Developing sustainable breast cancer services in the West Bank of occupied Palestinian territories (oPt)
To reduce rates of significant morbidity and five year mortality associated with breast cancer in Palestine.
• To reduce the number of unnecessary mastectomies.
• To support the development of robust diagnostic, treatment and follow-up pathways for patients with breast cancer.
• To support the development of effective multi-disciplinary team (MDT) meetings for breast cancer.
• To improve patient satisfaction with breast cancer services.
• To support integrated palliative care throughout the cancer journey.
Key UK Colleagues and Partners
Medical Aid for Palestinians – charity- Melanie Coyne, Andy Ferguson
West Bank visits: Colleagues:
Jane Macaskill, Consultant Breast Surgeon NHS Tayside
Ahmed Mustafa, Consultant Surgeon NHS Borders,
Janet Litherland, Consultant Breast Radiologist NHS Greater Glasgow and Clyde,
Nabanita Bose, Consultant Oncologist, NHS Greater Glasgow and Clyde,
Amanda Dunn, Breast Specialist Nurse, NHS Greater Glasgow and Clyde,
Yazan Masannat,Consultant Breast Surgeon NHS Grampian,
Michelle Johnston, Breast Specialist Nurse, NHS Manchester University NHS Trust,
Tony Maxwell, Consultant Breast Radiologist, NHS Manchester University NHS Trust,
Saed Ramzi,Consultant Breast Surgeon, Southampton
Wafa Tahir, Consultant Breast Surgeon
Cairdeas- Mhoira Leng, Palliative Medicine
Cairdeas- Mhoira Leng
Palestinian territories Ministry of Health
Medical Aid for Palestinians
Sustainable development goals
- SDG 3 - Good health and well-being
- SDG 5 - Gender equality
- SDG 10 - Reduced inequalities
- SDG 16 - Peace, justice and strong institutions
Medical Aid for Palestinians
Educational grant from Association of Breast Surgeons
A breast cancer pathway mapping exercise was performed by UNFPA, and Palestinian Ministry of Health, as well as identification of needs in this area by Medical Aid for Palestinian teams. Dr Philippa Whitford undertook a fact finding visit for MAP in 2016 and the project has developed from there with teams to the west Bank and Gaza.
Evidence of need
Breast cancer is one of the best understood, and most treatable, forms of cancer. In the UK, far more women now survive the disease than die from it, with 81% of women living beyond five years after being diagnosed. In Israel, the five-year survival rate is higher still, at over 86%. For Palestinian women living under military occupation for nearly 50 years, the situation is far bleaker. Breast cancer is the most common cancer among Palestinian women, but for those diagnosed with the disease estimates of five-year survival rates can be as low as 40%. This makes breast cancer the highest cause of cancer deaths among Palestinian women. Challenges posed by restrictions on the right to movement for both patients and doctors, shortages of essential medicines, and the shortcomings of the health system in the occupied Palestinian territory (oPt), all constitute obstacles to continuous and effective treatment and care for Palestinian women with breast cancer. A detailed needs assessment (available on request) informed the project design.
Radiologists: Diagnostic pathways are recommended to streamline clinical assessment to avoid overuse of tests such as CT. For the diagnostic breast clinic mammography, ultrasound and facility and expertise in diagnostic biopsies (stereotactic and ultrasound) is required. A local radiologist with a breast interest has been identified and an observership undertaken.
Surgeons: Specific surgical techniques have been demonstrated to local surgeons including axillary sentinel node with blue dye, and breast conservation techniques, which will minimise morbidity for patients.
Breast Nurse Specialists: There are no breast care nurse specialists at present, so local experienced nurses have attended training days including post-operative care, exercises, prosthesis fittings and lymphoedema care. Plan for nursing secondments between surgical and oncology units.
Oncologists: There is one oncologist serving a population of 320,000, seeing 35-40 chemotherapy patients per day, limiting clinic slots of 15-20 minutes for each patient.
Multi-disciplinary approach: A dedicated diagnostic breast clinic in the north of the West Bank has been established with radiology and surgical input. There have been several live teleconferenced MDT meetings between UK sites and West Bank based teams. Encrypted social media platforms have been used to discuss clinical issues.
Dr Ayman Kalbouneh, a radiologist from the West Bank spent one month on a clinical observership in Glasgow and Manchester. Dr Ehab Yousef, a surgeon from the West Bank spent one month as a clinical observer in Dundee and Aberdeen breast units, and attended the Association of Breast Surgery Advanced Breast Cancer Management course in Cambridge.
The Palestinian Authorities Ministry of Health have hosted and facilitated this project, and are instrumental in the development and adoption of national diagnostic and treatment policies and protocols.
A national cancer registry has been setup, facilitating collection of audit data and outcomes for cancer patients.
Social media platforms are being utlilised by West Bank based clinicians to highlight and disseminate information regarding guidelines for breast cancer management to the wider clinical community such as non-governmental organisations and private providers.
Improve outcomes for patients with breast cancer in the oPt by:
Regular multi-disciplinary specialist team visits to hospitals in the north of the West Bank
Development of national diagnostic and treatment pathways
Training in relevant surgical and radiological techniques
Hosting UK based observerships for Palestinian staff
Provision of diagnostic equipment and medical disposable items
Continuing video-conferencing for team meeting support
There can be societal pressures to avoid direct conversations about diagnosis and prognosis with patients which need to be improved with population level education.
Lack of access to facilities for radiotherapy due to permit requirements and frequency of these being declined risks patient cancer outcomes.
Ongoing advocacy is required to achieve and maintain health and dignity for those living in occupied Palestinian Territories.
Surgical techniques require to be modified as radioisotope for sentinel node biopsy is subject to prohibitive import regulations and cannot be procured.
National level agreement for reform has been instrumental to allow goveernmental, NGO and prvates sectors to align better, this is ongoing.
Politically the situation is complex, international lobbying for the rights of individuals in Palestine are key.