{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T03:17:51Z","timestamp":1782443871322,"version":"3.54.5"},"reference-count":40,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,1,21]],"date-time":"2026-01-21T00:00:00Z","timestamp":1768953600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Toxics"],"abstract":"<jats:p>Background: Prostate cancer in the Middle East and North Africa (MENA) region is shaped by a complex interplay of behavioral and environmental risk factors, yet comprehensive estimates of preventable cases remain scarce. To address this gap, we estimated population-attributable fractions (PAFs) for a range of modifiable exposures among men aged 50 years and older and assessed potential reductions in incidence under feasible intervention scenarios. Methods: Regional prevalence data were combined with relative risks from meta-analyses to compute closed-form PAFs for tobacco smoking, obesity, physical inactivity, high dairy and calcium intake, heavy alcohol use, drinking water nitrates, trihalomethanes, arsenic, lead, selenium status, ambient PM2.5 and NO2, and occupational diesel exhaust, covering an estimated 47 million men. Estimates were validated using a synthetic cohort simulation of 100,000 individuals, with uncertainty quantified through Monte Carlo sampling. Results: Results showed that drinking water nitrate exposure accounted for the largest single fraction (17.4%), followed by tobacco smoking (9.5%), physical inactivity (6.7%), and trihalomethane exposure (5.0%), while other exposures contributed smaller but meaningful shares. Joint elimination of all exposures projected a 45.5% reduction in incidence, and simultaneous feasible reductions in four targeted exposures yielded a combined potential impact fraction of 12.1%. Conclusions: These findings suggest that integrated water quality management, tobacco control, lifestyle interventions, and targeted environmental surveillance should be prioritized to reduce prostate cancer burden in the MENA region. However, estimates of drinking-water nitrate exposure rely on limited evidence from a single case\u2013control study with a relatively small sample size, and should therefore be considered exploratory and primarily hypothesis-generating.<\/jats:p>","DOI":"10.3390\/toxics14010096","type":"journal-article","created":{"date-parts":[[2026,1,21]],"date-time":"2026-01-21T08:48:08Z","timestamp":1768985288000},"page":"96","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Prostate Cancer in the MENA Region: Attributable Burden of Behavioral and Environmental Exposures"],"prefix":"10.3390","volume":"14","author":[{"given":"Magie","family":"Tamraz","sequence":"first","affiliation":[{"name":"Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh, Beirut 1107, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Razan","family":"Al Tartir","sequence":"additional","affiliation":[{"name":"Division of Oncology\/Hematology, Department of Internal Medicine, American University of Beirut Medical Center, Riad El Solh, Beirut 1107, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara El","family":"Meski","sequence":"additional","affiliation":[{"name":"Division of Oncology\/Hematology, Department of Internal Medicine, American University of Beirut Medical Center, Riad El Solh, Beirut 1107, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8995-7946","authenticated-orcid":false,"given":"Sally","family":"Temraz","sequence":"additional","affiliation":[{"name":"Division of Oncology\/Hematology, Department of Internal Medicine, American University of Beirut Medical Center, Riad El Solh, Beirut 1107, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,21]]},"reference":[{"key":"ref_1","first-page":"209","article-title":"Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries","volume":"71","author":"Sung","year":"2021","journal-title":"CA A Cancer J. Clin."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Abbasi-Kangevari, M., Saeedi Moghaddam, S., Ghamari, S.H., Azangou-Khyavy, M., Malekpour, M.R., Rezaei, N., Rezaei, N., Kolahi, A.-A., GBD 2019 NAME Prostate Cancer Collaborators, and Amini, E. (2022). The burden of prostate cancer in North Africa and Middle East, 1990\u20132019: Findings from the global burden of disease study. Front. Oncol., 12.","DOI":"10.3389\/fonc.2022.961086"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Sayan, M., Langoe, A., Aynaci, O., Eren, A.A., Eren, M.F., Kazaz, I.O., Ibrahim, Z., Al-Akelie, O.T., Al-Mansouri, L., and Abu-Hijlih, R. (2024). Prostate cancer presentation and management in the Middle East. BMC Urol., 24.","DOI":"10.1186\/s12894-024-01427-6"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Mansour, R., Al-Ani, A., Al-Hussaini, M., Abdel-Razeq, H., Al-Ibraheem, A., and Mansour, A.H. (2024). Modifiable risk factors for cancer in the middle East and North Africa: A scoping review. BMC Public Health, 24.","DOI":"10.1186\/s12889-024-17787-5"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Ziglioli, F., Patera, A., Isgr\u00f2, G., Campobasso, D., Guarino, G., and Maestroni, U. (2023). Impact of modifiable lifestyle risk factors for prostate cancer prevention: A review of the literature. Front. Oncol., 13.","DOI":"10.3389\/fonc.2023.1203791"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1016\/S0140-6736(22)01438-6","article-title":"The global burden of cancer attributable to risk factors, 2010\u20132019: A systematic analysis for the Global Burden of Disease Study 2019","volume":"400","author":"Tran","year":"2022","journal-title":"Lancet"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1428","DOI":"10.1038\/sj.bjc.6605637","article-title":"Occupation and cancer in Britain","volume":"102","author":"Rushton","year":"2010","journal-title":"Br. J. Cancer"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Cui, H., Zhang, W., Zhang, L., Qu, Y., Xu, Z., Tan, Z., Yan, P., Tang, M., Yang, C., and Wang, Y. (2024). Risk factors for prostate cancer: An umbrella review of prospective observational studies and mendelian randomization analyses. PLoS Med., 21.","DOI":"10.1371\/journal.pmed.1004362"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"681","DOI":"10.1007\/s00345-019-02872-x","article-title":"Management of patients with high-risk and advanced prostate cancer in the Middle East: Resource-stratified consensus recommendations","volume":"38","author":"Mukherji","year":"2020","journal-title":"World J. Urol."},{"key":"ref_10","unstructured":"Global Burden of Disease Collaborative Network (2020). Global Burden of Disease Study 2019 (GBD 2019) Population Estimates 1950\u20132019, Institute for Health Metrics and Evaluation (IHME). Available online: https:\/\/ghdx.healthdata.org\/record\/ihme-data\/gbd-2019-population-estimates-1950-2019."},{"key":"ref_11","unstructured":"World Health Organization (2018). Noncommunicable Disease Country Profiles 2021, World Health Organization. Available online: https:\/\/www.who.int\/teams\/noncommunicable-diseases\/surveillance\/data\/profiles-ncd."},{"key":"ref_12","unstructured":"Food and Agriculture Organization of the United Nations (2021). FAO Food Balance Sheets 2015\u20132020, Food and Agriculture Organization of the United Nations. Available online: https:\/\/openknowledge.fao.org\/handle\/20.500.14283\/cd1656en."},{"key":"ref_13","unstructured":"World Health Organization (2018). Global Status Report on Alcohol and Health 2018, World Health Organization. Available online: https:\/\/www.who.int\/publications\/i\/item\/9789241565639\/."},{"key":"ref_14","unstructured":"Food and Agriculture Organization of the United Nations (2020). AQUASTAT: FAO\u2019s Global Information System on Water and Agriculture, Food and Agriculture Organization of the United Nations. Available online: https:\/\/www.fao.org\/aquastat\/en\/databases\/."},{"key":"ref_15","unstructured":"World Health Organization (2017). Guidelines for Drinking-Water Quality, 4th Edition, Incorporating the 1st Addendum, World Health Organization. [4th ed.]. Available online: https:\/\/www.who.int\/publications\/i\/item\/9789241549950."},{"key":"ref_16","unstructured":"WHO\/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (2023). Middle East and North Africa Data, United Nations Children\u2019s Fund (UNICEF). Available online: https:\/\/washdata.org\/data\/household?geoRegionCode=MEA."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"511","DOI":"10.2166\/wh.2007.046","article-title":"Multipathway risk assessment of trihalomethane exposure in drinking water of Lebanon","volume":"5","author":"Semerjian","year":"2007","journal-title":"J. Water Health"},{"key":"ref_18","unstructured":"World Health Organization (2024). WHO Ambient Air Quality Database, World Health Organization. Available online: https:\/\/www.who.int\/data\/gho\/data\/themes\/air-pollution\/who-air-quality-database."},{"key":"ref_19","unstructured":"Bank, W. (2023). Urban Population (% of Total Population)\u2014Middle East & North Africa, The World Bank. Available online: https:\/\/data.worldbank.org\/indicator\/SP.URB.TOTL.IN.ZS?locations=ZQ."},{"key":"ref_20","unstructured":"International Labour Organization (2023). ILOSTAT: Employment by Sector and Occupation, International Labour Organization. Available online: https:\/\/ilostat.ilo.org\/topics\/employment\/."},{"key":"ref_21","unstructured":"European Agency for Safety and Health at Work (EU-OSHA) (2021). Workplace Exposure to Dusts and Aerosols\u2014Diesel Exhaust, European Agency for Safety and Health at Work (EU-OSHA). Available online: https:\/\/osha.europa.eu\/en\/oshwiki\/workplace-exposure-dusts-and-aerosols-diesel-exhaust."},{"key":"ref_22","first-page":"19","article-title":"Cigarette smoking and prostate cancer: A systematic review and meta-analysis of prospective cohort studies","volume":"21","year":"2023","journal-title":"Tob. Induc. Dis."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Rivera-Izquierdo, M., P\u00e9rez de Rojas, J., Mart\u00ednez-Ruiz, V., P\u00e9rez-G\u00f3mez, B., S\u00e1nchez, M.J., Khan, K.S., and Jim\u00e9nez-Mole\u00f3n, J.J. (2021). Obesity as a Risk Factor for Prostate Cancer Mortality: A Systematic Review and Dose-Response Meta-Analysis of 280,199 Patients. Cancers, 13.","DOI":"10.3390\/cancers13164169"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1154","DOI":"10.1093\/annonc\/mdy073","article-title":"Physical activity in relation to risk of prostate cancer: A systematic review and meta-analysis","volume":"29","author":"Benke","year":"2018","journal-title":"Ann. Oncol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1714","DOI":"10.1017\/S0007114522002380","article-title":"The association between dairy products consumption and prostate cancer risk: A systematic review and meta-analysis","volume":"129","author":"Zhao","year":"2023","journal-title":"Br. J. Nutr."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e21539","DOI":"10.34172\/jnp.2024.21539","article-title":"Association between calcium intake and prostate neoplasm; a systematic review and meta-analysis","volume":"13","author":"Yadollahi","year":"2024","journal-title":"J. Nephropathol."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Zhao, J., Stockwell, T., Roemer, A., and Chikritzhs, T. (2016). Is alcohol consumption a risk factor for prostate cancer? A systematic review and meta-analysis. BMC Cancer, 16.","DOI":"10.1186\/s12885-016-2891-z"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"54003","DOI":"10.1289\/EHP12925","article-title":"Nitrates and Prostate Cancer: Long-Term Drinking Water Exposures Associated with Risk of Tumors","volume":"131","author":"Schmidt","year":"2023","journal-title":"Environ. Health Perspect."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"16001","DOI":"10.1289\/EHP14505","article-title":"Exposure to Drinking Water Trihalomethanes and Risk of Cancer: A Systematic Review of the Epidemiologic Evidence and Dose-Response Meta-Analysis","volume":"133","author":"Helte","year":"2025","journal-title":"Environ. Health Perspect."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"126992","DOI":"10.1016\/j.jtemb.2022.126992","article-title":"Arsenic exposures and prostate cancer risk: A multilevel meta-analysis","volume":"72","author":"Yang","year":"2022","journal-title":"J. Trace Elem. Med. Biol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1186\/s12302-025-01156-z","article-title":"A systematic review and meta-analysis of toxic elements exposure and risk of prostate cancer","volume":"37","author":"Zhu","year":"2025","journal-title":"Environ. Sci. Eur."},{"key":"ref_32","first-page":"1431","article-title":"The association between Selenium and Prostate Cancer: A Systematic Review and Meta-Analysis","volume":"19","author":"Sayehmiri","year":"2018","journal-title":"Asian Pac. J. Cancer Prev."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"5116","DOI":"10.1038\/s41467-024-48857-2","article-title":"Ambient air pollution and urological cancer risk: A systematic review and meta-analysis of epidemiological evidence","volume":"15","author":"Li","year":"2024","journal-title":"Nat. Commun."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1186\/s12940-025-01205-3","article-title":"Occupational Exposure to Engine Exhausts and Prostate Cancer Risk","volume":"24","author":"Barul","year":"2025","journal-title":"Environ. Health"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"178","DOI":"10.1016\/j.mrrev.2007.09.001","article-title":"Occurrence, genotoxicity, and carcinogenicity of regulated and emerging disinfection by-products in drinking water: A review and roadmap for research","volume":"636","author":"Richardson","year":"2007","journal-title":"Mutat. Res."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Al-Daghri, N.M., Hussain, S.D., Alnaami, A.M., Aljohani, N., and Sabico, S. (2023). Dietary Calcium Intake and Osteoporosis Risk in Arab Adults. Nutrients, 15.","DOI":"10.3390\/nu15132829"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1007\/s11657-023-01337-4","article-title":"Assessment of calcium intake and recognition of calcium-rich food sources among the Saudi population","volume":"18","author":"Alshahrani","year":"2023","journal-title":"Arch. Osteoporos."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1024\/0300-9831.75.4.281","article-title":"Dietary calcium and vitamin D intake in an adult Middle Eastern population: Food sources and relation to lifestyle and PTH","volume":"75","author":"Chemali","year":"2005","journal-title":"Int. J. Vitam. Nutr. Res."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Wu, H., Wang, M., Raman, J.D., and McDonald, A.C. (2021). Association between urinary arsenic, blood cadmium, blood lead, and blood mercury levels and serum prostate-specific antigen in a population-based cohort of men in the United States. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0250744"},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Jiang, J., Chen, B., Tang, B., and Wei, Q. (2023). Selenium in Prostate Cancer: Prevention, Progression, and Treatment. Pharmaceuticals, 16.","DOI":"10.3390\/ph16091250"}],"container-title":["Toxics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2305-6304\/14\/1\/96\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,21]],"date-time":"2026-01-21T09:16:10Z","timestamp":1768986970000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2305-6304\/14\/1\/96"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,21]]},"references-count":40,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["toxics14010096"],"URL":"https:\/\/doi.org\/10.3390\/toxics14010096","relation":{},"ISSN":["2305-6304"],"issn-type":[{"value":"2305-6304","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,21]]}}}