Supportive care needs of multicultural patients with cancer in the

Satish Chandrasekhar Nair1, Hassan Jaafar2, Mohamed Jaloudi2, Khaled Qawasmeh3, Afra AlMarar4 and Halah Ibrahim5

1Department of Academic Affairs, Tawam Hospital—Johns Hopkins Medicine Affiliate, 15258, , United Arab Emirates 2Department of Medical Oncology, Tawam Hospital—Johns Hopkins Medicine Affiliate, Al Ain 15258, Abu Dhabi, United Arab Emirates 3Department of Nursing, Tawam Hospital—Johns Hopkins Medicine Affiliate, Al Ain 15258, Abu Dhabi, United Arab Emirates 4Department of Surgical Oncology, Tawam Hospital—Johns Hopkins Medicine Affiliate, Al Ain 15258, Abu Dhabi, United Arab Emirates 5Johns Hopkins Graduate School of Education, Baltimore, MD 21218, USA

Correspondence to: Satish Chandrasekhar Nair. Email: [email protected] and [email protected]

Abstract

Despite the high prevalence of cancer in the Middle East, there is limited published data reporting the needs of cancer patients in this region of the world. The purpose of this study is to assess the unmet supportive care needs of oncology patients in the United Arab Emir- ates (UAE). From December 2014 to December 2016, a cross-sectional survey of cancer patients was conducted at a large tertiary care hospital and an oncology referral centre in the UAE, using a validated translation of the supportive care needs survey––short form (SCNS-SF34-A), assessing cancer-specific perceived needs across five domains: psychological, health system information, patient care Research and support, physical and daily living and sexuality. Chi-square test and Pearson’s correlation coefficient were used to assess the associa- tion between variables. Participant responses were tabulated as mean ± standard error of the mean (SEM). The response rate was 78%

Published: 29/05/2018 Received: 29/01/2018 ecancer 2018, 12:838 https://doi.org/10.3332/ecancer.2018.838

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1 for thesepatientsand,thereby, positivelyimpactingtheiroverallquality oflife services care supportive the improving of goal the with UAE, the in patients cancer of needs unmet the assess to is study this of purpose symptoms and treatment side-effects, improved physician–patient communication and better adherence to treatment regimens [7, 15]. The with disease to cope better ability outcomes, including patient to manypositive can lead these unmetneeds addressing and Identifying Gulf Cooperation Council (GCC) countries, consisting of Kuwait, Qatar, , Saudi Arabia, Bahrain and the United Arab Emirates (UAE). There is a paucity of published data and limited understanding of the unmet needs of cancer patients in the Middle East, particularly in the beliefs andvaluescanserveasimportantdeterminantsofclinicaloutcomesfollowingcancerdiagnosistreatment[14] . cultural patients, culturehasbeenshowntoinfluenceperceptionsandcopingmechanismsrelateddiseasemanagement[13] . Therefore, all typesandstagesofcancer[11]. Supportivecareneedsalsodiffer acrosscountries andcultures[12]. Among ethnicallydiversegroupsof experiences canalsobe a reflectionofhealthcaredeliverysystemsthat do not account for patient and family needs substantially withcomfort,qualityoflifeandtheabilitytomakesuitabledecisionsoradheretreatment[9].Negativepatientfamily family dynamics, all affect cancer patients, with levels of accompanying distress that vary from patient to patient Physical complaints,includingillnessanddisability, psychologicalconcernsmanifestedasfearofpainordeathandsocial issues,suchas are atriskforadversephysical,psychological,spiritualandsocialproblemsthroughoutthecourseoftheirdiagnosis andtreatment[7]. 6], butdonotaddressthesupportivecareneedsofoncologypatients. There isalargebodyofliteraturedocumentingthatcancerpatients as 100–180% years, the Middle East is likely to experience the highest increase in cancer incidence among WHO regions, with predicted increases as high [2]. The prevalence of cancer in the Middle East is high and growing treatment options,thecancerburdencontinuestoriseglobally, fuelledbyanageingpopulationandincreasinglifestyle-relatedriskfactors Cancer isthesecondleadingcauseofdeathinworld,withover8millionfatalitiesannually[1].Despiteadvancesbothpreventionand Introduction Keywords: cancer, supportivecareneeds,MiddleEast,psychologicaloncology and easytoimplementinterventionsthatcansignificantlyimprovethecarewellbeingofoncologypatientsinUAE. are feasible treatment decisions in all women fully engaging and groups support of cancer care teams,introduction cancer multidisciplinary differencesCultural of services, development Improvements inmentalhealth system informationdomain. werenotedonlyinthehealth 0.08, ± (1.79 needs sexuality low with 0.001), < ± 0.24,p (2.95 by physicalanddailylivingneeds(3.04± 0.029, p<0.001),healthsysteminformation(3.03± 0.02, p<0.001),patientcareandsupport followed needs, high or moderate unmet prevalent most 10 the constituted domain psychological the from items 10 the of Five (210/268). atcptn sbet wr abltr ptet dansd ih acr h peetd o h oclg otain ciis Potential clinics. outpatient oncology the participants were randomly selected using the patient appointment booking module of Malaffi, to the hospital information system. Inclusion presented who cancer with diagnosed patients ambulatory were subjects Participating 31 patientsfromtheoncologyoutpatientclinic. did not alter during translation. Both the English (n = 14) and Arabic (n = 17) versions were pretested for reliability in the local setting using items survey the of intent and content structure, the that ensure to and translation the of quality the ensure to English into translated back mencement, the SCNS-SF34 was translated by a certified legal translator into Arabic, the preferred local language of the patients, and then, (3 items)[16]. The SCNS-SF34 was provided by Dr. Allison Boyes (University of Newcastle upon Tyne, Australia) (11system information items), health (10 logical sexuality (5 items)and living daily and (5 items),physical support care and items),patient of unmetneeds domains short form of the SCNS-SF34 was used for the study, primarily because of its feasibility and ease of use and coverage of many of the major December 2016 at a tertiary care, Joint Commission International accredited hospital and a regional oncology referral centre. The validated A cross-sectional survey was conducted by a bilingual (Arabic and English) physician and, nurse researcher between December 2014 and Methods [5, [3, 4].Recentimprovementsinmulti-regimenmodalitieshaveresultedsignificantincreasesdisease-freesurvivalrates[5, [7]. The SCNS-SF34 assesses cancer-specific perceived needs across five analytically derived domains: psycho- p <0.001).Womenneeds. unmet psychological higher significantly had [3]. The World HealthOrganization(WHO)reportsthatwithinthenext15 2 www.ecancer.org [15]. [8]. The distress can interfere ecancer [10]. Patientneedsaffect [16]. Priortostudycom- 2018,12:838

Research men expressinghigherunmetneedthanwomen(r Table 3reportsgenderdifferences inparticipantresponses.Gendercorrelatedstronglywithsexuality(changes insexualfeelings),with low (noneedorsatisfied)foralmost85%ofthepatientpopulationsurveyed,datanotshown. Needs related to participants. sexuality,the of such as three-quarters receiving information than about sexual more relationships (16.7%) in and changes prevalent in were sexual feelings (74.8%), (9.5%), scored activities living daily and physical their affecting pain as well as tain future (80%) and feelings about death and dying (77.1%) (Table 2). Moderate or high feelings of lack of energy and tiredness (75.2%), constituted the 10 most prevalent unmet moderate or high needs of oncology patients in the UAE, including concerns regarding an uncer- 0.08, ± (1.79 needs sexuality low with 0.001), < ± 0.24, p and dailylivingneeds(3.04± 0.029, p<0.001),healthsysteminformationneeds(3.03± 0.02, p physical by followed 0.023), ± (3.63 need psychological high significantly a indicated domains derived analytically five the of Comparison n =144),married(76%,159),withcollege-leveleducation(54%, p The need to be informed about cancer directly from the doctor, rather than a relative, was also moderately high among women (r ‘feeling downordepressed’ (r rate). in are given participants of thepatient The demographics patient participants for the study. Two hundred and ten completed questionnaires were returned out of 268 administered 203 (78.3% response of size sample minimum a obtaining 5%), interval confidence 95%, level (confidence 169 of size sample original the to added were population this in 80% of rate return survey completed fully a of experience previous our year.on every Based outpatient clinics recurrence aretreatedattheseoncology or adiagnosed 300 patientswitheitheranewcancerdiagnosis Approximately Results was accomplishedusingMedCalcsoftware[20]. The studywasapprovedbytheregionalresearch ethicscommittee(AAMDHREC12/55). required, when means, of Comparison SEM. ± mean as tabulated were items the of each to responses Participant variables. between tion subscales weretabulatedusingCronbach’s alpha.Inadditiontodescriptivestatistics,theChi-squaretestwasadoptedassessassocia- (to assessthestrengthofrelationshipamongvariables)werealsoappliedtoconstruct[19]. The reliabilityoftheinventoryandits tests Bartlett’s and adequacy sampling (KMO) Kiaser–Meyer–Olkin domains. the identify to used was matrix pattern and calculated was tor measure a construct was also conducted using the correlation coefficient matrix method and varimaxrotationwasusedtorotatethefactorsbetterfitdata[19].Convergentvalidityassessifsurveyitemsconverged where else- reported as identified were domains The USA). Chicago, Inc. (SPSS Version20 Software Statistical SPSS using analysed were Data were obtainedfromtherespondents. Additional information,ifrequired,wasobtainedfromthepatient’s medicalrecordandthehospital’s cancerregistry. Written consents need with thefollowingresponseoptions:1=noneed,notapplicable;2satisfied;3lowneed;4moderateneedand5high dents wereaskedtoindicatetheirlevelofneedforhelpduringthelastmontheachitemonsurveya5-pointLikertscale, cognitive disorders and thoseunabletounderstandorunwilling to provideinformed consent wereexcluded from the study. Respon- European the on based questionnaire, survey the can- completing (0–3) status (ECOG) Group the Oncology and Cooperative of consent informed informed were providing who of diagnosis, capable cancer were recurrent and or diagnosis new cer confirmed a with 18–75 aged women or men included criteria between UAEnationalsandnon-nationals,or Arabs andnon-Arabs(datanotshown). differencessignificant other statistically No domain. the healthsysteminformation were noted needs care of unmetsupportive in reports differencesCultural in aregivenn amongstthepatientrespondents inresponses data notshown). (r age patient with correlated directly was future’(psychological) the about ‘Uncertainity women. < 0.001). Physical limitation, such as ‘feeling unwell a lot of time’, positively correlated (r [18]. Surveyparticipantswhoselectedascoreof4or 5 indicatedmoderateorhighunmetneedsthatrequiredassistance[16]. [16]. The widelyusedprincipalcomponentanalysis(PCA)wasastheextractionmethodtoundertakeexploratoryfactoranalysis; =0.42,p <0.001)and‘feelingsofsadness’ (r =0.901,p . Patient participants unable to meet the ECOG status, patients with mental or mental with patients status, ECOG the meet to unable participants Patient [17]. ). Five out of 10 items (50%) from the psychological domain psychological the from (50%) items 10 of out Five 1). p <0.001)(Figure <0.001).Women hadsignificantlyhigherpsychologicalunmetneedsof Te aoiy f h sre rsodns ee eae (69%, female were respondents survey the of majority The Table1. 3 www.ecancer.org n =113). = 0.26, = . UAE nationals reported higher unmet needs in needs unmet higher reported Tablenationals UAE 4. p [19]. The percentage of total variance by each fac- <0.001),ascomparedwithmalerespondents. = 0.28, < 0.001),patientcareandsupport(2.95 = 0.14, p < 0.001) with the unmet needs for p < 0.05 2-tailed significance, [19], 34moreparticipants ecancer 2018,12:838 = 0.37,

Research daily living,healthsysteminformation,patientcareandsupportsexuality(N=210). Figure 1.PatientresponsestotheSCNS-SF34-A surveyareindicatedasMean±SEMforeachofthefivedomains:psychological,physicaland Table 1.Demographics of thepatientparticipants(N=210). Others Married Single Marital status Africa Asia Middle East UAE/GCC Nationality 51–70 Y 31–50 Y 21–30 Y 18–20 Y Age Male Female Gender 71 + Y Categories 159 144 23 28 56 95 45 79 99 66 18 n 9 9 2 76 13 27 45 21 38 47 31 69 11 % 4 4 1 9 N =210 4 www.ecancer.org

III/IV II I Cancer stage Others Lung Prostate Testicular Gynaecological 5+ Less than5 None Children (#) > HighSchool None Education Breast Malignancy Categories 141 126 113 61 94 55 21 19 17 18 42 27 37 n 9 ecancer 67 54 29 45 26 10 20 13 18 60 % 4 9 8 9

2018,12:838

Research construct washighat0.79. of each of the four domains rangedbetween0.73 and 0.84 (Table coefficient Correlation of totalvariance. in between theitemsisgiven relationship indicating 81.2% explaining 14.9, of value eigen an with component a of presence the PCArevealed The (0.000). significant was sphericity of test The consistency of the SCNS-SF-A was measured using the PCA, obtaining a KMO value of 0.88, reaching statistical significance. Bartlett’s Table 4.Comparisonbetween UAEnationalsandnon-nationals(expatriates),cancerpatientsreportingunmetsupportivecareneeds. Health systeminformation Health systeminformation Table 2.Top tenunmetsupportivecareneedsofcancerpatients. Psychological Health systeminformation Health systeminformation Psychological Physical anddailyliving Physical anddailyliving Psychological Psychological Health systeminformation Psychological Table 3.Genderdifferences amongcancerpatientsreportingunmetsupportivecareneeds. Female/psychological Female/physical anddailyliving Female/health systeminformation Female/psychological Male/sexuality Domain Domain

Gender/domain another case Being treatedlikeapersonnotjust for whichyouwouldlikeanexplanation Being givenexplanationsofthosetests Keeping apositiveoutlook like anexplanation Being givenexplanationsofthosetestsforwhichyouwould rather thantoyourrelativeorfamily Receiving informationaboutcancertestresultstoyou Feelings ofsadness Pain Lack ofenergy/tiredness Feelings aboutdeathanddying Anxiety Being informedaboutyourtestresultsassoonfeasible Uncertain aboutthefuture What wasyourlevelofneedforhelpwith: Items Feelings ofsadness Feeling unwellalotoftime to youratherthanyourrelativeorfamily Receiving informationaboutcancertestresults Feeling downordepressed Changes insexualfeeling What wasyourlevelofneedforhelpwith:

5). The overall Cronbach’s α reliability score for all 34 items for the final Expatriates (n=158) UAE nationals( Expatriates (n=158) UAE nationals( 5 www.ecancer.org Population n =47) n =47) Mean response±SEM Pearson correlation coeffecient{r} 3.72 ±0.092 3.49 ±0.060 4.08 ±0.072 4.08 ±0.079 4.17 ±0.063 3.98 ±0.082 4.14 ±0.090 4.28 ±0.071 4.14 ±0.088 4.0 ±0.052 . Cronbach’s α reliability assessment Tablereliability α Cronbach’s 5. 0.261 0.281 0.378 0.417 0.901

Moderate/high need 25 (16) 14 (30) 95 (61) 36 (76) n(%) Significance sig. ecancer Moderate tohigh p <0.001 p <0.001 p <0.001 p <0.001 p <0.001 129 135 151 157 157 158 162 165 166 168 (2-tailed) n 2018,12:838 P Value 0.001 0.023 61.4 64.3 74.8 74.8 75.2 77.1 78.6 79.0 80.0 72 %

Research Cronbach’s alphaandPCA wasusedastheextractionmethodtoundertakefactoranalysis. Table 5.ReliabilityandvalidityoftheSCNS34-A construct.Internalconsistencyoftheinventoryanditssubscalesweretabulatedusing

10 13 12 15 14 16 17 18 20 19 21 22 23 24 25 26 27 28 29 31 30 32 33 34 11 # 2 1 3 4 5 7 6 8 9 Physical anddailyliving Physical anddailyliving Physical anddailyliving Physical anddailyliving Physical anddailyliving Psychological Psychological Psychological Psychological Psychological Psychological Psychological Psychological Psychological Psychological Sexuality Sexuality Sexuality Patient careandsupport Patient careandsupport Patient careandsupport Patient careandsupport Patient careandsupport Health systeminformation Health systeminformation Health systeminformation Health systeminformation Health systeminformation Health systeminformation Health systeminformation Health systeminformation Health systeminformation Health systeminformation Health systeminformation Domain Lack ofenergy/tiredness Pain Feeling unwellalotoftime Work around thehome Not beingabletodothingsthatyouused Feeling downordepressed Anxiety Feelings ofsadness Fears aboutcancerspreading Worry that resultsoftreatmentarebeyondyourcontrol Uncertain aboutthefuture Keeping apositiveoutlook Learning tofeelincontrolofyoursituation Concerns abouttheworriesofthoseclosetoyou Feelings aboutdeathanddying Changes insexualfeeling Changes inyoursexualrelationships Being giveninformationaboutsexualrelationships More choiceaboutavailablebesttreatmentforyourdisease More choiceaboutwhichcancerspecialistsyousee Reassurance bymedicalstaff thatthewayyoufeelisnormal Hospital staff attendingpromptlytoyourphysicalNeeds tional needs Hospital staff acknowledging,showingsensitivitytoyourfeelingsandemo Being givenwritteninformationabouttheimportantaspectsofyourcare managing yourillnessandsideeffects athome Being giveninformation(written,diagramsanddrawings)aboutaspectsof explanation Being givenexplanationsofthosetestsforwhichyouwouldlikean before youchoosetohavethem Being adequatelyinformedaboutthebenefitsandsideeffects oftreatments Being informedaboutyourtestresultsassoonfeasible Being informedaboutcancertoyouratherthanyourrelativeor family worker, counsellorandnursespecialist)ifyou,familyorfriendsneedit Having accesstoprofessionalcounselling(examples:psychologist, social Being informedaboutthingsyoucandotohelpyourselfgetwell Being treatedlikeapersonnotjustanothercase Being treatedinahospitalorclinicthatisasphysicallypleasant possible aspects ofyourcondition,treatment andfollow-up Having onememberofhospitalstaff withwhomyoucantalktoaboutall Items 6 - Correlation coeffcient 0.791 0.633 0.641 0.643 0.546 0.661 0.627 0.702 0.636 0.701 0.684 0.528 0.651 0.907 0.914 0.606 0.658 0.637 0.629 0.767 0.717 0.752 0.638 0.568 0.521 0.493 0.433 0.504 0.635 0.736 0.639 0.711 .536 .448 ecancer www.ecancer.org 2018,12:838 Cronbach’s alpha 0.78 0.81 0.73 0.84 0.8

Research personality.patient individual the that hasassessed this isthefirststudyinregion these limitations,toourknowledge, Notwithstanding are influencingfactors that may not have beenfullyaddressedinthis study, family/caregiver andsocial support, spiritualityand including there life, of quality as such issues, complex of self-report any to Finally,inherent important. are cancers, gastrointestinal including cies, countries. bouring Perspectives ofpatientswithothermalignan malignancies. Also, mostpatientparticipantshad breastorgynaecologic neigh and UAE the for centre referral regional the is one and units oncology large have hospitals participating however,both surveyed; were institutions two only from Patients inference. causal not but correlation, provides design study cross-sectional the First, limitations. effectconfidentiality.respondent bias byassuring response desirability ofsocial Ourresults,however,in lightofsome be viewed should patients. Weof multi-ethnic participation rate and response the high The strengthsofthisstudyinclude attempted tominimisethe also that possible also is it UAE, the of respondents hadalreadyassimilatedtoUAEculture. residents were patients all As world. Arab the around and in from were respondents most because perhaps UAE, the in patients oncology the among needs care differencessupportive cultural unmet significant in reveal not did study The of patientcareneedsismet. Routinely addressingsexualissuesas part of cancer treatment may overcome someof these culturalbarriersandensurethat this aspect symptom. concerns. sexual to discuss of thepatient unwillingness to an due were needs sexual low that thereported Also, itispossible presenting a not often is it as patients, care palliative and cancer in wellbeing sexual assess routinely to practice standard not is it UAE, KongChinesewomenwithbreastcancer,on Hong 26]. In the similarlowunmetneedsrelatedtosexuality[12,13,18,21, also showed care needsdifferChinese and Japanese Caucasians, among care services health across culturesand (r =0.901,p <0.001). towomen ality ascompared that patternsofunmetsupportive studies demonstrating This isconsistentwithprevious Interestingly, sexualityscoredlowasanunmetneedforcancerpatientsinourstudy,unmet needforsexu- higher men expressed although resolve potentialfamilydynamicissues. help toalleviatethisconcern. of socialworkersintocancercareteamstodirectlyaddress femalepatientneedsmayhelp Also, theaddition in treatmentdiscussions. theneedforallpatientstobeincluded als understand women inalltreatmentdecisionswill Actively involving profession care health that cancer patients. Itisimportant of female instead family members results with,male discuss from, and consent of a family member, is not surprising given that the UAE, as much of the Arab world, is a patriarchal society where physicians often receive process. during thediagnostic The findingthat women weremoreconcernedaboutreceivingtest results directlyfrom the doctor, instead some patientfears and helpalleviate can provideaccurate,timelyinformation care teamsforcancer management the multidisciplinary to delays inreportingresults. mens overseasforgeneticandmutationalanalysis,leading as partof of geneticcounsellors The inclusion an provided be to and manner timely a in explanation about their test results tests indicate that system changes are required. In the UAE, it is common practice to send diagnostic speci- diagnostic their about informed be to patients cancer of need unmet the Furthermore, patients. cancer of needs psychological the of several meet to help and information of channels viable as serve can UAE the throughout centers tion incancersupportgroupsimprovespatients’ quality of life and wellbeing manage patientneeds. and help misinformation cancer supportgroupstoaddress Athat participa demonstrates body ofliterature large for cancerpatients[21]. to controlpainmayweakentheimmunesystemandisinevitable medicine These beliefsidentifyaneedfor progression, disease signifies pain that increasing pain, specifically regarding misconceptions that patientshaveseveral reported been of cancer care. Oncology units in the UAE should consider inculcating these specialities into multidisciplinary cancer care teams. It has also concerning. This highlights the need to as focus important components pain managementandphysicalrehabilitation on earlyandadequate lack ofenergy,of physicalsymptoms,including In addition,thehighprevalence is quite tiredness andpainlimitingphysicaldailyliving, ment andrecruitmentoffemalecancerpatientsintocounsellingservicescanhelpmitigatesometheirneeds. men. This findingsuggeststhat the improvementof mental healthservicesfor cancer patientsisanurgentpriority. Proactive encourage than needs psychological higher significantly expressing women with nature, in psychological were 50% surveyed, patients 7 [22, 23]. As such, the development of this service at oncology [10, 11]. Ourstudydemonstratesthatcancerpatients [24, 25, studies, based 26]. Previous ecancer www.ecancer.org 2018,12:838 - - - - -

Research

References The studywasnotfundedbyanyfundingsources. Funding declaration The authorsdeclarenoconflictsofinterest. Conflicts ofinterest study.the complete to order in us to provided system scoring and survey SCNS-SF the for thanked is Australia Newcastle, Boyes, Allison sor Ghada Houssneh, Charge Nurse, Breast Care Center, Tawam Hospital is acknowledged for her technical help with data collection. Profes- Acknowledgments of cancerpatientsinthepan Arab region. needs the addressing society,in useful wellbeing. multicultural be and to multi-ethnic prove a may is study UAE this the of As findings the improve patientcareand that cansignificantly and easytoimplementinterventions all treatmentdiscussionsanddecisions,arefeasible in women fully engaging and groups support of cancer care teams,introduction cancer of multidisciplinary patients, development oncology of cancerpatients. care needs approach toidentifyandmeetthesupportive multifaceted services for of mentalhealth The improvement integrated, an develop should UAE the in centres Oncology available. services support and care the improve to identi opportunities several fied has study Our patients. oncology of needs the meet and understand fully to important is it UAE, the in climb rates cancer the As Conclusion cancer patients’ andfamilies’ lives. UAE of quality the improve help to needed are services support cancer to approaches multidimensional integrated of implementation the on focusing studies Future needs. their meet to services community and hospital of development the in step first a is perspectives patient cancer to improvepatientcare.Identifyingandunderstanding information valuable of cancerpatientsandprovides care needs supportive 3. 2. 4. 1. established riskfactorsBMCCancer D, Mukherji and SH, Olson MA, Charafeddine doi.org/10.1016/S0140-6736(14)62038-9 for 25,676,887 patients from 279 population-based registries in 67 countries (CONCORD-2) C, WeirAllemani analysis ofindividual H, etal(2015)Global HK,andCarreira surveillance ofcancersurvival1995-2009:data org/10.1016/S0140-6736(12)61728-0 accessed: 23/04/17 Region 2009–2013 Mediterranean Eastern World Health Organization, Regional Office for the Eastern Mediterranean (2010) in 1990 and analysis for 2010: asystematic the Global Burden of Disease Study 2010 Lancet K, Foreman and M, Naghavi R, Lozano PMID: 17(1)337https://doi.org/10.1186/s12885-017-3304-7 et al(2012)Global and regional mortality from235causesofdeathfor20agegroups PMCID:4588097 23245604 Geneva: WHO[http://applications.emro.who.int/dsaf/EMRPUB_2010_1278.pdf (2017) (2017) et al Proportion of cancer in a Middle Eastern country attributableto in aMiddleEastern Proportion of cancer 8 www.ecancer.org Strategy forcancerprevention and control in the PMID:

Lancet (9859) 2095–2128 380(9859) 28521815 385(9972) 977–1010 ecancer PMCID:5437575 2018,12:838 https://doi. https:// ] Date -

Research

10. 23.

22. 21. 20. 19. 18. 17. 16. 12. 15. 14. 13. 11. 7. 6. 9. 8. 5. Okediji PT, Salako O, and Fatiregun OO (2017) Teshome MandHuntKK(2014) https://doi.org/10.3322/caac.21349 family members,providersandexperts SM, Greene and EJ, Bowles EH, WagnerAiello PMID: 25992204 socscimed.2005.10.034 not? The experienceofpeersupportgroupsforpeoplewith cancer Ussher J, Kirsten L, and Butow P, Public Health T(2012) Paraskevi Gregurek R, Bras M, and Dordević V, 9(5) e1234PMID:28620565 Miller KD, Siegel RL, and Lin CC, etal Lin RL, and KD, Siegel Miller (2016) logical wellbeing? A pilotstudy C, StrangP,Lindemalm M (2005) andLekander management IndianJPallCare Nayak MG,George A, and Vidyasagar M, [https://www.medcalc.org/calc/comparison_of_means.php Nair SC, Satish KP, J, and Sreedharan (Newcastle: CentreforHealthResearchandPsycho-Oncology)pp1–69 McElduffP, Boyes Zucca and A, A, Am JClinOncol5649–655 and TormeyRH, Creech MM, Oken DC, validation ofthe34-itemsupportivecareneedssurvey(SCNS-SF34)JEvalClinPract15(4)602–606 (2009) C Lecathelinais and A, Girgis A, Boyes doi.org/10.1111/j.1365-2354.2012.01356.x Chinese and German Caucasian women with breast cancer Lam WW, Au AH, andWong JH,etal(2011)needs: across-culturalcomparisonbetweenHongKong Unmet supportivecare review SupportCareCancer Harrison JD, Young JM, and Price MA, module French versions (SCNS-SF34-Fr and SCNS-BR8-Fr) in breast cancerpatients module Frenchversions(SCNS-SF34-FrandSCNS-BR8-Fr) AC, Griesser and JL, Kop A, Brédart Daher M(2012) 14 905–923 J, WilkeandPintadoI(2004) Coreil s10549-011-1592-1 https://doi.org/10.1177/1049732304266656 16831https://doi.org/10.1186/s12889-016-3488-9 Cultural beliefsandvaluesincancerpatients PMCID:4419638 PMID: Quality oflifeoutcomesinpatientswith breast cancer 21617919 https://doi.org/10.1097/00000421-198212000-00014 PMCID:5467772 17(8)1117–1128 https://doi.org/10.1007/s00520-009-0615-5 21(3)349–354 Neoadjuvant therapyinthetreatmentofbreastcancerSurgOncolClinN Am 23(3) 505–523 SupportCareCancer et al (2006) PMID: et al (2004) TheSupportiveCareNeedsSurvey: A Guide to Administration, Scoring and Analysis et al (2010) Psychological problems of patients with cancer et al (2009) What are the unmet supportive care needs of people with cancer? A systematic Cultural models of illness and recovery in breast cancer support groups cancer in breast Cultural modelsofillnessandrecovery et al(2012)Validation of the 34-itemsupportive care needssurveyand8-itembreast (2016) et al et al(1982) QualSafHealthCare 27253694 et al(2015)Symptomsexperiencedbycancerpatientsand barriers to symptom Cancer treatment and survivorshipstatistics,2016 treatment Cancer What do cancer support groups provide which other supportiverelationships do Pattern and predictors of unmet supportive care needs in cancer patients needs incancer and predictorsofunmetsupportivecare Pattern Brief assessment of adult Brief assessment cancer patients’ perceivedneeds:development and https://doi.org/10.4103/0973-1075.164893 Support group for cancer patients. Doesitimprove theirphysicalandpsycho- Support group forcancer The quality of cancer patient experience: perspectives of patients, perspectives patient experience: Thequalityofcancer et al(2010) Assessing health literacy in the eastern and middle-eastern cultures ToxicityCooperative Oncology andresponsecriteriaoftheEasternGroup 13(8)652–657 PMID: ] Dateaccessed:02/03/17 9 www.ecancer.org 15296663 PMID: 19(6)484–489 AnnOncol366–69https://doi.org/10.1093/annonc/mds091

Breast CancerResTreat https://doi.org/10.1007/s00520-005-0785-8 27538529 Soc SciMed

Onc Rev PMCID:4991078 10) 2565–2576 62(10) PMID: 6(1) Eur J Cancer Care Eur JCancer (2) 531–541 130(2) https://doi.org/10.4081/oncol.2012.e2 19319577

CAJ Clin Cancer

Psychiatr Danub ecancer https://doi.org/10.1016/j. https://doi.org/10.1007/ 21(4) 450–459 PMID: Qual HealthRes 2018,12:838

66(4) 271–289 22(2) 227–230 16041464 Cureus https:// BMC

Research 10 www.ecancer.org 24. 26. 25. e75755 among HongKongandTaiwaneseshort-form (SCNS-SF34-C) Survey patients Chinesecolorectalcancer Li WW, LamWW,SC, etal(2013) andShun J CancerSurviv Wen KY, Fang CY, and Ma GX (2014) PMCID: individual differences,beforeclinicalfactors Fielding R, Lam WWT, and Shun SC, https://doi.org/10.1371/journal.pone.0075755 3669056 8(1)94–107 https://doi.org/10.1007/s11764-013-0320-8 Attributing variance in supportive care needs during cancer: culture-service, and et al(2013)Attributingvarianceinsupportivecareneedsduringcancer:culture-service,and Breast cancerexperienceand survivorship among Asian Americans: a review systematic Psychometric assessment of the Chinese version of the Supportive Care Needs of theChineseversionSupportiveCare assessment Psychometric PLoS One PMID: 8 (5) e65099 (5) 24146774 PMCID:3795709 https://doi.org/10.1371/journal.pone.0065099 PMID:23741467 PMCID:3945715 ecancer PLoS One 2018,12:838 8(10)

Research