Breast Cancer in Women in Gaza: A Review of Clinical Characteristics and Short-Term Survival.

PURPOSE: To understand how breast cancer is diagnosed in Gaza, and disease stage distribution, treatment, and survival. MATERIALS AND METHODS: A clinical record case series study of women diagnosed in 2017 and 2018 was conducted with follow-up until December 31, 2020. Breast cancer crude incidence rates and age-specific incidence rates were calculated. Clinical characteristics, including investigation, diagnosis, and treatment methods by year of diagnosis, were compared using the chi-square test. The 2-year cumulative risk of death from any cause was estimated using the Kaplan-Meier method, and univariate and multivariate Cox proportional hazard regressions estimated hazard ratios and their 95% CIs. RESULTS: Five hundred twenty-four new diagnoses (mean age, 53 years; range, 23-100) were recorded, giving a crude annual incidence rate of 27 per 100,000 population. Six percent (32/524) were diagnosed at stage I, 35% (185/524) at stage II, 33% (171/524) at stage III, and 19% (99/524) at stage IV. More than one half (52%, 271/524) underwent modified radical mastectomy. Seventy-seven percent (405/524) received chemotherapy, 70% (368/524) hormone therapy, and 39% (204/524) radiotherapy. Data on key prognostic factors were mostly available-stage (93%), estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2; 82%), tumor grade (77%), and tumor size (70%). The overall survival was 95.4% at 1 year and 86.6% at 2 years. CONCLUSION: Women with breast cancer in Gaza have a high short-term survival after diagnosis. However, one half were diagnosed with advanced disease, and their investigations were incomplete. Better reporting on family history, tumor grade, size, and ER, PR, and HER2 receptor status is needed for future studies.

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.

Promoting cancer prevention and early diagnosis in the occupied Palestinian territory.

Cancer is the second leading cause of mortality in the occupied Palestinian territory (oPt), and a more than 65 % rise in all cancer mortality is expected by 2030, with potentially devastating consequences which could overwhelm an already strained Palestinian health system. Advanced stage at diagnosis and the pervasive shortages in basic treatment options are to blame These factors are accompanied by a lack of infrastructure and trained human resources, the absence of reliable and timely data, and poorly coordinated healthcare systems. At present, resources for cancer control in the country are not only inadequate, but some of them are misallocated because of decisions that have been made that have not been based on evidence. This could lead to a waste of badly needed resources in a system that is already gravely short of funding. This paper highlights the challenges facing national primary cancer prevention measures in the oPt that will be needed to reduce exposure to cancer-related risk factors. The paper aims to provide evidence-based recommendations on how the oPt can detect in good time and thus treat the three most common cancers in the country - lung, breast, and colorectal cancer.

Factors affecting delay in the presentation of breast cancer symptoms among women in Gaza, occupied Palestinian territory: a cross-sectional survey.

OBJECTIVE: To identify factors related to women's delay in presenting with breast cancer symptoms to improve diagnosis in the occupied Palestinian territory (oPt). DESIGN: Cross-sectional. SETTING: Two government cancer hospitals. PARTICIPANTS: A consecutive sample of 130 Palestinian women living in Gaza with newly diagnosed breast cancer were approached in the waiting rooms of cancer hospitals in Gaza between 1 January 2017 and 31 December 2017. 120 women took part and returned the completed questionnaire. PRIMARY AND SECONDARY OUTCOME MEASURES: Clinical information about breast cancer was collected from hospital cancer records. An interval of 3 months or more between women's self-discovery of symptoms and their first presentation to a medical provider was considered as a delay. RESULTS: 94% (122/130) of women attending cancer hospitals in Gaza agreed to take part in the study. Their mean age was 51 years (range: 23-72), 33.6% (31/122) had a family history of breast cancer and 74.5% (41/55) of those whose cancer stage was known had been diagnosed at stage III or IV. Around one-half (62/122) said they had not recognised the seriousness of their breast changes but only 20% (24/122) of women delayed seeking healthcare by 3 months and more. The two only factors associated to late presentation were that the woman considered their symptoms not serious (p<0.001) and lack of pain (p=0.012). Lower socioeconomic status, older age, lower education and negative family history of breast cancer were not statistically associated with women's delay. CONCLUSIONS: Women's awareness about the seriousness of breast changes and the critical importance of seeking prompt diagnosis needs to be improved using context-relevant and evidence-based awareness campaigns. This should be accompanied with training of female nurses on promoting early detection and improvement in diagnostic facilities to ensure timely diagnosis of cancer in the oPt.

Mammographic Screening in the Occupied Palestinian Territory: A Critical Analysis of Its Promotion, Claimed Benefits, and Safety in Palestinian Health Research.

PURPOSE: To critically review the evidence and opinions expressed about mammographic screening (MS) in research reports on breast cancer in the occupied Palestinian territory (oPt) and to assess whether benefits and harms in MS are presented in a balanced way. METHODS: Searches of PubMed, Cochrane, MEDLINE, EMBASE, CINAHL, and gray literature identified 14 eligible research reports relating to the oPt. We reviewed these documents and then used a thematic analysis to describe and analyze the evidence and the opinions about MS expressed in them. RESULTS: All 14 research reports mentioned that MS would improve survival rates in the oPt. Only three gave information on major harmful effects, and only two emphasized that MS must be accompanied by effective treatment to have any beneficial effects on population mortality. There was no consistency in the recommended frequency of MS. CONCLUSION: Most information presented by Palestinian health researchers was selective and failed to address the important established harms of MS. Thus, calls to support MS in the oPt are not based on a measured discussion of the risks and benefits for women or grounded in the systemic readiness of health care necessary for its effectiveness. As long as diagnostic and treatment facilities remain deficient, screening cannot lead to reduced mortality from breast cancer.

Additional challenges faced by cancer patients in Gaza due to COVID-19.

Cancer patients in conflict settings experience significant barriers in accessing chemotherapy and radiotherapy as well as palliative care and psychosocial support. Now they face an additional possible risk of infection by SARS-CoV-2 novel coronavirus and the indirect impact of the COVID-19 pandemic on movement restrictions and their access to care. In this commentary, we highlight that despite the low COVID-19 burden in conflict settings like Gaza, COVID-19 could lead to further inequity in cancer care and poorer outcomes for Palestinians with cancer. This is due to the pre-existing shortage in cancer resources as well as the lack of context-specific guidelines to prepare for COVID-19 in war-torn settings.

Breast cancer in Gaza-a public health priority in search of reliable data.

Gaza has experienced 12 years of isolation which has crippled the health system infrastructure, reduced the quality of living conditions, damaged the health of the population and reduced health service capacity and capability. This paper presents a context-setting review of what is already known about breast cancer in Gaza to identify which interventions are applicable to help prevent women there from dying unnecessarily from breast cancer. A search of the published and unpublished literature was conducted to identify potentially relevant studies on breast cancer which were either done in Gaza or elsewhere in the occupied Palestinian territory. This paper highlights the pervasive lack of basic modalities of cancer care (surgery, radiotherapy, systemic therapies and pathology/imaging) in Gaza. Poor access to breast cancer services in Gaza leaves women with only one alternative-to seek treatment outside of Gaza. However, women are sometimes forced to wait months before receiving permits to leave Gaza for treatment. Furthermore, a lack of complete and reliable data remains a major challenge for improving breast cancer services in Gaza. There is a need to develop and evaluate interventions to promote infrastructure for pathology and drug delivery, medical training and cancer registration and monitoring.