Medical Aid for Palestinians’ Work Enhancing the National Plan for Breast Cancer Treatment in oPt

Breast cancer is the most common type of cancer in the Occupied Palestinian territories (oPt), constituting 18% and 16.9% of all registered cancer cases in Gaza and West Bank (WB) respectively (2019). Of all cancers affecting women breast cancer is the most common at 32.8% of all cancers in Gaza and 31.8 % in the WB. The incidence rate of breast cancer is 32 and 40 per 100,000 females in Gaza and WB respectively. Every year about 316 cases are diagnosed with cancer in Gaza and around 385 in WB (UNFPA,2016). Cancer is the second leading cause of death in Palestine (15.5% in 2019) and breast cancer comes as third killing cancer at a percentage of 11.2% of all cancer deaths in Palestine, with 15% of all cancer deaths reported in Gaza[2].

Despite the fact that breast cancer is one of the best understood and most treatable cancers, the journey of a woman diagnosed with breast cancer in the oPt, is unlike anywhere else in the world. It is unfortunate that in Gaza, 1 in three women diagnosed with breast cancer will not survive after five years of her diagnosis. This makes breast cancer a main contributor to years of life lost. 

In the oPt, the health system has been struggling under a protracted emergency and more than 50 years of illegal occupation. More recently the last added calamity was COVID 19, all of which are vastly distressing the internal capacity to deliver the effective care that those women are in need of.  

In 2017, Medical Aid for Palestinians (MAP) conducted a scoping mission to assess breast cancer services in the oPt led by the UK MP and breast surgeon, Dr. Phlippa Whitford, whom was joined by a multidisciplinary team of BC experts. The scoping mission identified systemic weaknesses in the awareness, availability, affordability and quality of BC services in the WB and Gaza. The issues discovered are summarized as:

• Weak screening capacity given that there is no nationally organized screening program
• Remoteness of some communities and the need to travel through Israeli checkpoints to reach BC centres, especially for Bedouin communities in ‘Area C’ [3]
• Lack of resources such as specialized equipment, hormonal receptors, chemotherapy drugs, medical disposables
• Lack of breast cancer dedicated health specialists 
• Lack of resources limits surgeons’ capacity to provide safer surgical options for patients. Consequently, there is a trend for full mastectomy with axillary clearance
• No standard national guidelines for the diagnosis and treatment of breast cancer
• Lack of radiography treatment in the oPt which forces patients to seek medical referral to Israel for treatment
• Public awareness in the community, and amoung health workers, about all aspects of breast cancer is limited, leading to late detection of the disease, thereby reducing the chances of recovery
• Breast cancer services are fragmented between the governmental, nongovernmental and private sectors
• No clear pathway or guidance exists for patients to follow, causing delays between the detection of symptoms and the completion of diagnosis before the start of the treatment

These limitations force doctors to refer breast cancer patients outside Gaza and WB which, as well as being costly for the fragile health system, does not guarantee that a patient will get approval for permits from the Israeli authorities. For example, only 22% of all medical referrals from Gaza were approved in August 2020. [4]

Based on this assessment; MAP designed its intervention, establishing the “Support for Breast Cancer care” project, with a vision to reduce rates of significant morbidity and five years mortality associated with breast cancer in the oPt. The intervention addressed many of the gaps existing in the BC pathway from detection, through diagnosis to treatment and beyond. 

Between2017-2020, MAP recruited 26 UK breast cancer specialized consultants from multiple disciplines, who volunteered to support the development of breast cancer care in Gaza and the WB. On total, MAP hosted 11 multidisciplinary medical training missions in Gaza and 6 missions in the WB. During the missions, the volunteers work alongside their local peers, building their capacity in various aspects of breast cancer care. 

• Conducting theoretical training workshops, symposiums and conferences targeting local multidisciplinary health professionals to update their knowledge in different aspects of cancer management. Gaza’s first ever MDT cancer conference  was conducted in November 2019. This dedicated two-day cancer/palliative care conference focused on diagnosis, staging, communication, symptom control, and end of life care, bringing together health professionals from all over the oPt. 
• Providing on-the-job training for all MDT subspecialties. For example, surgeons in the oPt are now proficient in Sentinel Node Biopsy and Radiologists in Wire Localization techniques.
• Procurement of breast-specific drugs, medical disposables, equipment, and diagnostic and treatment items for oncology, radiology, pathology and surgical units contributing to the breast cancer pathway. The procurement included the first ever immunostaining machine in Gaza.
• Weekly breast cancer e-Multidisciplinary Team (MDT) meetings, established for the first time, engaging UK and local medics to discuss patient diagnosis, treatment options to ensure the best treatment and follow up decisions. 
• Monthly educational sessions between Gaza and UK pathologists given the limited number of pathologists in Gaza and their limited access to both specialized medical training as well as advanced pathology techniques.
• Undergraduate education support to address the lack of cancer awareness among clinicians, and to stimulate interst amoung young residents equipping them with basic level knowledge of cancer management. MAP with the UK experts established the first ever oncology course targeting medical students at the Islamic University of Gaza (IUG). The oncology course was integrated within the school of medicine’s curriculum at the IUG. 
• MAP is building and equipping a new breast unit in the north of the WB to increase access to quality services and decrease unnecessary referrals outside the area.
• MAP established national operating procedures and quality standards relevant to the Palestinian context to support the overall management of breast cancer care. They were approved by the Ministry of Health (MoH) and disseminated as the nationally accredited standard operating procedures to be followed by all health care providers in Gaza and the WB. 
• Sending Palestinian radiologists and surgeons to attend month-long observerships in UK breast units in 2019, to gain a better understanding of well-managed, busy units. 

Evaluation

In September 2020, MAP completed an evaluation of the impact of the MDT approach we introduced to the oPt to compare the desired outcomes with what has been achieved. It was found that significant improvements have been achieved at the different levels of the breast cancer management system and pathways. In particular, breast cancer specialization, the overall local clinicians’ performance and team dynamics and improvements in breast cancer diagnosis, and treatment.

The intervention succeeded in supporting the Palestinian MoH to adopt breast cancer as a stand-alone speciality. The MoH decided to limit clinicians allowed to perform breast cancer diagnostic and treatment care to only those involved and trained in through MAP’s project. There are now two accredited breast cancer units at MoH hospitals (Shif and Nasser) covering all of Gaza and committed to the nationally approved breast cancer operating procedures and quality standards. As described by Dr. Philippa Whitford “this has allowed the development of a specialised team who can deepen their knowledge, understanding and skills in treating breast cancer – thus improving the care delivered to the women of Gaza. This has been supported by MAP supported visits since 2017“.

Moreover, remarkable improvements have been witnessed in the diagnosis stage, inradiology, pathology and the interconnections between them, in addition to the staging of breast cancer. Importantly, newly learned/adopted best practices have contributed to widening the treatment options available for Breast Cancer patients, thereby improving their quality of life.

For breast radiology, improved performance was observed in the delivery of scans, biopsies and reporting.  A UK consultant radiologist proudly stated about the work of the local team “I now have a lot of faith in scans, reporting and biopsies done by the local team; they have dealt with difficult cases very well and provided very good support to the surgeons“

One of the behavioural changes seen during the project was for MoH clinicians to adopt multidisciplinary teamwork as a best practice. Feedback from the UK team members showed that team communication and spirit have improved where “the diagnostic team of radiologists and surgeons at Shifa works very well together; it is good that the pathologist has now started attending“. In addition, changes have been seen in local team performance through MDT meeting dynamics, like case presentations, case discussions and decision-making processes. These demonstrate that the team now has clear and defined roles and responsibilities. Moreover, the local team is perceived to be more confident and independent. This is deduced from their willingness to engage in debates with the UK specialist volunteers, rather than just accepting their suggestions and also by proposing treatment plans. 

“I think the MAP Breast Cancer project has had a profound effect on the treatment and care available to Gaza women with Breast Cancer. I think the challenges ahead in Gaza relate to documentation audit and access to treatments.” Dr. Philippa Whitford

 I am immensely proud of what has been achieved by the MAP project, the commitment of my Scottish Colleagues but particularly by the Gaza Team who have transformed the way they work. This has dramatically improved what they are able to provide to women in Gaza with Breast Cancer.” Dr. Philippa Whitford

MAP is committed to building on these achievements to support the capacity of breast cancer care in Gaza and WB to contribute to the reduction of significant mortality and morbidity associated with breast cancer and to remove the barriers towards the survival of breast cancer patients. We will work towards:

• Improving the community awareness towards breast cancer in order to enhance early detection and diagnosis. 
• Enhancing the local diagnostic and treatment capacity with focusing on the surgical aspect of breast cancer. 
• Supporting clinical audit and research studies of breast cancer care. 
• Liaising among the different health care providers to enhance the BC pathway.
• Advocating for BC patients to have better access to health services, particularly those unavailable in the oPt such as radiotherapy.

Filters: Breast Cancer, Gaza, Palestine, Women

Contributors

[1]: Program Officer, Medical Aid for Palestinians, Gaza City

[6]: Senior Programme Manager

[7]: Programme Officer

[8] : Programme Manager

References 

[2]: MoH Health Annual report 2020 – West Bank http://site.moh.ps/index/Books/BookType/2/Language/ar 

[3]: 60% of the WB where Israel maintains civil and military control

[4]: WHO’s monthly referral report in oPt, August 2020.