Figure
7).\textsuperscript{1 \&17} Increasing hygienic standards, enhanced food
preservation, increased intake of fresh fruits and vegetables, and
Helicobacter pylori eradication could explain this downward
trend.\textsuperscript{1\&18}

Our results indicates that male and female Saudis in Riyadh, Najran, and
the Eastern region had the highest overall ASIRs for GC from 2004 to
2017. This suggests that males and females in Riyadh, Najran, and the
Eastern region of Saudi Arabia are exposed to a significant risk factor
for GC. In contrast, men and women in Jazan, Saudi Arabia, were the
least affected by GC, indicating that they were more exposed to GC
protective factor than persons in other regions of Saudi Arabia.
However, a further epidemiological study should be conducted in the
region of Riyadh, Najran, and Eastern region to find out the potential
risk factors that lead to the increase of ASIR of GC among Saudis men
and women. Furthermore, the protective factors of GC in the Jazan region
that contributed to the lower rates of GC, should be investigated.

In Saudi Arabia, the estimated ASIR for GC among both genders in 2020
was 2.7\% per 100,000 people. The rate is significantly lower compared
to other~countries. Oman had the highest rate of GC among both genders
in the Arabian Gulf, at 8.0 per 100,000 people; this rate was 2.9 times
greater than Saudi Arabia (Figure 8). Furthermore, the ASMR of GC was
observed in Saudi Arabia at a rate of 2.1 per 100,000 people among both
sexes. Compared to other Arab countries, this mortality rate was
slightly lower (Figure 9). However, Oman had the greatest ASMR of GC
among both genders, at 6.9 per 100,000 people, which was 3.2 times
greater than Saudi Arabia. The results of this study also indicate that
the overall ASIR of GC is extremely low in Saudi Arabia compared to
Mongolia (32.5 per 100,000 people), Japan (31.6 per 100,000 people), and
Korea (27.7 per 100,000 people); these rates were 9 to 10 times higher
than in Saudi Arabia.\textsuperscript{9}

This study investigates the actual distribution of GC in Saudi Arabia.
It helps other researchers in formulating a new hypothesis regarding the
potential risk-protective factors of GC among male and female Saudis
residing in different regions. However, these studies have some
limitations, including the absence of a comparison group and the
inability to evaluate the statistical association between
factors.\textsuperscript{19} In this research, the average death rates
of GC in various regions of Saudi Arabia could not be determined since
the SCR reports lacked information on the number of GC-related deaths.

\textbf{Conclusion}

This study demonstrated a small decline in the CIRs and ASIRs of GC in
the Saudi population between 2004 and 2017. Riyadh, Najran, and the
Eastern Region had the highest overall ASIRs of GC among male and female
Saudis, whereas Jazan had the lowest rates for both sexes. From 2004 to
2017, the ratio of GC cases in male Saudis was double that of female
Saudis. Further epidemiological studies are required to determine the
potential risk factors for GC in Saudi Arabia.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Machlowska J., Baj j., Sitarz M, et al. Gastric Cancer: Epidemiology,
  Risk Factors, Classification, Genomic Characteristics and Treatment
  Strategies. International Journal of Molecular Sciences. 2020; 21(11):
  4012
\item
  Ferlay J., Bray F., Forman D., et al. Estimates of worldwide burden of
  cancer in 2008: GLOBOCAN 2008.~Int. J. Cancer.~2010;127:2893--2917.
  doi:~10.1002/ijc.25516.
\item
  Mukkamalla SKR, Recio-Boiles A., Babiker HM. Gastric Cancer.
  {[}Updated 2022 Jul 10{]}. In: StatPearls {[}Internet{]}. Treasure
  Island (FL): StatPearls Publishing; 2022 Jan-.~Available from:
  https://www.ncbi.nlm.nih.gov/books/NBK459142/
\item
  Ang T, Fock K.M. Clinical epidemiology of gastric cancer.~Singap. Med.
  J.~2014;55:621--628. doi:~10.11622/smedj.2014174
\item
  Ferro, A., Peleteiro, B., Malvezzi, M., et al. Worldwide trends in
  gastric cancer mortality (1980--2011), with predictions to 2015, and
  incidence by subtype. European Journal of Cancer. 2014; 50(7),
  1330--1344. https://doi.org/10.1016/j.ejca.2014.01.029
\item
  Edwards B.K., Noone A.-M., Mariotto A.B., et al. Annual Report to the
  Nation on the status of cancer, 1975--2010, featuring prevalence of
  comorbidity and impact on survival among persons with lung,
  colorectal, breast, or prostate cancer.~Cancer.~2013;120:1290--1314.
  doi:~10.1002/cncr.28509.
\item
  Kaneko S., Yoshimura T. Time trend analysis of gastric cancer
  incidence in Japan by histological types, 1975--1989.~Br. J.
  Cancer.~2001;84:400--405. doi:~10.1054/bjoc.2000.1602.
\item
  American Cancer Society. Key statistics about stomach cancer; 2022.
  Available from:
  https://www.cancer.org/cancer/stomach-cancer/about/key-statistics.html.
  Accessed September 20, 2022.
\item
  GLOBOCAN (IARC).~Maps: Section for Cancer Incidence and Mortality;
  2020. Available from: https://gco.iarc.fr/today/home. Accessed
  September 20, 2020.
\item
  Kong X., Wang J.-L., Chen H.-M., et al. Comparison of the
  clinicopathological characteristics of young and Elderly patients with
  gastric carcinoma: A meta analysis.~J. Surg. Oncol.~2012;106:346--352.
  doi:~10.1002/jso.23004.
\item
  Takatsu Y., Hiki N., Nunobe S., et al. Clinicopathological features of
  gastric cancer in young patients.~Gastric Cancer.~2015;19:472--478.
  doi:~10.1007/s10120-015-0484-1.
\item
  Milne A.N., Sitarz R., Carvalho R., et al. Early onset gastric cancer:
  On the road to unraveling gastric carcinogenesis.~Curr. Mol.
  Med.~2007;7:15--28. doi:~10.2174/156652407779940503.
\item
  Forman D., Burley V. Gastric cancer: Global pattern of the disease and
  an overview of environmental risk factors.~Best Pract. Res. Clin.
  Gastroenterol.~2006;20:633--649. doi:~10.1016/j.bpg.2006.04.008.
\item
  Suryawala K., Soliman D., Mutyala M., et al. A regional health-center
  seven year retrospective study. World J Gastroenterol. 2015 Jul
  7;21(25):7805-13. doi: 10.3748/wjg.v21.i25.7805. PMID: 26167080;
  PMCID: PMC4491967.
\item
  Rawla P. and Barsouk A. Epidemiology of gastric cancer: global trends,
  risk factors and prevention. Prz Gastroenterol. 2019;14(1):26-38. doi:
  10.5114/pg.2018.80001. Epub 2018 Nov 28. PMID: 30944675; PMCID:
  PMC6444111.
\item
  Yang D, Hendifar A, Lenz C, et al. Survival of metastatic gastric
  cancer: Significance of age, sex and race/ethnicity.~Journal
  Gastrointest Oncol.~2011;\textbf{2} :77--84.
\item
  Cancer of the Stomach - Cancer Stat Facts. Retrieved September 26,
  2022, Available from
  https://seer.cancer.gov/statfacts/html/stomach.html
\item
  Sitarz R., Skierucha M., Mielko J., et al. Gastric cancer:
  Epidemiology, prevention, classification, and treatment.~Cancer Manag.
  Res.~2018;10:239--248. doi:~10.2147/CMAR.S149619.
\item
  Rakesh A, and Priya R. Study designs: Part 2 -- Descriptive studies.
  Perspective in Clinical Research. 2019; 10(1): 34-36
\end{enumerate}

\textbf{Conflict of Interest (COI)}

\emph{The authors declare that they have no conflict of interest.}

\textbf{Ethical Approval and Patient Confidentiality}

The author declares that the paper does not raise any ethical concern.
The data regarding Gastric cancer incidence in Saudi Arabia are publicly
available and easily accessible through the Saudi Cancer reports;
therefore, no ethical approval was required for this observational
descriptive epidemiological study.

All reports can be directly downloaded from the National Health
Information Centre's website, available from:
https://nhic.gov.sa/en/eServices/Pages/TumorRegistration.aspx\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure legends}

\textbf{Figure 1:} \textbf{A} Gastric cancer cases among male Saudis
(Number and percentage) between 2004 and 2014. \textbf{B:} Gastric
cancer cases among female Saudis (Number and percentage) between 2004
and 2017.

\textbf{Figure 2: I} ncidence rate (age specific) of Gastric cancer
cases among the Saudi population from 2004 to 2017.

\textbf{Figure 3:} Incidence rate (Crude) of Gastric cancer cases among
the Saudi population from 2004 to 2017.

\textbf{Figure 4:} Incidence rate (Crude) of Gastric cancer cases among
the Saudi population by region from 2004 to 2017.

\textbf{Figure 5:} Incidence rate (age-standardised) of Gastric cancer
cases among the Saudi population from 2004 to 2017.

\textbf{Figure 6:} Incidence rate (age-standardised) of Gastric cancer
cases among the Saudi population by region from 2004 to 2014.

\textbf{Figure 7:} Trend line of Gastric cancer in the USA from 2004 to
2019.

\textbf{Figure 8:} Incidence rate (age-standardised) of Gastric cancer
(World) in 2020, both sexes, all ages\textbf{.}

\textbf{Figure 9:} Mortality rate (age-standardised) of Gastric cancer
(World) in 2020, both sexes, all ages.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1A/Figure-1A}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1B/Figure-1B}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-4/Figure-4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-5/Figure-5}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-6/Figure-6}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-7/Figure-7}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-8/Figure-8}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-9/Figure-9}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

