The incidence of breast cancer in female patients in the Middle East may be lower than in Western countries, but mortality rates are considerably higher.
In the World Health Organization’s latest published figures for its East Mediterranean Region – which spans from Tunisia in the west to Pakistan in the east – there were 99,000 cases of breast cancer in 2012 and 42,000 deaths from the disease. Compared with the EU, for example, which reported 362,000 cases and 92,000 deaths, there is no question that the rate with which sufferers in the East Mediterranean are dying from the disease is striking.
The figures are especially tragic given that the average age at which patients in Arab countries are affected by the disease is around a decade younger than those in the West. In Oman, for example, nearly half of patients are diagnosed before their 50th birthday, while in the UK, 80% of breast cancer cases are diagnosed in the over-50s.
Naturally, the reasons for such high mortality rates are numerous and differ between countries. They are also largely still being established, with a lack of comprehensive data and region-specific research. But one frequently cited cause is the absence of robust national screening programmes.
Early detection
An expert who has witnessed such issues first-hand is Dr Rola Shaheen. Currently medical director of diagnostic imaging at Peterborough Regional Health Center in Ontario, Canada, Shaheen worked for Abu Dhabi’s Mafraq Hospital in 2012–2015, where she spearheaded the planning of breast imaging services. She was the Susan G Komen foundation’s regional director for the Middle East in 2011, and is currently leading a comparative study on breast cancer awareness in the region, sponsored by the charity.
A particular problem contributing to the high mortality rate is the issue of late presentation, Shaheen explains, with a large number of patients being diagnosed with aggressive cancer at a late stage.
“When a woman presents late, that obviously means that she didn’t have early detection,” she says. “And the reasons for there being so few early detections are: number one, the lack of a robust national screening programme; and number two, awareness, awareness, awareness. A lot of women don’t know how important it is to diagnose breast cancer at the early stages. So if they feel a lump, they may ignore it and think it’s nothing.”
This is especially the case in younger patients who are still at an age where they may be pregnant and breastfeeding, Shaheen says, and so may not associate a lump or cyst with something being amiss as readily as older patients might.
“Unfortunately, breast cancer tends to affect younger women in the Middle East,” Shaheen says, “hitting those at least ten years younger than the West. The incidence is higher in the 40–50 age group – or I would even push it to 35–45 – compared with the higher ages of women affected in the West.”
Arab women also tend to have a larger tumour size on first presentation, and some studies have shown that Arab populations have a higher incidence of breast cancer spreading to the axillary (armpit) lymph nodes, as highlighted in a 2013 Lancet Oncology review of research into breast cancer in Arab women, led by Professor Lotfi Chouchane of Qatar’s Weill Cornell Medical College.
Such trends make early detection ever more vital, but women are often held back by fear of what a diagnosis and subsequent treatment could entail, Shaheen says.
“If a woman finds a breast lump and she is scared, she may not know who her support circle should be, whether it’s her family or her doctor; and she may not know which doctor to go to. And she thinks, ‘if I go there, what will the doctor do? Are they going to chop off my breast?’”
Shaheen adds, “I feel like the women are lost. For example, I’m a radiologist, so I’m not supposed to be providing counselling, but when I was working in the Middle East, I ended up counselling women when it came to breast cancer because of the lack of multidiscipline breast centres.
“We need more of these, in my opinion. We can do breast exams and breast awareness, all the way from nurse practitioner to our social workers, our general practitioners, surgeons, radiologists, pathologists, oncologists; we really need a good collaborative centre, where a woman can walk in and be taken care of.”
Stopping the stigma
Some reports have suggested that a different sentiment may also play a role in women’s unwillingness to be diagnosed and treated, pointing to a certain stigma or shame attached to the illness. For example, Suzan Murad, director of the Al-Wa’ad Society for Cancer Advocacy and Survivorship in Amman, Jordan, was quoted by Al Jazeera last year saying, “Women are terrified of the possibility of a mastectomy and what outcomes this could have; many worry that their husbands will leave them.”
For Shaheen, however, this ‘shame’ is not an issue that she has encountered during her time working in and researching the region. Such research has recently included surveying women and physicians in ten Arabic countries as part of her comparative study for Susan J Komen.
“We did think that a factor could be that they don’t want to be labelled; these cultural barriers,” Shaheen says. “But to my surprise, when I did a small study in the Gaza Strip, for example, that just was not the case. It’s the fear. It’s the thought that screening will not help, the thought of ‘why should I go and look for trouble for myself; I only go to the doctor when I’m sick’. So you’d be surprised what the behavioural issues are – and these are behavioural issues that can be changed through awareness.”
At the same time, Shaheen acknowledges that there is a degree to which the concern of ‘labelling’ may be an issue when it comes to genetic investigations into the cause of the disease, with families not wanting to be branded as susceptible.
While thorough research needs to be undertaken to determine the precise factors for the early age at which breast cancer affects Middle Eastern women, it is likely that there is a genetic element to this as well as environmental. Women in the Middle East have in place many of the lifestyle factors that wider research into breast cancer has shown to be protective, to a degree, such as childbirth and breastfeeding – and yet they are still falling victim to the disease at an earlier age.
Sensitive, regional-specific research into the social factors surrounding breast cancer diagnosis and the medical factors triggering the disease in Middle Eastern women will be vital to defeating it and improving patient outcomes.
“We need to have our own research,” Shaheen emphasises. “We are following in the footsteps of the West but, as you can see, our risk factors are different; our patients are getting hit at younger ages and they are getting the aggressive cancer. And that raises the point that we need our own research, and to pull recommendations from our own internal resources.”
Patient-first policies
Shaheen also believes that Middle-East-focused research is likely to provide further evidence of the need for rigorous screening programmes, even as some Western experts have begun to argue that such programmes may not necessarily be helpful. Shaheen says that screening based upon medical evidence should be tailored to the requirements of individual women, some of whom will be candidates for physical examination, others for MRI, mammograms or ultrasounds. A careful approach of this kind could help to weed out problems such as the difficulties of imaging dense breast tissue in younger patients, and will also allow the diagnostic work-up that is needed to identify the follow-up investigations and treatments patients require.
Shaheen feels that multidisciplinary breast assessment centres offering screening, diagnosis and treatment provide the best model for achieving this, backed up by consistent education in the community to raise awareness.
“Early detection of breast cancer should be a priority for the policy makers, because it can have a huge impact on the quality of life of patients: it may save them from chemotherapy and radiotherapy, and there is, of course, also the cost of these things,” she says. “Whether the patient or the government is paying, we can save a huge amount. But they also shouldn’t forget the age group. Breast cancer is affecting women at their peak of giving to society, when they often have young children, and so the cancer is not just affecting the patient, but also her family.”
Shaheen and her co-authors hope to publish the results of their comparative study in April 2016. For patients in the Middle East, meanwhile, it will be a longer wait before the large-scale developments required in research, policy and awareness take shape within different countries in the region. However, Shaheen is positive about the changes that are already occurring and the active role that breast cancer survivors themselves are playing.
“It’s very inspiring to work in the Middle East, because you can see there are now huge efforts and a genuine interest from governments to improve breast cancer care. Everybody in our society has been touched by breast cancer through someone they know, and the good news is that there are now survivors, including young survivors who have had early detection and continued with their lives.
“This is the big difference from 15 or 20 years ago, when breast cancer was seen as a lethal disease. Survivors in the Middle East are getting together in big groups, and I highly encourage them to build on their activities so that more people are aware of the really positive effects of early detection.”
