Perimesencephalic subarachnoid hemorrhage as a rare delayed complication of radiation therapy in a patient with parotid basaloid squamous cell carcinoma

In this case report, we address a rare entity of parotid cancer: basaloid squamous cell carcinoma, which was surgically unresectable and had thus far only been treated with radiation therapy. Following twenty years of continuous remission, our patient presented with an acute perimesencephalic subarachnoid hemorrhage. The cause of the acute perimesencephalic subarachnoid hemorrhage was a delayed complication of radiation therapy.

Prostate cancer presentation and management in the Middle East

BACKGROUND

Although prostate cancer is a prevalent malignancy worldwide, its clinical presentation and management in the Middle East are not well-documented. This study aims to provide insights into the initial clinical presentation and management of prostate cancer in this region.

METHODS

A retrospective review was conducted on seven institutional databases from six Middle Eastern countries, including Türkiye, Lebanon, Iraq, Syria, Bahrain, and Jordan, to identify patients diagnosed with prostate cancer in 2021. Descriptive analysis was performed on the collected data to provide an overview of the demographic, clinical, and treatment variables.

RESULTS

A total of 1,136 patients were identified with a median age of 70 (range, 50-84). Most patients (78%) received their prostate cancer diagnosis after presenting with symptoms, as opposed to routine PSA screening. At the time of diagnosis, 35% of men had clinical T3 or T4 disease, 54% with Stage IV disease and 50% with Gleason score ≥ 8. Regarding treatment, 20% of non-metastatic and 22% of metastatic patients received no treatment.

CONCLUSION

Most men in this study sought prostate cancer evaluation due to symptoms and were subsequently diagnosed with advanced-stage disease, providing a foundation for future research aimed at understanding the underlying factors behind the observed trends and enabling informed interventions.

Intensifying the Hormonal and Radiation Treatment in Prostate Cancer Presenting With Bulky Pelvic Lymph Nodes: An Opportunity for a New Paradigm

Locally advanced prostate cancer may rarely present with bulky pelvic lymph nodes without distant metastasis. Patients may be treated with curative intent. Dual hormonal therapy including luteinizing hormone-releasing hormone agonist in combination with abiraterone or enzalutamide can be utilized neoadjuvantly to shrink bulky disease. This can be followed by radical doses of radiotherapy. This intensified treatment is tolerable. Prostate-specific membrane antigen scan can be utilized to assess staging and treatment response. Here, we present a case of a non-metastatic locally advanced prostate cancer with bulky pelvic lymph nodes. The patient was treated neoadjuvantly with dual hormonal therapy followed by radical doses of radiotherapy. The patient tolerated the treatment well and had a promising early response.

Prostate Cancer Awareness in the Middle East

PURPOSE/OBJECTIVE(S)

A better understanding of cancer awareness is crucial to allow the appropriate implementation of interventions to improve screening and diagnosis. While the incidence of prostate cancer has been reported to increase over the last decade in the Middle East, data on prostate cancer awareness in this region remains limited. Therefore, an assessment of prostate cancer awareness is critically needed. The current study addresses this urgent need by investigating the level of awareness of prostate cancer among the general public in the Middle East.

MATERIALS/METHODS

A cross-sectional survey of men residing in 13 Middle Eastern countries was conducted in 2022. A validated prostate cancer awareness questionnaire was used to assess participants' knowledge on several domains of prostate cancer. Men younger than 40 years of age or history of prostate cancer were excluded from the study.

RESULTS

A total of 4,431 men completed the survey. The median age was 49 (range, 40-81) and the majority of participants (81%) had a formal education. Most participants (90%) were married and only 30% had a family history of cancer. Most participants (84%) reported hearing about prostate cancer in the past but only 31% of the participants recognized that prostate cancer is the most common malignancy in men and 22% thought that prostate cancer affects both men and women. Awareness of risk factors for prostate cancer was low: 29% of the participants recognized family history as a risk factor and 30% associated increasing age with prostate cancer. Most participants were not aware of screening, specifically only 19% of the participants knew that PSA test is used for PC screening. In terms of prognosis, participants thought that the majority of prostate cancer patients (mean, 75%) die due to their disease as opposed to old age or another cause of death.

CONCLUSION

Although the Middle Eastern men are familiar with the existence of prostate cancer, they are uninformed about the disease outcomes, risk factors, and screening. Overall, these results indicate critically low levels of awareness of prostate cancer in the Middle East. Thus, there is a vital need to target this population for practical interventions to increase awareness, in addition to screening and earlier diagnosis.

Clinical Presentation and Management of Prostate Cancer in the Middle East

PURPOSE/OBJECTIVE(S)

Prostate cancer is one of the most common malignancies worldwide and the incidence rate continues to increase in the Middle East. In the absence of large well-established cancer registries, there are no data to reflect the disease stage at initial presentation and patterns of care in this region. In order to mitigate the disease burden and help stakeholders to implement new policies to improve patient outcomes, it is important to study the disease stage at the initial presentation. The purpose of this study was to evaluate the clinical presentation and treatment of prostate cancer in the Middle East.

MATERIALS/METHODS

We performed a retrospective review of 7 institutional databases in 6 Middle Eastern countries to identify patients diagnosed with prostate cancer in 2021. Demographic, clinical, and treatment variables were abstracted. Patients who missed ≥2 scheduled radiation therapy (RT) appointments (excluding planned treatment breaks) were deemed "noncompliant."

RESULTS

A total of 1,132 patients were identified with a median age was 70 (range, 50-84). Most of the patients (78%) were diagnosed after developing symptoms and not on routine PSA screening. Diagnostic workup was completed in 87% of the patient. At time of diagnosis, 35% men presented with clinical T3 or T4 disease, 53% with metastatic disease and 42% with Gleason score ≥ 8. Mean PSA at time of presentation was 84 ng/ml. Among the nonmetastatic patients, 23% underwent a prostatectomy, 48% received definitive RT with or without androgen deprivation therapy (ADT), 9% received ADT alone and 20% received no treatment. No brachytherapy was used. Hypofractionated RT was used in 49% patients and only 8% were deemed "noncompliant". Among the metastatic patients, 74% received ADT with or without additional systemic therapy, 25% had palliative RT and 22% received no treatment.

CONCLUSION

In this large cohort of prostate cancer patients in the Middle East, most men presented with symptoms and were found to have advanced-stage disease. However, substantial proportion of patients did not receive any treatment. Further interventions to optimize prostate cancer diagnosis and treatment in in the Middle East are urgently needed.

Cancer Research in Vulnerable Populations: A Call for Collaboration and Sustainability From MENAT Countries

PURPOSE

Cancer is a major burden across Middle East, North Africa, Türkiye (MENAT). Many MENAT countries experience multiple conflicts that compound vulnerabilities, but little research investigates the linkages between vulnerability and cancer research. This study examines the current level and the potential for cancer research among vulnerable populations in the MENAT region, aiming to provide direction toward developing a research agenda on the region's vulnerable populations.

METHODS

Expert-driven meetings were arranged among the 10 authors. After obtaining institutional review board approval, a self-administered online survey questionnaire was circulated to more than 500 cancer practitioners working in 22 MENAT countries.

RESULTS

Two hundred sixteen cancer practitioners across the MENAT region responded. Fifty percent of the respondents identified clinical research in vulnerable patients with cancer as a significant issue; 21.8% reported previous research experience that included vulnerable populations, and 60% reported encountering vulnerable populations in their daily clinical practice. The main barriers to conducting research were lack of funding (60%), protected time (42%), and research training (35%). More than half of the respondents believed that wars/conflicts constituted an important source of vulnerability. The most vulnerable cancer populations were the elderly, palliative/terminally ill, those with concomitant mental health-related issues, those with other chronic illnesses, and socioeconomically deprived patients.

CONCLUSION

Results support that a major effort is needed to improve cancer research among vulnerable cancer populations in the MENAT region. We call for interdisciplinary research that accounts for the region's unique, compounding, and cumulative forms of vulnerability. This cancer research agenda on different vulnerable populations must balance sociobehavioral studies that explore sociopolitical barriers to quality care and clinical studies that gauge and refine treatment protocols. Building a research agenda through collaboration and solidarity with international partners is prime time.

Redefining Cancer Research Priorities in Low- and Middle-Income Countries in the Post-COVID-19 Global Context: A Modified Delphi Consensus Process

PURPOSE

The post-COVID-19 funding landscape for cancer research globally has become increasingly challenging, particularly in resource-challenged regions (RCRs) lacking strong research ecosystems. We aimed to produce a list of priority areas for cancer research in countries with limited resources, informed by researchers and patients.

METHODS

Cancer experts in lower-resource health care systems (as defined by the World Bank as low- and middle-income countries; N = 151) were contacted to participate in a modified consensus-seeking Delphi survey, comprising two rounds. In round 1, participants (n = 69) rated predetermined areas of potential research priority (ARPs) for importance and suggested missing ARPs. In round 2, the same participants (n = 49) rated an integrated list of predetermined and suggested ARPs from round 1, then undertook a forced choice priority ranking exercise. Composite voting scores (T-scores) were used to rank the ARPs. Importance ratings were summarized descriptively. Findings were discussed with international patient advocacy organization representatives.

RESULTS

The top ARP was research into strategies adapting guidelines or treatment strategies in line with available resources (particularly systemic therapy) (T = 83). Others included cancer registries (T = 62); prevention (T = 52); end-of-life care (T = 53); and value-based and affordable care (T = 51). The top COVID-19/cancer ARP was strategies to incorporate what has been learned during the pandemic that can be maintained posteriorly (T = 36). Others included treatment schedule interruption (T = 24); cost-effective reduction of COVID-19 morbidity/mortality (T = 19); and pandemic preparedness (T = 18).

CONCLUSION

Areas of strategic priority favored by cancer researchers in RCRs are related to adaptive treatment guidelines; sustainable implementation of cancer registries; prevention strategies; value-based and affordable cancer care; investments in research capacity building; epidemiologic work on local risk factors for cancer; and combatting inequities of prevention and care access.

68Ga-DOTA-peptide PET/CT for radiotherapy planning and evaluating treatment response in the management of meningiomas

Meningiomas overexpress somatostatin receptors (SSTR). PET imaging with SSTR ligands such as 68Ga-DOTA-peptide has recently shown high diagnostic accuracy in identification of meningiomas due to lack of normal bone and brain activity. PET-derived parameters, especially gross tumour volume (GTV) delineation improves inter-observer variability and appears to be particularly promising for RT planning. The potential strength of 68Ga-DOTA in the ongoing assessment of treatment response and disease progression in meningioma, particularly in the post-surgical and post-radiation settings is encouraging. More prospective randomized studies with large cohorts of patients are required to define the effective role of this modality.

Is Using Closed Incision Negative Pressure Therapy in Reconstructive and Oncoplastic Breast Surgery Helpful in Reducing Skin Necrosis?

Introduction Skin necrosis is a major concern of morbidity in patients undergoing reconstructive and oncoplastic breast surgery (ROBS) as it may lead to a poor aesthetic outcome, necessitate further surgery, and delay adjuvant chemotherapy and radiotherapy if required postoperatively. Some studies have reported that closed incision negative pressure therapy (ciNPT) immediately after surgery can reduce the incidence of wound complications. Our study aimed to investigate the effect of ciNPT on skin necrosis rate after ROBS. Methods Our study included 82 patients in a single center who underwent 121 ROBS procedures. We used conventional dressing in 42 patients (62 procedures, group A), while we used ciNPT in 40 patients (59 procedures, group B). When ciNPT dressing was introduced in our breast unit, 40 patients with 59 ROBS procedures who had ciNPT dressing were studied prospectively. The risk factors recorded were age, body mass index (BMI), history of previous radiotherapy, history of smoking, type of incision, type of operation, breast tissue specimen weight, use of neoadjuvant chemotherapy, and implant size. Skin necrosis was classified as "minor" if it was managed conservatively with regular dressings and "major" if surgical debridement in theater and/or exchange or implant removal was necessary. Results The incidence of overall skin necrosis in the conventional dressing group was 17.7% (11/62), while in the ciNPT group, it was higher at 25.4% (15/59), although this was not statistically significant (p = 0.51). ciNPT also did not show a statistically significant difference from the conventional dressing in the rate of minor necrosis (18.6% versus 11.2%, respectively; p = 0.44) and major necrosis (6.7% versus 6.4%, respectively; p = 1.00) Conclusion Our data has shown no superiority of ciNPT in reducing skin necrosis rate in a patient undergoing reconstructive and oncoplastic breast surgery, contrary to many other published reports. However, it may have reduced rates of other wound complications such as wound dehiscence, wound infection, and hypertrophic scar formation, which were not studied in our cohort. Further studies are needed to confirm its benefits, especially in high-risk patients.

War and oncology: cancer care in five Iraqi provinces impacted by the ISIL conflict

War and cancer have been intertwined in Iraq for over three decades, a country where the legacies and ongoing impacts of conflict have been commonly associated with both increased cancer rates as well as the deterioration of cancer care. Most recently, the Islamic State of Iraq and the Levant (ISIL) violently occupied large portions of the country's central and northern provinces between 2014 and 2017, causing devastating impacts on public cancer centers across central and northern Iraq. Focusing on the five Iraqi provinces previously under full or partial ISIL occupation, this article examines the immediate and long-term impacts of war on cancer care across three periods (before, during, and after the ISIL conflict). As there is little published data on oncology in these local contexts, the paper relies primarily upon the qualitative interviews and lived experience of oncologists serving in the five provinces studied. A political economy lens is applied to interpret the results, particularly the data related to progress in oncology reconstruction. It is argued that conflict generates immediate and long-term shifts in political and economic conditions that, in turn, shape the rebuilding of oncology infrastructure. The documentation of the destruction and reconstruction of local oncology systems is intended to benefit the next generation of cancer care practitioners in the Middle East and other conflict-affected regions areas in their efforts to adapt to conflict and rebuild from the legacies of war.

Evaluating Pain Management Practices for Cancer Patients among Health Professionals: A Global Survey

Background: Cancer incidence in the world is predicted to increase in the next decade. While progress has been in diagnosis and treatment, much still remains to be done to improve cancer pain therapy, mainly in underserved communities in low-income countries. Objective: To determine knowledge, beliefs, and barriers regarding pain management in both high- and low-income countries (according to the WHO classification); and to learn about ways to improve the current state of affairs. Design: Descriptive survey. Setting/Subjects: Fifty-six countries worldwide; convenience sample of 1639 consisted of 36.8% physicians; 45.1% nurses, and 4.5% pharmacists employed in varied settings. Results: Improved pain management services are key elements. Top barriers include religion factors, lack of appropriate education and training at all levels, nonadherence to guidelines, patients' reluctance to report on pains, over regulation associated with prescribing and access to opioid analgesics, fear of addiction to opioids, and lack of discussions around prognosis and treatment planning. Conclusion: The majority of patients with cancer in low-income countries are undertreated for their pain. Promoting cancer pain accredited program of training and education on pain management for physicians and nurses is crucial, as well as advocating policymakers and the public at large.

Prevalence and Risk Factors of Burnout Among Female Oncologists From the Middle East and North Africa

Background

Burnout (BO) is a recognized challenge among the oncology workforce. It affects both genders with a higher frequency among women. This study examined the factors contributing to the development of burnout among female oncologists from the Middle East and North Africa (MENA).

Methods

An online cross-sectional survey was distributed to oncology professionals from different countries in the MENA region. The validated Maslach Burnout Inventory (MBI) of emotional exhaustion (EE), Depersonalization (DE), and Personal Achievement (PA) plus questions about demography/work-related factors and attitudes toward oncology were included. Data were analyzed to measure BO prevalence and related factors.

Results

Between 10 February and 15 March 2020, 545 responses were submitted by female oncologists. The responses pre-dated the COVID-19 pandemic emergence in the region. BO prevalence was 71% among female professionals. Women aged <44 years represented 85% of the cohort. Sixty-two percent were married, 52% with children and one-third practiced a hobby. Two-thirds worked in medical oncology, worked for <10 years and 35% worked in academia. The majority (73%) spent >25% on administrative work daily. Nearly half of the respondents (49%) expressed a recurring thought of quitting oncology and 70% had no burnout support or education. Inability to deliver optimal care was reported as distressing for career development in 82%. Factors significantly influencing the BO risk were identified. Marital status, having children, academia and years in practice did not impact the risk of BO among female oncologists from MENA.

Conclusion

Female oncologists from the Middle East and North Africa (MENA) were found to have a high prevalence of BO. In this cohort, the majority of women oncology workers were young and in their early to mid-career stages. Burnout was linked to being younger, practicing in North African nations, having a heavy administrative load, and having persistent thoughts of quitting. Practicing a hobby and engaging in oncology communication, on the other hand, reduced the chance of BO. Burnout support and education, specifically for oncology women, is required.

Cancer Burden Among Arab World Males in 2020: The Need for a Better Approach to Improve Outcome

PURPOSE

Cancer is a leading cause of increased morbidity and mortality worldwide. This work aims to study the Arab world males' cancers (AMCs) and the similarities and disparities with the world males' cancers (WMCs) from different burden points of view.

MATERIALS AND METHODS

A descriptive review of the 2020 Global Cancer Observatory revealed AMCs compared with the 2020 WMCs and the 2018 AMCs. Data on the top 27 AMCs were compared among the region's countries and the world groups.

RESULTS

In 2020, a total estimate of 217,203 new AMCs, 2.2% of WMCs, with an average age-standardized rate of 133.5/100,000 population, compared with 222/100,000 population of WMCs, was observed. Death estimates were 148,395, 2.7% of WMCs, with an average age-standardized rate of 95/100,000 population, compared with 120.8/100,000 population of WMCs. The five-year prevalence was observed in 442,014, 1.8% of WMCs. The average AMC mortality to incidence ratio (MIR) was 0.68, compared with 0.55 in WMCs and 0.54 in Arab females. Lung cancer was the top in incidence and mortality, whereas penile cancer was the lowest. The range of MIRs among the 27 cancer types was 0.19-0.96.

CONCLUSION

The descriptive review of the 2020 males' cancers in the Arab world revealed a relatively high MIR, compared with males' cancers worldwide and the females' cancers in the Arab world. This requires further evaluation to discern the underlying causes and address them systematically. More cancer control actions are warranted.

Cancer Burden Among Arab-World Females in 2020: Working Toward Improving Outcomes

PURPOSE

Cancer is the leading cause of morbidity and mortality worldwide. This work presents the Arab-world females' cancers (AFCs) statistics in 2020, compared with the 2018 AFCs statistics, the Arab-world male cancers statistics, and the world females' cancers (WFCs) statistics in 2020. This can help set the stage for a better policy for cancer control programs and improve outcomes.

MATERIALS AND METHODS

A descriptive review of the 2020 Global Cancer Observatory concerning AFCs was performed. Data on various cancers were compiled and compared among the countries in the region and WFCs.

RESULTS

A total estimate of 244,317 new cases and 132,249 deaths is reported in AFCs; representing 2.65% and 2.99% of WFCs, respectively, with an average crude incidence/mortality ratio of 116.2 (/100,000 population)/62.9 (/100,000 population) and an age-standardized incidence/mortality ratio of 137.7(/100,000 population)/77.2(/100,000 population) compared with 238.8(/100,000 population)/114.6(/100,000 population) and 186(/100,000 population)/84.2(/100,000 population) of WFCs, respectively. Five-year prevalent cases were 585,295; 2.28% of WFCs. In comparison to males, females accounted for 47.8% of the whole population, 52.9% in incidence, 46.9% in mortality, and 56.9% in the prevalence of patients with cancer. Mortality-to-incidence ratio (MIR) was 0.54 (range 0.39-0.62 in Arab countries, compared with 0.48 globally), and it ranged from 0.14 to 0.97 in the 30 AFC types. Breast cancer was the most common cancer in incidence and mortality, with an MIR of 0.39.

CONCLUSION

The 2020 descriptive analysis of the females' cancers in the Arab world revealed a relatively high MIR compared with females' cancers worldwide; a lower MIR compared with the males; and comparable MIR to 2018 one. We call for more in-depth studies to determine the causes of these differences that might translate into actionable interventions and better outcomes.

Treatment of Trigeminal Neuralgia With Stereotactic Radiosurgery Improved Symptoms of Morbihan Syndrome

Trigeminal neuralgia (TN) is a neuropathic pain disorder characterized by paroxysmal pain in the maxillary and mandibular regions of the face. Morbihan syndrome is a disease that classically presents with dermatologic findings, including progressive facial edema and erythema. There are no previous reports of the onset of trigeminal neuralgia with Morbihan syndrome or previous reports describing improvement in symptoms of Morbihan syndrome with treatment of trigeminal neuralgia. We describe the case of a 62-year-old female who presented with trigeminal neuralgia and shortly thereafter developed significant facial edema and was diagnosed with Morbihan syndrome. The neuralgia was refractory to medical management and was effectively treated with stereotactic radiosurgery (SRS). This coincided with an improvement in her Morbihan syndrome that is now controlled following stereotactic radiosurgery and continued lymphatic massage.

Impact of High-Dose-Rate Brachytherapy Training via Telehealth in Low- and Middle-Income Countries

PURPOSE

Our objective was to demonstrate the efficacy of a telehealth training course on high-dose-rate (HDR) brachytherapy for gynecologic cancer treatment for clinicians in low- and middle-income countries (LMICs).

METHODS

A 12-week course consisting of 16 live video sessions was offered to 10 cancer centers in the Middle East, Africa, and Nepal. A total of 46 participants joined the course, and 22 participants, on average, attended each session. Radiation oncologists and medical physicists from 11 US and international institutions prepared and provided lectures for each topic covered in the course. Confidence surveys of 15 practical competencies were administered to participants before and after the course. Competencies focused on HDR commissioning, shielding, treatment planning, radiobiology, and applicators. Pre- and post-program surveys of provider confidence, measured by 5-point Likert scale, were administered and compared.

RESULTS

Forty-six participants, including seven chief medical physicists, 16 senior medical physicists, five radiation oncologists, and three dosimetrists, representing nine countries attended education sessions. Reported confidence scores, both aggregate and paired, demonstrated increases in confidence in all 15 competencies. Post-curriculum score improvement was statistically significant (P < .05) for paired respondents in 11 of 15 domains. Absolute improvements were largest for confidence in applicator commissioning (2.3 to 3.8, P = .009), treatment planning system commissioning (2.2 to 3.9, P = .0055), and commissioning an HDR machine (2.2 to 4.0, P = .0031). Overall confidence in providing HDR brachytherapy services safely and teaching other providers increased from 3.1 to 3.8 and 3.0 to 3.5, respectively.

CONCLUSION

A 12-week, low-cost telehealth training program on HDR brachytherapy improved confidence in treatment delivery and teaching for clinicians in 10 participating LMICs.

National approaches to managing cancer care: responses of countries in the MENA region to the COVID-19 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic presents serious challenges to cancer care because of the associated risks from the infection itself and the disruption of care delivery. Therefore, many professional societies have published recommendations to help manage patients with cancer during the current pandemic. The objective of our study is to assess the national responses of Middle East North Africa (MENA) countries in terms of publishing relevant guidelines and analyse various components of these guidelines.

METHODS

A survey based on the preliminary review of the literature regarding cancer care adaptations has been developed and then completed by a group of oncologists from the following Arab countries affected by the pandemic: Algeria, Egypt, Iraq, Jordan, Kuwait, Lebanon, Morocco, Oman, Saudi Arabia, Syria, Tunisia, United Arab Emirates and Yemen. The survey inquired about COVID-19 cases, national recommendations regarding general measures of COVID-19 prevention and patient care in oncology as well as their implementation about cancer care adaptations during the pandemic.

RESULTS

Analysis of the COVID-19 pandemic-related guidelines revealed at least 30 specific recommendations that we categorised into seven essential components. All included countries had national guidelines except one country. Estimated full compliances with all specific category recommendations ranged from 30% to 69% and partial compliance ranged from 23% to 61%.

CONCLUSION

There is a very good response and preparedness in the Arab Middle East and North Africa region surveyed. However, there are inconsistencies in the various components of the guidelines across the region, which reflects the evolving status of the pandemic in each country as well as the lack of clear evidence-based guidelines for many of the issues in question. There is a need for a clear framework on essential components that should be included in these guidelines to assure providing the best guidance to the oncology community.

Impact of the COVID-19 Pandemic on Oncologists: Results of an International Study

PURPOSE

As frontline workers facing the COVID-19 pandemic, healthcare providers should be well-prepared to fight the disease and prevent harm to their patients and themselves. Our study aimed to evaluate the knowledge, attitude, and practice of oncologists in response to the COVID-19 pandemic and its impact on them.

METHODS

A cross-sectional study was conducted using a validated questionnaire disseminated to oncologists by SurveyMonkey. The tool had 42 questions that captured participants' knowledge, attitude, and practice; their experiences; and the pandemic's impact on various aspects of their lives. Participants from Middle East and North African countries, Brazil, and the Philippines completed the electronic survey between April 24 and May 15, 2020.

RESULTS

Of the 1,010 physicians who participated in the study, 54.75% were male and 64.95% were medical or clinical oncologists. The level of knowledge regarding the prevention and transmission of the virus was good in 52% of participants. The majority (92%) were worried about contracting the virus either extremely (30%) or mildly (62%), and 84.85% were worried about transmitting the virus to their families. Approximately 76.93% reported they would take the COVID 19 vaccine once available, with oncologists practicing in Brazil having the highest odds ratio of intention to receive the COVID-19 vaccine (odds ratio, 11.8, 95% CI, 5.96 to 23.38, P < .001). Participants reported a negative impact of the pandemic on relations with coworkers (15.84%), relations with family (27.84%), their emotional and mental well-being (48.51%), research productivity (34.26%), and financial income (52.28%).

CONCLUSION

The COVID-19 pandemic has adverse effects on various personal and professional aspects of oncologists' lives. Interventions should be implemented to mitigate the negative impact and prepare oncologists to manage future crises with more efficiency and resilience.

Burnout in oncology: Magnitude, risk factors and screening among professionals from Middle East and North Africa (BOMENA study)

BACKGROUND

Burnout (BO) among oncology professionals (OP) is increasingly being recognized. Early recognition and intervention can positively affect the quality of care and patient safety. This study investigated the prevalence, work and lifestyle factors affecting BO among OPs in the Middle East and North Africa (MENA).

METHODS

An online survey was conducted among MENA OPs between 10 February and 15 March 2020, using the validated Maslach Burnout Inventory of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA), including questions regarding demography/work-related factors and attitudes towards oncology. Data were analysed to measure BO prevalence and risk factors and explore a screening question for BO.

RESULTS

Of 1054 respondents, 1017 participants (64% medical oncologists, 77% aged less than 45 years, 55% female, 74% married, 67% with children and 40% practiced a hobby) were eligible. The BO prevalence was 68% with high levels of EE and DP (35% and 57% of participants, respectively) and low PA scores (49%). BO was significantly associated with age less than 44 years, administrative work greater than 25% per day and the thought of quitting oncology (TQ). Practising a hobby, enjoying oncology communication and appreciating oncology work-life balance were associated with a reduced BO score and prevalence. North African countries reported the highest BO prevalence. Lack of BO education/support was identified among 72% of participants and TQ-predicted burnout in 77%.

CONCLUSIONS

This is the largest BO study in MENA. The BO prevalence was high and several modifiable risk factors were identified, requiring urgent action. TQ is a simple and reliable screening tool for BO.

CSF Rhinorrhea: A Rare Clinical Presentation of Choroid Plexus Papilloma

Choroid plexus papilloma (CPP) is a rare brain tumour occurring mostly in infants and children. Most CPPs are intraventricular and present with symptoms and signs of increased intracranial pressure (ICP). This case report describes a middle-aged female who presented with spontaneous cerebrospinal fluid (CSF) rhinorrhea from a tumour located in the cerebellopontine angle (CPA). She underwent craniotomy with subtotal tumour resection and remained progression and rhinorrhea-free for several years. Upon clinical progression, the patient was treated with Cyberknife stereotactic radiosurgery. The patient clinically improved and demonstrated a favourable radiologic response to radiosurgery.

Brain Metastasis from Breast Cancer: risk factors and radiotherapy perspective from a tertiary Middle Eastern facility

BACKGROUNDS

Breast cancer represents the second most frequent cause of brain metastases after lung cancer. Previous studies have identified the subgroups of patients with triple-negative and HER2-positive as having an increased risk for the development of brain metastases. We are not aware in Kurdistan - Iraq of any national studies that are in parallel with these findings.

PATIENTS AND METHODS

A cross-sectional descriptive study conducted on 57 patients who were known cases of breast cancer with brain metastasis, managed with whole brain radiotherapy at a tertiary radiotherapy institute in two years (January 2015 to December 2016), as a convenient sample. Data were collected from patients' archives and phone calls and then analyzed using SPSS version 23.

RESULTS

Younger age at diagnosis and cancers with HER2-positive receptor phenotype are risk factors for brain metastasis. Median survival post-brain metastasis is significantly affected by receptor phenotypes (2 months in triple negative versus 7 months in hormone receptor positive) and performance status (18 months if performance score of 70% and above versus 1.5 months if it is 60% and less).

CONCLUSION

Primary breast cancer patients have more risk to develop brain metastases if they are at younger age and HER2-positive and the survival post-brain metastases is dramatically affected by both triple negative receptor phenotype and lower performance score.

Impact of the COVID-19 Pandemic on Cancer Care: A Global Collaborative Study

PURPOSE

The COVID-19 pandemic affected health care systems globally and resulted in the interruption of usual care in many health care facilities, exposing vulnerable patients with cancer to significant risks. Our study aimed to evaluate the impact of this pandemic on cancer care worldwide.

METHODS

We conducted a cross-sectional study using a validated web-based questionnaire of 51 items. The questionnaire obtained information on the capacity and services offered at these centers, magnitude of disruption of care, reasons for disruption, challenges faced, interventions implemented, and the estimation of patient harm during the pandemic.

RESULTS

A total of 356 centers from 54 countries across six continents participated between April 21 and May 8, 2020. These centers serve 716,979 new patients with cancer a year. Most of them (88.2%) reported facing challenges in delivering care during the pandemic. Although 55.34% reduced services as part of a preemptive strategy, other common reasons included an overwhelmed system (19.94%), lack of personal protective equipment (19.10%), staff shortage (17.98%), and restricted access to medications (9.83%). Missing at least one cycle of therapy by > 10% of patients was reported in 46.31% of the centers. Participants reported patient exposure to harm from interruption of cancer-specific care (36.52%) and noncancer-related care (39.04%), with some centers estimating that up to 80% of their patients were exposed to harm.

CONCLUSION

The detrimental impact of the COVID-19 pandemic on cancer care is widespread, with varying magnitude among centers worldwide. Additional research to assess this impact at the patient level is required.

Mode of Presentation of Laryngeal Cancer: A Single Radiotherapy Institute Experience in Iraq

PURPOSE

Laryngeal cancer is relatively common and usually presents with hoarseness due to a lesion in the glottis. We noticed that many of our patients had presented with supraglottic lesions and we could not find local literature in support of this observation. Mode of presentation and site of the lesion of these patients will be addressed in this review.

MATERIALS AND METHODS

A retrospective cross-sectional descriptive study for laryngeal cancer patients who received radiotherapy at a tertiary radiotherapy center in Iraq, from January 2010 to December 2015, and who are residents in the Sulaimani governorate.

RESULTS

In 6 years, laryngeal cancer patients from Sulaimani were 83 (out of 123 in total), which constituted the most common, 40.8%, head and neck cancers. 86.7% were males and the median age was 68.3 year. Most common presentation was hoarseness, 79.5%, and the least was dysphagia and stridor, 28.9%. Pain and neck swelling were found in 51.8%, 34.9%, respectively. Site of the cancer lesions were in supraglottis in 53%, glottis in 32.5%, transglottis in 8.4%, and subglottis in 6%. Commonest stage was IVA in 54.2% while the least was IVB 2.4%. Squamous cell carcinoma was the pathological type in all of our patients.

CONCLUSION

Laryngeal cancer is the most common head and neck cancer in our institutional registry. While all the pathologies were of squamous cell carcinoma, hoarseness was the most common presentation and supraglottis was the most common site of involvement.

High-Cost Cancer Treatment Across Borders in Conflict Zones: Experience of Iraqi Patients in Lebanon

PURPOSE

Conflict-induced cross-border travel for medical treatment is commonly observed in the Middle East. There has been little research conducted on the financial impact this has on patients with cancer or on how cancer centers can adapt their services to meet the needs of this population. This study examines the experience of Iraqi patients seeking care in Lebanon, aiming to understand the social and financial contexts of conflict-related cross-border travel for cancer diagnosis and treatment.

PATIENTS AND METHODS

After institutional review board approval, 60 Iraqi patients and caregivers seeking cancer care at a major tertiary referral center in Lebanon were interviewed.

RESULTS

Fifty-four respondents (90%) reported high levels of financial distress. Patients relied on the sale of possessions (48%), the sale of homes (30%), and vast networks to raise funds for treatment. Thematic analysis revealed several key drivers for undergoing cross-border treatment, including the conflict-driven exodus of Iraqi oncology specialists; the destruction of hospitals or road blockages; referrals by Iraqi physicians to Lebanese hospitals; the geographic proximity of Lebanon; and the lack of diagnostic equipment, radiotherapy machines, and reliable provision of chemotherapy in Iraqi hospitals.

CONCLUSION

As a phenomenon distinct from medical tourism, conflict-related deficiencies in health care at home force patients with limited financial resources to undergo cancer treatment in neighboring countries. We highlight the importance of shared decision making and consider the unique socioeconomic status of this population of patients when planning treatment.

Board-certified specialty training program in radiation oncology in a war-torn country: Challenges, solutions and outcomes

BACKGROUND

Residency programs leading to board certification are important for safe and competent Radiation Oncology (RO) practice. In some developing nations, there is a gap in this field. This work addresses the experience that was accomplished to establish such a program in Iraq despite all the challenges that faces a country under war.

METHODS

Descriptive report of challenges faced in a developing country that is still reeling from war, the steps taken to overcome these challenges and outcomes after graduation of two classes.

RESULTS

After over 18 months of prerequisite technical and logistical preparations, a group of local and external faculty members were invited to establish the required syllabus of a structured RO residency program in Iraq. It is comprised of a total of 100 post-graduate academic credits over a 48-months period after clinical internship. First year evaluations included regular practical assessments; seven in-house papers covering RO, cancer and radiation biology, medical physics, radiological anatomy and diagnostic oncology, tumor pathology, onco-pharmacology, and medical statistics, research methodology, and cancer epidemiology, followed by a comprehensive examination. Subsequent evaluations were on an annual bases with enrollment in the American College of Radiology In-Training examination in RO. Final assessment included logbook and skills' reviews, graduation thesis or peer-review publication, two-papers' written examination, and an exit practical examination.

CONCLUSIONS

Given the political, economic and social difficulties in post-war Iraq, it was a major challenge to establish a residency program in RO. Despite the significant difficulties, the first residency program leading to board certification in RO was successfully started in Iraq. The new specialists will help in addressing the shortage of radiation oncologists in the country.

Is economic status the main determinant of radiation therapy availability? The Arab world as an example of developing countries

BACKGROUND AND PURPOSE

Arab countries share a common location, history, language and culture with different economic characteristics. In this study, we analyze the availability and factors influencing radiotherapy services and cancer mortality incidence ratio (MIR) in Arabic countries.

MATERIALS AND METHODS

Data were collected from GLOBOCAN report, World Health Organization, World Bank, United Nation and Directory of Radiotherapy Centre databases.

RESULTS

The average number of megavoltage machines (MVM) in Arab countries is 0.84 machine per 1000 cancer patients. The number of MVM per 1000 cancer patients was found to be significantly correlated with gross domestic product (GDP) per capita (r = 0.583, P = 0.006). In addition, it was found to be significantly more in politically stable countries compared to unstable ones (P = 0.004) and more in high and upper-middle income countries (median 0.94 ± 1.0) compared to lower-middle and low income countries (median 0.3 ± 0.51) (P = 0.013). MIR was found to be significantly correlated with GDP per capita, physicians per 1000 population, MVM per 1000 cancer patients and absolute MVM deficit (r = -0.555, -0.625, -0.42, -0.436 and P = 0.009, 0.006, 0.047, 0.043, respectively). On multivariate regression analysis, the number of physicians per 1000 population had the strongest prediction of MIR in Arabic countries (P = 0.01).

CONCLUSION

Although the economic status is of paramount importance, it is not the only factor determining the quantity and quality of radiotherapy services in the Arab world. More efforts are urgently needed to improve the status of radiation oncology and fill its gap in the Arab countries.

Correction to: Human Development Index and its association with staff spiritual care provision: a Middle Eastern oncology study

Incorrect family name of Layth Mula-Hussain.

Treatment Outcomes of Pediatric Patients With Ewing Sarcoma in a War-Torn Nation: A Single-Institute Experience From Iraq

PURPOSE

Ewing sarcoma (ES) is a relatively rare, highly malignant tumor of the musculoskeletal system. It is the second most common malignant bone tumor in children and adolescents in the age group of 5 to 20 years. The aim of this study was to identify the treatment outcomes of pediatric patients with ES in Sulaimani governorate, Iraq.

PATIENTS AND METHODS

This was a retrospective study that reviewed the medical records of pediatric patients with ES who were managed between 2009 and 2015, with follow-up until late 2017. Patient- and tumor-related factors were correlated with clinical outcomes.

RESULTS

A total of 31 pediatric patients with ES were included in this study. All the patients received chemotherapy and radiotherapy, whereas only 14 patients underwent surgical resection and just eight had free surgical margins. The median age at diagnosis was 13 years, 58% were male, and 42% were female. The presenting symptoms at diagnosis were mostly pain (67.7%) and palpable mass (25.8%). The primary tumor was located in the extremities (51.6%), the thoracic cage (19.4%), the pelvis (16.1%), and the lumbar vertebrae (12.9%). Approximately two thirds of the patients (61.3%) had localized disease at the time of presentation. The 5-year overall survival was 19%, and the 5-year recurrence-free survival was 34%.

CONCLUSION

Clinical outcomes of ES in pediatric patients in our war-torn nation, Iraq, are still markedly inferior to the published outcomes from stable, developed nations. Additional large and multicenter national studies are required. Diagnostic and therapeutic measures need improvement, and multidisciplinary and comprehensive cancer-integrated approaches are vital for better outcomes.

Geriatric radiotherapy in a war-torn country: Experience from Iraq

INTRODUCTION

Cancer prevalence and geriatric patients (GP) are increasing and about half of the patients with cancer will be offered radiotherapy (RT). Addressing GP and their RT needs is an important issue in order to understand this heterogeneous group of patients.

MATERIALS AND METHODS

A descriptive cross-sectional study, using a convenience sample from Sulaimani city's inhabitants, aged 70-year and more, who were treated with RT at the only city's RT center, Zhianawa Cancer Center (ZCC), in 2015.

RESULTS

153 patients' charts were reviewed. GP represented 20% of the patients referred to ZCC. Male: Female ratio was 3:1. One third presented with distant metastases, and 46% were treated with curative intent versus 54% with palliative intent. 94% completed the planned sessions of the curative RT vs 90% of the palliative RT. 23% of GP who were referred for RT didn't receive it. 9% got interruptions during RT course. 10% of GP living >40 km away from the treatment center refused treatment. Mean time interval between the date of referral and the date of starting treatment in the palliative setting was 19 days. Only 41% of patients with curative setting had regular follow-up.

CONCLUSIONS

Being the 1st study in this regard in a war-torn nation, Iraq, our results demonstrated that GP is a sizable group of ZCC patients and that RT is a valuable modality in GP cancer treatment. "Age per se" is not a factor to avoid this modality when there is an indication to use it. Longer distance to reach the center was a challenge in some of our GP. Due to inadequate number of RT machines, GP have to wait long time before getting their RT, even for palliative purposes. Further studies in this field are warranted.

The changing landscape of brachytherapy for cervical cancer: a Canadian practice survey

BACKGROUND

We documented changes in practice from 2009 to 2012 for cervical cancer brachytherapy in Canada.

METHODS

Centres with gynecologic brachytherapy services were sent an e-mail questionnaire querying their 2012 practice. Responses are reported and compared with practice patterns identified in a similar survey for 2009.

RESULTS

The response rate was 77% (24 of 31 centres). Almost all use high-dose-rate brachytherapy (92%); low-dose-rate brachytherapy has been completely phased out. Most continue to move patients from the site of applicator insertion to the radiation treatment simulation suite (75%) or to a diagnostic imaging department (29%), or both. In 2012, the imaging modalities used for dose specification were computed tomography [ct (75%)], magnetic resonance imaging [mri (38%)], plain radiography (21%), and cone-beam ct (8%). The number of institutions using mri guidance has markedly increased during the period of interest (9 vs. 1). Most respondents (58% vs. 14%) prescribed using guidelines from the Groupe Européen de Curiethérapie and the European Society for Therapeutic Radiology and Oncology, but they also used point A as a reference. Commonly used high-dose radiation regimens included 30 Gy in 5 fractions and 24 Gy in 3 fractions.

CONCLUSIONS

In Canada, image-guided brachytherapy for cervical cancer continues to evolve. Although ct-based imaging remains the most commonly used modality, many centres have adopted mri for at least 1 brachytherapy treatment. More centres are using fewer fractions and a slightly lower biologically effective dose, but are still achieving EQD2 (2-Gy equivalent) doses of 80-90 Gy in combination with external-beam radiation therapy.

Afro Middle East Asian symposium on cancer cooperation

This manuscript captures the discussion and recommendations that came out of a special Afro Asian symposium involving 13 countries. Unmet needs and cost-effective solutions with special emphasis on training form the backbone of practical next steps.

Practical steps for establishing ocular plaque therapy in developing countries

INTRODUCTION

Retinoblastoma and uveal melanoma are the most common ocular tumors in children and adults, respectively. Enucleation and external beam radiation therapy are integral in the management of ocular tumors. However, these tumors could also be treated effectively by plaque therapy, which has the potential of preserving the globe and maintaining vision.

METHODS AND MATERIALS

We reviewed our experience with the introduction of this technique to our center. Furthermore, we highlighted the critical role of a specialized multidisciplinary team in the successful implementation of this procedure.

DISCUSSION

This review represents a detailed report addressing the practical steps for successfully establishing plaque therapy in developing countries.

RESULTS

Plaque therapy was successfully implemented at our center in 1.5 years. Integration with an advanced cancer center is crucial for the correct transfer of this complex technology.

CONCLUSION

Complex brachytherapy procedures could be successfully established and implemented in developing countries.