Mapping breast cancer journal publications in conflict settings in the MENA region: a scoping review

Rima A Abdul-Khalek1*, Ghassan Abu-Sitta1, Nassim El Achi1, Walaa Kayyal1, Ahmad Elamine1, Aya Noubani1, Marilyne Menassa1, Fahad Ahmed2, Richard Sullivan3 and Deborah Mukherji1

1Conflict Medicine Program Global Health Institute, American University of , Beirut, Lebanon 2Institute of Oncology, Hacettepe University, Ankara, Turkey 3King’s Health Partners Comprehensive Cancer Centre and Institute of Cancer Policy, King’s College London, London, UK

Abstract

Background: Breast cancer is a major cause of cancer-related morbidity and mortality among women in the the Middle East and North Africa (MENA) region. Conflict and polit- ical instability in the region may affect medical research output, including that on breast cancer. This scoping review aims to systematically identify and map breast cancer pub- lications across different stages of the cancer care pathway and across conflict-affected countries within the MENA region. The findings of this work will highlight the impact of conflict on cancer research that could be mitigated with the proper contextualised Review capacity strengthening intervention.

Methods: We followed the PRISMA-Scr methodology. We searched for peer-reviewed publications on topics related to breast cancer in 11 databases: Medline, PubMed, EMBASE, Web of , PROQUEST, CINAHL, Global Index Medicus, Searches Complete, Popline, Scopus and Google Scholar using both controlled vocabulary and keywords. Publication abstracts and full-text versions were screened for duplicates and included in our study based on pre-specified eligibility criteria: focused on breast cancer, related to the specific country of analysis and human or health system studies. We used a structured data extraction form to extract information related to the article, its methodology and the cancer care pathway being studied.

Results: A total of 19,215 citations were retrieved from our search. After removing dupli- cates, a total of 8,622 articles remained. Title and abstract screening retained 1,613 articles. Publications with first author affiliations to Turkey were consistently the highest Rima A. Abdul-Khalek across all categories of the cancer care pathway. Trends show an increase in articles from Correspondence to: Email: [email protected] Lebanon, Jordan and Palestine after 2015. Early exploratory and epidemiological studies represented the majority of breast cancer research, followed by policy and implementa- ecancer 2020, 14:1129 https://doi.org/10.3332/ecancer.2020.1129 tion research and lastly experimental research. Most research conducted followed an observational study design. Important gaps were identified in the research output related Published: 29/10/2020 to advanced breast cancer and palliative care (Libya, and Yemen), mental health Received: 22/06/2020 (Libya), and knowledge and education of breast cancer (Libya and Syria). Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access Conclusion: This scoping review has identified key areas in breast cancer research that article distributed under the terms of the lack significant research activity in conflict MENA settings. These areas, including but Creative Commons Attribution License (http:// are not limited to palliative care, mental health, and education, can be prioritised and creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and developed through regional collaboration and contextualised capacity strengthening reproduction in any medium, provided the original initiatives. work is properly cited.

ecancer 2020, 14:1129; www.ecancer.org; DOI: https://doi.org/10.3332/ecancer.2020.1129 1 r4hc-mena.org/. Accessed 14 Jan 2020). and cancerhealth developing (R4HC-MENA: capability, partnerships andresearch intheMiddle East andNorth Africa; available at: https:// in ties and conductingcapabilities health researchimpactful in the region with an additional focus on mental economyhealth, political of articles. This reviewof ispart theGCRFproject funded Research for Health inConflict MENA (R4HC-MENA)that aimsto develop capaci- areas of research inbreastcancer selected inthe countriesand was completed by extracting specific data from alarge number of research the MENA region specifically affected by conflict. This review followed scoping review methodology in order to broadly explore thedifferent different areas of cancer care, an analysiswith of trends inpublications andresearch methodologies usedby different selected countries in Theof aim scoping this review isthereforeof tolandscape the map research inbreast cancer andassesstheproductivity inresearch across outcomes research to inform policy-makers. added to the complexity of reporting on cancer in general and developing insights from research activity, economic evaluations and patient non-Arab countriesof Middle the East particular, areview onbreastcancer researchactivity showed that breast cancer research hasbeenlimited in Arab countries compared to and difficultyfunding ofcouldjournals in high-impact publishing all contribute to thispaucity of medicalresearch. For breast cancer in study suggest thatinstability, political regional conflicts,lack of research infrastructure, ‘brain-drain’ (researchers leaving the area), lack of worldwideaverage asreported inabibliometricanalysis onmedicalresearch productivity inthesecountries [14]. The authors inthelatter output varies significantly across the MENA region, with thenumber of publications per one million people equivalent to one fourth of the research,non-communicable diseases represent categorya distinct in cancontributewhich LMICs to better research [13].Medical research on cancer researchacross theregion thatis relevant to policy. Based onthe World Health Organisation’s (WHO) priority areas for health Despite theimportance of epidemiological anddemographicdata to inform policy, there remains apaucity of high-quality information Iraq (38.4), Yemen (24.9)andLibya (23.2)[12]. comparisonbetween countries;for example,estimates showfollowing the figures: Lebanon (97.6),Syria (67.3), Jordan (57.4), Turkey (45.6), The IARC reportsbreast cancer incidence estimates per 100,000(ASR)for the year 2018andtheseestimates canbeusedfor anapproximate ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 following: an average of 91.7 per 100,000 (ASR) in Lebanon for the year 2005–2015 of reportingavailabilityon the anddepends of registry dataand thenational coverage of registries. For example, reported rates includethe breast cancer. Reportingof age-standardised incidence rates for breast cancer incountries of theMENA region varies by country and year Nevertheless,high-quality registry dataare notavailable low- inmost andmiddle-income countries (LMICs) to estimate thereal burden of North America breastcancer inthe Arab region are diagnosedatan age below 50 years, with amedianof 49–52 years compared to 63 years inEurope and incidence of breast cancer in Arab countries issignificantly lower,is steadily but increasing [5]. Almost half of thepatients diagnosed with and North Africaregion (MENA) includes Arab countriesin additionto Turkey andIran [4].Compared to Europe andNorth America, the Morocco, Oman, occupiedPalestinian territory, Qatar, Yemen, Somalia, Sudan, Syria, Tunisia andtheUnited Arab Emirates. The Middle East North Africato Western Asia: Algeria, Egypt,Bahrain, Comoros, Djibouti,Iraq, Jordan, Saudi Arabia, Kuwait, Lebanon, Libya, Mauritania, Arab countriescomprise 22 countriesthe of the Arab world, alsomembers of theLeague of Arab States andare spread geographically from higher burden of breast cancer mortality [3]. incidence remains higher inhigh-incomecountries employing radiographic screening programs, women inthepoorestcountries stillbear a lung cancer [2]. The vast majority of breast cancer casesoccur in women, with incidence rates increasing with age. Although breast cancer cancer worldwide in2018[1], 626,700cancerwith deaths According to GLOBOCANestimates from theInternational Agency for Research onCancer (IARC), there were 2.1millionnew casesof breast Introduction Keywords: breast cancer; research capacity; conflict [6]. The tendency for a younger age atpresentation hasbeensupported by data from Lebanonand Yemen [7],Egypt [8] [15]. Many Arab countries inMENA region have conflictswitnessed of different durations. This has [2], makingbreastcancer aleadingcancer with thesecond highestincidence after [10] and 33.7 per 100,000 (ASR) in Turkey for 2006 [11]. [9]. 2

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 example.Studies could intobe mapped oneor more cancer care pathway category. Details of onthetype riskfactor or treatment studied as perceivedtopics,such barriers to healthcare, asmany studies were designedto assess knowledge, attitude andpractices collectively, for notintofit existing the categories. Knowledge andeducationgroup of attitudes, included studies behaviour, beliefs, perceptions andrelated HealthInitiative (BHGI) governance.ship The cancer care pathway areas were definedbased onspecifiedareas usedinguidelinedevelopment by theBreast Global the followingincluded categories: service delivery, health workforce, healthinformation systems, essential medicine,financingandleader ‘mentalhealth’ system and‘health studies’. Healthsystem areas were determined usingthe WHO’s building blocksfor healthsystems, and as ‘riskfactors’,such ‘screening andprevention’, ‘knowledge andeducation’, ‘diagnosis andtreatment’, ‘palliative care andmetastatic disease’, and biomedical vs.health), public characteristicsof study the population (general population, migrants) andplace onthecancer care pathway, body name(s),of type publication, studyof design,type research (e.g., early exploratory, epidemiological), area specific of research (clinical of first author, country of affiliation of senior author,of institution affiliation of first andlastauthor, countries of analysis, funding, funding informationfollowing: the included oftitle publication, the of name authors, year of publication, journalof publication, country of affiliation A data chartingform was created, updated when necessary andusedto extract information from the includedpublications. The collected Charting the data or were conducted onhumancell linesor animalstudies. analysis;or and3)human healthsystem studies. Articles were excluded if they reported benignconditions, asgranulomatous such mastitis, by two reviewers (RAand inclusion andNE) wasfollowing basedonthe criteria: 1)focus isonbreast cancer; 2)related to specificcountry of sion andexclusioncriteria, andincaseof uncertainty, athird reviewer was consulted. Full-text articlesof includedabstracts were reviewed Teamsof two reviewersand NE (RA, independentlyAN) screened citations retrieved from allthedatabases according to pre-specified inclu- Study selection No language restrictions were applied. were removed. In additionto thedatabase search, we searched thereference listsof relevant articlesonbreast cancer inthesamecountries. countries, Levant, EMRO,and developingLMICs MENA, countries. All retrieved citations were compiled into one database andduplicates non, Jordan, Iraq, Syria,Palestine, Yemen,Libya and Turkey. Other terminologies usedto search for research inthesecountries were Arab need to beurgently addressed. The selected MENA countriesof analysis recently affected by conflicts andincludedinour search were Leba- along diseases andmalnutrition the burdenwith of existing communicable andnon-communicable diseasesincludingcancer; allof which Lebanon (since 2019),continueto affectthe whole region [17]. The region isalready facing major risinghealthchallenges like communicable thatcrises started earlier in2011,the Iraqi (since 2003)andPalestinian (since 1948)conflicts along with other emerging conflicts, asin such emergency situations, whereongoing the conflicts armed are getting more andmore protracted. For example, theSyrian, Yemeni andLibyan the form of an influxof refugees or internally displaced populations in Turkey. MENA region isenduringtheburden of multipleandcomplex indicate areas that may notbruntbe bearingthe of violence,still experience but socialandpoliticalupheaval asaresult of conflict, e.g.,in neoplasm’, ‘breast cancer’, ‘breast tumour’, ‘breast carcinoma’, ‘metasta*’, ‘adenocarcinoma’, ‘brca’ and‘hboc’. We used‘conflict-affected’ to to search foron breast articles cancercountries inspecific of theMENA region. We usedterminologies for breast cancer as‘breast such librarianmedical andusingacombination of keywords and controlled vocabulary words that were tailored to the appropriate database Complete (1972),Popline (1970),Scopus(1823) andGoogle Scholar. Search strategies were built theconsultationwith of anexperienced EMBASE(1947), Web of Science (1900),PROQUEST (1905),CINAHL (1937),Global Index Medicus (includingIMEMR), Arab World Searches 2018, we searched thefollowing 11 databases for peer-reviewed publications journal on breast cancer: Medline (1946), PubMed (1946), A review protocol was developed following thePRISMA-Scr methodology Search strategy andstudy design Methods [18]. We added‘mentalhealth’ and‘knowledge andeducation’ asdistinctareas of research, since many studiesdid [16] and registered onthe Open Science Framework. During July 3 -

Review University of Aden in Yemen. Similar findingsare shown for senior authors from top of institutions affiliation (Table 4). of Beirutin Lebanon, The , An-Najah University inPalestine, Baghdad University inIraq, University inSyria and analysis of thepublication, are presented in (n =42),andtheEuropean Journalof Cancer (n Mostof publications the were inthe published in in 2011,followedstarting by Libya, Syria and Yemen. Journals retrieved with thehighestnumber of publications onbreast cancer are listed breastcancer research(Figure 4).Publishingshowed anupward trend for Lebanon, Jordan andPalestine, while itshowed adecrease inIraq breast cancer (Figure 4).However, afterfor adjusting population size, Jordan andLebanon appeared to alsohave significantly contributed to Trends of publicationsaccording to firstauthors’ countriesof affiliation alsoshowed Turkey to beleadinginthenumber of publications on MENA population. Results show that authors from allcountries across allcontinents have onbreast published cancer intheMENA region. non (Figure 2). When measured by countries of affiliation of first author, Turkey exhibited thehighestnumber of publications, followed by Jordan andLeba- (n =34),French (n=4), (n=2)andItalian (n=1)Table 1). also includedasresearch papers according to the Web of Science’s definition. were alsoextracted. We considered publications asresearch papers if they were primary or secondary research papers. Casereports were ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 then experimental research (Figure 5). In terms of researchofmost type, research the published were early epidemiological andexploratory, followed by policy andimplementation Publications across the cancer care pathway primary andsecondary researchstudies; elsewhere, the latterwith beingnegligiblecompared to theformer. The majority of includedpublications were originalresearch papers (both egories: general population (n studies From those,1,613 were considered eligiblefor this study and1,273 were excluded. These excluded publications pertainedto two broad cat- Froma total of 19,215publicationsretrieved (Figure 1 ), 8,622 were assessedby titleandabstract and2,886remained for full-text screening. Mapping the characteristics of thepublications Results publications was adjusted to thepopulation size usingpopulation numbers obtained from the WHO’s worldwide population prospects. WeSTATA used 3.6.0 for 15.1andR statisticalanalysis. Frequencies andpercentages were usedfor categorical variables. The number of Statistical analysis Table 2. Figure 3shows thegeographical ofdistribution countries of affiliation of first authors of papers related to breastcancer inthe = 1,167) and studies on migrants= 1,167)andstudies or ethnic minority groups (n n = 1,397).Mostof articles the were inEnglish (n=1,572),andtheother languages were Turkish Table 3.Most publications were reported from Istanbul University in Turkey, American University = 32). Top of institutions affiliation of primary authors, distributed ontheprimary countries of Asian Pacific Journal of Cancer Prevention (n = 161),followed by theJournal of Clinical Oncology = 106)from theMENA region residing but 4

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 Figure 1.Study flow chart. Table 1. Type of publications. Total Other News Report Letter to editor; Opinion piece; commentary; editorial Abstract Research paper Type 1397 (86.60) 135 (8.36) 12 (0.74) 13 (0.80) 49 (3.03) 7 (0.43) N (%) 1613 5

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 lation size. Figure 4. Figure 3. Total number of publications related to conflict-affected countries oftheMENA region by firstauthor’s country of affiliation. Figure 2. Total number of publications from conflict-affected countries by firstauthor’s country of affiliation. Trendsin breast cancer publicationsby countriesof first authors from theMENA region: (a) unadjusted (b) andadjusted for popu- 6

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 with significant variations between thecountries assessed. related to advanced breast cancer andpalliative care, healthsystem research, knowledge andeducation onbreast cancer andmental health, ofmost research the followedpublished anobservationalstudy design.Important gapsinresearch from outputs theMENA region were as conflict,crises, such in humanitarian and leadingto isolationof research groups [19].Most of thepublications were research articles,and countriessuch experiencingconflicts, collaborations across andbetween disciplines partners will behindered, creating abarrier to research in prioritiesto rapidrelief humanitarian rather thanto research, or dueto theresearch sanctionsimposed onsomecountries inconflict. In Libya, Syriaand Yemen,there was asignificantin publicationsdecline between 2010and2015. The declinecould beattributed to theshift to breast cancer research intheregion upwardwith trends for Lebanon, Jordan andPalestine. As for theconflict-affected countries, like Iraq, showed that Turkey hadthehighestnumber of publications. Following Turkey, Lebanon and Jordan appear to have contributed significantly This scoping review of peer-reviewed breast cancer publications from Lebanon, Jordan, Iraq, Syria, Palestine, Yemen, Libya and Turkey Summary of findings Discussion focusedon chemotherapy (n Researchon riskfactors was mostly ongeneticand mutationspolymorphisms associated with breast cancer (n of healthsystem publications. and education publications, 74%of both screening andprevention andof diagnosisandtreatment, 63%of riskfactor publications and43% pathway categories: 86%of mental healthpublications andquality of life, 83%of palliative care andmetastatic disease,80%of knowledge When stratifiedby thecountry of affiliation of thefirst author, publications from Turkey were consistently thehighestinallcancer care minority were classifiedunder palliative care andmetastatic (4.46%)(Figure disease 6). These publications(both research and reviews) articles were primarily related to diagnosisandtreatment of breastcancer (32.44%) andthe ecological), while other designs were more variable between countries of analysis shows thatcommon themost design across allcountries was theobservational (cross-sectional, case-control, cohort studies, in countries other than Turkey (14%for Lebanon and 13%for Jordan). With respect to thestudy designsadopted, stratification by country health system research, there was asignificant gapinthisarea of research inPalestine andSyria, but was researched inhigher proportions gap inLibya, Iraq andSyria, onlywith (1%)of related publications retrieved. Similarly, palliative care isagap for Yemen, Syria andLibya. As for tion, knowledge andeducation seemto benon-existent amongtheresearch focusing published onSyria andLibya. Mental healthisalsoa areas inbreast cancer intheeight countries analysed; gaps were shown in the remaining areas. For example, research onscreening, preven - Table 2. Top journals with more than20publications onbreast cancer. Eastern Mediterranean Health Journal European Journal of Breast Health Journal of Cancer Education European Journal of Oncology Nursing Journal of Balkan Union of Oncology Cancer Nursing MedicalJournal Saudi Diagnostic andInterventional Radiology European Journal of Cancer Journal of ClinicalOncology Asian Pacific Journal of Cancer Prevention = 110),followed by surgery (n Journal = 93). While riskfactors anddiagnosistreatment were themajor research Frequency 161 16 17 26 21 27 24 29 29 32 42 Percentage 0.99 1.05 1.61 1.31 1.67 1.49 1.80 1.80 1.98 2.60 9.98 = 195).Research ontreatment 7

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 (N =1,613). Table3. Topof institutions affiliation of primary authors inpublicationsfrom countries of theMENA region Libya ( Yemen ( Syria ( Iraq ( Palestine ( Jordan ( Lebanon ( Turkey (N=895) N =76) N =16) N =22) N =118) Country N =30) N =94) N =19) Qariunis University Garyounis University Benghazi University Tripoli Medical Centre Management andScience University Sanaa’ University Hadhramout University Universityof Aden Damascus Cancer Centre Atomic Energy Commission of Syria Bairouni University Universityof Aleppo Al-Nahrain University Universityof Al-Qadisiyah University of Basrah University of Babylon Kufa University Baghdad University Al-Aqsa University Islamic University of Gaza Al-Quds University An-Najah National University Zarqa University Mutah University King Hussein Cancer Centre Jordan University of Science and Technology The University of Jordan LebaneseUniversity American Hotel Dieu deFrance SaintUniversity Joseph American University of Beirut American University of Beirut Medical Centre Akdeniz University Onodokuz Mayis University Maramara University Uludag University Gazi University Dokuz Eylul University Hacettepe University Ege University Istanbul University Institution Name 10 15 10 17 19 24 15 21 42 17 23 25 26 29 36 45 51 95 N 2 2 4 6 3 5 8 1 1 1 1 3 3 3 5 6 7 8 1 1 3 3 3 5 5 6 1 5 8

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 Table 4. Top institutionsof affiliation of senior authors inpublications from countries of theMENA region. Libya (N=16) Yemen (N=22) Syria (N=12) Iraq (N=61) Palestine (N=18) Jordan (N=92) Lebanon (N=86) Turkey (N=833) Country Qariunis University Benghazi University Tripoli Medical Centre Management andScience University Universityof Aden Sanaa’ University Hadhramout University Tishreen University Bairouni University Universityof Aleppo Damascus University Univesityof Aleppo Al-Nahrain University University of Babylon Universityof Al-Qadisiyah University of Basrah University of Baghdad Kufa University Ministry of Health Birzeit University Islamic University of Gaza Al-Quds University An-Najah National University Bethlehem University Ministry of Health King Hussein Medical Centre King Hussein Cancer Centre Hashemite University Jordan University of Science and Technology The University of Jordan Ministry of Public Health Hotel Dieu deFrance SaintUniversity Joseph American University of Beirut American University of Beirut Medical Centre Ankara University Onodokuz Mayis University Uludag University Gazi University Maramara University Dokuz Eylul University Ege University Hacettepe University Istanbul University Institution N 11 11 14 20 17 38 18 23 24 27 28 39 47 50 94 N 2 4 4 3 4 4 5 1 1 1 3 4 3 3 4 5 8 7 2 2 3 3 4 2 4 5 5 8 8 9

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 Figure 6.Percentage of publications across thebreast cancer care pathway (by country and by pathway). Figure 5. Type of research: early exploratory andepidemiological, trialsor healthservices research. 10

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 trials, international and national academic collaboration issupportedby a way to improve cancer therapy andpatient outcomes [29,30]. ofinvestigator,and non-LMIC LMIC to beassociated higherwith levels of evidence andthushigher quality studies[28].In cancer treatment to increase researchquality inotherresearchas orthopaedic such fields identified inLMICs academiccollaboration, defined astheinclusion evidence isavailable ontheperception of theimportance of research quality incapacity buildingstudiesfrom theMENA region. Approaches been indicated as an important strategy in research capacity building[26], and capacity for clinicalresearch in the Middle East infrastructure,others, amongst asimportantstrategies for breastcancer control [3].Similarly, training inclinicalresearch amongnurses has in different regions of Asia, Latin Americaand theMiddle East have identified capacity buildinginresearch anddevelopment of research whether they includestrategic entitiesor individualhealthcare providers. Stakeholder interviews exploring breast cancer control strategies Implementation of capacity buildinginitiatives will require that stakeholders beaware of theimportance of research capacity building, breast cancer shouldbecarriedoutthrough robust research that isusablefor evidence generation andfor policy-making. tantto identify factors thatimprove can researchquality andincorporate theminto capacity buildinginitiatives. Thus, filling research gapsin Evidence from a systematic review, for example, shows that thequality of breast cancer economic research in is LMICs poor However, improving thequality of medicalresearch through capacity building will be more complex than increasing therate of publications. has thepotential, if properly addressed, to improve thequality of evidence generated as well asthequality of medicalservices provided. period time same this 2007–2016 (189 versus 695per onemillionpeople), therate of increase was higher for Arab countries incomparison to globalrates over researchAlthoughmedical in Arab countries was estimated to belower inquantity compared to therest of the world for thetime period Implications for capacity building our study andthat identify gapsinsocial,cultural, economic barriers and political to treatment of breast cancer are needed. are implemented [24].Infuture addition, that studies look into the typeof qualitative into mapped studies, theexploratory typeof studiesin limited compared to other countriesis expected but to improve over thenext decadealastheproper capacity strengthening interventions of evidenceapplicability andits [23]. Theof use real-world evidence to inform healthdecision-makinginhealthcare isstill decision-making methods for healthsystems andpolicy research andby buildingthecapacity of policy-makers inassessingthequality, cost-effectiveness larly, healthsystemsand policy research evidence neededfor healthpolicy-makinginMediterranean countries isfacilitated by theimproved required in order to ensure the uptake of scientificand clinical research findings and to detect improvements in cancer outcomes research, focuseswhich knowledgeon the of how ahealthcare system functionsinterms of cancer detection, diagnosisandtreatment, isalso ence and cost-effectiveness studiesthat canguidetheestablishment of programs for early detection of breast cancer contributed inacceptable proportionsto thisresearch area. This isinline previouswith recommendations byof BHGI implementation sci- on our findings,there isanurgent need foran initiative such to beimplemented specifically inPalestine andSyria, astheother countries have policy, asimproving survival incancer needsto consider thesystem that delivers cancer care andnot only riskfactors for thedisease.Based Our resultsshow thatthere isaneedto strengthencapacitythe buildinginspecificareas asconducting such research onhealthsystem in Lebanon with theestablishment of research committees intheNational Task Force onPain relief andPalliative care [21]. region can explore this practice, especially in Libya, Syria and Yemen. Initiatives for advancing palliative care research have been implemented of palliative care elsewhere, thisbeingmediated by thehealthcare financingmechanism[20].Further research onpalliative care inthe Arab Researchon palliative care isparticularly important,has beenshownas it that there are gapsbetween recommendations andthepractice researchers from publishingresearch, if conducted [14]. ties which were notincluded scopethe within of review. this Funding andsecuringfees for publications canbeanother barrier preventing conductresearch inhigherfactor impact journals,or toknowledge limiting dissemination to localjournalsof or institutions specific universi- proportions, except [14]. Therefore, capacityof building professionals health inaregion where research isimproving interms of quantity [22]. Implementation [25]. It is impor [27]. Limited [18]. Simi- 11 -

Review sary to complement strategies of health research capacity buildingincancer. researchareas of mentalhealth, palliative care andeducation. thetypesof Exploring barriers inqualitative exploratory studiesisalsoneces- pillara basic cancer inthe control strategies [35]. Additional research endeavours tailored to theidentified gapsare recommended inhealth improving data collectionon clinicopathological characteristics was developed to cancer support research, thisresearch beingregarded as region,amount andthe of trainingprofessionals health are provided with to analyse andreportdata onbreastcancer. In Iraq, aninitiative for in particular, there islimited evidencebreadth onthe of research the usedto describebreast cancer intheconflict settings of theMENA others advocate for better resource allocation andutilisation to minimiseinequalitiesinbiomedicalresearch productivity. For breast cancer review oncancer research in Arab countries. The authors propose more high-quality research evidence oncancer from the Arab world, while ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 settings researchers fromsome research using methodologies, andsodifferent methodologies have beenproposed to conduct research inconflict The difficulty inaccessing andgenerating data iscomplicated by thepoliticalinstability intimesof war andconflict that may prevent related to socialstigmaandfear from socialexclusion that arisefrom cultural normsinsomesocieties. samples arebut include, notlimited to, access to informationand respondents, andproblems of generalisation of findingsdueto unrepresentative in certain areas will needto take into consideration thegeneral challenges for conducting research of intimes conflict; thesechallenges Middlein the East faces problemsas data such availability andquality when compared to more developed countries [32].Increasing research The limited amount of reliable data and real-world data in the Middle East contributes to the data poverty in the region. Conducting research of affairs inresearch. fortions moreresearch impactful and for improvingcapacity the to conductresearch necessitate abetter understanding of thecurrent state Thus, integrating research into healthsystems indeveloping countries hasbecome necessary to improve health[31].However, recommenda- Lower mortality rates in high-income countries have been attributed to investments in research and improvements in early detection [22]. Implications for research context andpractice and capacity buildingactivitiesintheregion. cer pathway. The review hasalsoidentifiedkey researchareas andregional academichubsthat canbethefocus for research collaboration The review highlightedstrengths the and weaknesses ofof each thecountries assessedinthedifferentresearch areas alongthebreast can- and impermissivecapacities along policies the naturewith of conflict that deprioritisesresearch incomparison to rapid relief. humanitarian betweencountries the assessed that be attributedcan to a rangewide of limitations, like funding,facilities andinfrastructure, localresearch This review is thefirst to assess thetrends of cancer research in conflict-affected countries in the MENA region. It has shown huge disparities Conclusion in research capacity building. Future research canalsoexplore theeffectof additionalfactors onbreast cancer research, aseconomic such development and investment topublications journal article for comparabilityhowever, purposes; afuture grey literature review cancomplement thefindingof thisreview. due to theaffiliations andcontent of thepapers not beingamenableto data capture usingour methods. We have limited thisscoping review published byarticles localuniversities.It is alsopossiblethat we didnot capture articlesby authors from theselected countries of interest complete forin international articles databases;however, we may have missedsomearticlesnot indexed by any of thedatabases, as such The limitations of thisstudy, as with other reviews, are related to themethodology of conducting scoping reviews. Our study coverage was Limitations [33]. Some related approachesto improving researchmethods andthat address data quality are suggested by Hamadeh et al [32]. Some ofidentifiedgaps the in thisreview, mental including healthresearch andresearch data generation, alsoface issues [34] ina 12

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 References ity, partnerships andresearch intheMiddle andNear East grant (MENA) number ES/P010962/1. This publicationthrough isfunded Research theUK andInnovation GCRF Research for Health inConflict (R4HC-MENA);developing capabil- Funding The authors acknowledge Ms. Aida Farha from American University of Beirut-Libraries for her ondeveloping support thesearch strategy. Acknowledgment articles. RA analysed thedata and wrote thefirst draft. All authors reviewed andcommented onthefinaldraft. and GARA, RS designedthescoping review.and RA, NS AN screened theretrieved articles. RA, AE and WK extracted data from full-text Authors’ contributions All authors have noconflicts of interest. Conflict of interest WHO: World Health Organisation MENA: Middle East andNorth Africa LMICs: Low- andMiddle-Income Countries IARC: International Agency for Research onCancer List of Abbreviations 7. 6. 5. 4. 3. 2. 1. adjusted incidence rates of younger-aged groups at presentation JMed Liban 50(1–2)3–9 El SaghirShamseddine NS, AI, andGeara F, et (2002)Age al distributionof breast cancer in Lebanon: increased percentages andage a literature andregistry analysis El Saghirand EidMK, Khalil NS, T, et al(2007)Trends inepidemiology and management of breast cancer indeveloping Arab countries: implications L, BoussenChouchane H,andSastry(2013) Breast KS cancer in Arab populations: molecular characteristics anddiseasemanagement States LoA Member States [https://arab.org/directory/league-of-arab-states/] specific economic development and prevention strategies? JGlob Oncol 41–16PMID:30085889PMCID:6223528 Bellanger M,Zeinomar N,and Tehranifar P, et (2018) alAre globalbreast cancer incidence andmortality patterns related to country- sources andmethods Ferlay J, Colombet M,andSoerjomataram I,et al (2019)Estimating cancer theglobal incidence andmortality in2018:GLOBOCAN worldwide for 36cancers in185countries CA Cancer J Clin Bray F, Ferlay J, andSoerjomataram I,etcancer al (2018)Global statistics 2018:GLOBOCAN estimates of incidence andmortality Lancet Oncol 14(10)e417–e424https://doi.org/10.1016/S1470-2045(13)70165-7 PMID: Int J Cancer Int 144(8)1941–1953https://doi.org/10.1002/ijc.31937 J Int J Surg J Int 5(4)225–233https://doi.org/10.1016/j.ijsu.2006.06.015 PMID:17660128 68(6)394–424https://doi.org/10.3322/caac.21492 PMID:30207593 23993386 13

Review 26. 25. 24. 23. ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 22. 21. 20. 10. 19. 18. 17. 16. 15. 14. 13. 12. 11. 9. 8. cancer control BlauveltPodderB, and S, Abulkhair O, etal (2011)An international perspective: The role of nurse involvement inimproving breast review Syst Rev 220https://doi.org/10.1186/2046-4053-2-20 Zelle SGandBaltussen(2013) RM 19.1568243 PMID: considerationscal futureand directions Akhras KS, Alsheikh-Ali AA, andKabbani(2019) Use S of real-world evidence for healthcare decision-makingintheMiddle East: practi- 22236561 PMCID: ern Mediterraneancountries: viewspracticesand of researchers El-Jardali F, Lavis and JN, Ataya N,et al(2012)Useof systems health andpolicy research evidence ineast- inthehealthpolicymaking breast.2011.02.007 PMID: tries (LMCs): consensusstatement from the Breast Health Global Initiative Harford OteroJB, IV, and Anderson BO, etal (2011)Problem forsolving breast healthcare delivery inlow resource andmiddle coun- 204 https://doi.org/10.12816/0001460 Abu-Saad HH,Deeband Ghusn M, H, et (2013) alPalliative care research inLebanon.Le Journal medicallibanais patients JPalliat Med 19(9)957–963https://doi.org/10.1089/jpm.2015.0514 PMID: Gidwani R, Joyce N,andKinosianB,et al (2016)Gap between recommendations andpractice of palliative care andhospice incancer e001870 https://doi.org/10.1136/bmjgh-2019-001870 Fares MY, Salhab HA,andKhachfe HH, Abdul Hamid G, Tayeband Bawazir MS, AA (2001)Breastcancer insouth-eastRepublic of Yemen HealthAssoc 77(3–4)329–345 Public Hosny GandElkaffas(2002) A SM predictionformodel theincidence patterns of female breast cancers in Alexandria, Egypt KohrtBA, Mistry and AS, Anand N, health Anderson BO, Ilbawi and ElAM, Saghir(2015) Breast NS cancer in low and middle income countries (LMICs): a shifting tide in global T P, P W (2015)Armed conflict, 1946–2014 Med Tricco AC, LillieE,andZarin W, et al (2018)PRISMA extensionfor scoping reviews (PRISMA-ScR): andexplanation checklist 4381665 Arab MiddleEastern countries Sweileh WM, Zyoud SH,and Al-Jabi SW, et al (2015) Contribution of Arab countries tobreast cancer research: comparison with non- Glob Health El RassiMeho R, and Nahlawi LI, A, et (2018)Medicalal research productivity inthe Arab countries: 2007-2016 bibliometric analysis World Health Organisation (2010)Background Paper: Non Communicable Diseases inLow andMiddle Income Countries(Geneva: WHO) Cancer IAfRo (2018)Cancer Today (Geneva: World Health Organization) [https://gco.iarc.fr/today/online-analysis-map Cancer Prev 11(6)1731–1739 Eser S, YakutC, andÖzdemir R, (Kaunas) 55(8) 169(7)467-473https://doi.org/10.7326/M18-0850 BreastJ 21(1)111–118https://doi.org/10.1111/tbj.12357 8(2)020411https://doi.org/10.7189/jogh.08.020411 PMID:30410737PMCID:6220353 JClinOncol 29(27_suppl)152 3286421 30626231 21376593 etal (2010)Cancer incidence rates in Turkey in2006:adetailed registry basedestimation BMC WomensBMC Health et al(2019)Healthresearch inhumanitariancrises:anurgent imperative global Economicanalyses of breast cancer control in low- andmiddle-income countries: asystematic etal (2019)Breast cancer epidemiology amongLebanese women: an 11-year analysis

Expert RevExpert Pharmacoecon Outcomes Res JPeace Res 52536–550https://doi.org/10.1177/0022343315595927 https://doi.org/10.1200/jco.2011.29.27_suppl.152

15 25https://doi.org/10.1186/s12905-015-0184-3 PMID: PMID: PMID: PMID: 31798999 PMCID: 30178033 Implement Sci 23566447 PMCID: Breast 19(3) 245–250https://doi.org/10.1080/14737167.20 7 2https://doi.org/10.1186/1748-5908-7-2 PMID: 6861060 27228478 20(Suppl 2)S20–S29https://doi.org/10.1016/j. 3651267 East Mediterr Health J LebaneseMed J BMJ GlobBMJ Health 25783656 PMCID: ] 7(6) 1012–1016 Asian PacAsian J Ann Intern Medicina J Egypt 61(4)

4(6) 14 J

Review ecancer 2020, 14:1129; www.ecancer.org; DOI:https://doi.org/10.3332/ecancer.2020.1129 35. 34. 33. 32. 31. 30. 29. 28. 27. J Glob Oncol 2(5)255–258https://doi.org/10.1200/JGO.2015.003087 PMID:28717711PMCID:5493264 Alwan(2016) Breast NAS cancer Iraqi among women:preliminary findingsfrom aregional comparative breast cancer research project 5488814 between 2000–2013 HamadehBorgan RR, and Saibai SM, AM (2017)Cancer Research inthe Arab World: A review of publications from seven countries World Q23(5)991–1003https://doi.org/10.1080/0143659022000028530 Barakat S,Chard M,and Jacoby T, et al(2002)The composite approach: research designinthecontext of war conflict andarmed journals Lages CR,Pfajfar G,andShoham A (2015)Challengesin conducting andpublishingresearch ontheMiddle East and Africa inleading MALansang andDennis(2004) Building R capacity research inhealth inthedeveloping world network to facilitate breast cancer research ClinOncol (RColl Radiol) 32(1)e16–e18https://doi.org/10.1016/j.clon.2019.06.019 Cheng VWT, Heetun A, andRobinson T, etal (2020)The Breast Cancer Trainees Research Collaborative Group: anew multidisciplinary treatment trials TrimbleEL, Abrams and MeyerJS, RM, low- andmiddle-income countries SICOT J36https://doi.org/10.1051/sicotj/2016042 PMID:28134090PMCID:5278648 WuM, andPatelLiu HH, KR, North Africa: aqualitative(Philadelphia: AACR) horizon scanning analysis Bridges J, Coates A, andPiccartM, Int Market Rev 32(1)https://doi.org/10.1108/IMR-12-2014-0374 JClinOncol 27(30)5109–5114https://doi.org/10.1200/JCO.2009.22.5771 PMID: Sultan Qaboos Univ Med J et al(2017)Impactof collaboration academic andquality of clinicalorthopaedicresearch conducted in et al(2009)Thefuture of breast cancer research andpractice in Asia, Latin America, and Middlethe East/ et al(2009)Improving cancer outcomes through international collaboration inacademiccancer 17(2) e147https://doi.org/10.18295/squmj.2016.17.02.003 PMID: Bull World Health Organ 19720905 PMCID: 28690885 PMCID: 82(10) 764–770 2799058 Third 15

Review