The economic burden of cancer care for Syrian refugees: a population-based modelling study

The impact of humanitarian aid on financial toxicity among cancer patients in Northwest Syria

INTRODUCTION

The ongoing crisis in Syria has divided the country, leading to significant deterioration of the healthcare infrastructure and leaving millions of people struggling with poor socioeconomic conditions. Consequently, the affordability of healthcare services for the population has been compromised. Cancer patients in Northwest Syria have faced difficulties in accessing healthcare services, which increased their financial distress despite the existence of humanitarian health and aid programs. This study aimed to provide insights into how humanitarian assistance can alleviate the financial burdens associated with cancer treatment in conflict-affected regions.

MATERIALS AND METHODS

This research employed a quantitative, quasi-experimental design with a pre-test-post-test approach, focusing on evaluating the financial toxicity among cancer patients in Northwest Syria before and after receiving humanitarian aid. The study used purposeful sampling to select participants and included comprehensive demographic data collection. The primary tool for measuring financial toxicity was the Comprehensive Score for Financial Toxicity (FACIT-COST) tool, administered in Arabic. Data analysis was conducted using SPSS v25, employing various statistical tests to explore relationships and impacts.

RESULTS

A total of 99 cancer patients were recruited in the first round of data collection, out of whom 28 patients affirmed consistent receipt of humanitarian aid throughout the follow-up period. The results of the study revealed that humanitarian aid has no significant relationship with reducing the financial toxicity experienced by cancer patients in Northwest Syria. Despite the aid efforts, many patients continued to face significant financial distress.

CONCLUSION

The research findings indicate that current humanitarian assistance models might not sufficiently address the complex financial challenges faced by cancer patients in conflict zones. The research emphasizes the need for a more comprehensive and integrated approach in humanitarian aid programs. The study highlights the importance of addressing the economic burdens associated with cancer care in conflict settings and calls for a re-evaluation of aid delivery models to better serve the needs of chronic disease patients. The findings suggest a need for multi-sectoral collaboration and a systemic approach to improve the overall effectiveness of humanitarian assistance in such contexts.

Lung Cancer Diagnoses and Outcomes During the Syrian War, 2011-2018

Importance

Protracted wars, which disproportionately affect low-resource countries, exacerbate the challenges faced by cancer care systems, with lung cancer being the most affected as the most fatal oncological condition.

Objective

To characterize the presentation and survival of patients with lung cancer during the decade-long Syrian war.

Design, Setting, and Participants

This cohort study included patients at a large oncology center in Syria during the first 8 years of the Syrian armed conflict (2011-2018). All patients with a new diagnosis of lung cancer were included. Variables investigated included histological subtypes, TNM classification (tumor, lymph nodes, and metastasis), and staging at diagnosis as well as the yearly follow-ups up to 5 years after presentation.

Exposure

The Syrian war divided the country into temporary regions with different political influences and heterogeneously impacted health care accessibility among these regions.

Main Outcomes and Measures

Change in prevalence of advanced lung cancer cases at presentation; change in overall survival odds.

Results

The study included 5160 patients from all Syrian governorates (mean [SD] age, 59.6 [10.8] years; 4399 men [85.3%]). New diagnoses sharply declined during the first 3 years of the war, with partial recovery afterward. Regardless of their tempo-geographical regions, 60% to 80% of the yearly diagnoses presented with metastases. The 1-year and 5-year survival rates were 13.1% (423 of 3238 patients with follow-up results) and 0.1% (2 of 1853 patients), respectively. Patients who presented from regions more involved in the armed conflicts showed poorer survival rates with odds ranging between 0.51 (95% CI, 0.44-0.59) and 0.61 (95% CI, 0.49-0.74) across follow-ups for up to 2 years in comparison with patients presenting from safer regions. War-related health care inaccessibility explained a greater percentage of the variability in survival (Nagelkerke R2 = 7.5%; P < .001) than both patients' age and the stage of the disease combined (Nagelkerke R2 = 3.9%; P < .001).

Conclusions and Relevance

The Syrian war has been associated with a marked decline in the management of patients with lung cancer, with limited access to specialized care, delayed diagnoses, and substantial decrease in survival rates correlating with the intensity of armed conflict in the respective regions. The profound repercussions of the prolonged armed conflict on patients with lung cancer in Syria necessitates urgent comprehensive strategies to improve the accessibility and quality of health care services, especially in conflict-ridden zones.

Addressing cancer care in low- to middle-income countries: a call for sustainable innovations and impactful research

Most new cancer cases are currently arising in low- and middle-income countries, where their outcomes are significantly poorer compared to high-income countries. Innovative solutions are imperiously needed to prevent, detect early, and manage cancer in low- and middle-income countries, aiming to improve the chances of survival.

Central nervous system tumors in patients coming from areas of conflict in the Middle East/North Africa region: an experience from King Hussein Cancer Center

Introduction

The global cancer burden has been disproportionately shifting towards low- and middle-income countries (LMICs). Limited availability and accessibility to screening, treatment and surveillance, increase in the prevalence and lack of control of risk factors, and underdeveloped healthcare infrastructures have greatly contributed to the disparity in the global cancer burden.

Methods

A retrospective cohort study was conducted that included adult and pediatric patients with an established diagnosis of Central Nervous System (CNS) tumors including brain or spinal tumors of which different demographic, clinical characteristics, and financial burden were presented.

Results

749 patients were included stemming from various countries in the Middle East/North Africa (MENA) region including Libya (34.2%), Palestine (19.8%), Iraq (15.4%), Syria (14.6%) Yemen (14.5%), and Sudan (1.5%). Most patients were adults (66%) with a median age of 34-year-old. 104 patients had died (13.9%), 80 patients were still alive (10.7%) and most of the patients (n= 565, 75.5%) were lost to follow-up. The added cost of managing these patients is 10,172,935 Jordanian Dinars (JOD), with King Hussein Cancer Foundation (KHCF) covering around 34.3% of the total cost.

Conclusion

Our study aimed at taking a closer look at patients coming from areas of conflict in the MENA region diagnosed and treated for CNS tumors at King Hussein Cancer Center (KHCC) over a 12-year period. It was found that even with the contributions of the Jordanian sources almost half of the patients were faced with the entire financial burden of treatment alone.

Colorectal Cancer Screening in the Middle East: What, Why, Who, When, and How?

The incidence of colorectal cancer (CRC) in the Middle East is increasing, especially among those younger than 50 years. Risk factors including obesity, sedentary lifestyle, and dietary changes are associated with the epidemiologic shift and are a result of socioeconomic changes happening in the region. Worldwide, CRC screening is associated with decreased incidence and mortality of CRC, but screening uptake is still low in the Middle East because of cultural barriers and lack of awareness; in addition, most countries do not have national screening programs. Knowledge of CRC screening and participation rates vary among different countries, but overall they are low. Both primary and secondary prevention approaches are needed in the Middle East, and cost-effectiveness is important in choosing screening modalities. Although colonoscopy is considered the most robust screening method, stool-based testing may be an acceptable screening strategy in resource-limited settings, and focusing on high-risk individuals such as those with hereditary CRC might be the most cost-effective strategy. In addition to financial limitations in many countries in the Middle East, human displacement places an extra toll on cancer control strategies in the region.

Providing person-centered palliative care in conflict-affected populations in the Middle East: What matters to patients with advanced cancer and families including refugees?

Introduction

Universal health coverage highlights palliative care as an essential component of health services. However, it is unclear what constitutes person-centered care in populations affected by conflict, as they may have specific concerns in the dimensions of physical, emotional, social, and spiritual wellbeing. This study aimed to identify what matters to patients with advanced cancer and family caregivers in Jordan including refugees, to inform appropriate person-centered assessment and palliative care in conflict-affected populations.

Methods

Cross-sectional face-to-face, semi-structured interviews were conducted at two sites in Amman. Adult patients with advanced cancer and family caregivers were purposively sampled to maximize diversity and representation. Interviews were digitally audio recorded, anonymized, and transcribed verbatim for thematic analysis.

Findings

Four themes were generated from 50 patients (22 refugees; 28 Jordanians) and 20 caregivers (7 refugees; 13 Jordanians) (1). Information, communication, and decision-making. Truth-telling and full disclosure from clinicians was valued, and participants expressed concerns that information was not shared in case patients would disengage with treatment. (2) Priorities and concerns for care and support. Participants’ top priority remained cure and recovery (which was viewed as possible). Other priorities included returning to their “normal” life and their “own” country, and to continue contributing to their family. (3) Role of spirituality and Islam. Most participants had strong faith in God and felt that having faith could comfort them. For refugees whose social network was fractured due to being away from home country, prayer and Quran reading became particularly important. (4) Unmet support needs of family caregivers. Family caregivers were affected physically and emotionally by worrying about and caring for the patients. They needed support and training, but often could not access this.

Discussion

Truth-telling is highly valued and essential to achieving person-centered care and informed decision-making. This study also reveals specific concerns in conflict-affected populations, reflecting the experience of prior losses and fracturing of existing social networks and support. The role of religion is crucial in supporting refugee communities, and consideration should be paid to the needs of patients and caregivers when caring for a patient at home without access to their communities of origin and the support they accessed.

The Effects of the Ukrainian Conflict on Oncological Care: The Latest State of the Art

BACKGROUND

The COVID-19 pandemic has dramatically affected all aspects of the patient's pathway to cancer diagnosis and subsequent treatment. Our main objective was to evaluate the status of cancer trials in Ukraine as of September 2022.

METHODS

Initially, we examined with a narrative review the state of breast, colorectal, and cervical cancer population-based screening. Subsequently, we assessed each trial status for the years 2021 and 2022.

RESULTS

Estimates of participation in breast and cervical cancer screening are different from region to region. Moreover, regarding cervical cancer screening, extremely different participation estimates were reported: 73% in 2003 vs. <10% 2020. Our data show that from 2014 to 2020, despite the pandemic, cancer trials in Ukraine significantly increased from 27 to 44. In 2021 no trials were completed; in fact, we observed that out of 41 trials, 8 were active not recruiting, 33 were recruiting, and 0 were completed or terminated. In 2022 in Ukraine, for oncological pathologies, only 3 trials were registered, while in 2021, 41 trials were registered. The suspension of trials regarded above all concern hematological tissue (66.7%) and the genitourinary tract (60%).

CONCLUSIONS

Our work has highlighted how the areas most affected by the conflict present criticalities in oncological care.

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.

The burden and scope of childhood cancer in displaced patients in Jordan: The King Hussein Cancer Center and Foundation Experience

Introduction

Jordan hosts one of the highest numbers of refugees per capita in the world, with the Syrian crisis leading to an influx of displaced persons to the already vulnerable population. However, limited resources and a lack of cancer-care strategies have made it difficult for refugees in Jordan to access quality cancer care. The King Hussein Cancer Center (KHCC) and Foundation (KHCF) have played a pivotal role in providing financial and medical support for displaced children with cancer, treating 968 non-Jordanian children with cancer between 2011-2022, with a median age of 6 years. Of these, 84% were fully funded by KHCF, and nationalities included Syrians (29%), Palestinians (26%), Iraqis (23%), and Yemenis (17%). Cancer diagnoses included solid tumors (44%), leukemia (23%), lymphoma (13%), bone sarcomas (9.5%), and retinoblastoma (9.1%). The median cost of treatment was JOD 18,000 (USD 25,352), with a total estimated cost of JOD 23.8 million (USD 33.5 million). More recently, in partnership with St. Jude Children's Research Hospital (SJCRH), two successive humanitarian funds (HF) were established to optimize cancer care for displaced children in Jordan.

Results

Between February 2018 and September 2022, 51 children were fully treated on KHCC-SJCRH-HF, with a median age of 6 years and nationalities including Syrians (80%), Iraqis (6%), and Yemenis (8%). The most common cancer diagnoses were leukemia (41%), lymphoma (25%), solid tumors (24%), retinoblastoma (6%), and brain tumors (4%). Of these, 94% are alive and 51% are still receiving coverage. The median coverage for patients was JOD 21,808 (USD 30,715), and the total cost of treatment on KHCC/KHCF-SJCRH/American Lebanese Syrian-Associated Charities HF1 and HF2 was JOD 1.44 million (USD 1.97 million) and JOD 1.18 million (USD 1.67 million), respectively.

Conclusion

This experience highlights the high burden of displaced children with cancer in Jordan, and the importance of local foundations like KHCC/KHCF and partnerships with international partners like SJCRH in providing lifesaving humanitarian initiatives and quality cancer care. Innovative cancer-care delivery models and sustainable financing are essential to ensure continuous coverage and access to cancer care for displaced persons in Jordan.

Investigating the impact of COVID-19 on patients with cancer from areas of conflict within the MENA region treated at King Hussein Cancer Center

Background

There is a paucity of evidence regarding the impact of COVID-19 on cancer care among refugees or patients from areas of conflict. Cancer care for these populations remains fragmented due to resource scarcity and limited infrastructure.

Aims

To explore the effect of COVID-19 on cancer care among patients from areas of conflict treated at King Hussein Cancer Center (KHCC).

Methodology

We performed a retrospective chart review of all patients from areas of conflict, treated at KHCC from 2018 to 2021. Patients' demographics and clinical characteristics are presented in the form of descriptive statistics. Interrupted Time Series (ITS) analysis was utilized to investigate the impact of COVID-19 on the number of admissions throughout the study's period.

Results

A total of 3317 patients from areas of conflict were included in the study. Among these, 1546 were males (46.6%) while 1771 (53.4%) were female. Libyans (34.6%), Palestinians (24.8%), Iraqis (24.5%), Syrians (15.3%), and Sudanese patients (0.9%) constituted our study sample. ITS analysis demonstrated that the start of the COVID-19 lockdown significantly decreased admissions by 44.0% (p = 0.020), while the end of the COVID-19 restriction significantly improved admissions by 43.0% (p = 0.023). Among those with available SEER stages, more than a quarter of patients had distant metastasis (n = 935, 28.2%) irrespective of age and biological sex. Advanced presentations during 2020 had approximately a 16% and 6% increase compared to 2018 and 2019, respectively. Breast cancer (21.4%), hematolymphoid cancers (18.1%), and cancers of the digestive system (16.5%) were the most common cancers among our cohort.

Conclusion

Restrictions associated with COVID-19 had a significant effect on the number of admissions of patients from areas of conflict. In the long term, this effect may impact the survival outcomes of affected patients.

Syrian Refugee and Turkish Women with Breast Cancer: A Comparison on Clinicopathological Features and Survival

BACKGROUND

Cancer is a significant health problem for refugees and host countries. Breast cancer is the most common cancer among refugees. The subject of our study is to examine the clinical and pathological features of Syrian refugees with breast cancer and compare them with Turkish patients with breast cancer.

METHODS

Data of patients with breast cancer between January 2018 and December 2020 were retrospectively reviewed. The clinical and histological features, treatment modalities and overall survival were collected and analyzed.

RESULTS

A total number of 338 women with breast cancer were included in this study. Ninety-nine of the 338 (29.3%) patients were Syrian refugees and 239 patients (70.7%) were Turkish. The median follow-up time was significantly lower in Syrian patients (P<0.001). Median OS was 146 months in Turkish and 116 months in Syrian group (P=0.022). Independent risk factors associated with long survival were receiving adjuvant chemotherapy (HR 0.465; 95% CI 0.234-0.926; P=0.029), adjuvant radiotherapy (HR 0.372 95% CI 0.182-0.758; P=0.007), and adjuvant hormonotherapy (HR 0.367; 95% CI 0.201-0.669; P=0.001). The rates of receiving adjuvant chemotherapy, adjuvant radiotherapy, and adjuvant hormonal therapy were significantly lower in the Syrian group (P=0.023, P=0.005, P=0.002, respectively).

CONCLUSION

Syrian refugees with breast cancer are more likely to receive suboptimal treatments. They have inferior survival compared to local patients. Our findings highlight the need for the provision of cancer therapy in such vulnerable populations. We suggest that more attention should be paid to breast cancer, as it is the most common cancer among refugees.

Cancer diagnosis in areas of conflict

To date, many Arab countries within the Middle East are facing political, financial, and social instability from war and conflicts. These conflicts have led to severe resources shortages and sometimes complete breakdowns in cancer care and diagnosis. Cancer diagnosis at early stages is the most vital step in achieving optimal cancer care and outcomes. Shortages in cancer diagnostic services have meant that many people within areas of conflict are ultimately deprived of these services in their own countries. Therefore, many of these cancer sufferers must bear travel expenses to neighboring countries in order to seek these services. A lack of prevention, screening, and diagnostic services for this population is known to deepen the cancer care deficit within these areas. Additionally, the financial burden of traveling abroad alongside the need to secure childcare and time off work can be overwhelming. As a result, patients within areas of conflict are frequently diagnosed at later stages and are less likely to receive optimal management plans. Though conflict-affected regions encounter many similar challenges in delivering quality cancer care, pronounced region-specific differences do exist. Therefore, it is important to build a roadmap that can provide tailored solutions to deficits in instruments, manpower, and facilities for each and every region involved. Keeping in mind the importance of collaboration and coordination on national and international levels to address the ground disparity in cancer diagnostic services, the main objective of this review article is to examine the significant problems, shortages, and difficulties in providing cancer diagnosis with a focus on imaging to conflict-affected populations in the Middle East (mainly Iraq, Syria, Yemen, and Sudan). Finally, we discuss how access to cancer diagnostic imaging services has been impacted by these conflicts.

Cancer care for Ukrainian refugees: Strategic impact assessments in the early days of the conflict

BACKGROUND

The invasion of Ukraine by Russia in February 2022 has resulted in destruction of healthcare infrastructure and triggered the largest wave of internally displaced populations and refugees since World War Two. Conflicts in transitioned countries such as Ukraine create new non-communicable disease (NCD) challenges, especially for cancer care for refugees and humanitarian assistance in host countries. In the early days, rapid attempts were made to model possible impacts.

METHODS

By evaluating open source intelligence used in the first three months of the conflict through snowball search methods, we aimed to address: (i) burden of cancer in Ukrainian population, specifically considering translating to the refugees population, and its cancer care capacity; ii) baseline capacity/strengths of cancer systems in initial host countries. Moreover, using a baseline scenario based on crude cancer incidence in Ukraine, and considering data from UNHCR, we estimated how cancer cases would be distributed across host countries. Finally, a surveillance assessment instrument was created, intersecting health system's capacity and influx of internally displaced populations and refugees.

FINDINGS AND CONCLUSIONS

The total new cancer patients per month in pre-conflict Ukraine was estimated as 13,106, of which < 1 % are paediatric cases. The estimated cancer cases in the refugee population (combining prevalent and incident), assuming 7.5 million refugees by July 2022 and a female:male ratio of 9:1, was 33,121 individuals (Poland: 19284; Hungary: 3484; Moldova: 2651; Slovakia: 2421; Romania: 5281). According to our assessments, Poland is the only neighbouring country classified as green/yellow for cancer capacity, i.e. sufficient ablility to absorb additional burden into national health system; Slovakia we graded as yellow, Hungary and Romania as yellow/red and Moldova as red.

Cancer among syrian refugees living in Konya Province, Turkey

BACKGROUND

With more than 3.6 million Syrian refugees Turkey hosts the world's largest number of Syrians. Considering the morbidity, mortality, and healthcare spending, cancer is one of the leading health and economic burden for patients and healthcare systems. However, very limited information available in the scientific literature to understand the burden and characteristics of cancer in countries hosting Syrian refugees. The aim of the present study is to evaluate the demographic and clinical characteristics, treatment outcome of Syrian cancer patients living in Konya, Turkey.

METHODS

We retrospectively reviewed medical records of Syrian cancer patients at three major institutions from 2005 to 2020. The information regarding demographic and clinical characteristics of patients were identified. The number of days between the first symptom and diagnosis was considered as the "diagnostic interval". Patients who failed to attend clinics within four weeks of appointment were assumed abandoned treatment. Survival curves were estimated using the Kaplan-Meier method.

RESULTS

We identified 230 adult and 38 children refugee diagnosed with cancer during the study period. With regards to adult patients, there were 114 (49.6%) male and 116 (50.4%) female. The median age at diagnosis was 52.4, 47.3 years for male, female respectively. The five most common cancer by site among all were; breast (24.8%), colorectal (10.9%), lung (7.4%), central nervous system (CNS) (7.0%), and stomach (5.2%). 93 (40.4%) had metastatic disease at diagnosis. The overall survival probability was 37.5% at five years for the adult population. Data were extracted for 20 boys and 18 girls with childhood cancer. Their median age at diagnosis was 5.8 and 6.0 years respectively. The three most common childhood cancer were; leukemias (21.1%), lymphomas (21.1%), and CNS (13.2%). Excluding leukemia, 13 (43.3%) of childhood cancer cases had the advanced disease at diagnosis. Three year survival probality was 69.5%. The median diagnostic interval for adult and childhood cancer was 96.5 (IQR = 53-165) and 23 (IQR = 13.5-59) days respectively. Twenty-one adults and four children had treatment abandonment.

CONCLUSION

This study contributes to understanding the burden of cancer among Syrian refugees living in Konya, growing health issue for refugees. Larger and prospective studies will help to measure the real burden and compare the difference in cancer risk factors, care, and outcomes among the refugee and host populations.

The UK's contribution to cancer control in low-income and middle-income countries

Cancer mortality rates in low-income and middle-income countries (LMICs) are unacceptably high, requiring both collaborative global effort and in-country solutions. Experience has shown that working together in policy, clinical practice, education, training, and research leads to bidirectional benefit for LMICs and high-income countries. For over 60 years, the UK National Health Service has benefited from recruitment from LMICs, providing the UK with a rich diaspora of trained health-care professionals with links to LMICs. A grassroots drive to engage with partners in LMICs within the UK has grown from the National Health Service, UK academia, and other organisations. This drive has generated a model that rests on two structures: London Global Cancer Week and the UK Global Cancer Network, providing a high-value foundation for international discussion and collaboration. Starting with a historical perspective, this Series paper describes the UK landscape and offers a potential plan for the future UK's contribution to global cancer control. We also discuss the opportunities and challenges facing UK partnerships with LMICs in cancer control. The UK should harness the skills, insights, and political will from all partners to make real progress.

Late presentation and suboptimal treatment of breast cancer among Syrian refugees: a retrospective study

Objectives

The crisis in Syria has had a profound impact on the entire region. In this study, we report the patterns of presentation and management of Syrian patients with breast cancer treated at our institution.

Methods

We retrospectively collected data on Syrian refugees treated for breast cancer over the past 10 years at our center. Management was compared against our approved clinical practice guidelines.

Results

A total of 113 patients were eligible and included. The median age (range) at diagnosis was 47 (21–84) years and most women presented with locally advanced or metastatic disease (n = 74, 65.5%). Breast-conserving surgery and breast reconstruction were performed in 27 (33.8%) and 11 (35.4%) patients, respectively. Only a few patients received targeted (35.5%) or advanced endocrine therapy (30.0%). In total, 37 (32.7%) patients had considerable deviations from our institutional treatment guidelines and had worse outcomes.

Conclusions

Syrian refugees with breast cancer present late, have more advanced-stage disease, and are more likely to receive delayed and suboptimal therapy. An international systematic approach for cancer care among such vulnerable populations is urgently needed.

Compounded trauma: A qualitative study of the challenges for refugees living with advanced cancer

BACKGROUND

Although palliative care is now an essential health service under Universal Health Coverage, ensuring access and appropriate care for refugees is a specific challenge for this large population.

AIM

To identify the needs and experiences of adult refugees in Jordan with advanced cancer and informal caregivers.

DESIGN

A qualitative study using semi-structured interviews.

SETTING/PARTICIPANTS

Participants were purposively sampled at two Jordanian hospitals to achieve heterogeneity by age, gender, country of origin, and primary diagnosis.

RESULTS

Twenty-nine refugees (22 patients, 7 caregivers) participated, and four themes were generated: (1) Psychological distress and sustaining social support. Refugees often experienced unmet psychosocial needs. However, psychosocial support was reported either absent or limited. (2) Knowledge and uncertainty. Lack of information and poor communication between healthcare providers and patients caused significant distress due to uncertainty. (3) Family anxiety and support roles. Being away from the home country cut patients and caregivers off from their wider social support network, which added increased anxiety and responsibilities to caregivers. (4) Compounded trauma and poverty. Many refugees have experienced trauma related to war that may affect their physical and mental health. They faced serious financial crises caused by the rising cost of medicines and treatment.

CONCLUSIONS

This study reveals the impact of fractured families and networks on social support in advanced cancer, and the compounding trauma of the disease for refugees. Detailed person-centred assessment and emphasis on psychosocial support is essential, and home-based care should not presume community support for patients to remain at home.

Changing Mortality and Place of Death in Response to Refugee Influx: A Population-Based Cross-Sectional Study in Jordan, 2005-2016

Background: Jordan faces complex health care challenges due to refugee influx and an aging population. Palliative care planning and delivery require data to ensure services respond to changing population needs. Objectives: To determine the trend in mortality and place of death in Jordan. Design: Population-based study. Setting/Subjects: Death registry data of adult decedents (n = 143,215), 2005-2016. Measurements: Descriptive statistics examined change in demographic and place of death (categorized as hospital and nonhospital). Binomial logistic regression compared the association between hospital deaths and demographic characteristics in 2008-2010, 2011-2013, and 2014-2016, with 2005-2007. Results: The annual number of deaths increased from 6792 in 2005 to 17,018 in 2016 (151% increase). Hospital was the most common place of death (93.7% of all deaths) in Jordan, and percentage of hospital deaths increased for Jordanian (82.6%-98.8%) and non-Jordanian decedents (88.1%-98.7%). There was an increased likelihood of hospital death among Jordanian decedents who died from nonischemic heart disease (odd ratio [OR]: 1.11, 95% confidence interval [CI]: 1.09-1.13, p < 0.001), atherosclerosis (OR: 1.10, 95% CI: 1.08-1.13, p < 0.001), renal failure (OR: 1.05, 95% CI: 1.02-1.08, p < 0.001), hemorrhagic fevers (OR: 1.09, 95% CI: 1.06-1.13, p < 0.001), and injury (OR: 1.18, 95% CI: 1.06-1.33, p < 0.001) in the period 2014-2016, compared with 2005-2007. There were similar increases in the likelihood of hospital death among non-Jordanians in 2014-2016 for the following conditions: malignant neoplasms (except leukemia), nonischemic heart disease, atherosclerosis, injury, and HIV, compared with 2005-2007. Conclusions: Country-level palliative care development must respond to both internal (aging) and external (refugee influx) population trends. Universal Health Coverage requires palliative care to move beyond cancer and meet population-specific needs. Community-based services should be prioritized and expanded to care for the patients with nonischemic heart disease, atherosclerosis, renal failure, hemorrhagic fevers, and injury.

Cancer research in the 57 Organisation of Islamic Cooperation (OIC) countries, 2008-17

Background and objectives

The 57 countries of the Organisation of Islamic Cooperation (OIC) are experiencing rapid increases in their burden of cancer. The First Ladies Against Cancer meeting at the 2016 OIC meeting in Istanbul committed to the importance of cancer control and the need for more evidence to support national cancer control planning (NCCP). Strong research systems are a crucial aspect of NCCP, but few data exist to support policy-makers across this political grouping

Methodology

We identified all cancer research papers from OIC countries in the Web of Science from 2008 to 2017 with a filter based on journal names and title words, with high precision and recall. We analysed the country outputs, the cancer sites investigated, the types of research, sources of funding and the citations to the papers.

Results

There were 49,712 cancer research papers over this period. The leading countries in terms of output were Turkey, Iran, Egypt and Malaysia, but the most cited papers were from Qatar, Indonesia and Saudi Arabia. International collaboration was low, except in Qatar and the United Arab Emirates. The site-specific cancers accounting for most research were breast and blood, correlating with their disease burden in the OIC countries, but lung, cervical and oesophageal cancers were relatively under-researched. Most funding from within the OIC countries was from their own university sector.

Conclusion

Cancer is seriously under-researched in most of the OIC countries. This will undermine the ability of these countries and OIC as a whole to deliver on better cancer control for their populations. New policies, OIC leadership and funding are urgently needed to address this situation.