1.1 Background

Stretching from Asia towards Africa and passing through the Middle East and the Arabian Gulf, Arab countries have been listed as a group of 22 Arabic speaking countries that have a population of approximately 620 million (Fig. 1.1) [1].

Fig. 1.1
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Map representing the Arab countries. [Source: https://mapchart.net/]

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Arab countries share a considerable deal in terms of culture, yet there is great variability in their economic capabilities and growth. There is considerable heterogeneity between and within populations when it comes to disease epidemiology and profile, although cancer burden remains significant across all countries. According to available data, cancer incidence rates are increasing due to developing age and population, with crucial consequences for the healthcare system and community [2].

1.2 Cancer Profile in the Arab World: An Overview

Cancer is a global public health issue. The most common cancers worldwide, in both genders, include breast, lung, colorectal, prostate, and stomach cancers. An analogous pattern exists in the Middle East and North Africa (MENA) region, whereas bladder and stomach cancers comprise the fifth and sixth most frequently occurring malignancies. In Gulf Cooperation Council (GCC) countries, colorectal, non-Hodgkin’s lymphoma, lung, and liver cancers are most prevalent in males, whereas breast cancer, followed by thyroid, colorectal cancer and non-Hodgkin’s lymphoma are most prevalent among females [3]. Cancer is the fourth leading cause of death in the Eastern Mediterranean Region (EMR), with approximately 419,000 deaths, in 2018; with breast, bladder, colorectal, liver, and lung cancers being the most prevalent. In EMR, the most frequent cancer cases among males include lung, liver, and prostate with 10.4%, 8.4%, and 8%, respectively; whereas the most predominant cancer cases among females include breast, colorectal, and cervical cancer with 34.7%, 5.7%, and 4.6%, respectively [1]. The EMR and GCC states demonstrate a startling growth in oncology patients’ tally. Long-term estimation illustrates that by 2030, there would be a 1.8-fold spike in cancer incidence rate [4]. GLOBOCAN (2020) reported the rank of new cancer cases, among both genders and of all ages, in the Arab region (Table 1.1) [5].

Table 1.1 The rank of cancer cases in the Arab world [5]. Used with permission from the International Agency of Research on Cancer (IARC)/GLOBOCAN, 2020
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Population expansion, lifestyle modifications, industrialization, increase in lifespan, urbanization, and higher frequency of exposure to prospective causative factors are all expected to promote increased cancer incidence [1].

The observed variation in new cancer cases in the Arab world, which has been presented by different Arab countries in this book, reflects the fluctuating predominance and risk factors’ distribution within and between Arab countries. This also suggests variation in delivery of efficient cancer control measures. The strategies should be introduced to lessen the disease burden in Arab countries to reflect the similarities and differences in cancer rates among the region.

1.3 Cancer Risk Factors

Although cancer etiology is multifactorial, an array of well-known risk factors has been contemplated as a major contributor to the advancement of cancer epidemiology (Table 1.2) [4, 6].

Table 1.2 Prevalent cancer risk factors
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1.4 Current Circumstantial Analysis

When compared with other MENA countries, Lebanon has a high Central Nervous System (CNS) cancer incidence rate in both genders. A study published in 2020 reported that males were more affected (34% increased risk) by CNS cancer compared with females in Lebanon. The association of various risk factors with the increased incidence of CNS cancers in the Lebanese community was observed. This includes pesticide exposure (agricultural workers are at high risk of such exposures due to their work-setting), ionizing radiations (CT scans), high level of uranium depletion (due to war and conflicts in the country), and genetic susceptibility [7].

In 2014, a study on high breast cancer incidence among Arab women showed obesity and strong family history were the prevailing risk factors in the community [8]. The significant economic progress in some parts of the Arab world has resulted in rapid urbanization in the region. Subsequently, lower physical activity, more accessibility to personal conveyance, and high caloric food intake have led to higher rates of obesity among the Arab population. Moreover, it was observed that women are more likely to become obese or overweight compared with men due to cultural norms [9].

From the hereditary cancer aspect, several Arab communities suffer from genetic disorders. This could be the result of increased inbreeding frequency (25–60% of all marriages are consanguineous, usually first cousin marriages). The absence of public health measures has aggravated the situation, along with legal, cultural, and religious limitations in the Arab world. Comprehensive research on familial cancers is needed in the Arab region, specifically broad-scale genetic screening programs coupled with genetic counseling. Few Arab countries (Saudi Arabia, Qatar, Egypt, and the United Arab Emirates) have launched their respective human genome project initiatives, which may pave the way to understanding of familial cancer genes [10].

Tobacco smoke is considered one of the most prevalent causes of lung cancer. Most Arab countries (Bahrain, Tunisia, Algeria, Morocco, and Libya) were able to illustrate a clear association between the risk of lung cancer and tobacco smoking prevalence in both genders. Few Arab countries, however, showed moderate (Egypt, Syria, and most GCC countries, except Bahrain) and low (Djibouti, Sudan, Yemen) cancer incidence rates despite high rates of smoking [11].

Asbestos exposure is associated with lung cancer, pulmonary fibrosis, and malignant pleural mesothelioma (MPM). In Egypt, mesothelioma cases represent 0.5% of all cancer cases. Studies from Lebanon, Jordan, and Tunisia have also reported the oncogenic effects due to asbestos exposure [11,12,13]. Considering the harmful effects of asbestos, the Government of Jordan issued a decree in 2005 to prohibit all kinds of asbestos [14].

A unified cancer control strategy is required at different community levels in the Arab region. Reducing exposure to avoidable risk factors can be the most effective strategy to control cancer. This can be achieved by adapting to an active lifestyle, following governmental policies, making healthy choices, and developing a commitment to maintain a better and healthier environment.

1.5 Oncology Care in the Arab World

1.5.1 Role of Cancer Registries

A cancer registry is an exclusive source of information. It is quite helpful for countries to develop strategies for cancer care and health programs. Several Arab countries have started to realize the importance of cancer registries which led to the establishment of the Gulf Center for Cancer Registration (GCCR), for the generation of population-based incidence data from GCC countries including Saudi Arabia, Bahrain, Kuwait, Qatar, the United Arab Emirates, and Oman. The registry started collecting data from 1st January 1998. The system works by assembling the data from the National Cancer Registry (NCR) of each individual country, followed by quality assurance measures. Data is received by GCCR in various formats (e.g., Epi-Info, Excel). Subsequently, GCCR converts all files to CanReg format (a validated software developed by the International Agency for Research on Cancer (IARC) to process cancer data) and then performs relevant analyses [15].

The most important element in cancer registration is to document mortality data, which can be affected by the extent to which the details have been provided and accuracy of the recorded cause of death along with completing the death registration process. These can vary significantly between countries and over time [6]. Most countries in the Arab world possess population-based cancer registries. However, all cancers are not well-documented and statistics for cancer mortality are also limited [4].

Comparative situational analysis can critically assess the cancer incidence, mortality, and survival patterns [6] in the Arab world, but this requires proper documentation for cancer mortality and morbidity rates to allow comparisons with Western countries.

1.5.2 Functionality of Oncology Societies in the Arab Region

The main responsibilities of cancer societies are to promote and foster the multidimensional care of cancer patients, by connecting practicing oncology professionals across all the disciplines (Fig. 1.2). Such associations support optimization of the expertise level among cancer professionals, augment the efficiency of cancer treatment, and strengthen collaborations with foreign oncology health bodies and encourage them to participate in Multidisciplinary Tumor Board Meetings (MDTs).

Fig. 1.2
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Renowned cancer societies in the Arab world

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1.6 Cancer Control Framework Recommendations

Various interventions can determine cancer outcomes, stretching from primary prevention to end-of-life care. A healthcare infrastructure that has been designed to deliver public health programs which can improve cancer outcomes along with turning down the cancer mortality rate (including clinical services for cancer diagnosed patients) is inevitably complex. This involves a broad range of highly competent professionals, together with input from their respective establishments at all stages of the healthcare journey [6].

Planned initiatives taken by healthcare authorities can lead to improved cancer outcomes among their country’s population as well as at the individual’s level. The following are excerpts from a study which suggested a complete range of interventions that can improve European cancer patients’ outcomes [6]. The Arab world can also draw advantages by incorporating these suggestions into their healthcare infrastructure.

These recommendations include [6]:

  • The population requires efficient cancer prevention, screening, and early diagnosis programs with the aim of achieving an overall reduction in cancer mortality rate.

  • Individuals, who might have cancer, require a quick approach to appropriate professionals, for detailed examination, following proper clinical management.

  • An effective cancer care system depends on a wide spectrum of cancer specialties, including multidisciplinary clinical professionals. This integrative approach executes the best plan for their respective patients’ diagnosis, management, and support. Clinicians must also ensure safe and efficient treatment delivery to their patients.

  • Diagnostic and treatment services should be accessible at all levels: primary, secondary, and tertiary. The majority of cancer patients reach out to different providers in the healthcare system during their treatment period. Hence, it is compulsory for the entire system to practice exceptional operational skills and develop the logical cancer care management plan.

  • Effective communication and coordination skills among healthcare professionals must exist in the oncology care structure at every stage, to ensure the well-functioning delivery of cancer treatment.

  • Complicated diagnostic interventions (like in lymphoma cases) or treatment (e.g., surgery, chemotherapy, or radiation for esophageal cancer cases) should be concentrated in a cancer-dedicated place, where all such essential expertise can be assembled in a cost-effective manner and the outcomes can be assessed persistently.

  • The patients’ views on therapeutic options along with the expected outcomes should be taken in consideration while making clinical decisions.

  • A comprehensive cancer care plan should also implicate quality of life and psychosocial issues.

The need for high standard clinical cancer care services and a rise in patients’ expectations for good outcomes has strained the entire healthcare system, even in countries with a strong economy. The growing expense of oncology treatments (including a speedy hike in anticancer drugs’ cost) further increases the pressure on healthcare systems [6]. The Arab countries can cope with such a burden if they follow certain suggestions such as:

  • Adopt systematic health technology assessment

  • Assort the public health and clinical preferences

  • Set the plan for the type of cancer treatment to be given and under what circumstances [6]

The aforementioned strategies, if applied in the Arab world, can support a framework for analytical decision-making, under inevitably limited resources.

The management of cancer patients can be reformed by advancing knowledge. Outstanding research determines the standard of care, and the significant relationship between research and the quality of patient care. Few studies have suggested that entities which take active part in clinical trials may generate improved outcomes. Advanced countries such as the United Kingdom and France have acknowledged this by extending links between clinical research, specifically Randomized Clinical Trials (RCTs) and oncology treatment systems. This kind of alliance is expected to improve cancer care delivery [6]. The field of cancer research has started developing in the Arab world. However, when compared with other regions, the total research output is nominal. Various gaps have been identified in a study that reviewed cancer research in the Arab World. The study found a deficiency in research that involves elderly individuals and analysis of certain risk factors, such as diet [3].

1.7 Cancer in the Arab World Book

There have been several articles, papers, and reviews that have attempted to quantify the cancer burden across the Arab region, yet these papers often target a specific site of cancer. So far, no comprehensive cancer analysis including epidemiological findings, oncology care services, education, and research for Arab countries has been presented. Hence, the editors came up with the notion of a book, entitled “Cancer in the Arab World.” This book features general cancer care together with indications of challenges and suggested solutions for the Arab world.

The authors were invited to write about the general cancer care approach for their respective countries. Included countries were Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen.

Moreover, eight special chapters were also included based on specific relevance and importance in the Arab region. These tackle common questions on breast and colorectal cancer, cancer care in conflict zones, palliative care, pediatric oncology, radiation therapy, challenges associated with medical tourism, and cancer research in the Arab World.

We do acknowledge that there were few countries for which we had difficulty in identifying authors or who had limited access to cancer related databases. Every author had gathered as much accessible and published data and relevant information from their respectful country as they could. However, there were several barriers related to the lack of data, or scattered information, or cancer statistics that have not been updated at the time of data collection.

The book analyzes the landscape of cancer care perspectives in Arab countries, to identify the gaps and opportunities in oncology care. This resource explores the issues associated with access and barriers to a high standard cancer care delivery throughout the region. The oncology field in the Arab world is complex. The cancer care burden in the region has been unevenly distributed based on gender, location, together with other various factors. Moreover, crises such as conflict zones and the growing number of immigrants have placed additional stress on oncology care organizations and providers in several countries.

1.7.1 Book Structure

This book attempted to incorporate the most crucial clinical service elements, recommended by the World Health Organization (WHO) for cancer control program [16]. An excellent approach to the complete spectrum of clinical services is important for prompt and suitable cancer diagnosis and treatment. Such services are crucial to timely curing cancer. The components have been elaborated under the aegis of more than 50 authors for their respective Arab countries (Fig. 1.3). Furthermore, in this volume, we tried to include the subjects that encompass the challenges in oncology core services, in accordance with the accessibility of the data for each country (Fig. 1.4). The cancer core services rely upon the center’s capacity, and the allocation of healthcare facilities (stand-alone, union of health providers, or part of a larger hospital).

Fig. 1.3
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Key cancer control components

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Fig. 1.4
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Basic oncology core services

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This project has been initiated to determine the void areas in cancer care prospects in the Arab world. It allows the readers to acquire a unique source of information to anyone tackling this subject in the region. Lastly, the book also aims to hopefully encourage all Arab countries to contribute and share cancer information among each other and internationally, to help analyze the areas that need to focus on cancer research and treatment in the future.

1.8 Closing the Gaps in the Cancer Care System

The comprehension of the shortfall in standards of current cancer services, along with other methods to improve the effectiveness and quality of the healthcare system, are the fundamental elements of any competent cancer control strategy. The oncology care system is complex as it requires multidisciplinary fields; hence, it poses critical challenges [16].

A broad range of differences, e.g., in education, availability of healthcare facilities, and quality of life has been observed among Arab countries, despite sharing a common language and culture. The Arab world stretches across an array of natural resources, from prosperous countries to the poverty, conflicts, and famine afflicted countries [17]. The chief target for the Arab region’s healthcare authorities must be to transcribe the existing knowledge into an efficient plan of action at a population-level. Few approaches at the government level can steer cancer care services, subsequently producing good patients’ outcomes in the Arab region (Fig. 1.5).

Fig. 1.5
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Key suggestions to improve cancer care in the Arab world

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1.9 Concluding Remarks

The cancer burden in the Arab region has been increasing. This chapter is a preface to the “Cancer in the Arab World” book. It presents the general cancer care approaches of included Arab countries. The illustration of complications and future perspectives in exceptional cancer care delivery along with the explanation of shortcomings in the respective countries has also been comprehended in this volume.

Conflict of Interest Authors have no conflict of interest to declare.