Despite Challenges, Initiatives Bring Gradual Improvements to Cancer Care in Lebanon

A Conversation with Nagi S. El Saghir, MD, FACP

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When ASCO began licensing overseas Best of ASCO meetings, Lebanon became one of the first countries to host one, and it is now an annual tradition.

—Nagi S. El Saghir, MD, FACP

Nagi S. El Saghir, MD, FACP, Professor of Clinical Medicine and Hematology-Oncology at the American University of Beirut, is the founding President of the Lebanese Society of Medical Oncology (LSMO). Dr. El Saghir has focused much of his research on the early detection, prevention, and treatment of young Lebanese and Arab women with increasing breast cancer incidence rates. The ASCO Post recently spoke with Dr. El Saghir about his experiences as a global oncologist.

Medical Training

Please describe your introduction to medicine.

I went to high school in Beirut, Lebanon, and then traveled to Belgium for a 7-year program that incorporates college and medical school. I originally wanted to become an engineer; however, on the day I was leaving for college, my father walked me across the tarmac to the airplane, and before I boarded, he said, “Please go into medicine, it’s more worthwhile for us.” In those days, particularly in Lebanon, we sought to honor our fathers, so his advice greatly influenced my first step toward a medical career.

I traveled throughout France learning the language, and then I went to Brussels, Belgium. I really liked Belgium, so I decided to enroll at the Free University of Brussels, where I received my medical degree in 1978.

Where did you do your residency?

After graduating medical school, I came to the United States and did my residency in internal medicine at The Brooklyn Hospital, affiliated with the State University of New York–Downstate Medical Center. In 1983, I completed my fellowship in Hematology-Oncology at St. Luke’s–Roosevelt Hospital Center, Columbia University, New York.

Was there a specific turning point—a mentor, perhaps—that helped steer your decision to pursue oncology?

Not really; the decision was more of a natural progression. I actually started my career in hematology. I found the laboratory work in blood cancers very exciting. I later moved to oncology and solid tumors. I also had two friends who had cancer, one in Brussels with melanoma, and one in Brooklyn who had leukemia. Maybe seeing the effects of cancer on a human level, combined with the intellectual scientific challenges in oncology, in some way, helped inform my career decisions.

Continued Travel

When did you return to Lebanon?

There was a civil war in Lebanon that began in 1975 and lasted until 1990. It was a very difficult period in the country’s history. After a couple of years of practice at Long Island College Hospital and Brooklyn Hospital–SUNY Downstate, I went to Saudi Arabia and worked at the King Khalid University Hospital for a couple of years, then moved to Michigan, where I worked at Oakwood Hospital in Dearborn and was also on the clinical faculty of Wayne State University.

In 1993, a few years after the civil war ended, I decided to return to Lebanon and take a position at the American University of Beirut.

Day-to-day Activity

What does your current work entail?

My normal day begins with hospital rounds with fellows and house staff at about 8:30 in the morning. Then I have clinical hours about four times a week. Naturally, there are numerous conferences, tumor boards, and meetings with research fellows and administrative personnel. I also do quite of bit of traveling in the Arab region to give lectures. So my schedule is full, and my current activities are varied.  I often end up writing my articles, reviewing manuscripts, and completing my PowerPoint slides in the evenings and on weekends.

Lebanese Society of Medical Oncology

You are the founding President of the Lebanese Society of Medical Oncology. What inspired the development of the organization?

When I returned home in 1993, I became aware that many of the region-specific needs in developing countries like Lebanon were unmet. In particular, there wasn’t enough of a collaboration network for Lebanese oncologists.

Lebanon is a small country, with roughly 4 million people. Even so, at the time the Lebanese Society of Medical Oncology was founded in 1997, we had only 30 oncologists. We now have more than 100, which is an improvement. We needed to collaborate, have CME programs, look after the rights of oncologists and help improve patients’ access to care.

Interestingly, we held our first ASCO Highlights meeting at our first LSMO meeting in 1997. I presented a summary of that year’s ASCO Annual Meeting in Denver, and it was an exciting way to kick off the LSMO’s activities. When ASCO began licensing overseas Best of ASCO meetings, Lebanon became one of the first countries to host one, and it is now an annual tradition. At this year’s Best of ASCO in Lebanon, we had more than 400 attendees from within the country as well as neighboring Arab and Middle Eastern countries.

Challenges to Cancer Care in Lebanon

What are the main challenges you face in ensuring that your patients have access to high-quality cancer care?

We do our best to deliver care to our patients, but access to care in Lebanon is complicated by a rather difficult situation. Lebanon is a beautiful, small, but overall low-income country. Around 10% of the population has a relatively high income. The health insurance structure is fractured between private payers and the government. Although doctors and hospitals struggle to provide care to all patients, regardless of their economic status, there are holes in the system. Some people have started to obtain private insurance coverage but still pay many expenses out-of-pocket.

The Ministry of Health allocates part of its budget to pay for cancer care for those who don’t have the money or insurance, but the needs sometimes exceed the budget. Reimbursement for medical services is difficult, and most doctors in Lebanon work very hard to make a living.

Another big challenge here is that many people in Lebanon have a college education, are well-read, and demand the most advanced diagnostic and surgical technologies as well as the latest systemic therapies regardless of the costs. Therefore, we struggle with ensuring cost-effectiveness.

The challenges of caring for breast cancer patients in a developing country push me to be more involved with international societies such as ASCO, the European Society for Medical Oncology (ESMO), the European Organisation for Research and Treatment of Cancer (EORTC), the European School of Oncology (ESO), and the Breast Health Global Initiative (BHGI). On the ASCO International Affairs Committee, we have major international projects to improve access to education for oncologists and to cancer care for patients worldwide. 

Closing Thoughts

Any last thoughts about your work in oncology?

I practice medicine as an art and a science. Oncologists have a special relationship with their patients and families, one that is built on trust and caring. Moreover, the advances we’ve seen over the past decades have increased survival, and so our relationships with patients have become much longer and richer. I have patients who have invited me to their children’s weddings and birthdays. The personal relationships that I’ve developed over the years sustain me through the difficult clinical times. Caring for patients through the continuum of care, right to the end of life, or most often nowadays with the goal of cure and survivorship, is what I consider the best personalized care.

Also, since we have begun various campaigns to raise awareness about the importance of screening and early detection, we’ve seen a decrease in the number of patients presenting with advanced disease. These step-by-step improvements in care demonstrate that despite the challenges, we are making considerable progress in the battle against cancer. ■

Disclosure: Dr. El Saghir reported no potential conflicts of interest.