How the Middle East's 'cancer divide' can mean the difference between life and death

Figures from the World Health Organisation show a vast difference between cancer detection and mortality rates across the Mena region

A mobile breast cancer check-up clinic in a lorry is part of a campaign in Gaza to raise awareness of early tests to detect the disease. All photos: Reuters

Palestinian women take part in the breast cancer awareness campaign.

Health authorities and charities in Gaza are stepping up efforts to persuade women to be tested for breast cancer. They hope to overcome social stigma in the enclave about dealing with the disease.

Breast cancer accounts for 32 per cent of cases of cancer among women in Gaza, the health ministry said.

Waiting in the car, a boy watches as women go to be tested.

A Palestinian doctor prepares a woman for a breast cancer check-up inside a mobile clinic set up in a lorry.

A woman waits to be examined inside the lorry, which is decorated in pink.

The "There's no shame in it" campaign was launched by private charity Fares Al Arab with the health ministry.

The Middle East and North Africa region faces a cancer divide, with developing nations recording high mortality rates while richer countries are often detecting and treating the disease before it becomes terminal.

Israel had the highest rate of new cancer cases in the region last year.

But despite its high number of new cases (240.7 per 100,000 people), the country had only the fifth-highest cancer mortality rate among Mena countries.

Around 90 people died from cancer in Israel per 100,000 of the population last year, according to the World Health Organisation.

By contrast, Egypt had the highest cancer mortality rate in the region – even though its rate of new cases was much lower than Israel’s.

An estimated 108 people died from cancer per 100,000 of the population in Egypt last year.

Lack of early detection, poor public awareness of cancer and the huge cost of treatment are factors fuelling higher mortality rates in developing countries, experts said.

“The majority of patients are being diagnosed in advanced stages,” said Dr Emad Shash, medical director of the Breast Cancer Comprehensive Centre at the National Cancer Institute at Cairo University.

Late diagnosis reduces survival chances. This was a common problem across developing countries, Dr Shash said.

Egypt ranked 116th out of 189 nations last year in the UN’s human development index, which measures factors such as a country’s gross national income per capita and its citizens’ expected years of schooling.

By contrast, Israel was 19th on the index.

Liver cancer caused the most deaths out of all cancers in Egypt last year.

The Egyptian government launched a 100 Million Healthy Lives campaign in 2018 to increase screening and testing of hepatitis C, which can lead to liver cancer. It also aims to increase early screening for breast cancer.

Dr Shash called for caution when interpreting WHO figures as they are estimates. In fact, medics have long called for more accurate data on cancer in the Mena region.

“Only then will we be able to invest properly according to what we need,” said Dr Mohanad Diab, consultant medical oncologist at NMC Royal Hospital in Abu Dhabi.

Lockdowns triggered by the coronavirus pandemic also meant fewer cancer cases may have been detected last year, said Dr Diab. This means more advanced cases could be coming to light this year.

Meanwhile, stigma continues to claim lives said Prof Michael Silbermann, head of the Middle East Cancer Consortium, a regional initiative for cancer research and treatment.

“If you have cancer in the family, it has a big stigma for the entire family,” he said.

He described meeting a woman of 38 in a cancer ward in Jordan. She was terminally ill with breast cancer.

“So, I asked her: 'Why did you wait so long? Why didn’t you come earlier?'” he said.

“Her response was: ‘If my neighbour knew that I had cancer, my daughters would not get the chance to marry.’"

People need to know that a cancer diagnosis does not mean “automatic death” and that the disease is not only hereditary, but environmental factors play a huge role too, said Prof Silbermann.

After Egypt, Gaza and the West Bank had the Mena region’s second-highest cancer mortality rate. It was followed by Syria, which had the third-highest cancer mortality rate.

Conflict has worsened the situation.

In April, The National reported the plight of cancer patients in Gaza who faced delays to treatment because of the complex system of permits required to allow them to travel to health facilities.

More than a decade of conflict and economic sanctions in Syria have led to the destruction of institutions and resources and limits on the import of new equipment and technology, wrote Dr Maha Manachi, haematologist and oncologist at Al Bairouni University Hospital in Damascus, in Cancer in the Arab World, a book to be published later this year.

For residents of richer Mena countries, health outcomes appear more promising.

Saudi Arabia had the lowest rate of cancer-related deaths. An estimated 51 deaths per 100,000 of the population were registered last year.

The kingdom was followed by the UAE, which registered around 56 cancer-related deaths per 100,000 of the population last year.

But even in these countries cancer remains a pressing problem.

The cancer incidence rate among young people in both countries was found to be very high, in a study by Dr Humaid Al Shamsi, professor of oncology at the University of Sharjah.

In the UAE, the cancer incidence rate among those aged between 20 and 49 was more than 37 per cent. It was more than 39 per cent among this age group in Saudi Arabia.

This was extremely high when compared to countries such as the US, where the cancer rate among this age group was less than 9 per cent.

“The incidence is alarming and requires focused research to address potential risk factors,” wrote Dr Al Shamsi in the report, which was released this April.

Dr Al Shamsi, lead author and editor of Cancer in the Arab world, identified obesity and smoking as risk factors in the UAE.

Dancer's battle with cancer ends in double mastectomy

Israeli dancer and choreographer Eylon Nuphar was 33 when she felt a lump the size of a pencil tip in her breast.

Her doctor assured her it was nothing to worry about and advised her to continue with work plans to travel to Argentina.

But she began having dreams about her hair falling out and ants crawling over her body. When she returned to Israel, she visited her doctor again.

“We discovered it was triple-negative cancer that had travelled to the lymph nodes,” said Ms Nuphar, now 50.

Triple-negative breast cancer is usually a more aggressive type of breast cancer and can be harder to treat.

“It was based on my intuition. I felt fine, I felt great – but my body was telling me there was something strange going on” said Ms Nuphar.

“So, my first message would be to always listen to your instincts and not just somebody else’s.”

More than 4,300 women in Israel were diagnosed with cancer last year.

Ms Nuphar had a lumpectomy, radiation therapy and chemotherapy. The cancer went into remission. But 16 years later she was diagnosed with breast cancer again.

This time she chose not to have chemotherapy because research showed it would be less effective and produce harsher side effects a second time around.

Instead, Ms Nuphar chose to have a double mastectomy and rejected the offer of breast reconstruction surgery.

When she compares her experience with that of friends and family members in the US, who did not receive access to adequate health care when they needed it, Ms Nuphar says the healthcare system in Israel has made her feel “safe”.

“I am very appreciative of being able to use the system when I needed it,” she said.

But she believes life in Israel is stressful and could be contributing to the high incidence of cancer.

She is also passionate about raising awareness of breast cancer.

Last year, Ms Nuphar posed on a magazine cover wearing a pink trouser suit baring her scarred and flat chest.

She wanted the world to see that there is more than one way for breast cancer survivors to look.

The prospect of having seven to eight further operations to rebuild her breasts struck Ms Nuphar as “insane”.

“I don’t need my breasts in order to feel beautiful,” she said. “I’m just going to live without them and try to live as healthy as I can.”

Globally, 2.3 million women were diagnosed with breast cancer last year and 685,000 died.

Early detection can save lives.

“Every woman should be able to be checked for breast cancer because it’s such a huge phenomenon,” said Ms Nuphar.

“Every woman should be able to do that. It should be as basic as water and food.”