Syrian migrants, including refugees, may be more likely to be diagnosed with a more advanced stage of breast cancer at a younger age when compared with individuals from Jordan, according to a recent study published by Hazra et al in JAMA Network Open. The new findings suggest the trauma associated with forced displacement may contribute to these cancer disparities.
Background
War and other conflicts are capable of impacting individuals’ health in ways that extend far beyond the active combat zone.
Prior to the start of the Syrian Civil War, the country was burdened by a severe drought that devastated local agriculture and the economy. More recently, several large earthquakes have destroyed infrastructure. Although investigators have spent over a decade documenting widespread cancer cases among refugees fleeing the crises, little was known about the types of disparities that patients who had been displaced may have experienced when searching for cancer care.
“We know there is stigma, a delay to accessing care, and competing interests for funding with regard to treating breast cancer in Syrian refugees,” explained lead study author Aditi Hazra, PhD, MPH, Assistant Professor of Medicine in the Division of Preventive Medicine at Harvard Medical School and an associate epidemiologist at Brigham and Women’s Hospital. “What this paper adds is a quantitative description of the tumor characteristics of refugee patients,” she added.
Earlier Studies on the Impact of Cancer on Syrian Refugees
When investigators began analyzing cancer outcomes for Syrian refugees in 2014, they noted that breast cancer was the most common malignancy these individuals faced. And to receive treatment, the Syrian refugees had to apply for treatment funds from the United Nations High Commission for Refugees. However, many of the patients with advanced breast cancer were expected to have poorer survival rates and, therefore, denied care.
“Many of these refugees did not have access to early cancer detection. They were diagnosed late, and they were not going to receive care because of it,” Dr. Hazra stressed. “That seemed at odds with the idea of health as a human right,” she emphasized.
Earlier studies struggled to collect the quantitative data needed to describe the characteristics of the Syrian refugees’ tumors.
Study Methods and Results
In the recent study, the investigators used the Jordan Cancer Registry to analyze the data of 7,891 cases of breast cancer—375 of whom were Syrian refugees. The investigators discovered that patients with breast cancer who were refugees tended to be younger than patients who were Jordanian natives. Additionally, the investigators noted that Syrian refugees and patients from Jordan—considered a middle-income country—developed breast cancer at younger ages than patients from high-income countries such as the United States.
The breast cancers diagnosed in Syrian refugees also appeared to be further developed than those diagnosed in Jordanian patients—with nearly 25% of the Syrian refugees with breast cancer exhibiting late-stage cancers that had metastasized to distant locations vs 12% of Jordanian patients.
The investigators hypothesized that delays in care coupled with the trauma from displacement may have been associated with these disparities. The Syrian refugees’ breast cancers had likely evaded detection that would have been part of routine care prior to the crises in Syria, allowing them to advance to later stages.
The researchers indicated that gaps in the data may have limited some of their findings. For instance, 23% of the cases they reviewed did not include data on the stage of the patients’ cancers. Data on the treatment the patients received after their breast cancer diagnoses were also incomplete. The investigators recommended that these limitations be addressed by digitizing medical records to scale data collection and facilitate the continuity of cancer care.
The investigators hope that the new findings could help researchers and policymakers identify treatment gaps for refugees and improve their cancer outcomes. They proposed that multistakeholder support, Syrian refugee and local perspectives, integration of the refugees in national cancer plans, and resources for scaling early cancer detection with the Jordan Breast Cancer Program for Jordanian patients and Syrian refugees may all be viable strategies to improving health systems and survival rates.
“Only 1% to 2% of global health funding goes to noncommunicable diseases—including [cardiovascular] disease, diabetes, and cancer,” Dr. Hazra stated. “Those are the major killers. We need multistakeholder support to reduce delays in care, provide trauma-informed cancer care, and improve [noncommunicable disease] outcomes,” she concluded.
Disclosure: For full disclosures of the study authors, visit jamanetwork.com.
