Strengthening capacity for cancer research in conflict settings: key informant insights from the Middle East

Prostate cancer screening in the Middle East and North Africa: a cross-sectional study on current practices

BACKGROUND

Prostate cancer is a substantial health concern in the Middle East and North Africa region, with many cases diagnosed at advanced stages, a high mortality to incidence ratio, and low prostate cancer awareness. This study aimed to evaluate prostate cancer screening practices in the region to inform effective early detection and management strategies.

METHODS

A cross-sectional survey was conducted from July 1, 2023, to November 8, 2024, among physicians from 19 countries in the Middle East and North Africa region. The study used a validated questionnaire to assess prostate cancer screening practices, barriers, and educational needs.

RESULTS

The survey had a response rate of 96.8% and 1163 participants. Of these participants, 34.7% routinely performed prostate cancer screenings, with 61.1% using prostate-specific antigen tests. The primary barrier was lack of patient awareness (51.2%). In addition, 65.3% of participants had no formal training. To improve screening rates, participants suggested better patient education (63.5%), increased training for health-care professionals (41.9%), and improved access to screening equipment (38.9%).

CONCLUSION

This study revealed that prostate cancer screening rates were low, with barriers including a lack of patient awareness and formal training among physicians. Addressing these issues through culturally tailored education programs may improve early detection rates and ultimately reduce the burden of prostate cancer in the Middle East and North Africa region.

Cancer and Syria in conflict: a systematic review

BACKGROUND

Armed conflict can disrupt oncology care profoundly, resulting in worsened health outcomes for cancer patients. Syria has endured armed conflict for over a decade, resulting in a severe breakdown of its healthcare services. The aim of this systematic review was to assess the available evidence on the burden of cancer and oncology services in Syria and how they have been affected during the conflict.

METHODS

Eight academic and six grey literature databases were searched for English- and Arabic-language studies published from March 2011 until February 2024. Studies reporting any outcomes relating to the burden of cancer or the state of oncology services in wartime Syria were considered for inclusion, although case reports and scoping reviews were excluded. A narrative synthesis of findings was performed.

RESULTS

Of 5,801 studies identified, 28 studies from academic (23) and grey literature (5) were eligible. Papers which reported on the burden of cancer showed an overall increase in cancer incidence and mortality between 2012 and 2022 (most recent data available). Most services were noted to be concentrated in Syria's capital, Damascus. The main identified themes related to the challenges of providing oncology services with staff shortages, chemotherapeutic drug shortages, insufficient radiotherapy services, and a lack of screening and palliative care noted.

CONCLUSION

There is insufficient high-quality exploration of the burden of cancer and the state of oncology services across Syria in academic and grey literature. Syria's health system is divided, creating disparities in access to oncology services, most of which are concentrated in Damascus, exacerbating pre-existing inequalities. The sparsity of robust data reinforces the need for high-quality data, including the use of national or other cancer registries with data from all regions of Syria, including those under opposition control. As the country rebuilds its healthcare systems, policymakers should focus on addressing inequities in oncology service availability to support equity of services.

Characteristics of injuries during the 2006 Lebanon conflict: a three-center retrospective study of survivors, 16 years after the conflict

Background

Armed conflict injury is a growing public health concern, particularly in regions like the Middle East and North Africa (MENA). The protracted conflicts and political unrest in this region have led to a substantial number of injuries. Despite this, there is still limited understanding of the specific injury patterns stemming from conflicts, such as the 2006 Lebanon conflict. This study aimed to assess the characteristics and burdens of injuries resulting from this conflict, which occurred 16 years prior to this research.

Methods

This retrospective study analyzed data of individuals affected by the 2006 Lebanon conflict, across three tertiary care centers. Demographics, injuries, complications, injury management, and hospitalization expenses were extracted from medical records and analyzed using SPSS version 29.0. Categorical variables were presented as counts and proportions, and continuous variables as mean ± standard deviation (SD). Hospital comparisons utilized chi-square or Fisher's exact tests for categorical variables, and one-way ANOVAs for continuous variables. Analysis was conducted from September to November 2023.

Results

Across three hospitals, 341 patients were studied, comprising 73.6% males and 26.4% females. Among them, a notable proportion (57.3% males and 34.1% females) fell within the 18-39 age range. Children and adolescents under 18 years accounted for 15.9% of males and 25.9% of females. Blast-related injuries predominated, with 24.5% resulting from direct damage caused by explosive parts and 33.3% from blast wave forces. Extremity trauma occurred in 49.0% of patients, and head/neck trauma in 24.9%. Common injuries, including penetrating, musculoskeletal, and traumatic brain injuries affected 34.9%, 31.1, and 10.0% of patients, respectively. Wound repair, fracture treatment, and debridement were the most performed procedures on 15.5, 13.5 and 9.7% of the patients, respectively. The total cost of care was USD 692,711, largely covered by the Ministry of Public Health (95.9%).

Conclusion

Conflict-related injuries significantly contribute to the global burden of disease. Therefore, there is a pressing need to improve national guidelines to prioritize life-threatening cases and potential long-term disabilities. Furthermore, enhancing electronic registry systems to collect clinical data on injured patients is essential for conducting research and better understanding the needs of conflict casualties.

HealthCare Access Barrier (HCAB) framework for the barriers to cancer care during conflicts: perspective from Iraq

The Iraqi population has lived under four decades of conflicts, warfare and political instability. The health consequences of the protracted conflict continue to persist. This work critically analyses Iraq's barriers to delivering and accessing cancer care during the conflicts that Iraq passed through from 1980 to 2017. To identify the barriers to accessing and delivering cancer care services, we used the HealthCare Access Barriers framework, which categorises the barriers into three groups: financial, structural and cognitive. Moreover, a structured search was performed in multidisciplinary databases. To produce a comprehensive body of literature, further materials were retrieved using alternative methods, such as hand-searching and snowballing. The key findings and themes identified in the literature were issues related to funding and affordability (within the financial), destruction and inaccessibility of facilities, therapeutic and diagnostic shortages, workforce and human resources and lack of national guidelines and awareness programmes (within the structural), awareness and knowledge and finally attitudes and beliefs (within the cognitive). These results demonstrated that the barriers to cancer care delivery are complex and inter-related. The financial and structural barriers were particularly intertwined with the protracted conflict, but this relationship was not demonstrable within the findings of the cognitive barriers. We concluded that the barriers facing the delivery and access to cancer care in Iraq are intertwined mainly with its protracted conflict. To ensure that future generations do not continue to pay the price of war, improved reconstructive efforts and further research are necessary.

Digital Determinants of Health: Health data poverty amplifies existing health disparities-A scoping review

Artificial intelligence (AI) and machine learning (ML) have an immense potential to transform healthcare as already demonstrated in various medical specialties. This scoping review focuses on the factors that influence health data poverty, by conducting a literature review, analysis, and appraisal of results. Health data poverty is often an unseen factor which leads to perpetuating or exacerbating health disparities. Improvements or failures in addressing health data poverty will directly impact the effectiveness of AI/ML systems. The potential causes are complex and may enter anywhere along the development process. The initial results highlighted studies with common themes of health disparities (72%), AL/ML bias (28%) and biases in input data (18%). To properly evaluate disparities that exist we recommend a strengthened effort to generate unbiased equitable data, improved understanding of the limitations of AI/ML tools, and rigorous regulation with continuous monitoring of the clinical outcomes of deployed tools.

Access to advanced cancer care services in the West Bank-occupied Palestinian territory

Introduction

Universal Health Coverage (UHC) identifies the provision of palliative care for people with advanced disease as an essential health service. Palliative care is also stipulated as a human right under existing covenants. Oncology services provided by the Palestinian Authority under Israeli military occupation are limited to surgery and chemotherapy treatment. Our study aimed to describe the experiences of patients with advanced-stage cancer in the West Bank in accessing oncology services and meeting their health care needs.

Methodology

We conducted a qualitative study among adult patients diagnosed with advanced lung, colon, or breast cancer in three Palestinian governmental hospitals, and with oncologists. Thematic analysis was conducted on the verbatim interview transcripts.

Results

The sample consisted of 22 Palestinian patients (10 men and 12 women) and 3 practicing oncologists. The findings reveal that cancer care is fragmented, with limited access to the services needed. Patients face referral delays in accessing treatment which worsen their health condition in some cases. Some patients reported difficulties in getting Israeli permits to access radiotherapy treatment in East-Jerusalem, and others experienced interruptions of their chemotherapy treatment sessions due to the unavailability of chemotherapy medications caused by Israeli-side delays. Other reported problems were related to the Palestinian health system and service delivery and quality, including fragmentation of services, infrastructure issues, and unavailability of medications. Advanced diagnostic services and palliative care are almost absent at Palestinian governmental hospitals, and patients need to seek these services in the private sector.

Conclusion

The data demonstrate specific access restrictions to cancer care in the West Bank due to Israeli military occupation of Palestinian land. This affects all stages of the care pathway, from restricted diagnosis services, to limited treatment and then poor availability of palliative care. Cancer patients will continue to suffer if the root causes of these structural constraints are not addressed.

The state of cancer research in fragile and conflict-affected settings in the Middle East and North Africa Region: A bibliometric analysis

Background

Cancer represents a disproportionate burden in LMICs, especially conflict-affected countries in the MENA region. Research output on cancer fails to match the growing burden in the region. This bibliometric study aims to examine the status and trends of cancer research in fragile and conflict-affected settings in the MENA region from 2000 to 2021, while also incorporating economic and demographic indicators as additional factors of analysis.

Methods

The Web of Science databases were searched for publications related to cancer research in Iraq, Lebanon, Libya, Palestine, Syria, and Yemen from January 1, 2000, to December 31, 2021. The retrieved publications were screened based on preset eligibility criteria and the final list was analyzed using the Bibliometrix Package in R to generate the annual scientific production and citations, journals, institutions, authors, collaborations, keywords, and title co-occurrence. Each country's annual scientific production was analyzed against its annual GDP per capita.

Results

A total of 4,280 documents met the inclusion criteria in this research. The annual number of publications revealed a significant increase over the past 20 years. These publications were mostly published in international journals that had impact factors rated in the 3rd or 4th quartiles. The overall contribution of researchers from Fragile and Conflict-Affected Settings (FCS) to cancer research was 6.5% of the MENA cancer research productivity, despite comprising around 23% of the total MENA region's population. Lebanon had the highest publication productivity at the country level, followed by Iraq and Syria. GDP per capita was not significantly correlated with cancer research across the countries under investigation. At the institutional level, the American University of Beirut was the most prolific institution and had the highest number of collaborations and the widest range of cooperative partners. Most first authors were male researchers. There is an interest in cancer expression, prevalence, diagnosis, and management in terms of commonly researched topics.

Conclusion

This study underscores the need for a concerted effort to improve cancer research outcomes in FCS, which can be achieved through targeted research, increased investment in research infrastructure and capacity-building initiatives, and greater regional and global collaboration.

Burden of female breast cancer in the Middle East and North Africa region, 1990–2019

Background

There is no region-specific publication investigating the attributable burden of breast cancer, particularly among females. This article reported the burden of female breast cancer in the Middle East and North Africa (MENA) region, and its attributable risk factors between 1990 and 2019, by age, sex, and socio-demographic index (SDI).

Methods

Publicly available data on the incidence, death and disability-adjusted life years (DALY) were retrieved from the Global Burden of Disease (GBD) 2019 study for the 21 countries and territories in MENA, between 1990 and 2019, along with 95% uncertainty intervals (UIs). The relationship between the burden of female breast cancer, in terms of DALYs, and the SDI were also assessed using Smoothing Spline models.

Results

In 2019, the regional age-standardised incidence and death rates of female breast cancer were 37.5 and 15.2 per 100,000, which represent a 90.9 and 24.0% increase since 1990, respectively. In addition, in 2019 the regional age-standardised DALY rate was 472.7 per 100,000, which was 19.5% higher than in 1990. In 2019, the death rate increased steadily with advancing age, while the DALY rate increased steeply with age and reached its peak in the 70–74 age group. There was a positive association between SDI and the burden of breast cancer over the period 1990 to 2019. Moreover, in 2019 high fasting plasma glucose (6.9%) contributed to the largest proportion of attributable DALYs for female breast cancer in the MENA region.

Conclusions

There was a significant increase in the incidence rate of female breast cancer in MENA over the past three decades, although the death and DALY rates were both largely unchanged. Preventive programs targeting the major risk factors should be implemented in the region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00918-y.

The Armed Conflict and the Impact on Patients With Cancer in Ukraine: Urgent Considerations

On February 24, 2022, a war began within the Ukrainian borders. At least 3.0 million Ukrainian inhabitants have already fled the country. Critical infrastructure, including hospitals, has been damaged. Children with cancer were urgently transported to foreign countries, in an effort to minimize interruption of their life-saving treatments. Most adults did not have that option. War breeds cancer—delaying diagnosis, preventing treatment, and increasing risk. We project that a modest delay in care of only 4 months for five prevalent types of cancer will lead to an excess of over 3,600 cancer deaths in the subsequent years. It is critical that we establish plans to mitigate that risk as soon as possible.

Ukraine conflict may cost 3600 lives or more because of a delay and lack of access for patients with cancer.