Abstract
BackgroundExisting evidence suggests that women who develop breast cancer in Gaza experience relatively poor survival. This is believed to reflect (i) delay in presenting for diagnosis and treatment; and (ii) lack of basic elements of treatment. Delay in presenting for diagnosis and treatment is believed to result from fear, embarrassment, and fatalism among women who experience symptoms that may be attributable to breast cancer. The poor rates of survival are likely to reflect a lack of access to even basic elements of treatment. These were the issues that contributed to the design of this investigation into factors that might be responsible for the low survival of women with breast cancer in Gaza, and to identify which policies and interventions might be needed to improve survival.
Methods
The study was based on a case series of clinical records of women diagnosed with breast cancer in Gaza between 1 January 2017 and 31 December 2018. Women were followed-up until 31 December 2020 using clinical and mortality records. Detailed clinical and treatment data were extracted from the medical records. Quantitative variables were presented as medians and means (Inter Quartile Range – IQR). The one-year and two-year overall survival probabilities were estimated using the Kaplan-Meier method, and univariate and multivariate Cox proportional hazard regressions were used to estimate hazard ratios (HR) and their 95% confidence intervals (95% CI). In addition, semi-structured interviews with 10 healthcare providers and 20 patients diagnosed during the study period were conducted to examine the experiences of giving and receiving cancer care in Gaza. Interviews were transcribed verbatim and translated from Arabic to English. The Framework approach was used to analyse the interviews.
Results
Five hundred and twenty-four women were diagnosed with breast cancer in 2017 and 2018, giving a crude annual incidence rate of 27 per 100,000 population, and a mean age at diagnosis of 53 (range 23-100) years. Half of these women (260/524) had sought healthcare within a month of experiencing a possible symptom of breast cancer. Eight percent of the women (44/524) had sought healthcare between one and three months after experiencing a symptom, and about 10% (54/524) did so more than three months after experiencing a symptom. Thirty-five percent of the women (185/524) were diagnosed at stage two, 33% (171/524) at stage three, 19% (99/524) at stage four, and 6% (32/524) at stage one. Data on key prognostic factors were available in most cases – stage (93%), ER, PR, HER2 (82%), and slightly less often for tumour grade (77%) and tumour size (70%). Fifty-two percent of the women underwent modified radical mastectomy. By 31 December 2020, 99 (19%) of the women in this study had died. The total estimated median time between diagnosis and death was 22·7 months. The one-year overall survival was 95%, and the two-year overall survival was 86·6%.
During the interviews, many women reported negative experiences at cancer hospitals, especially misdiagnosis and lack of effective communication between them and their doctors. They also reported lack of treatment being the main barrier to effective cancer care, especially for Goserelin and radiotherapy. This issue was also cited by oncologists who described the difficulty of adhering to treatment protocols for early-stage breast cancer because radiotherapy was not available in Gaza and because of frequent disruption in drug supplies. The huge workload, and the lack of financial and staff support, alongside the lack of diagnostic materials and treatments seem likely to have had a significant negative effect on how the health system operates to improve early diagnosis and treatment in Gaza.
Conclusion
Lack of hospital facilities for diagnosis and treatment are barriers to effective cancer care in Gaza. Despite major challenges, Palestinian women with breast cancer have a high short-term survival after diagnosis.
| Date of Award | 1 Aug 2022 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Richard Sullivan (Supervisor) & Elizabeth Davies (Supervisor) |