Newsdesk

Cancer and peace in the Middle East

On April 27, 2006, the Middle East Cancer Consortium (MECC) published a monograph detailing the incidence of all major types of cancer in four MiddleEastern populations for the period 19962001: Cancer incidence in four member countries (Cyprus, Egypt, Israel and Jordan) of the Middle East Cancer Consortium compared with US SEER. As the title suggests, the report also compares its ndings with US cancer statistics. This comprehensive work is the rst major publication of the Consortiums cancer registry project and shows the often great dierences in the types of cancer aecting these populations; raises questions about why; and provides vital information that will help health providers prioritise services to ght the disease. However, this report is important on another level: it exemplies what can be achieved when peace is sought between countries that have long been in conict. MECC was established on May 20, 1996, when the health ministers of Cyprus, Egypt, Israel, Jordan, and Palestine (Gaza and the West Bank) witnessed by the US Secretary of Health and Human Servicessigned an agreement to establish the Consortium, and thereby to cooperate to increase awareness and reduce the burden of cancer. MECC, which receives funding from the US National Cancer Institute, became possible because of breakthroughs in the Middle-East peace process during the mid-1990s, and is a legitimate child of the IsraeliPalestine Liberation Organisation Declaration of principles. In the more-troubled mid-2000s, with the Middle-East peace process bruised and the political conict caused by the division of Cyprus still unresolved, the present report is a tribute to the Consortiums tenacity and the spirit of cooperation it has developed. Old enemies are now ghting side by side in the war against a common enemycancer. Indeed, Turkey, which has no diplomatic relations with the (Greek) Republic of Cyprus, became a full member of MECC in June, 2004. Since its inception, one of the major objectives of MECC has been to establish population-based cancer registries, which are vital for dening cancer burden in any population. In January, 1998, the Cancer Registry Project, which gave rise to the present report, was born. At the time few countries in the Middle East had such registries, says Michael Silbermann (Executive Director of MECC, Haifa, Israel), and of the MECC signatories only Israel had a fully working system. However, by the sharing of expertise and experience across international frontiers, for example in the training of registry sta in standardised data collection and coding methods, the MECC countries were able to accelerate the establishment of reliable cancer registries that could collect quality and comparable information. The new report is easy to read. Its 167 pages are divided into: an executive summary stating the main ndings; an overview of the populations covered plus the history and functioning of the registries; and 14 chapters comparing the incidence of dierent cancers (ie, oesophageal, stomach, liver and intrahepatic bile duct, lung, laryngeal, breast, CNS, colorectal, cervical and uterine, ovarian, bladder, thyroid, lymphoma and leukaemia, and that in childhood). Comparisons are made with the 2004 US Surveillance Epidemiology and End Results (SEER) statistics. The report uses data for age-standardised and age-specic incidence. The results show that populations of the Middle East are not homogeneous as far as cancer incidence is concerned, says Silbermann. Sometimes the dierences between them are very great, probably reecting dierences in their genetic make-up, their lifestyles and diets, environmental factors, and the lack of screening centres (eg, for mammographies in women [aged] 50 [years] and above). While suggestions are made that might explain these dierences, it was beyond the scope of this work to determine their exact causes, but these results still alert nations to undertake certain preventive measures that could reduce their cancer burdens. The results show that Jordanians are the least aected by cancer (1133 cases per 100 000 people), whereas Israeli Jews (2744) and the US SEER population (3186) are the most aected. Cancer incidence for Cypriots (1642), Israeli Arabs (1498), and Egyptians of the Gharbiah region (the area for which registry results
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MECC aims to increase cancer awareness and reduce cancer burden in the Middle East

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were available; 1430) was between these extremes. However, this distribution changes when you look at specic types of cancer, says lead editor of the report Laurence Freedman (Sheba Medical Center, Tel Hashomer, Israel). For example, Israeli Jews had the highest [incidence] of colorectal cancer (369 cases per 100 000 people) higher than that seen in the SEER population (320)while the other MECC populations had much lower [incidence] (60173). Non-Hodgkin lymphoma was . . . much more common in Israeli Jews (152) than in most other MECC populations, and . . . even higher than in the SEER population (129). It may be that Israeli Jews suer typically Western cancers more frequently than other MECC populations because their lifestyle is more similar to that of Western populations. Egyptians were at greater risk of liver and bladder cancer than any other MECC population or the SEER population. Indeed, Egyptian liver cancer incidence was more than three times that of the USA (125 people per 100 000 vs 38) and four times higher in men than in women. Similarly, Egyptian bladder-cancer incidence was 166 cases per 100 000 people compared with 122 for the SEER population, 151 for Israeli Jews, 112 for Cypriots, 86 for Israeli Arabs, and 76 for Jordanians. The higher [incidence] of bladder cancer in Egypt could be due to [an association] with . . . schistosomiasis. The disease has recently been coming under control in most provinces, says Amal Samy Ibrahim (National Cancer Institute, Cairo University, Egypt). Certainly, the incidence of squamous-cell bladder cancer, the type associated with this parasitic disease, is [decreasing]. However, we cannot rule out smoking . . . as a cause of the persistence of the high incidence of bladder cancer. Hepatitis virus and aatoxins might be behind the very high liver cancer rates.
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Cyprus had the worst results for total cancer in paediatric patients (mainly because of high leukaemia and CNS cancer incidence) at 170 per million compared with 1533 in the SEER population, and 11481333 for the other MECC populations. The report suggests genetic factors may play a crucial part in these gures. Over the years, the work of MECC has attracted the attention of other countries, some with no diplomatic relations with Israel. Iraq, Morocco, Tunisia. Algeria, Qatar, Pakistan, India, and Lebanon have all participated in MECC activities such as congresses and meetings, and some have inquired about becoming full members, although they are waiting until the Middle-East peace process is back on track before taking the plunge. Should any further evidence be needed that international cooperation can have profound eects under challenging circumstances, decision-makers need only read how a recent collaboration between Italy and Iraq has helped treat children with acute promyelocytic leukaemia (APL) in Iraq (Haematologica 2006; 91: 50912). Although this aggressive form of leukaemia is rare in other nations, it accounts for more than a third of all leukaemia in paediatric patients in Iraqyet no specic APL treatment was available. The article reports how eight children are now in complete remission after establishment of all-trans retinoic acid chemotherapy adapted to the special circumstances of wartorn Baghdad. The statistics in the new monograph will be of great importance to the health authorities of MECC countries. With limited funding available, knowledge of the types of cancer that aect their populations will help maximise the returns from investment, such as from education programmes or the purchase of medical equipment. The Cancer registry project must continue and expand for this very reason, says Silbermann, but we are now in a position to go one step further. Our

MECC cancer incidence Egyptians Highest incidence of bladder and liver cancer. High incidence of non-Hodgkin lymphoma and lymphoma in paediatric patients Jordanians Lowest overall incidence of cancer Israeli Arabs High incidence of lung cancer in younger men Israeli Jews High incidence of cancer overall. Highest incidence of colorectal cancer. High incidence of non-Hodgkin lymphoma Cypriots Highest incidence of cancer in children younger than 15 years, due mainly to high incidence of leukaemia and CNS cancers

next major project, palliative care to cancer patients, will go beyond the bureaucratic or administrative level and help meet the needs of individual cancer patients. In the Middle East, patients receive very little in the way of palliative care. It is our aim to start [training] medical personnel to provide this, some of which will be [funded] by fellowships for ongoing education. We hope to make an impact in many areas from pain control to how to explain to patients about their condition; this should make an impact in hospitals, hospices and even in home-care situations. Every MECC country is strongly behind this idea. The new MECC report is an essential development for strategic planning and the improvement of care for people living with cancer in the Middle East, says Isabel Mortara (International Union Against Cancer [UICC], Geneva, Switzerland). The fact that such an erudite and essential publication can be produced by the quiet collaboration of scientists, doctors, and public-health administrators, whose countries are living [through] dicult times should be a lesson to us all. Cancer can be as deadly as war and civil unrest in the Middle East: this work sets the example of where our guns should really be pointed.

Adrian Burton
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