Cancer Care

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Humaid O. Al-Shamsi
Editor

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123
Cancer Care in the United Arab Emirates
Humaid O. Al-Shamsi
Editor

Cancer Care in the United

Arab Emirates
Editor
Humaid O. Al-Shamsi
Burjeel Cancer Institute
Burjeel Medical City, Burjeel Holdings
Abu Dhabi, United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University
Ras Al Khaimah, United Arab Emirates
Gulf Medical University
Ajman, United Arab Emirates
Emirates Oncology Society
Emirates Medical Association
Dubai, United Arab Emirates
College of Medicine
University of Sharjah
Sharjah, United Arab Emirates
Gulf Cancer Society
Alsafa, Kuwait

This book is an open access publication.

ISBN 978-981-99-6793-3    ISBN 978-981-99-6794-0 (eBook)
https://doi.org/10.1007/978-981-99-6794-0
Emirates Oncology Society

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore
Pte Ltd. 2024
Open Access This book is licensed under the terms of the Creative Commons Attribution 4.0
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Foreword

The United Arab Emirates (UAE), established in 1971, has undergone an unparal-
leled transformation over the past 50 years. The country has experienced rapid
growth in its native and expatriate populations, with an enormous and steady influx
of tourists. Likewise, the UAE’s healthcare delivery system has undergone incredi-
ble growth and modernization, becoming a regional beacon for contemporary,
patient-centric healthcare.
A key milestone in the UAE’s healthcare evolution is the establishment of infra-
structure supporting world-class medical facilities and care providers. From state-
of-the-art hospitals to specialized clinics, these facilities are equipped with
cutting-edge medical technology and are increasingly staffed by highly skilled pro-
fessionals from across the globe. Among the significant advancements over the past
five decades in the UAE has been the evolution of cancer care. However, until now,
there has been no comprehensive documentation encapsulating this development.
Cancer Care in the United Arab Emirates fills this gap. This unprecedented and
inclusive reference seeks to fully characterize the landscape of cancer care in the
UAE and is poised to become an invaluable resource for those seeking to understand
the current state of cancer care across the seven emirates.
The book embarks on a comprehensive analysis of cancer and its management
through the UAE’s relatively short history. Included are summaries of key regula-
tory policies regarding medical education and training, cancer control, and care
delivery. It also describes the impressive expansion of innovative diagnostic and
treatment modalities, with a growing emphasis on precision medicine. In doing so,
the book’s authors can celebrate a number of notable achievements while acknowl-
edging persistent challenges and unmet needs. Authored by an esteemed group of
experts from various arenas, it brings together perspectives from oncology special-
ists, researchers, healthcare policymakers, patient advocates, and other key stake-
holders involved in the cancer care delivery system.
In addition to addressing general aspects of cancer care, this pioneering book
sheds light on unique factors and challenges specific to the UAE. It explores cultural
and societal impacts, healthcare infrastructure, regulatory frameworks, and the
incorporation of technological advancements in cancer care. The critical role of
patient support organizations, patient empowerment, and community engagement
in reducing the current burden of cancer is also examined in detail.

v
vi Foreword

Each chapter of Cancer Care in the United Arab Emirates provides valuable
insights into the challenges faced by different disciplines involved in cancer care
and offers a roadmap for transformative change. By presenting an overarching
vision and strategic outlook for the future, it catalyzes positive change in cancer
prevention, control, and care across the UAE.
I wholeheartedly commend Professor Humaid O. Al-Shamsi for his remarkable
vision and effort in compiling this book over the past few years, making it broadly
accessible and ensuring widespread benefit.
Endorsed by prestigious organizations such as the Emirates Oncology Society,
Emirates Medical Association, and the Gulf Cancer Society, Cancer Care in the
United Arab Emirates stands as a testament to its credibility and relevance. It is a
tour de force and will undoubtedly play a pivotal role in reducing the burden of
cancer with its emphasis on prevention, screening, and enhanced cancer care.
Furthermore, with its call for collaboration, it is certain to facilitate better outcomes
for the country and the wider region.
In summary, Cancer Care in the United Arab Emirates heralds a new dawn in our
collective understanding of cancer care in the UAE. As we navigate the complex
systems of care required to promote outstanding cancer care, this book offers guid-
ance, inspiration, and the knowledge required to make meaningful strides. It is an
invitation to all stakeholders to come together, learn, and contribute to the noble
cause of defeating cancer. Here’s to a future where we rise to the challenge, foster
collaborations, and continue our journey towards a healthier and cancer-free UAE.

July 15, 2024 Robert A. Wolff

Clinical and Educational Affairs,
Division of Cancer Medicine,
Department of Gastrointestinal Medical Oncology
The University of Texas, MD Anderson Cancer Center
Houston, TX, USA
Acknowledgment

Dedicated to my Creator, who may accept this work for His honorable sake.
To my father and idol, the late Sheikh Zayed bin Sultan Al Nahyan, the founder
and first president of the United Arab Emirates, may Allah have mercy on him, for
his love for this land and his belief in his people (us).
To the late Sheikh Hamdan bin Rashid Al Maktoum, the father of the Emirates
Medical Association, for his support of sciences and research in the UAE and
the region.
To my country and my leaders, whom I do not have enough words to thank.
To the UAE armed forces that have taken care of and supported me during my 20
years of medical education and training, believing, and trusting in me.
To my late father, may Allah Almighty have mercy on him who always blamed
me for my long travel and absence away from him.
To my dear mother, who has planted the love of science and medicine in me since
childhood. I hope I am today the man you dreamed I would be.
To my dear wife and best friend, Khadija, the love of my life, who has been there
for me at all times.
To my kids, Sarah, Abdullah, Muhammad, Noor, Aseel, and Sama, who are my
source of strength and inspiration. Forgive me if I’m away from you due to my work
and my national mission to fight cancer.
To my brother, Hassan, and my sisters, Fatima, Eng. Nabila, Salma, and Dr.
Nada, for being away from them for many years and for their support and prayers
for me always.
To Prof. Parveen Wasi, my internal medicine program director during my resi-
dency at McMaster University in Canada, for her support and encouragement to
pursue clinical research.
To Prof. Robert Wolff, Prof. Bindi Dhesy, and Prof. Peter Ellis for their support
and mentorship during my oncology fellowship and early career in oncology.
To Dr. Mouza AlSharhan, the Past President of the Emirates Medical Association,
for her support for the Emirates Oncology Society over the years.
To Dr. Shamsheer Vayalil for his continuous support to transform cancer care in
the UAE and the region through the Burjeel Holdings oncology program.

vii
viii Acknowledgment

To my dear friends: Dr. Sherif Almarzooqi, Dr. Mitref Altunaiji, Dr. Abdullah
Alqimzi, Dr. Khaled Alfarsi, Dr. Uthman Alao, Dr. Ibrahim Abu Ghida, and Tariq
Elfikki, for being there for me in my ups and downs.
To my friend and role model in science, medicine, and clinical research, Prof.
Waleed Al-Hazzani, it is hard to follow your steps. You set the bar very high in clini-
cal research for all of us.
To my past, current, and future teachers, and to everyone who supported me
throughout my life journey.
To all my past and future patients: I promise you that I will take care of you as I
take care of my own family.
For humanity, believing in the words of Allah Almighty: “We have sent you
nothing but a mercy for the world.”
To cancer, which taught me a lot and which we will eliminate, Allah willing.

Sharjah, UAE Humaid O. Al-Shamsi

July 15, 2024
Contents

1 Introduction������������������������������������������������������������������������������������������������   1
Humaid O. Al-Shamsi
2  ancer Care in the UAE���������������������������������������������������������������������������� 15
C
Humaid O. Al-Shamsi and Amin M. Abyad
3  AE National Cancer Registry���������������������������������������������������������������� 57
U
Alya Zaid Harbi, Buthaina Abdulla Bin Belaila, Wael Shelpai,
and Hira Abdul Razzak
4  ancer Prevention, Screening, and Early Detection in the UAE���������� 79
C
Saeed Rafii and Humaid O. Al-Shamsi
5  Proposal for Cancer Control Plan in the UAE������������������������������������ 91
A
Humaid O. Al-Shamsi and Amin M. Abyad
6  omprehensive Cancer Centers in the UAE ������������������������������������������ 127
C
Humaid O. Al-Shamsi and Amin M. Abyad
7  mirates Oncology Society������������������������������������������������������������������������ 137
E
Humaid O. Al-Shamsi and Amin M. Abyad
8  actors Influencing Seeking Cancer Care Abroad for UAE
F
Citizens�������������������������������������������������������������������������������������������������������� 153
Humaid O. Al-Shamsi
9  ongovernmental Organizations’ (NGO) Role in Cancer Care
N
in the UAE: Friends of Cancer Patients as an Example������������������������ 163
Aisha Al Mulla and Majed Mohamed
10  linical Cancer Research in the UAE������������������������������������������������������ 175
C
Subhashini Ganesan, Humaid O. Al-Shamsi, Mohamed Mostafa,
and Walid Abbas Zaher
11  asic Cancer Research in the UAE���������������������������������������������������������� 193
B
Ibrahim Yaseen Hachim, Saba Al Heialy,
and Mahmood Yaseen Hachim

ix
x Contents

12  ncology and Hematology Fellowship Training in the UAE ���������������� 209

O
Humaid O. Al-Shamsi
13  ncology Nursing in the UAE������������������������������������������������������������������ 215
O
Lois Nyakotyo
14  enomic Medicine in Cancer Care in the UAE�������������������������������������� 225
G
Faraz A. Khan and Maroun El Khoury
15  enetic Testing for Cancer Risk in the UAE ������������������������������������������ 235
G
Rita A. Sakr and Hassan Ghazal
16  ertility Preservation and Oncofertility in the UAE������������������������������ 245
F
Nahla Kazim
17  sycho-Oncology in the UAE�������������������������������������������������������������������� 271
P
Melanie C. Schlatter
18  rtificial Intelligence (AI) in Oncology in the UAE�������������������������������� 281
A
Khalid Shaikh and Sreelekshmi Bekal
19  raditional, Complementary, and Integrative Medicine
T
and Cancer Care in the UAE�������������������������������������������������������������������� 313
Heidi Kussmann
20  adiation Oncology in the UAE���������������������������������������������������������������� 337
R
Ibrahim H. Abu-Gheida, Rana Irfan Mahmood, Fady Geara,
and Falah Al Khatib
21  urgical Oncology in the UAE������������������������������������������������������������������ 349
S
Faek R. El Jamali, Chafik Sidani, and Stephen R. Grobmyer
22  alliative Care in the UAE������������������������������������������������������������������������ 359
P
Neil A. Nijhawan and Humaid O. Al-Shamsi
23  uclear Medicine in the UAE ������������������������������������������������������������������ 377
N
Abdulrahim Al Suhaili
24  ediatric Cancer in the UAE�������������������������������������������������������������������� 389
P
Zainul Aaabideen Kanakande Kandy, Ammar Morad,
and Eman Taryam Alshamsi
25  eriatric Oncology in the UAE���������������������������������������������������������������� 403
G
Hassan Shahryar Sheikh and Kiran Munawar
26  reast Cancer in the UAE ������������������������������������������������������������������������ 417
B
Aydah Al-Awadhi, Faryal Iqbal, Hampig R. Kourie,
and Humaid O. Al-Shamsi
Contents xi

27 Colorectal Cancer in the UAE������������������������������������������������������������������ 435

Humaid O. Al-Shamsi, Faryal Iqbal, Hampig R. Kourie,
Adhari Al Zaabi, Amin M. Abyad, and Nadia Abdelwahed
28  astric Cancer in the UAE������������������������������������������������������������������������ 451
G
Nadia Abdelwahed, Salem Al Asousi, Faryal Iqbal, Amin M. Abyad,
Neil A. Nijhawan, Hampig R. Kourie, Ibrahim H. Abu-Gheida,
Basil Ammori, and Humaid O. Al-Shamsi
29  ancreatic Cancer in the UAE������������������������������������������������������������������ 473
P
Humaid O. Al-Shamsi, Faryal Iqbal, Neil A. Nijhawan,
Hampig R. Kourie, Nadia Abdelwahed, Ibrahim H. Abu-Gheida,
and Basil Ammori
30  epatocellular Carcinoma (HCC) in the UAE���������������������������������������� 491
H
Salman Wahib Srayaldeen and
Mohamed Ahmed Mohamed Elkhalifa
31  ead and Neck Malignancies in the UAE������������������������������������������������ 535
H
Ashish V. Chintakuntlawar, Hani Al-Halabi, and Aref Chehal
32  hyroid Cancer in the UAE���������������������������������������������������������������������� 545
T
Riyad Bendardaf, Iman M. Talaat, Noha M. Elemam,
and Humaid O. Al-Shamsi
33  ung Cancer in the UAE �������������������������������������������������������������������������� 559
L
Saeed Rafii, Batool Aboud, and Humaid O. Al-Shamsi
34  ynecologic Malignancies in the UAE ���������������������������������������������������� 569
G
Saladin Sawan, Faryal Iqbal, and Humaid O. Al-Shamsi
35  enitourinary Malignancies in the UAE ������������������������������������������������ 581
G
Mohammed Shahait, Hosam Al-Qudah, Layth Mula-­Hussain,
Ibrahim H. Abu-Gheida, Thamir Alkasab, Ali Thwaini,
Rabii Madi, Humaid O. Al-Shamsi, Syed Hammad Tirmazy,
and Deborah Mukherji
36  arcoma in the UAE���������������������������������������������������������������������������������� 593
S
Aydah Al-Awadhi and Philipp Berdel
37  euroendocrine Tumors (NETs) in the UAE������������������������������������������ 597
N
Aydah Al-Awadhi and Humaid O. Al-Shamsi
38  ematological Malignancies in the UAE ������������������������������������������������ 603
H
Shahrukh Hashmi
xii Contents

39  ematopoietic Stem Cell Transplantation (HSCT) in the UAE������������ 611

H
Humaid O. Al-Shamsi, Amin M. Abyad,
Zainul Aaabideen Kanakande Kandy, Biju George,
Mohammed Dar-Yahya, Panayotis Kaloyannidis,
Amro El-Saddik, Shabeeha Rana, and Charbel Khalil
40  ancer Survivorship Programs in the UAE�������������������������������������������� 625
C
Aydah Al-Awadhi, Ramanujam A. Singarachari, and Rita A. Sakr
41  uggested Quality Control Measures for Cancer Care in the UAE������ 629
S
Humaid O. Al-Shamsi

 ppendix A: The National Guideline for Breast Cancer

A
Screening and Diagnosis������������������������������������������������������������������������������������ 639

 ppendix B: Breast Cancer Screening Pathways ������������������������������������������ 649

A
References ���������������������������������������������������������������������������������������������������������� 650

 ppendix C: National Breast Cancer Screening

A
Recommendation (Table C.1)���������������������������������������������������������������������������� 651

 ppendix D: Pedigree: First-, Second-, and Third-Degree

A
Relatives of Proband������������������������������������������������������������������������������������������ 655

 ppendix E: National Breast Cancer Screening Clinical

A
Performance Indicators ������������������������������������������������������������������������������������ 657

 ppendix F: Requirement for Breast Screening and Diagnosis

A
Services���������������������������������������������������������������������������������������������������������������� 659

 ppendix G: BI-RADS® Final Assessment Categories���������������������������������� 663

A
References ���������������������������������������������������������������������������������������������������������� 664

 ppendix H: The National Guideline for Cervical Cancer

A
Screening and Diagnosis������������������������������������������������������������������������������������ 665

Appendix I: Definitions������������������������������������������������������������������������������������� 675

 ppendix J: Eligibility Criteria for a Facility to Participate

A
National Cervical Cancer Screening Program������������������������������������������������ 677

Appendix K�������������������������������������������������������������������������������������������������������� 679

Appendix L �������������������������������������������������������������������������������������������������������� 681

Contents xiii

 ppendix M: Cervical Cancer Screening Program—Timeframes

A
for Appointments������������������������������������������������������������������������������������������������ 683

 ppendix N: Responsibilities of the Facility Cancer

A
Screening Program Coordinator���������������������������������������������������������������������� 685

 ppendix O: The National Guideline for Colorectal Cancer

A
Screening and Diagnosis������������������������������������������������������������������������������������ 689

Appendix P: Colorectal Cancer Screening and Diagnosis Pathway ������������ 701

 ppendix Q: Colorectal Cancer Clinical Performance Indicator ���������������� 703

A
References ���������������������������������������������������������������������������������������������������������� 704

 ppendix R: Colorectal Cancer Screening Endoscopy

A
Unit Infrastructure, Equipment and Personnel���������������������������������������������� 705

Appendix S: Risk Assessment for Colorectal Cancer ������������������������������������ 707

 ppendix T: American Society of Anesthesiology

A
Classification System ���������������������������������������������������������������������������������������� 713

 ppendix U: DOH Standard for Center of Excellence in

A
Hematopoietic Stem Cell Transplantation (HSCT) Services
for Adults and Pediatrics ���������������������������������������������������������������������������������� 715

 ppendix V: Accredited of HSCT Program���������������������������������������������������� 723

A
References ���������������������������������������������������������������������������������������������������������� 724

Appendix W: Cervical Cancer Screening Program Requirements �������������� 725

Appendix X: Definitions������������������������������������������������������������������������������������ 735

 ppendix Y: Eligibility Criteria for a Facility to Participate

A
in DOH’s Cervical Cancer Screening Program���������������������������������������������� 737

Appendix Z: Cervical Cancer Screening Care-Pathway�������������������������������� 739

 ppendix AA: Cervical Cancer Screening Program—Clinical

A
Quality Indicators���������������������������������������������������������������������������������������������� 741

 ppendix AB: Cervical Cancer Screening Program—Timeframes

A
for Appointments������������������������������������������������������������������������������������������������ 743
xiv Contents

 ppendix AC: Responsibilities of the Facility Cancer Screening

A
Program Coordinator���������������������������������������������������������������������������������������� 745

 ppendix AD: DOH Colorectal Cancer Screening Program

A
Specifications������������������������������������������������������������������������������������������������������ 747

Appendix AE: Colorectal Cancer Screening—Care-Pathway���������������������� 755

Appendix AF: Colorectal Cancer Clinical Performance Indicators ������������ 757

 ppendix AG: Pre-colonoscopy Risk Assessment

A
for Colorectal Cancer���������������������������������������������������������������������������������������� 759

 ppendix AH: Colorectal Cancer Screening Endoscopy

A
Unit Infrastructure, Equipment and Personnel���������������������������������������������� 761

 ppendix AI: DOH Recommendation for Colorectal Cancer

A
Screening and Surveillance, Increased and High-Risk Disease
Family Group ���������������������������������������������������������������������������������������������������� 763

 ppendix AJ: DOH Recommendations for Colorectal Cancer

A
Screening and Surveillance in Moderate Risk Disease Family Groups�������� 765

 ppendix AK: DOH Summary of Recommendations for

A
Colorectal Cancer Screening and Surveillance in High-Risk
Disease Family Groups�������������������������������������������������������������������������������������� 767

Appendix AL: Genetic Test ������������������������������������������������������������������������������ 769

Appendix AM: Pre-colonoscopy Assessment�������������������������������������������������� 771

 ppendix AN: Pre-colonoscopy Assessment—American

A
Society of Anesthesiology Classification System �������������������������������������������� 773

Appendix AO: Colonoscopy Procedure������������������������������������������������������������ 775

Appendix AP: Post-colonoscopy Procedures �������������������������������������������������� 777

Appendix AQ: Colonoscopy Findings Colonoscopy Findings������������������������ 779

Appendix AR: Colonoscopy Report ���������������������������������������������������������������� 781

 ppendix AS: Example of—Techniques for Colonoscopic—

A
Tattooing Protocol���������������������������������������������������������������������������������������������� 783
Contents xv

Appendix AT: E-Notification Cancer Screening Referral Form�������������������� 785

 ppendix AU: Cancer Screening Data Requirement—

A
Screening Visit Outcome����������������������������������������������������������������������������������� 787

 ppendix AV: JAWDA KPI Quarterly Guidelines for

A
Hematopoietic Stem Cell Transplant (HSCT) Service Providers������������������ 791

Appendix AW: DOH Lung Cancer Screening Service Specifications ���������� 797

Appendix AX: Related Regulations������������������������������������������������������������������ 807

Appendix AY: Care Pathway���������������������������������������������������������������������������� 809

Appendix AZ: Lung Cancer Screening Centre Application Form���������������� 811

Appendix BA: Lung Cancer Screening Performance Indicators������������������ 813

Appendix BB: Calculation of Pack-Year Tobacco Use ���������������������������������� 815

Appendix BC: DOH E-Cancer Screening Form �������������������������������������������� 817

 ppendix BD: Lung Cancer Screening Multi-­disciplinary Team

A
Composition�������������������������������������������������������������������������������������������������������� 819

 ppendix BE: Lung Cancer Screening RAD Reporting

A
Lung-RADS™ Version 1.0 Assessment Categories April 28, 2014���������������� 821

Appendix BF: Standards for Oncology Services: Version (1)������������������������ 823

 ppendix BG: Healthcare Professionals Requirements

A
for Clinical Radiation Therapy������������������������������������������������������������������������ 849

 ppendix BH: Standards for Autologous Haematopoietic Stem Cell

A
Transplantation: Version 1�������������������������������������������������������������������������������� 851

 ppendix BI: Equipment Needed to Start a Cell Processing Lab

A
(Adopted from Leemhuis et al., 2014. Essential requirements for
setting-up a stem cell processing laboratory. Bone Marrow
Transplant 49, 1098–1105)�������������������������������������������������������������������������������� 881

 ppendix BJ: Essential Requirements for Setting-Up a Stem Cell

A
Processing Laboratory (Adopted from Leemhuis et al., 2014.
Essential requirements for setting-up a stem cell processing laboratory.
Bone Marrow Transplant 49, 1098–1105)�������������������������������������������������������� 883
xvi Contents

 ppendix BK: Training for Clinical Program Directors and Attending

A
Physicians (Adopted from BSBMT 2012)�������������������������������������������������������� 885

Appendix BL: Minimum Requirements for Consent ������������������������������������ 889

 ppendix BM: Patient Pathway for Haematopoietic Stem Cell

A
Transplantation (Adopted from Welsh Health Specialised
Services Committee 2019) �������������������������������������������������������������������������������� 891

 ppendix BN: Steps for Haematopoietic Stem Cell

A
Transplantation (AHSCT) (Adopted from Research Australia 2021)���������� 893
About the Editor

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer of Burjeel Cancer
Institute in Abu Dhabi, UAE, President of the Emirates Oncology Society, Lead of
the Gulf Cancer Society, Full Professor of Oncology at the Ras Al Khaimah Medical
and Health Sciences University, Ras Al Khaimah, UAE, and an Adjunct Professor
of Oncology at the College of Medicine, University of Sharjah. He is the first
Emirati to be promoted as a professor in oncology in the UAE. He is also the
Chairman for Colorectal Cancer in the MENA region, appointed by the prestigious
National Comprehensive Cancer Network®. He is also the only member of Lung
Cancer Policy Network in the MENA region that aims to advance lung cancer
research and screening globally. He is the Chairman of the Oncology and Hematology
Fellowship Training Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN Consortium
which is comprised of organizations representing all stakeholders in personalized
cancer medicine globally.
He is board-certified in both internal medicine and oncology from the UK, USA
(ABIM), and Canada (FRCPC). He has also been awarded the FRCP (London) in
2023 and FRCP (Glasgow) in 2024. He is the only physician in the UAE with a
subspecialty fellowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fellowship in pallia-
tive care. He was an assistant professor at the University of Texas MD Anderson
Cancer Center between 2014 and 2017. He has published more than 140 peer-
reviewed articles in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision oncology and
cancer care in the UAE. In 2016, he published with his group from MD Anderson
the JCO paper describing a new distinct subgroup of CRC, NON V600 BRAF-
mutated CRC. In 2022, he published the first book about cancer research in the UAE
and also the first book about cancer in the Arab world, both of which were launched
at Dubai Expo 2020. Cancer in the Arab World has been downloaded more than
450,000 times in its first 18 months of publication and is the ultimate source of
cancer data in the Arab region. He also published the first comprehensive book
about cancer care in the UAE which is the first book in UAE history to document
the cancer care in the UAE with many topics addressed for the first time, e.g., neu-
roendocrine tumors in the UAE. He is passionate about advancing cancer care in the

xvii
xviii About the Editor

UAE and the GCC and has made significant contributions to cancer awareness and
early detection for the public using social media platforms. He is considered as the
most followed oncologist in the world with over 300,000 subscribers across his
social media platforms (Instagram, Twitter, LinkedIn, and TikTok). In 2022, he was
awarded the prestigious Feigenbaum Leadership Excellence Award from Sheikh
Hamdan Smart University for his exceptional leadership and research and the
Sharjah Award for Volunteering. He was also named the Researcher of the Year in
the UAE in 2020 and 2021 by the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice President of the
United Arab Emirates, awarded him the first place in the Emirati Talent
Competitiveness Council (NAFIS) program for outstanding leadership in the pri-
vate sector across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels of research
training for medical trainees to enhance their clinical and research skills. His mis-
sion is to advance cancer care in the UAE and the MENA region and make cancer
care accessible to everyone in need around the globe.
Introduction
1
Humaid O. Al-Shamsi

1.1 Introduction

During my personal experience with cancer, I consistently sought a reliable source

of current information on cancer care in the United Arab Emirates (UAE).
Regrettably, I encountered difficulties in finding the specific information I sought.
Recognizing the pressing need for a comprehensive reference on cancer care in the
UAE, I have resolved to transform this aspiration into a tangible resource that will
endure for years to come, serving the welfare of my country and fellow citizens.
To begin my endeavor, I embarked on a comprehensive examination of existing
literature pertaining to cancer care in the UAE. I diligently explored various sources,
including official health websites within the country as well as reputable platforms
like PubMed and Google Scholar. Additionally, I reached out to prominent health-
care organizations such as the UAE Ministry of Health and Prevention (MOHAP),
the Dubai Health Authority (DHA), and the Abu Dhabi Department of Health
(DOH), seeking relevant data and accessible resources.
The second part was to get the experts in each topic and oncology subspecialty
to contribute to this project, and I have received an overwhelmingly positive
response to participate and contribute from all the cancer institutions in the UAE. I
have also provided the opportunity for all oncologists and hematologists to suggest

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 1

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_1
2 H. O. Al-Shamsi

topics and chapters. This made me confident that we are covering as many oncology
topics as possible in the UAE without missing any major topics or issues.
The objective of this book is to offer a comprehensive and profound examination
of the demographic, economic, and prevailing trends in oncology practice that have
an impact on cancer care in the UAE. Its purpose is to chart a path for healthcare
providers, regulators, decision-makers, patients, and all other relevant parties to
propel the progress of cancer care in the UAE. By providing valuable insights, this
book aims to guide and inform stakeholders in their efforts to enhance cancer care
within the country.
Within the pages of this book, you will discover a thorough exploration of the
evolution of cancer care in the UAE, along with a detailed analysis of the national
cancer incidence. Dedicated chapters are devoted to addressing the most prevalent
types of cancer. Furthermore, the book elucidates the current challenges faced in the
UAE, some of which are unique to the region, while also highlighting opportunities
for improvement. The author presents recommendations and proposes a compre-
hensive cancer control plan intended for all stakeholders, policymakers, healthcare
providers in the oncology field, and the UAE community as a whole. The ultimate
goal is to deliver cutting-edge, high-quality cancer care to our population and effec-
tively manage the anticipated rise in the cancer burden in the coming years and
decades.
We have also addressed many topics that have not been addressed before, like
non-governmental organizations’ (NGO) role in cancer care in the UAE, clinical
cancer research in the UAE, basic cancer research in the UAE, oncology and hema-
tology fellowship training in the UAE, oncology nursing in the UAE, genomic med-
icine in cancer care in the UAE, genetic testing for cancer in the UAE, oncofertility
in the UAE, psycho-oncology in the UAE, traditional, complementary, and integra-
tive medicine and cancer care in the UAE, artificial intelligence (AI) in oncology in
the UAE, geriatric oncology in the UAE, cancer survivorship programs in the UAE,
suggested quality control measures for cancer care in the UAE and many others.

1.2 The UAE

The UAE was established on December 2, 1971, and is located in Asia in the south-
east of the Arabian Peninsula on the Arabian Gulf and Gulf of Oman. It is a federa-
tion of seven states (Emirates) composed of Abu Dhabi, the largest state in size
(which serves as the capital); Dubai, which is considered the trade hub; Sharjah, the
cultural hub; Ajman; Ras Al Khaimah; Fujairah; and Umm Al-Quwain (the last five
Emirates/States are known collectively as the Northern Emirates, which we will
refer to throughout this book) (Fig. 1.1). The UAE’s population statistics from 2010
to 2020 are given in Appendix 1 (Source: Federal Competitiveness and Statistics
Centre).
In order to grasp the UAE’s healthcare system, including cancer care, it is cru-
cial to have an understanding of the demographic makeup of the UAE population.
As of 2013, the estimated population of the UAE stood at 8.6 million. It is worth
1 Introduction 3

Fig. 1.1 The UAE map

noting that the most recent official census was conducted in 2005 [1, 2]. Although
the UAE is relatively small in terms of land area, it possesses the world’s third-
largest reserves of conventional oil and the fifth-largest reserves of natural gas [3].
The UAE’s 2015 gross domestic product (GDP) per capita ranked in the 95th per-
centile globally [4, 5]. In 2000, the World Health Organization ranked the UAE’s
healthcare system as the 27th best globally [6]. Healthcare services in the UAE are
financed through government-funded health insurance plans available to all UAE
citizens, private insurance options, or self-payment for legal residents [7].
Government-funded health coverage is provided to all UAE citizens, and the extent
of coverage varies depending on the Emirate of residence. Additionally, according
to UAE immigration regulations, all expatriates are required to have at least basic
health insurance.
Cancer continues to be a significant public health concern in the UAE, resulting
in considerable loss of life and health complications that incur substantial expenses
for the UAE healthcare system. It ranks as the third-highest cause of death in the
country, following cardiovascular diseases and injuries, and contributed to approxi-
mately 10% of all deaths in the UAE in 2010 [8]. The UAE government is commit-
ted to decreasing cancer-related fatalities. Decreasing the mortality rate caused by
cancer is a significant benchmark within the UAE’s national agenda’s “Pillar of
World-Class Healthcare” [9].
4 H. O. Al-Shamsi

1.3 The Healthcare System in the UAE

Before providing any recommendations that apply to the entire UAE, it is crucial to
have a comprehensive understanding of the intricate nature of the healthcare system
in the country. Initially, the healthcare system in the UAE was primarily overseen at
the federal level, starting in 1971. However, in 2005, a significant change occurred
with the introduction of regional authority in Abu Dhabi [10]. Presently, the regula-
tions governing the healthcare system in the UAE are implemented through the
cooperative endeavors of various authorities. The Ministry of Health and Prevention
(MOHAP) assumes a central role as the primary federal regulatory body responsi-
ble for overseeing the health sector in the UAE [11]. In the emirate of Abu Dhabi,
which includes Abu Dhabi, Al-Ain, and the Western region, the healthcare system is
overseen by the Department of Health—Abu Dhabi (DOH), which was established
in 2007. It is worth mentioning that from January 1, 2005, to January 1, 2007, DOH
operated under the name “the General Authority of Health Services for the Emirate
of Abu Dhabi” [12]. Similarly, in Dubai, the regulatory body responsible for over-
seeing the healthcare system is the Dubai Health Authority (DHA), which was
established in June 2007 [13]. In a similar vein, the Sharjah Health Authority (SHA),
founded in 2010, along with MOHAP, is responsible for regulating health services
in Sharjah. However, the remaining Northern Emirates, namely Ajman, Fujairah,
Ras Al Khaimah, and Umm Al-Quwain, have their health services solely regulated
by MOHAP.

1.4 History of Cancer Care in the UAE

From the 1940s to the 1970s, there was a lack of comprehensive records regarding
cancer care in the UAE. The initial scientific documentation and publication on
cancer care in the country appeared in the medical literature from Al-Qassimi
Hospital, located in Sharjah. This report, published in 1981, consisted of a case
series encompassing five instances of hepatocellular carcinoma (liver cancer) [14].
The inaugural cancer care center introduced in the UAE emerged as Tawam Hospital,
situated in Al-Ain City within the Emirate of Abu Dhabi, commencing operations in
September 1979. Tawam Hospital proudly held the distinction of being the nation’s
pioneer facility to provide both chemotherapy and radiation therapy services [14].
In February 1983, Tawam Hospital was designated as the official tertiary referral
hospital for cancer cases in the United Arab Emirates [14]. In the past, individuals
from all over the UAE would journey to Tawam Hospital to receive specialized
cancer treatment.
In August 1983, Al Mafraq Hospital, situated 35 km away from Abu Dhabi,
commenced operations and offered specialized medical care encompassing vari-
ous fields, including oncology services [14]. By September 1983, Al Mafraq
Hospital had established both medical oncology and radiation services.
Nevertheless, the radiation service was discontinued in 2007, while the medical
oncology service persisted until November 2019. At that time, it was relocated to
1 Introduction 5

the recently inaugurated Sheikh Shakhbout Medical City (SSMC) [15]. Sheikh
Khalifa Medical City (SKMC) in Abu Dhabi, formed in 2005 through the consoli-
dation of various publicly operated healthcare organizations on Abu Dhabi island,
has been delivering specialized oncology and hematology services for both adults
and children since its inception. SKMC had one of the most extensive leukemia
programs in the UAE until it transferred this service to Sheikh Shakhbout Medical
City in 2020. In 2020, SKMC ceased providing adult oncology services, but it has
continued to offer pediatric oncology services up to the present time
(February 2023).
Established in 1983, Dubai Hospital stands as the third hospital funded by the
government. It offers a comprehensive array of medical and surgical oncology ser-
vices for adults, as well as pediatric oncology and hematology services. However,
radiation therapy services are presently not offered at Dubai Hospital. The hospital
is equipped with a renowned nuclear medicine department that delivers a variety of
diagnostic and therapeutic services. Additionally, in 2018, the hospital introduced
PET/CT as part of its imaging capabilities.
Cleveland Clinic Abu Dhabi (CCAD), managed by Mubadala, is a leading mul-
tispecialty hospital with 364 beds. Affiliated with the Cleveland Clinic Foundation
in the USA, CCAD has been serving the public in Abu Dhabi since May 2015. The
hospital offers a wide range of surgical and medical oncology services. Additionally,
in December 2022, CCAD expanded its offerings to include radiation oncology
services.
The private sector in the UAE has displayed reluctance to offer oncology care
services due to several factors. These include a shortage of specialized personnel
and equipment, as well as the potential high costs associated with capital invest-
ment. Another contributing factor was the provision of free cancer treatment to all
UAE residents, irrespective of citizenship or residency status, until 2007. Visitors to
the country who had been diagnosed with cancer were also eligible for complimen-
tary cancer treatment, leading to a significant influx of patients from Asian countries
seeking free cancer care in the UAE until 2007. In 2005, the first privately owned
outpatient facility providing chemotherapy was established at the American Hospital
in Dubai. Subsequently, in 2011, radiation therapy services were added. The Gulf
International Cancer Center (GICC) in Abu Dhabi commenced its operations in
2007, offering both chemotherapy and radiation therapy. Notably, the center intro-
duced the first PET/CT scanner in the UAE in 2009 [16]. The American Hospital in
Dubai introduced the second PET/CT scanner in the UAE. In 2013, the Tawam
Molecular Imaging Centre, which is privately owned and unrelated to the previ-
ously mentioned Tawam Hospital, became the third facility in the UAE to offer PET
scans [17]. The center referred to is presently recognized as the Cleveland Clinic
Abu Dhabi—Al Ain. Following the closure of the radiation service at Al Mafraq,
and in addition to Tawam Hospital and GICC, the American Hospital in Dubai
emerged as the third facility to offer radiation treatment in the UAE. Subsequently,
the government-­funded Sheikh Khalifa Specialty Hospital in Ras Al Khaimah,
which opened in February 2015, became the fourth provider of radiation therapy in
the country. Notably, it was the first and only radiation facility available in the
6 H. O. Al-Shamsi

Northern Emirates. In 2016, Mediclinic City Hospital became the fifth provider of
radiation therapy in the UAE, introducing the country’s first stereotactic body radio-
therapy (SBRT). Advanced Oncology Cancer Center, a specialized private cancer
center in Dubai, commenced offering radiation therapy services in 2019. Other
notable private oncology hospitals in the UAE include Al Zahra Hospital and
Mediclinic City Hospital in Dubai, as well as Zulekha Hospitals in Dubai and
Sharjah [18]. Several private hospitals have established radiation facilities in recent
years. These include Burjeel Medical City in Abu Dhabi, which opened its facility
in February 2021; Mediclinic Abu Dhabi in 2022; Saudi-German Hospital Dubai in
2021; and Neurospinal Hospital Dubai in the summer of 2020.
Burjeel Medical City, which opened in October 2020, became one of the main
cancer centers in the UAE with unique services like the Brainlab© radiation facility
and adult and pediatric bone marrow transplantation [BMT]. Burjeel Medical City
is the only center in the UAE that provides adult and pediatric allogenic transplanta-
tion. The center has completed more than 55 BMTs for both adults and pediatrics in
its first 15 months of operation. Burjeel Medical City is the most publishing clinical
cancer research center in the UAE.
The primary cancer center catering to the Northern Emirates region is the Sheikh
Khalifa Specialty Hospital in Ras Al Khaimah, offering a semi-comprehensive
range of cancer services. Sharjah University Hospital, on the other hand, provides
cancer screening and treatment, including surgery and chemotherapy, but lacks a
radiation treatment facility.
The Al Jalila Foundation, an esteemed member of the Sheikh Mohammed Bin
Rashid Al Maktoum Global Initiatives, is in the process of establishing a ground-
breaking cancer charity hospital in Dubai called the “Hamdan Bin Rashid Cancer
Hospital.” This institution aims to unite top-notch experts to oversee the preven-
tion, diagnosis, and treatment of cancer within a single facility. Named after the
late Sheikh Hamdan Bin Rashid Al Maktoum, the hospital will provide a com-
prehensive range of services, including outpatient, ambulatory, and diagnostic
care, as well as inpatient and surgical treatments. Patient well-being will be pri-
oritized in an environment known for its personalized and compassionate
approach. The hospital will extend its services to patients from all across the
UAE, offering medical treatments that are either free or highly subsidized to
alleviate the financial burden faced by individuals unable to afford quality health-
care. The Al Jalila Foundation has committed an investment of AED 1.2 billion
towards this innovative project, which will be the region’s first fully modular-
built hospital. Anticipated to open in 2026, this all-in-one cancer care facility
will encompass prevention, diagnosis, and treatment services, with the capacity
to serve up to 30,000 patients annually [19].
1 Introduction 7

1.5 Oncology Manpower in the UAE

In 2018, the UAE had a total of 66 registered medical and radiation oncologists. The
Department of Health (DOH) had the highest number of oncologists, with 34 medi-
cal and radiation oncologists. The Dubai Health Authority (DHA) had 26 oncolo-
gists, while the Ministry of Health and Prevention (MOHAP) had 6 oncologists
[20]. In the UAE, the ratio of oncologists to the population is 0.6 per 100,000 peo-
ple. This figure is relatively low when compared to developed nations such as
Canada, where there were 1.6 oncologists per 100,000 individuals in 2016, and the
United States, which had 4 oncologists per 100,000 population in the same year
[21]. In 2010, Switzerland had a rate of 3.3 oncologists per 100,000 population,
while the United Kingdom had a rate of 3.6 oncologists per 100,000 population
[22]. The rate of oncologists per 100,000 in the UAE is higher than in other develop-
ing countries; for example, Turkey has 0.4 [22] and India has 0.0001 [23], most
likely due to the large populations of these countries.
The UAE represents a diverse and multicultural society, with over 190 nationali-
ties residing within its borders. Physicians seeking licensure in the UAE undergo a
meticulous evaluation process before obtaining their license. Medical oncologists,
radiation oncologists, and surgical oncologists originate from various backgrounds,
including Europe, North America, South Asia (Pakistan and India), South America,
Australia, Africa, and more. This diversity presents a challenge in delivering stan-
dardized, high-quality cancer care.

1.6 Cancer Registry in the UAE

In the UAE, there are an estimated 4500 new cases of cancer reported each year.
However, accurately describing and reporting cancer incidence in the country
requires addressing the challenges and limitations posed by the current frag-
mented and multiple tumor registries. The first tumor registry in the UAE was
established in 1983 as a hospital-based registry at Tawam Hospital, which serves
as the official cancer tertiary referral hospital in the country. Mr. Antony D. R. Beal,
a radiation physicist, spearheaded the establishment of this registry. It contained
valuable information regarding cancer occurrences in the UAE, and the data were
presented at the inaugural UAE Cancer Congress in 1985 [14]. The tumor registry
at Tawam Hospital did not include data on cases treated at other healthcare facili-
ties across the country, excluding patients who had received cancer treatment at
hospitals like Al Mafraq Hospital. In these hospitals, cancer data was being
reported to the Ministry of Health and Prevention (MOHAP) [14]. Under the
supervision of the Ministry of Health and Prevention (MOHAP), the first official
report on cancer incidence was published in 2002 by Dr. Falah Al-Khatib and col-
leagues at Tawam Hospital [24]. The collected data from the UAE was included in
the regional Gulf Countries Cancer Registry, which was centered in Riyadh at
King Faisal Hospital. This registry encompassed all the countries in the Gulf
Cooperation Council (GCC). The findings from this collective effort were
8 H. O. Al-Shamsi

published in a paper titled “Cancer incidence for common cancers in Gulf

Cooperation Council countries during 1998–2001” [25].
In 2011, the Department of Health (DOH) released its inaugural cancer statistics
specifically for the Emirate of Abu Dhabi, which included the data from Tawam
Hospital [26]. The available data at that time only presented information on cancer
mortality, lacking any data on cancer incidence. According to the report, cancer was
responsible for 14% of all deaths in the Emirate in 2011, with lung cancer account-
ing for 14.8% of male mortality and breast cancer contributing to 27% of female
mortality. In 2012, the Department of Health (DOH) initiated the Abu Dhabi Central
Cancer Registry (ADCCR) with the objective of monitoring cancer incidence rates,
assessing the effectiveness of cancer screening programs, identifying risk factors
for cancer, and planning interventions to control and prevent cancer. The first com-
prehensive data on cancer incidence in the Emirate of Abu Dhabi was published in
2012. The report indicated a total of 1729 cancer cases that year, with 28% of cases
involving UAE citizens and 72% involving expatriates. Among males, hematologi-
cal malignancies were the most common cancer (29%), while breast cancer was the
most prevalent among females (26%). The cancer mortality rate was recorded at
12.9% [27].
Dubai Hospital has been collecting tumor registry data since 2001; however, this
data has not been published separately. Instead, the data is reported annually to the
Ministry of Health and Prevention (MOHAP). In 2014, the MOHAP National
Cancer Registry was established as the official entity responsible for collecting can-
cer data from hospitals across the United Arab Emirates. It became mandatory for
both private and government hospitals to report all malignant cases to the registry.
The Ministry of Health and Prevention (MOHAP) endeavored to establish
comprehensive and accurate national disease registries that would provide access
to medical information across the entire country while ensuring the confidential-
ity of data. As part of this initiative, the United Arab Emirates National Cancer
Registry was established under the authority of MOHAP, following the directive
of the UAE Cabinet and the Minister of Health and Prevention. The National
Cancer Registry operates as a population-based cancer registry for the United
Arab Emirates. Its primary purpose is to systematically gather, store, summarize,
analyze, and disseminate information concerning individuals diagnosed and/or
treated for cancer within the UAE. The registry plays a crucial role in monitoring
cancer incidence, identifying patterns and trends over time, and offering insights
into the prevalence of cancer in the country. This data is invaluable for planning
cancer services, implementing cancer screening programs, and conducting can-
cer research initiatives. The Cancer Registry operates as part of the National
Disease Registries and operates under the jurisdiction of the Statistics and
Research Center. Annually, the UAE National Cancer Registry produces a report
on cancer incidence and mortality, which is available both online and in print,
starting in 2014. The registry’s ultimate goal is to uncover disease trends and
facilitate the study of disease distribution in different regions of the country [28].
1 Introduction 9

The registry follows the guidelines recommended by the International Agency

for Research on Cancer (IARC) to collect data on malignant neoplasms. Data is
sourced from various channels, including:

(a) The central cancer registry at the Department of Health (DOH): This registry,
known for its high level of expertise, serves as a centralized repository for can-
cer data in Abu Dhabi.
(b) The central cancer registry at the Dubai Health Authority (DHA): Similar to
the DOH registry, this centrally located registry in the DHA is also highly
qualified.
(c) Hospital admissions and medical records departments: Data is obtained from
these departments in public, private, and university hospitals throughout the
UAE. The data is classified using the International Classification of Diseases
and the International Classification of Diseases for Oncology.
(d) Notifications by medical professionals: Information is received through notifi-
cations made by healthcare professionals.
(e) Reports from pathology laboratories: Data is collected from reports generated
by pathology laboratories.
(f) Mandatory reporting: Starting in 2013, various sources, such as mortality data,
medical treatment abroad, and other notifications, were made compulsory for
reporting.

By leveraging these multiple sources, the registry ensures a comprehensive col-

lection of data on cancer cases in the UAE, following the established guidelines set
forth by the IARC.
According to GLOBOCAN, the projected growth of all malignancies in the UAE
is expected to increase from 4.81k in 2020 to 15.9K by the year 2040 [29]. The
substantial projected increase mentioned might be an overestimation and could
exceed the actual rise in cancer incidence by 2040 (Fig. 1.2).
Within the UAE, there are numerous prospects for enhancing cancer care. In this
publication, we have identified some of these opportunities, addressed challenges,
and presented practical solutions. Our recommendations align with the UAE gov-
ernment’s vision of reducing cancer mortality rates and providing optimal health-
care for the population. Throughout the book, we extensively discuss these
recommendations, covering areas such as enhancing data collection and cancer
reporting practices throughout the UAE, as well as promoting and facilitating can-
cer research specific to the UAE.
We propose a unified, multidisciplinary approach to clinical decision-making,
based on evidence-based medicine. Additionally, we advocate for improving exist-
ing cancer screening programs to instill greater trust in the general public and
increase screening uptake. The UAE Cancer Care Task Force remains committed to
closely collaborating with health authorities and policymakers to advance cancer
care across the UAE.
10 H. O. Al-Shamsi

Fig. 1.2 Estimated number of new cases from 2020 to 2040, both sexes and age [0–85+] (Source:
Used with permission from International Agency of Research on Cancer (IARC)/World Health
Organization (WHO))

Table 1.1 Number of population in the UAE by gender, 2010–2020

‫املجموع‬ ‫إناث‬ ‫ذكور‬ ‫السنة‬
Total Female Male Year
82,64,070 21,02,250 61,61,820 2010
83,94,019 21,49,356 62,44,663 2011
85,26,425 21,97,598 63,28,827 2012
86,61,345 22,47,008 64,14,337 2013
87,98,841 22,97,617 65,01,224 2014
89,38,974 23,49,456 65,89,518 2015
91,21,167 28,22,873 62,98,294 2016
93,04,277 28,88,335 64,15,942 2017
93,66,828 30,69,166 62,97,662 2018
95,03,738 32,01,014 63,02,724 2019
92,82,410 28,13,950 64,68,460 2020
‫ املركز االتحادي للتنافسية واإلحصاء‬:‫املصدر‬
Source: Federal Competitiveness and Statistics Centre

Conflicts of Interest The author has no conflict of interest to declare.

Appendix

See Tables 1.1 and 1.2.

1 Introduction 11

Table 1.2 Population and demographic indicators, 2020

‫املعدل‬
Item Rate ‫البيان‬
Sex ratio 229.9 ‫نسبة النوع‬
Life expectany at birth (in years) 79.7 (‫لعمر املتوقع عند امليالد (بالسنوات‬
Life expectany at birth for males (in 78.0 (‫العمر املتوقع عند امليالد للذكور (بالسنوات‬
years)
Life expectany at birth for females (in 81.4 (‫)العمر املتوقع عند امليالد لإلناث (بالسنوات‬
years)
Median age (in years) 32.8 (‫العمر الوسيط (بالسنوات‬
Median age for males (in years) 33.5 (‫العمر الوسيط للذكور (بالسنوات‬
Median age for females (in years) 31.2 (‫العمر الوسيط لإلناث (بالسنوات‬
Age dependancy ratio 20.0 ‫معدل االعالة العمرية‬
Children dependancy ratio 17.9 ‫معدل إعالة الصغار‬
Elderly dependancy ratio 2.1 ‫معدل إعالة كبار السن‬
Population density (per km2) 130.7 (2‫)الكثافة السكانية (لكل كم‬
Average annual population growth rate, 1.2% 2020–2010 ‫متوسط معدل النمو السكاين السنوي‬
2010–2020
Average annual population growth rate, 0.8% 2020–2015 ‫متوسط معدل النمو السكاين السنوي‬
2015–2020
Average annual population growth rate, −2.3% 2020–2019 ‫متوسط معدل النمو السكاين السنوي‬
2019–2020
‫ املركز االتحادي للتنافسية واإلحصاء‬:‫املصدر‬
Source: Federal Competitiveness and Statistics Centre

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Prof. Humaid Obaid Al-Shamsi is the Chief Executive

Officer of Burjeel Cancer Institute in Abu Dhabi, UAE, President
of the Emirates Oncology Society, Lead of the Gulf Cancer
Society, Full Professor of Oncology at the Ras Al Khaimah
Medical and Health Sciences University, Ras Al Khaimah,
UAE, and an Adjunct Professor of Oncology at the College of
Medicine, University of Sharjah. He is the first Emirati to be
promoted as a professor in oncology in the UAE. He is also the
Chairman for Colorectal Cancer in the MENA region, appointed
by the prestigious National Comprehensive Cancer Network®.
He is also the only member of Lung Cancer Policy Network in
the MENA region that aims to advance lung cancer research and
screening globally. He is the Chairman of the Oncology and
Hematology Fellowship Training Program for the National
Institute for Health Specialties in the United Arab Emirates. He
is the only member in GCC in the WIN Consortium which is
comprised of organizations representing all stakeholders in per-
sonalized cancer medicine globally.
He is board-certified in both internal medicine and oncol-
ogy from the UK, USA (ABIM), and Canada (FRCPC). He has
also been awarded the FRCP (London) in 2023 and FRCP
(Glasgow) in 2024. He is the only physician in the UAE with a
1 Introduction 13

subspecialty fellowship certification and training in gastrointes-

tinal oncology and the first Emirati to train and complete a clini-
cal post-doctoral fellowship in palliative care. He was an
assistant professor at the University of Texas MD Anderson
Cancer Center between 2014 and 2017. He has published more
than 140 peer-reviewed articles in JAMA Oncology, Lancet
Oncology, The Oncologist, BMC Cancer, and many others. His
area of expertise includes precision oncology and cancer care in
the UAE. In 2016, he published with his group from MD
Anderson the JCO paper describing a new distinct subgroup of
CRC, NON V600 BRAF-mutated CRC. In 2022, he published
the first book about cancer research in the UAE and also the first
book about cancer in the Arab world, both of which were
launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months
of publication and is the ultimate source of cancer data in the
Arab region. He also published the first comprehensive book
about cancer care in the UAE which is the first book in UAE
history to document the cancer care in the UAE with many top-
ics addressed for the first time, e.g., neuroendocrine tumors in
the UAE. He is passionate about advancing cancer care in the
UAE and the GCC and has made significant contributions to
cancer awareness and early detection for the public using social
media platforms. He is considered as the most followed oncolo-
gist in the world with over 300,000 subscribers across his social
media platforms (Instagram, Twitter, LinkedIn, and TikTok). In
2022, he was awarded the prestigious Feigenbaum Leadership
Excellence Award from Sheikh Hamdan Smart University for
his exceptional leadership and research and the Sharjah Award
for Volunteering. He was also named the Researcher of the Year
in the UAE in 2020 and 2021 by the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan,
Vice President of the United Arab Emirates, awarded him the
first place in UAE Nafis program for outstanding leadership in
private sector across all business and medical disciplines. Beside
his clinical and administrative duties, he is engaged in education
and various levels of research training for medical trainees to
enhance their clinical and research skills. His mission is to
advance cancer care in the UAE and the MENA region and
make cancer care accessible to everyone in need around
the globe.
14 H. O. Al-Shamsi

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Cancer Care in the UAE
2
Humaid O. Al-Shamsi and Amin M. Abyad

2.1 Introduction

Cancer remains a significant health concern in the United Arab Emirates (UAE),
resulting in substantial illness and loss of life. It represents approximately 8.2% of
all fatalities in the UAE, positioning it as the fifth leading cause of death in 2021 [1].
The UAE has made a dedicated commitment to decrease cancer-related deaths by
approximately 30% before the year 2030. The reduction of cancer mortality is a
significant benchmark within the UAE national plan, aligning with the objective of
achieving a “Pillar of World-Class Healthcare”.
There is a lack of comprehensive data regarding the state of cancer care in
the UAE. This data is crucial for recognizing deficiencies and enhancing the
provision of cancer care in the country [2–4]. This review offers the most
extensive and up-to-­date information on cancer care, addressing various previ-
ously unexplored subjects such as psycho-oncology, onco-fertility, oncology
medical tourism, cancer education and training, precision oncology cancer

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca
A. M. Abyad
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Burjeel Medical City, Abu Dhabi, United Arab Emirates

© The Author(s) 2024 15

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_2
16 H. O. Al-Shamsi and A. M. Abyad

research in the UAE, cancer survivorship, oncology nursing, cancer support

programs, and more. In conclusion, the review will provide recommendations
to different stakeholders, including regulators and policymakers, payers, and
the UAE oncology community, regarding the provision and future planning of
top-notch cancer care.

2.2 History of Cancer Care in the UAE

We have presented a concise summary of the historical development of cancer

care in the UAE, which can be traced back to 1981, when the inaugural special-
ized cancer center, Tawam Hospital in Al Ain, was established [2]. Over the past
decade, there has been a consistent and notable advancement in cancer care in the
UAE. Key achievements during this period include the integration of cutting-
edge technologies like cyberknife radiation and the initiation of hematopoietic
stem cell transplantation (HSCT) programs [5, 6], along with a significant rise in
the number of cancer centers. Figure 2.1 summarizes the UAE oncology land-
scape outline.

Population 0.28m 4.1m 8.2m∗ 8.6m∗ 9.5m∗ 12.4m

1st Incidence of
First UAE The state of cancer
documentation cancer in Gulf
Cancer care in the UAE in
1st Research of UAE cancer Cooperation
Congress and
Research paper published Cancer Week History Council 2020: A report by the Completion of
from UAE 14 countries, 1998– UAE Oncology task 100 BMT cases
Publications published 14
2001 published force Published at Burjeel
Medical City

1971 1979 1981 1983 1985 ------ 2002 2004 2005 2007 2010 2011 2013 2014 2015 2016 2 017 2019 2020 2021 2023 2022 2024 - 2040

Oncology Opening of Tawam 1-Tawam hospital

1-1st Oncology & Opening of Sheikh
Establishment of the BMT Opening of Hamdan Bin
unit at Burjeel Medical City Rashid Cancer Charity
Sheikh Khalifa 1st Private oncology
centers hospital in Al-Ain as named the official Medical City provider in the UAE ;
radiation center in the
northern emirates
Shakbout Medical
City with oncology
and American hospital
Dubai and service activated
Hospital in 2026
the first oncology cancer tertiary
established center and radiation referral hospital in
oncology service
started
The Gulf
International Cancer
opened - Sheikh Khalifa
speciality hospital in Ras
facility Opening of Burjeel Opening of Saudi
German hospital and
in the UAE Medical City Abu
UAE Center Al Khaimah Mediclinic Abu Dhabi
Dhabi & clemenceau
2- Opening of 2- Cleveland Clinic Abu Radiation facilities
Opening of Abu medical center
Almafraq Hospital Dhabi opened Dhabi Stem Cells Dubai
and Dubai Hospital
Center (ADSCC) Neuro Spinal Hospital
Cancer opened in Dubai with first
CyberKnife Radixact
System in UAE
1st unofficial digital The first official cancer
data Tumor Registry at incidence report from
Abu Dhabi Central MOHAP established UAE 1st UAE National cancer
Cancer Registry national cancer registry registry data published
UAE National cancer UAE National cancer
Tawam hospital by registry data published registry data for the
Tawam was published
registry Mr. Antony D. R. Beal in 2002 by the MOHAP
(ADCCR) established for the year 2014 for the year 2017 year 2018 & 2019 to be
published

1st oncology
Other 1st PET scan UAE Federal Law on
fellowship training Burjeel Medical city An estimated 355%
became available in Medical Liability
significant UAE - Gulf program established accredited as the increase in all
UAE was (Law No. 4 of 2016)
International Cancer at Tawam hospital first European malignancies in UAE
Established
landmarks Center
to allow natural Society for Medical by 2040 as per the
death approved Oncology accredited GLOBOCAN
DOH standard for
center of excellence center in the UAE
Emirates Oncology
DOH ; Department of Health , HSCT ; Hematopoietic Stem Cell Transplantation, MOHAP ; Ministry of Health and Prevention , in HSCT services 1st Autologus HSCT in
Society was 1st Allogenic HSCT in
PET ; Positron Emission Tomography scan , UAE ; United Arab Emirates approved UAE done at Abu
established UAE done at Burjeel
Dhabi Stem Cells
∗ Source: Federal Competitiveness and Statistics Centre Center (ADSCC)
Medical City

Fig. 2.1 UAE oncology landscape timeline as of July 2024

2 Cancer Care in the UAE 17

2.3 Cancer Incidence in the UAE in 2021

According to the UAE National Cancer Registry (UAE-NCR), a total of 5830

new cases of cancer, including both malignant and in-situ cases, were reported
during the period from January 1st to December 31st 2021 [1]. Out of the total
reported cases, 5612 (96%) were invasive cancers, while 218 (4%) were classi-
fied as in situ cases (as shown in Appendix 1). Women were more affected by
cancer, accounting for 3210 (55.1%) cases, compared to 2620 (44.9%) cases in
males. These statistics include both UAE citizens and expatriates. Among UAE
citizens, there were 1493 new cases reported, with 1431 (95.8%) categorized as
malignant and 62 (4.2%) as in situ cases. Similarly, among non-UAE citizens,
there were 4337 new cancer cases, with 4181 (96.4%) classified as malignant and
156 (3.6%) as in situ cases. The crude incidence rate for both genders combined
was 60.5 per 100,000. Notably, a higher incidence of cancer was observed in
females compared to males. The crude incidence rate for females was signifi-
cantly higher at 108.7 per 100,000, whereas for males, it was 39.5 per 100,000.
The overall age-standardized incidence rate (ASR) for both genders was recorded
as 107.8 per 100,000. Breast, thyroid, colorectal, leukemia, and skin were identi-
fied as the most prevalent cancers among both males and females, as indicated in
Table 2.1. Among males, the top-ranked cancers were colorectal, prostate, leuke-
mia, thyroid, and skin, as shown in Table 2.2. On the other hand, among females,
the leading cancers were breast, thyroid, colorectal, uterus, and cervix uteri,

Table 2.1 Top ten most common malignant primary sites among UAE population in 2021
Primary site ICD-10 Number of malignant cancer cases 2021 %
Breast 1139 20.3
Thyroid 595 10.6
Colorectal 532 9.5
Leukemia 304 5.4
Skin (Carcinoma) 273 4.9
Prostate 251 4.5
Bronchus and Lung 231 4.1
Non-Hodgkin lymphoma 228 4.1
Uterus 173 3.1
Lip, Oral cavity and pharynx 154 2.7
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021
18 H. O. Al-Shamsi and A. M. Abyad

Table 2.2 Top ten most common malignant primary sites among females and males in 2021

Primary site % Primary site %

Breast 36.9 Colorectal 12.5
Thyroid 13.8 Prostate 9.8
Colorectal 7.0 Leukemia 8.2
Uterus 5.7 Thyroid 6.8
Cervix uteri 4.6 Skin (Carcinoma) 6.4
Skin (Carcinoma) 3.6 Bronchus and Lung 6.3
Ovary 3.5 Non-Hodgkin lymphoma 5.6
Leukemia 3.1 Lip, Oral cavity and pharynx 4.6
Non-Hodgkin lymphoma 2.8 Kidney & Renal pelvis 4.2
Bronchus and Lung 2.3 Urinary bladder 4.0
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021

respectively, as expected, as displayed in Table 2.2. In 2021, a total of 154 chil-

dren aged 0–14 years were diagnosed with new invasive cases of cancer across
the UAE, with 45.4% being female and 54.5% being male. These cases accounted
for approximately 2.7% of all registered malignant cases. The most frequently
encountered cancers in boys and girls were leukemia, brain & CNS, non-­
Hodgkin’s lymphoma, Kidney and Renal pelvis, and bone and articular cartilage.
Cancer ranked as the fifth most common cause of death among the UAE popula-
tion. In 2021, there were 975 deaths from cancer (506 males and 469 females),
representing 8.2% of all deaths, irrespective of gender, nationality, or cancer
type, as illustrated in Table 2.3. This corresponds to an estimated age-­standardized
cancer mortality rate of 29.6 deaths per 100,000 for both genders combined.
Malignant neoplasm of colon emerged as the leading cause of cancer-related
deaths, accounting for an average of 11.9% of annual cancer mortality. Malignant
neoplasm of trachea, bronchus & lung ranked as the second most common cause
of cancer-related deaths in both genders, while malignant neoplasm of breast
stood as the third most common cause of cancer mortality for both males and
females, as depicted in Table 2.3 [1]. In our previous report, the young popula-
tion in the UAE indicated a higher incidence rate of breast and colorectal cancer
[98, 99].
2 Cancer Care in the UAE 19

Table 2.3 Distribution of malignant cancer deaths by type of cancer in the UAE in 2021
Underlying cause of death %
Malignant neoplasm of colon 11.49
Malignant neoplasm of trachea, bronchus and lung 9.85
Malignant neoplasm of breast 9.64
Leukemia 4.92
Malignant neoplasm of stomach 4.31
Malignant neoplasm of cervix uteri 1.33
Malignant neoplasm of rectum 1.33
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021

2.4 Cancer Screening Programs in the UAE

The United Arab Emirates (UAE) has achieved notable advancements in cancer
screening programs. In 2014, the Ministry of Health and Prevention (MOHAP), in
collaboration with various governmental and private healthcare sectors and interna-
tional experts, introduced national cancer screening guidelines for breast, cervical,
and colorectal cancers. These guidelines were subsequently updated in 2018 and
2023. However, there is a lack of officially published data on the participation rate
in cancer screening. Unofficial reports suggest that only around 25% of the eligible
population undergoes breast and colorectal cancer screenings, indicating low utili-
zation rates [7–12]. There is a significant requirement for the implementation of a
comprehensive nationwide screening program in the UAE, which should encom-
pass breast, colorectal, cervical, lung, and prostate cancers. This program should
adopt a unified approach and utilize a call and recall system, replacing the existing
screening methods [10, 13, 14]. It is important to investigate the disparity in cancer
screening rates between citizens and non-citizens, as the data show that 73% of all
cancer cases occur in non-citizens, whereas only 27% of cases are reported in UAE
citizens [15]. Consequently, the majority of cancer care resources are currently allo-
cated to non-citizens. It is crucial to address the social obstacles that hinder cancer
screening in an appropriate manner [12, 16–18]. The adoption of universally
approved blood-based cancer screening tools, such as Epi proColon, should be
taken into consideration as a less invasive alternative that has the potential to be
more socially acceptable for screening purposes [19]. We should contemplate active
involvement in clinical trials for blood-based cancer screening methods within our
population [20–22].
20 H. O. Al-Shamsi and A. M. Abyad

2.5 Modifiable Cancer Risk Factors in the UAE Population

2.5.1 Obesity/Fast Food/Smoking/HPV/HBV

The relatively elevated occurrence of obesity among the young population in the
UAE aligns with other neighboring Arab nations in the Middle East and is strongly
associated with the excessive consumption of unhealthy diets that are high in calo-
ries and low in nutritional value [23]. As mentioned earlier, the UAE has been mak-
ing endeavors to manage modifiable risk factors for cancer, including smoking and
various forms of obesity. These factors have been prioritized on the active agenda of
the UAE government, with initiatives in place to regulate and control them [2].
Tobacco control stands as a significant focal point for health authorities in the
UAE. Following the UAE’s endorsement of the WHO Framework Convention on
Tobacco Control in November 2005, the Ministry of Health devised an encompass-
ing strategy to combat this widespread issue through the National Tobacco Control
Program. Notably, the UAE Ministry of Industry and Advanced Technology
(MOIAT) became the first among GCC countries to enforce a compulsory standard,
known as UAE.S 5030:2018, governing electronic nicotine products to align them
with traditional tobacco products. Additionally, the UAE government implemented
a 100% taxation policy on tobacco products.
Due to the prevalence of obesity as a public health issue, the Ministry of Health
and Prevention (MOHAP) initiated a national strategy to address childhood obesity.
In 2017, an excise tax was implemented throughout the UAE, which was further
escalated in 2019. This tax structure included a 50% levy on carbonated and sweet-
ened beverages, a 100% levy on energy drinks, as well as a 100% levy on tobacco
products and associated items.
Additionally, we suggest the implementation of calorie labeling for all fast food
items and the restriction of advertising for fast food restaurants, as the growing
prevalence of such advertising is increasingly noticeable both online and in public
spaces [24].
Cervix uteri ranks as the fifth most prevalent cancer among females in the UAE
[1]. Due to this fact, the UAE took the lead in the Middle East and North Africa
(MENA) region by initiating an extensive human papillomavirus (HPV) vaccination
campaign. In 2008, the Abu Dhabi Department of Health (DOH) introduced HPV
vaccination for all eligible schoolgirls attending public and private schools.
Subsequently, in 2013, the vaccination program was expanded to include all females
between the ages of 15 and 26, encompassing both UAE nationals and non-nation-
als. The Dubai Health Authority (DHA) also advises vaccination for all eligible
girls aged 11–12 years [2]. In 2018, the inclusion of HPV vaccination in the national
vaccination program was implemented to encompass the entire UAE population.
The vaccination campaign aimed to target schoolgirls between the ages of 13 and
14, administering 2 doses, while girls aged 15 and above up to 26 years received 3
doses. As of 2022, the coverage rate for the 2-dose vaccination was reported at 82%
2 Cancer Care in the UAE 21

[26]. Our suggestion is to improve public, parental, and adolescent understanding

and awareness regarding HPV infection and vaccination. This focus aims to mini-
mize misconceptions and the associated stigma related to HPV vaccination [2, 27].
Since 1991, the Hepatitis B vaccine has been implemented and required for all
eligible female citizens in the UAE [28]. Since 2006, it has been mandatory for all
expatriates arriving in the UAE for employment to undergo testing for hepatitis B
and C infections. If an individual is found to be non-immune to Hepatitis B (HBV),
they are required to receive the HBV vaccination [2].

2.6 Established Comprehensive Cancer Center

There are over 30 oncology centers and clinics scattered throughout the UAE. In
previous discussions, we have provided a detailed overview of the significant
achievements and developments in establishing various cancer centers in the coun-
try [2]. A formal definition for a “comprehensive cancer center (CCC)” is currently
not available in the UAE. However, the Department of Health (DOH) has recently
issued general standards for “centers of excellence” in Abu Dhabi, which encom-
pass various healthcare facilities and are not exclusively applicable to oncology
centers [29].
The comprehensive cancer center (CCC) should serve as a convenient and com-
prehensive destination for fulfilling all cancer care requirements [30]. According to
our perspective, for a facility to be recognized as a comprehensive cancer center
(CCC), it should offer a range of services, including medical oncology for both
adult and pediatric patients, hematology, surgical oncology, radiation oncology,
nuclear medicine, and palliative care [30]. Presently, there are four centers that ful-
fill the criteria to be classified as comprehensive cancer centers (CCCs). However,
there are notable cancer centers, such as Dubai Hospital (DH), Saudi German
Hospital Dubai, Sheikh Shakhbout Medical City (SSMC), Cleveland Clinic Abu
Dhabi (CCAD), and Mediclinic Hospital Abu Dhabi, that do not meet the CCC
criteria. A list of these centers and hospitals providing oncology services across the
UAE can be found in Appendix 2, arranged alphabetically.
The Al Jalila Foundation, an organization affiliated with Sheikh Mohammed Bin
Rashid Al Maktoum Global Initiatives, is currently in the process of establishing the
first comprehensive cancer hospital in Dubai, named the “Hamdan Bin Rashid
Cancer Hospital.” This charitable hospital aims to bring together leading experts
and pioneers in the field of cancer care, with a focus on the comprehensive diagno-
sis and management of various cancer cases. The hospital will offer a range of ser-
vices, including outpatient ambulatory care, inpatient care, and surgical services. It
aims to provide advanced technology and diagnostic services within a compassion-
ate environment that prioritizes personalized patient care. The hospital is named in
honor of the late Sheikh Hamdan Bin Rashid Al Maktoum, in recognition of his
significant contributions to improving healthcare in the UAE. As a charitable
22 H. O. Al-Shamsi and A. M. Abyad

institution, the hospital will accept patients from across the UAE, regardless of their
place of residence. The medical services provided will be predominantly free or
heavily subsidized, aiming to alleviate the financial burden for patients who are
unable to afford high-quality healthcare. The Al Jalila Foundation has invested AED
1.2 billion in constructing the region’s first fully modular-built hospital. The planned
opening is set for 2026. The hospital aims to provide a comprehensive and inte-
grated approach to cancer care, encompassing prevention, diagnosis, and evidence-
based management, with a capacity to treat approximately 30,000 patients
annually [31].

2.7 Oncology Manpower in the UAE

According to the author’s knowledge, as of August 2022, there were approxi-

mately 100 specialized physicians practicing in the field of oncology in the
UAE. This includes medical oncologists, malignant hematology physicians, and
radiation oncologists. These oncologists are predominantly located in the emir-
ates of Abu Dhabi and Dubai. They come from diverse backgrounds, with a sig-
nificant number hailing from Arab countries such as Lebanon, Syria, and Jordan,
while others originate from the UK, USA, and various other western countries.
Many oncologists are choosing to relocate to the UAE due to its reputation for
better remuneration and the high quality of life it offers. These professionals have
received training from various sources, with a considerable portion holding certi-
fications from Canada and other western countries, including board certifications
from the American and UK medical boards. There are also oncologists who have
received their training in their home countries, including Syria, Jordan, and
Lebanon. The local UAE oncologists represent only a small percentage, approxi-
mately 10–12, of the total oncologists practicing in the UAE. Most local oncolo-
gists from the UAE have pursued their training in Canada and the United States,
with many having completed advanced fellowship programs at renowned institu-
tions like MD Anderson Cancer Centers. There is a need to foster the interest of
UAE medical graduates in pursuing careers in oncology by raising awareness
about the significance of this specialty among medical students and early-career
physicians.

2.8 Advanced Surgical Oncology and Robotic Surgeries

In the UAE, surgical oncology has been a part of medical practice for many years.
However, it is noteworthy that a significant number of general surgeons performing
oncology procedures have not undergone formal training in surgical oncology. Over
the past decade, there has been a gradual increase in the presence of formally trained
surgical oncologists in the UAE. Extensive research indicates that a surgeon’s train-
ing significantly impacts the outcomes of cancer patients. In a comprehensive anal-
ysis of 27 studies focusing on surgeon training, specialization, and associated
2 Cancer Care in the UAE 23

outcomes, it was consistently observed that well-trained and specialized surgical

oncologists achieved better surgical outcomes for cancer patients compared to non-
specialized general surgeons [32]. In recent times, the UAE has experienced an
expansion in the availability of robotic surgery technology, although only a limited
number of cancer centers currently provide this advanced surgical modality.
One of the persistent challenges in the field of surgical oncology in the UAE
relates to the types of surgeries performed for cancer patients. A conflict of interest
and competition, often driven by financial considerations due to involvement in
private practices, has led to a situation where surgeons without a background in
surgical oncology may hesitate to refer patients to specialized oncology surgeons
for surgical procedures. Moreover, surgeries performed by non-specialized sur-
geons are typically not discussed during multidisciplinary team meetings (MDT) or
tumor boards. Consequently, this can result in inappropriate surgical management,
particularly in complex cases such as colorectal and breast cancers, where patients
may benefit from neoadjuvant therapy to enhance surgical and long-term outcomes.
The regulatory bodies should take steps to tackle this concern by enforcing the
requirement for multidisciplinary team (MDT) evaluation and approval of all cancer
cases that are planned for surgical interventions. It is crucial that even insurance
approval for cancer surgeries is contingent upon MDT discussions, with the excep-
tion of emergency surgeries, which should undergo auditing for surgeons who fre-
quently perform cancer emergency procedures. Additionally, the utilization of
robotic surgery should be limited to surgeons who have received adequate and
appropriate surgical training [33]. This precaution is necessary as some surgeons
may have undergone only brief and simplified courses, falsely presenting them-
selves as proficient robotic surgeons, thereby impacting the appropriate selection of
surgery for cancer patients.

2.9 Radiation Therapy in the UAE

Presently, radiation therapy services are available at approximately ten centers

located across the UAE. Among these centers, four are situated in Abu Dhabi and
Al Ain, five are in Dubai, and one is in Ras Al-Khaimah, serving as the sole radia-
tion therapy center in the Northern Emirates. These facilities are equipped with a
total of seven linear accelerators (LINACs), one tomotherapy unit, and two brachy-
therapy units in the Abu Dhabi/Al Ain region. In Ras Al-Khaimah, there are cur-
rently two linear accelerators and one ViewRay MR Linac, while Dubai houses four
linear accelerators, one tomotherapy machine, one cyberknife machine, and two
brachytherapy units. The LINACs used in the UAE are mostly of recent generations,
with Elekta Versa HD™ and Varian—TrueBeam® being the most commonly uti-
lized models. Advanced radiation therapy techniques, including complex intensity
modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT),
and RAPID-ARC assisted by advanced image guidance radiation (IGRT), are
employed across all these sites. Cyberknife radiosurgery was introduced by the
Neurospinal Hospital in Dubai in 2022 [5]. This year (2022), Burjeel Medical City
24 H. O. Al-Shamsi and A. M. Abyad

in the UAE has introduced Novalis’ comprehensive system, which includes Brain
Lab and Elements software. This advanced tool enables the delivery of highly
precise radiotherapy and stereotactic radiosurgery (SRS) for the treatment of vari-
ous conditions [34]. In the Middle East, Sheikh Khalifa Hospital in Ras
Al-Khaimah stands as the sole provider of ViewRay—MRIdian, which is the first
Food and Drug Administration (FDA)-cleared MRI-Guided Radiation Therapy
system in the region. This innovative system combines the guidance of magnetic
resonance imaging with adaptive radiation therapy, allowing for enhanced preci-
sion and accuracy in radiation treatments [35].
The field of radiation therapy in the UAE is experiencing rapid growth and
achieving notable advancements in terms of technology and treatment outcomes.
Additionally, there are plans for at least four more centers to introduce radiation
oncology services in the coming months, incorporating advanced technologies like
the Gamma knife and artificial adaptive planning LINACS. Furthermore, there are
intentions to establish a proton therapy service at one of the centers; however, previ-
ous endeavors to introduce proton therapy to the UAE faced obstacles due to high
costs and a limited number of patients who require this particular form of treatment
[36]. This demonstrates the positive trend of growth and expansion in the number of
radiotherapy providers. However, we strongly advocate for implementing stricter
regulations and limitations on the establishment of additional radiation centers. This
approach is crucial to uphold quality control over existing practices and to preserve
the higher quality typically associated with centers that handle a higher volume
of cases.
To enhance radiation therapy in the UAE, it is crucial to establish an independent
and impartial regulatory body responsible for implementing a comprehensive qual-
ity control program across all radiation facilities in the country. Furthermore, a shift
in the payment model is necessary, moving away from the “per-fraction” approach
and transitioning toward a “per-site” model. This change aims to prevent unneces-
sary clinical and financial burdens on patients and healthcare systems while ensur-
ing the delivery of high-quality and effective therapy. Adopting an episode-based
payment approach, which may involve fewer treatment sessions, is expected to
reduce travel time, minimize treatment side effects, decrease the duration of hospi-
tal stays, and provide patients with more free time to engage in social activities,
ultimately enhancing their overall quality of life [37].

2.10 Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) is widely recognized as a stan-

dard and highly successful treatment approach, offering the potential to cure and
even save lives for various benign and malignant hematologic diseases, immune
disorders, and solid tumors. According to reports, between 2016 and 2018, a total
of 164 pediatric and 161 adult patients who were UAE citizens underwent HSCT
outside of their country [6]. Every year, around 200 patients, both citizens and
non-citizens, in the UAE are in need of hematopoietic stem cell transplanta-
tion (HSCT).
2 Cancer Care in the UAE 25

In 2019, the Abu Dhabi Stem Cell Centre established the first hematopoietic stem
cell transplantation (HSCT) service in the UAE. From that time until August 2022,
they successfully conducted 11 autologous non-cryopreservation HSCTs for low-
risk cases. In October 2021, Burjeel Medical City introduced the largest and most
comprehensive HSCT unit in the UAE, catering to both adults and pediatrics. This
marked the introduction of cryopreserved HSCT in the UAE, with 14 autologous
cases utilizing cryopreservation reported. Additionally, they achieved a significant
milestone by completing the first pediatric allogeneic HSCT, encompassing five
cases. The American Hospital Dubai (AHD) is the third healthcare provider in the
UAE offering HSCT services. They initiated their program in December 2021 and
have successfully performed nine autologous HSCT cases. It is important to note that
all the mentioned providers are private healthcare institutions. Sheikh Shakhbout
Medical City (SSMC), a public hospital, has announced plans to commence HSCT
services, with an expected launch of their program in late 2022 or early 2023.
Considering the relatively small number of potential HSCT candidates in the
UAE each year, it is of utmost importance to establish a national and trustworthy
center of excellence for HSCT. This approach would involve consolidating the num-
ber of providers and concentrating expertise in a single reference center that serves
the entire UAE. In addition, we strongly recommend the establishment of a National
Marrow Donor Program in the UAE. This program would facilitate lifesaving trans-
plants for patients who lack a matched related donor within their family, ensuring
access to suitable donors and improving the chances of successful transplant
outcomes.
At present, CAR-T cell therapy is not available in the UAE. However, Burjeel
Medical City has outlined its intentions to become the pioneering center in the
country to offer this treatment modality. In the coming 24 months, they have plans
to introduce CAR-T cell therapy as part of their expanding gene and cellular therapy
programs.

2.11 Gynecology Oncology

In 2021, women’s cancers ranked one of the most frequently observed cancers in the
UAE. Specifically, there were 173 reported cases of uterus cancer, 141 cases of
cervix uteri, and 108 cases of ovarian cancer, totaling 422 cases of women’s can-
cers. This accounts for approximately 7.5% of all malignancies reported in the UAE
during that year [1]. It is worth noting that many cases of women’s cancers are man-
aged by general gynecologists and general surgeons, as dedicated gynecology
oncology units are currently unavailable in the UAE. Furthermore, the UAE has a
scarcity of trained gynecology oncology surgeons, with fewer than ten available.
There are currently no laws or regulations limiting the role of general surgeons or
general gynecologists in the management of the more complicated gynecology
oncology cases. As mentioned earlier, the involvement of general surgeons in man-
aging these cases has been demonstrated to result in less than ideal clinical and
oncological outcomes [38]. Therefore, we advocate for the establishment of dedi-
cated gynecology oncology units throughout the UAE, with mandatory referrals to
26 H. O. Al-Shamsi and A. M. Abyad

these units, and for general surgeons and/or gynecologists to refrain from perform-
ing complex gynecology oncology surgeries.
Efforts must be made to effectively address the low participation in cervical can-
cer screening and promptly identify and tackle the obstacles preventing its uptake.
The inclusion of the HPV vaccine in the UAE’s national vaccination program for
girls is a positive step, and its successful implementation is crucial. Additionally, it
is important to note that gynecology oncology fellowship programs are currently
lacking in the UAE. Therefore, we strongly recommend the establishment of these
programs to provide clinicians with comprehensive and advanced training in this
specialized field.

2.12 Pediatric Oncology

Among children aged 5–14 years old, cancer is the second most common cause of
mortality, following accidents [39]. The occurrence of pediatric cancers varies sig-
nificantly across various countries globally, accounting for approximately 0.5–4.6%
of all cancer cases. The overall incidence rates worldwide typically range between
50 and 200 cases per one million children [40]. Although childhood cancer has a
relatively small number of newly diagnosed cases and cancer-related deaths, it
imposes a significant burden of disease.
Based on data from the UAE National Cancer Registry (NCR) [1] in 2021, there
were 154 newly diagnosed cases of cancer among children aged 0–14 years in the
UAE. This represents approximately 2.74% of all reported malignant cases, with a
slight majority of 54.5% being male and 45.4% being females. The data reveal that
the highest number of childhood cancer cases occurred in the age group of 0–4 years,
accounting for 72 cases or 46.8% of the total. The age group of 10–14 years fol-
lowed with 43 cases, making up 27.9% of the cases. The age group of 5–9 years had
the fewest reported cancer cases among the pediatric population.
The data represent that the most commonly reported cancer was leukemia
(42.9%), followed by brain and CNS tumors (14.9%), non-Hodgkin lymphoma
(8.4%), Kidney & Renal pelvis (6.5%), and bone and articular cartilage (4.5%) [1]
(Table 2.4).
In the UAE, there are seven hospitals offering pediatric hematology-oncology
services, with an approximate count of 28–30 specialized physicians in this field.

Table 2.4 Distribution of top five pediatric cancer cases by primary sites in the UAE, 2021
Primary sites ICD-10 Number of cancer cases %
Leukemia 66 42.9
Brain and CNS 23 14.9
Non-Hodgkin lymphoma 13 8.4
Kidney and Renal pelvis 10 6.5
Bone and articular cartilage 7 4.5
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021
2 Cancer Care in the UAE 27

Table 2.5 List of hospitals Hospital City

providing pediatric oncology Burjeel Medical City Abu Dhabi Private hospital
in the UAE
Tawam Hospital Alain Public hospital
Dubai Hospital Dubai Public hospital
American Hospital, Dubai Dubai Private hospital
NMC Hospital, Abu Dhabi Abu Dhabi Private hospital
Sheikh Khalifa Medical Abu Dhabi Public hospital
City
Mediclinic City Hospital Dubai Private hospital

Public hospitals such as Tawam Hospital, Sheikh Khalifa Medical City (SKMC),
and Dubai Hospital are among the facilities providing these services and experienc-
ing the highest influx of patients. It is important to mention that currently, there are
no pediatric hematology-oncology services available in the Northern Emirates
region (Table 2.5).
Burjeel Medical City, located in Abu Dhabi, is the sole hospital in the UAE offer-
ing a pediatric bone marrow transplant (BMT) program. This program has success-
fully conducted five allogeneic transplants, marking a significant milestone as the
first instance of such procedures in the UAE. The first transplant took place in April
2022 [41].
Pediatric hematology and oncology services in the UAE are currently spread
across multiple providers, serving a comparatively smaller patient population. To
enhance patient outcomes, it is recommended to consolidate and centralize pediatric
hematology-oncology services in the UAE [42].

2.13 Palliative and Supportive Care

A report titled “Palliative Care in the United Arab Emirates, a Desperate Need” was
published in 2018 [43]. Palliative and supportive care have developed markedly in
the UAE over the last few years, starting with only two centers providing palliative
care and now including four centers with palliative care services across the country.
The palliative care program at Tawam Hospital was established in 2007 with the aim
of providing support to oncology patients receiving treatment at the hospital. To this
day, it remains the sole palliative care program funded by the government in the
UAE. Additionally, the American Hospital in Dubai initiated its own palliative care
program in the latter part of 2014 [43]. Mediclinic Hospital, Dubai, started its ser-
vice in 2019. Recently, Burjeel Medical City (BMC) in Abu Dhabi was the latest
hospital to join, and it became the first palliative care program in Abu Dhabi City
since March 2020. In May 2022, Dr. Neil A. Nijhawan, the founding director of the
palliative care program at Burjeel Medical City in Abu Dhabi, became the first rep-
resentative of the UAE in the World Health Organization’s (WHO) palliative care
network and was appointed by the WHO as an expert member of the Eastern
Mediterranean Regional Office’s (EMRO) Expert Network on Palliative Care.
28 H. O. Al-Shamsi and A. M. Abyad

The Emirates Medical Association (EMA) has recently granted approval for the
establishment of the palliative and supportive care working group, which will oper-
ate under the Emirates Oncology Society (EOS). The launch of this group is sched-
uled for late 2022. This significant development aims to increase public awareness
of palliative care and foster its implementation throughout the UAE. The working
group will actively engage with stakeholders and regulatory bodies to advocate for
the specialty. Education and training initiatives will also be central to the group’s
objectives.
Enhancing the provision of palliative care in the UAE demands a comprehensive
and well-structured approach that goes beyond simply adopting the Western model
of supportive and palliative care. Our previous publication highlighted recommen-
dations for improving palliative care, and we have further refined and categorized
these recommendations as follows [44]:
• Implementation of a nationwide strategy for palliative and supportive care as an
integral component of the UAE’s cancer control strategy.
• Ensuring the availability of necessary pain and palliative care medications at all
healthcare levels, including injectable opioids, morphine pumps, and devices for
patients receiving end-of-life care at home.
• Providing essential palliative care training to healthcare professionals who are
not specialized in the field, emphasizing pain management and the effective
treatment of distressing symptoms. Additionally, incorporating palliative and
supportive care into the undergraduate curricula of medical and nursing students.
• Strengthening the capabilities and support for various essential members of the
multidisciplinary team involved in palliative care, such as clinical nurse special-
ists, imams, and chaplains, through training and ongoing development (palliative
care clinical governance).
• Regularly reviewing and updating the Allow Natural Death (AND) policy from
2016 to incorporate proactive advance care planning and treatment de-escalation
plans [44].

2.14 Cancer Survivorship Program

Cancer survivorship represents a crucial aspect of cancer care that is currently in its
early stages of development [45]. It encompasses both short-term and long-term
aspects of care, which involve monitoring and anticipating treatment complications,
assessing the risk of cancer recurrence, addressing potential increased risks of sec-
ondary malignancies, ensuring adherence to recommended adjuvant therapies, and
promoting lifestyle modifications such as weight management, increased physical
activity, and exercise [45, 46]. Cancer survivorship programs in the country are still
in the early stages of development, with only two centers, Tawam Hospital and
Burjeel Medical City in Abu Dhabi and Al Ain, offering comprehensive programs
2 Cancer Care in the UAE 29

for cancer survivors. However, there is a clear need for such programs in other emir-
ates as well. Existing programs should also facilitate knowledge sharing to improve
practices and address challenges. It is crucial to raise awareness among stakeholders
about the significance of these programs in ensuring seamless care for cancer
patients throughout their survivorship journey [47].

2.15 Onco-fertility

With the increasing number of younger adults with cancer, which is considered a
global phenomenon [48], as outlined earlier, the UAE is witnessing a rise in the
number of individuals diagnosed with cancer during their reproductive years,
emphasizing the growing importance of fertility preservation for these young
patients [49].
A notable disparity has been identified between international practice guidelines
and the current implementation of fertility preservation in Arab countries, including
the UAE. Several obstacles hinder the optimal delivery of these services, such as the
absence of certain advanced techniques, insufficient physician training or aware-
ness, and the absence of dedicated fertility teams or clinics within cancer cen-
ters [50].
The Fakih IVF Fertility Center and Al Ain Fertility Center are the leading institu-
tions in onco-fertility in the UAE. They specialize in cryopreservation techniques,
such as freezing ova or embryos, as well as ovarian tissue freezing for female
patients. For young male patients with cancer, the available options include sperm
freezing and/or testicular tissue freezing. Additionally, various procedures like ovar-
ian transposition, fertility-sparing surgery, and hormonal ovarian suppression are
readily accessible in cancer centers throughout the UAE.
Physician awareness and attitudes towards fertility preservation options for
young adults with cancer, as well as limited insurance coverage, present significant
challenges. Many insurance policies do not cover fertility preservation procedures,
which is particularly problematic for expat patients. On the other hand, UAE citi-
zens have insurance coverage for fertility preservation services.
The availability of pre-implantation genetic diagnosis, which involves testing
embryos or oocytes for genetic defects prior to implantation, such as BRCA testing
for carriers, is currently limited in the country. Patients in need of this procedure are
often referred to highly specialized fertility centers abroad.
To enhance access to fertility preservation for cancer patients in the UAE,
comprehensive workshops targeting healthcare providers in oncology and
involving various stakeholders, such as providers, regulators, and patient advo-
cacy groups, are essential. These workshops should aim to address the needs of
all indicated cancer patients, irrespective of their insurance coverage or
nationality.
30 H. O. Al-Shamsi and A. M. Abyad

2.16 Psycho-oncology

Patients who have been recently diagnosed with cancer or have experienced dis-
ease recurrence face the possibility of developing various emotional challenges,
including anxiety, depression, adjustment disorder, and a decrease in self-confi-
dence. Studies suggest that around 50% of cancer patients encounter emotional
difficulties to some extent. When these difficulties become severe, they can
impede the patient’s capacity to effectively manage the impact of cancer, its asso-
ciated symptoms, and treatment-related complications. Individuals with an
increased likelihood of experiencing psychiatric illness and depression are often
those diagnosed with advanced cancer, dealing with poorly managed symptoms
(particularly pain), having a history of previous mental health issues, and facing
additional life stressors simultaneously [51]. Psycho-oncology plays a significant
role in addressing the social, behavioral, and psychological well-being of cancer
patients. This specialized field focuses on two key psychological aspects of can-
cer. Firstly, it addresses the psychological responses of patients, their families,
and caregivers at every stage of the disease. Secondly, it explores the factors that
can impact the disease process, encompassing psychological, behavioral, and
social factors [52].
Psycho-oncology is a developing field in the UAE, and currently, there is a lack
of specifically trained and certified specialists in this area. However, many psychia-
trists and psychologists within cancer centers provide support to patients. To
enhance support for cancer patients, there is a growing initiative to establish dedi-
cated psycho-oncology clinics within UAE cancer centers. Important actions to
improve psycho-oncology in the UAE include attracting specialized physicians,
offering scholarships for psychiatry trainees to pursue psycho-oncology fellowships
and advanced training, and collaborating closely with regulators and healthcare pro-
viders. These steps are crucial in addressing the existing gap and advancing the field
of psycho-oncology throughout the UAE.

2.17 Cancer Support Programs and Support Groups

Cancer support programs aim to provide financial assistance to cancer patients,

while support groups offer psychological support and guidance. However, a com-
mon challenge with financial support programs is their limited budgetary allocation
for each patient, often falling short of covering the full cost of treatment. Exceptions
exist for complex cancer cases, with higher coverage options available. One notable
example is the weekly TV show “Alam W Amal” on Sharjah TV, which provides
coverage of up to 180,000 dirhams per case. Additionally, many pharmaceutical
companies offer patient support programs specifically for the cancer drugs they
manufacture, which can be beneficial for patients requiring expensive medications.
Numerous support programs are available to address the emotional and physical
well-being of cancer patients. Details of the current cancer support programs and
support groups in the UAE can be found in Table 2.6.
2 Cancer Care in the UAE 31

Table 2.6 Cancer support programs and cancer support groups in the UAE
Cancer support programs Funded by Location Service provided
Friends of Cancer Patients Charity Sharjah Financial support
(FoCP)
Cancer Patient Support Dubai government Dubai Oncology
Program (BASMAH)-ISAHD medication support
Cancer Patient Care Society Charity Abu Dhabi Financial support
RAHMA
Emirates Cancer Society Charity Al Ain Financial support
(previously known as
Moazzara)
UAE access programs – Medications support Dubai Oncology
Axios International medication support
Various Charity Treatment cost coverage Across the Financial support
Organizations in the UAE (cost allowed per case UAE
varies)
Brest Friends N/A Dubai Psychological
support
Majlis Al Amal-Al Jalila N/A Dubai Psychological
Foundation support
For female cancer
patients
The Cancer Majlis N/A Dubai Psychological
support
Bosom Buddies N/A Abu Dhabi Psychological
support

2.18 Genetic Testing and Counseling

Access to genetic counseling services in the UAE is extremely limited, with a lack
of dedicated genetic counselors in most centers. As a result, counseling and test-
ing are typically conducted by treating oncologists, leading to significant varia-
tion in knowledge, attitude, and skills in this specialized area. Moreover, many
health insurance policies exclude genetic testing from their coverage, making it
challenging for most patients in the UAE to access these services. The few centers
that do provide genetic counseling and testing experience long appointment wait-
ing times. Additionally, many tests are not covered by insurance, and when they
are, samples are sent overseas for testing, resulting in lengthy turnaround times of
4–6 weeks. To overcome these barriers, several pharmaceutical companies offer
free genetic testing for specific indications, such as BRCA testing for breast can-
cer patients. Our recommendation is to expand genetic counseling services in
comprehensive cancer centers throughout the UAE, facilitated by experienced
genetic counselors. Regulators and stakeholders should collaborate to ensure the
availability and accessibility of genetic testing for all cancer patients, regardless
of their insurance coverage, aligning with international guidelines and best prac-
tices in cancer care [53, 54].
32 H. O. Al-Shamsi and A. M. Abyad

2.19 Precision Oncology in the UAE

Precision oncology, which involves the use of advanced molecular profiling of

tumors to identify specific genetic changes that can be targeted, is a rapidly evolving
discipline that has become an integral part of clinical practice [55]. Targetable bio-
markers found in non-small cell lung cancer serve as a compelling illustration of the
significance of precision oncology at various stages, including initial diagnosis,
treatment, and disease progression. Treating patients with lung cancer without
incorporating precision oncology and assessing mutations is now deemed subopti-
mal [56].
Many oncologists in the UAE make use of widely accessible Next Generation
Sequencing (NGS) testing and other precision medicine tools. Various commercial
testing programs, including Illumina Inc. foundation medicine and The
Guardant360®, are available, but all testing is conducted abroad as no testing is cur-
rently performed within the UAE. These tests are generally not covered by insur-
ance providers in the UAE, except for a small percentage of premium private
insurance plans, which only benefit a limited number of cancer patients requiring
NGS testing. The cost of commercially available NGS testing panels remains a
significant barrier for many patients seeking more comprehensive tumor profiling.
The UAE would greatly benefit from the availability of a more affordable and reli-
able testing platform. While some small multinational companies offer more cost-­
effective NGS testing options in the UAE, further data is necessary to validate their
reliability and consider them as viable alternatives.
The Oncotype DX Breast Recurrence Score® Test is a commercially available
test in the UAE that examines the activity of 21 genes to predict tumor behavior and
chemotherapy response. This test assists clinicians in estimating the risk of breast
cancer recurrence in certain early breast cancer cases. Despite being recommended
by international guidelines, most insurance companies do not provide coverage for
this test. It is often excluded from health insurance policies due to being categorized
as a genetic test, even though it is not strictly a genetic test. Similarly, MammaPrint®
is a diagnostic test that analyzes 70 key genes associated with breast cancer recur-
rence. While some insurance companies have recently started covering this test, it is
important for insurance coverage to align with international guidelines and recom-
mendations to ensure these tests are covered for all appropriate cases of breast can-
cer [57].
The lack of insurance coverage poses a significant challenge in the field of preci-
sion oncology, particularly for non-FDA-approved drugs targeting specific genetic
mutations. These drugs are generally not covered by insurance companies, making
it difficult to obtain approval for such cases, although government-funded insurance
may provide some level of coverage. In light of this, the molecular tumor board
plays a crucial role in providing individualized recommendations for each patient.
However, currently, there is no molecular tumor board established in the UAE
where complex cases can be discussed and experiences can be shared. Most oncolo-
gists rely on their own expertise and institutional tumor boards to make clinical
decisions, while some seek guidance from international institutions with specialized
2 Cancer Care in the UAE 33

molecular tumor boards abroad. The establishment of a UAE-wide molecular tumor

board is necessary to enhance precision oncology practice and ultimately improve
outcomes for cancer patients.
In May 2021, Burjeel Medical City introduced the first specialized clinic for
precision oncology. This clinic focuses on utilizing the latest tools in precision med-
icine to provide personalized treatment recommendations for patients.
Launched in July 2021, the Emirati Genome Program is a government initiative
aimed at sequencing the genetic information of the UAE population. Its objective is
to provide personalized and preventive healthcare by analyzing genetic data. The
response from the general Emirati population has been predominantly positive,
expressing optimism about the potential benefits of this program and the associated
biobank for biomedical research [58].
The primary objective of the program is to equip clinicians, healthcare profes-
sionals, and decision-makers with accurate population-based data. This information
will enable them to offer precise diagnoses, treatment options, and personalized
preventive programs that align with the specific genetic characteristics of the popu-
lation. By analyzing individuals’ unique genetic profiles, the program aims to antic-
ipate and prevent genetic diseases more effectively. It also seeks to facilitate the
implementation of innovative therapies for rare and chronic conditions, including
cancer [59].
Advancing precision oncology in the UAE is a complex endeavor that necessi-
tates collaboration among various stakeholders and the development of national-­
level policies. This collaborative effort involves healthcare providers, payers,
policymakers, and patient advocacy groups. In order to enhance the affordability
and effectiveness of precision oncology, it is crucial to establish standardized and
interoperable protocols for NGS testing and indications. Adequate infrastructure,
funding, data management, and research initiatives must also be in place to support
these efforts and improve outcomes for cancer patients in the UAE [60].

2.20 Pathology, Molecular, and Cytogenetics Testing

Prior to the initiation of cancer treatment, it is necessary to examine a diagnostic

tumor tissue sample in a pathology laboratory. This evaluation is conducted by a
pathologist to confirm the type of malignancy and provide essential prognostic fac-
tors that guide the subsequent treatment approach [61]. The quality of pathology
reports in the UAE can vary significantly based on the pathologist’s background and
experience. Many laboratories in the country are accredited by the College of
American Pathologists (CAP), which mandates the use of tumor checklists for
reporting cancer histopathology. These checklists ensure that a minimum set of
essential pathology data is included in a synoptic report. Accredited laboratories are
also expected to have measures in place to ensure physician competency and to
benchmark performance in report categories such as cytology, cervical smears, and
thyroid FNAs. Comprehensive Cancer Centers (CCCs) tend to prioritize standard-
ized and more reliable pathology reporting compared to smaller clinics and
34 H. O. Al-Shamsi and A. M. Abyad

peripheral healthcare facilities. The presence of multidisciplinary tumor (MDT)

boards, which provide the pathologist with relevant clinical information, can
improve performance. International collaborations have published audited data on
pathology discrepancies and revisions of primary diagnoses.
In the UAE, there are experts specializing in various subspecialties of histopa-
thology, often grouped within one or two larger organizations. However, the provi-
sion of organ-specific expert practices is currently decentralized, with multiple
hospitals and laboratories offering these services. The number of organ-specific
specialists holding board certification in their subspecialties is limited, primarily to
American Boards (such as hematopathology, cytopathology, dermatopathology, and
neuropathology), as well as the Royal College UK. One significant unmet need is
the availability and accessibility of molecular and cytogenetic testing in the
UAE. While there are some exceptions, many advanced tests are typically sent out-
side of the country to international centers in the USA and Europe. This leads to
delays in diagnosis and treatment initiation, sometimes ranging from 2 to 4 weeks
in certain cases. To address this, there is a need to establish centralized pathology
reporting for complex suspected cancer cases. The use of digital pathology can
facilitate second-look reviews from specialized cancer centers abroad. A second
pathology reading is often required to confirm malignancies and is expected in
accredited laboratories. Incorporating second pathology reviews into cancer treat-
ment programs contributes to higher quality. While dramatic changes in diagnoses
are rare (usually around 3%), even subsidiary changes can have clinical significance
[62, 63]. Extensive testing, including molecular data, is becoming increasingly nec-
essary for the diagnosis and classification of soft tissue and brain tumors. Integrated
reports that provide clinically significant information and tumor classification are
essential in these cases. We believe that the advancements in human epidermal
growth factor receptor 2 (HER2) testing and its impact on therapy require a system-
atic and obligatory second review. Inconsistencies in HER2 testing can result in
significant errors in clinical management, emphasizing the importance of a thor-
ough and reliable evaluation process [64, 65].
An examination of malpractice data in the United States often highlights breast,
thyroid, and melanoma fine needle aspiration (FNA) as the pathology reports that
carry the highest risk of legal action. Analyzing national data can help identify areas
with high risk and prioritize them for improvement and mitigation through second
opinions or expert reviews [64–66].
The following are the recommendations for improving pathology, molecular, and
cytogenetic testing:

1. As digital pathology becomes more prevalent, pathologists in the UAE now have
access to a broader network of experts, leading to faster report generation. It is
recommended to have a second pathologist, preferably with organ-specific
expertise or specialization, review the initial diagnosis of malignancy.
2. All high-risk and organ-specific pathologies should undergo review by special-
ized experts who have received appropriate training. It is essential to establish
or identify centers of excellence for specific types of malignancies to ensure that
2 Cancer Care in the UAE 35

a sufficient number of cases are handled by specialists in those particular

organs. For instance, hematopathologists should handle lymphomas and leuke-
mias, cytopathologists should focus on thyroid FNAs, dermatopathologists
should specialize in melanomas, and neuropathologists should specialize in
brain tumors [57, 59, 60]. Similarly, a restricted number of central and refer-
ence laboratories should provide treatment-specific tests like HER2 FISH
and NGS.
3. The Department of Health Abu Dhabi and/or Dubai Health Authority (DHA)
should oversee and assess standard quality measures and the competence of
pathologists through monitoring and audits.
4. As we enhance our research capabilities, it is important to consider implement-
ing a centralized pathology review process.
5. The UAE should promote the establishment of biobanking facilities to facilitate
the collection of data and support future research endeavors.

2.21 Cancer Drug Availability and Cost

Cancer medications, including the latest approved drugs, are widely accessible in
the UAE. The approval process in the UAE has been remarkably swift, often grant-
ing approval shortly after FDA approval. As an example, the drug “Sotorasib” for
lung cancer was swiftly approved in the UAE, making it the second country to do so
after the USA [67]. Additional challenges arise when the parent company fails to
register certain drugs, leading to a prolonged and costly procurement process lasting
4–6 weeks.
Clinical evidence and real-world data have demonstrated the effectiveness and
safety of oncology biosimilar drugs [68]. In response to the rising cost of cancer
drugs globally, the utilization of biosimilars has become prevalent to mitigate the
escalating expenses. Several biosimilars have been approved and are accessible in
the UAE, although their usage varies among cancer centers and physicians. We
strongly advocate for the incorporation of approved biosimilar cancer drugs, when
suitable, into the cancer center’s formulary.

2.22 Oncology Nursing

The scarcity of oncology nurses in the UAE is an ongoing issue, and the COVID-19
pandemic has further intensified this shortage [69]. Similar to other countries, the
UAE also faces significant shortages of well-trained and experienced oncology
nursing staff, as seen in neighboring countries. Oncology nurses in the UAE primar-
ily come from Jordan, the Philippines, India, and Lebanon. These nurses often
rotate between different cancer centers within the UAE due to better salary pros-
pects. In an effort to address this shortage, the UAE has recently eliminated the
requirement of 2 years of experience for nursing licensure, aiming to attract more
nurses to join the workforce in the country.
36 H. O. Al-Shamsi and A. M. Abyad

The Emirates Oncology Nursing Society (EOHNS) serves as the official organi-
zation representing oncology nurses in the UAE. One of its primary focuses is
encouraging participation in continuing medical education (CME) activities. The
EOHNS aims to foster a sense of community among cancer nurses in the UAE,
working together to enhance nursing care for cancer patients and their families. This
is achieved through the development of nursing leaders and the promotion of nurses’
roles in cancer care, ultimately shaping the future of oncology nursing. Currently,
there is a lack of structured training programs for oncology nursing in the UAE. It
is recommended to establish a dedicated training program for oncology nursing to
address the existing shortage of nurses in this field in the UAE.
The role of a nurse practitioner is not widely recognized or established in the
UAE. Implementing this role may present challenges due to current medical prac-
tice laws and cultural attitudes among patients and their families. In the UAE, there
is a prevailing expectation for direct care from physicians rather than nurses.
Additionally, there is an abundance of oncologists in the UAE, which may impact
the demand for nurse practitioners compared to countries like the US, where there
is a shortage of oncologists and a greater emphasis on the role of nurse
practitioners.
The EOHNS has taken the lead in promoting nursing research and evidence-­
based practice in oncology nursing, aligning with its mission to ensure excellence in
cancer care and research for cancer patients in the UAE. The society has actively
advocated for oncology nursing research and has dedicated specific tracks in its
annual conference for nursing research and evidence-based practice. One of the key
focuses is the advancement of the advanced practice role in oncology nursing within
the UAE. Furthermore, efforts are being made to enhance oncology nursing research
and evidence-based practice through initiatives led by SEHA. SEHA plays a crucial
role in defining and addressing research-related issues, attracting skilled research
nurses, supporting research activities, and raising the profile of nursing research in
Abu Dhabi. The nursing research committee within SEHA has implemented a com-
prehensive program to facilitate education on evidence-based practice and research
processes for registered nurses, with a particular emphasis on oncology nursing
research studies.
We suggest promoting the active involvement of oncology nurses in cancer
research through the provision of research training programs and incentives for
career advancement throughout the UAE.

2.23 Artificial Intelligence and Cancer Care in the UAE

The UAE has embraced the use of artificial intelligence (AI) in cancer care ahead of
other countries in the region. In 2016, the IBM Watson oncology program was
implemented as a pilot project at Tawam Hospital with the aim of assisting clini-
cians in their daily management of cancer cases. However, the project was later
discontinued after IBM halted the Watson program due to the AI technology not
meeting the anticipated outcomes.
2 Cancer Care in the UAE 37

Table 2.7 The current AI uses in clinical practice in the UAE

AI technology Facility Year Format Status
IBM™ Watson SEHA— 2016 Clinical decision in oncology Suspended
Oncology—Pilot Tawam
Hospital
AI-enabled digital International 2021 AI-enabled independent reader Active
mammography Radiology for breast cancer screening and
system, Lunit Centre— lung cancer screening
INSIGHT MMG lung Sharjah
cancer screening-­ Commercial
Coreline-­Medical AI
solutions
Prognica Labs Dubai 2021 Prognica Labs uses artificial Active
Commercial intelligence to detect masses in
mammography screenings
Mammography UAE 2021 First and only AI-enabled Active
Intelligent Assessment Commercial independent reader for breast
(Mia)™ cancer screening to be
commercially available in the
UAE
The GI Genius™ Sheikh 2021 Is the first-to-market, computer-­ Active
intelligent endoscopy Shakhbout aided polyp detection system
module Medical City powered by AI
Abu Dhabi
Khalifa University Research Abu 2021 To identify cancer in tissue Active
researchers Dhabi samples, which could speed up
diagnosis and improve
outcomes in patients with
colorectal cancer
DoH—Abu Dhabi Research Abu 2022 First personalized precision Active
Dhabi medicine for oncology in
collaboration with Mubadala
Health, Cleveland Clinic Abu
Dhabi, NYU Abu Dhabi,
Mohamed bin Zayed University
of Artificial Intelligence and
G42 Healthcare
Mohamed bin Zayed Research Abu 2022 AI tool for better diagnosis and Active
University of Artificial Dhabi treatment of pancreatic cancer
Intelligence team

At present, several AI platforms are being employed in the UAE, primarily to

assist in the diagnosis of cancer through imaging techniques such as breast and lung
cancer screening. The current utilization of AI in clinical practice in the UAE is
outlined in Table 2.7.
The UAE has made significant contributions to AI and cancer research. A
collaborative team of researchers from New York University (NYU) in the
United States and NYU Abu Dhabi has successfully developed and presented a
novel AI system that aids in the identification of breast cancer using ultrasound
images. This system demonstrates accuracy comparable to that of a radiologist
38 H. O. Al-Shamsi and A. M. Abyad

and has been created as a decision-support tool for healthcare professionals.

The research, published in the journal Nature, reveals that the system is
designed to assist radiologists in reducing false-positive results and unneces-
sary biopsy rates, all while maintaining a high level of sensitivity [70, 71].
Results from a team of researchers at Mohamed bin Zayed University for AI
have been published, showcasing their progress in the development of machine
learning algorithms capable of predicting cancer type classification using
multi-omics data [72].

2.24 COVID-19 and Cancer Care in the UAE

The UAE demonstrated exceptional management of the COVID-19 pandemic,

achieving low mortality rates and conducting the world’s first phase 3 clinical trial
for a COVID-19 vaccine. They achieved a remarkable vaccination rate of 100%
among eligible subjects and ensured the continued management of acute and
chronic medical conditions throughout the pandemic. Furthermore, the UAE
played a vital role in providing crucial medical aid, ventilators, testing kits, per-
sonal protective equipment (PPE), and supplies to 135 countries worldwide. As a
result, the UAE has been recognized as one of the top countries to live in during
the pandemic [73].
During the initial phase of the pandemic, a significant number of cancer patients
returned to the UAE from other countries, and appropriate arrangements were made
to ensure the continuation of their treatment. In contrast to many other countries
where cancer services were disrupted, the UAE successfully maintained uninter-
rupted cancer care. Vital cancer treatment components such as chemotherapy infu-
sion centers, radiation therapy facilities, oncological surgeries, and outpatient
oncology clinics continued to operate seamlessly across the entire UAE [74]. The
successful continuity of cancer care during the pandemic can be attributed to the
effective communication efforts led by the Emirates Oncology Society. Through
educational webinars and awareness campaigns, the Society encouraged oncolo-
gists and healthcare providers to persist in delivering cancer care services despite
the challenges posed by the pandemic [75].
The UAE has played a pivotal role in advancing both cancer care and COVID-19
research and publication. Early on in the pandemic, the country published the first
international recommendations for cancer care during this challenging period.
These recommendations have gained significant recognition, with over 650 cita-
tions to date. In fact, they were honored as the Publication of the Year (2020) by
the renowned Oncologist journal in the United States [76, 77]. It ranked among
the highly cited articles from the Arab World during the pandemic [78]. Another
significant publication was the pioneering study on pre-chemotherapy COVID-19
screening, which gained considerable attention and was featured as a trending
article upon its publication in JAMA Oncology [79, 80]. Additional research stud-
ies from the UAE were also disseminated in both regional and global scientific
journals [81–86].
2 Cancer Care in the UAE 39

2.25 Research

We conducted a comprehensive and systematic literature search to locate publica-

tions related to breast cancer originating from the UAE. On August 8, 2021, we
utilized PubMed and employed the search terms “breast” AND “Cancer* OR
Oncol* OR malignant* OR tumor OR tumor” AND “emirates OR UAE.” This
search yielded a total of 203 journal publications authored by individuals from the
UAE, with the earliest publication dating back to 2001. The majority of the publica-
tions consisted of basic science/translational studies (45.8%) or observational stud-
ies (26.1%), while 40 publications (19.1%) were non-data-driven, such as reviews,
consensus statements, and editorials. Furthermore, we identified six clinical trials
within this dataset (Fig. 2.2). Notably, among the 163 data-driven publications, only
62 (38%) were conducted within the UAE.
Conversely, the remaining studies were carried out in foreign locations, with a
significant portion of the authors holding affiliations both within and outside the
UAE. This indicates a substantial level of international collaboration among
researchers [87].
In general, the UAE has been steadily progressing in cancer research, although
there are still many gaps in evidence. The country’s academic institutions and
research programs dedicated to cellular and molecular studies have been growing,
contributing to the advancement of both basic and translational research in the field
of cancer. Initially, observational studies have focused on fundamental

50
45.8
45
40
35
30
Percentage

26.1
25
19.7
20
15
10
5 3 2 3.4

Non-data driven Clinical trial

Meta-analysis Observational study
Case series/Case report Basic Science/Translational

Fig. 2.2 Cancer research output in the UAE by the type of publication over a 20-year period from
2001 to 2021
40 H. O. Al-Shamsi and A. M. Abyad

epidemiological aspects and screening parameters. Moving forward, it is important

to prioritize the expansion of national cancer registries and the collection of longi-
tudinal data on clinically relevant variables. This will help improve the molecular
and clinical understanding of different types of cancer in the UAE and provide valu-
able information on survival rates, which can inform therapeutic strategies. However,
there is a noticeable lack of therapeutic clinical trials, which is a shared challenge
faced by neighboring countries.
Previous efforts to launch large, randomized trials have been limited and
faced obstacles, particularly with participant enrollment. This highlights the
importance of increasing public and healthcare provider awareness regarding
the significance of clinical trials in providing access to cutting-edge cancer
treatments.
Given the progressive and adaptable resource and regulatory infrastructures in
place, ongoing efforts are being made to enhance collaborations with clinical trial
sponsors, with the aim of facilitating interventional studies within the country that
align with international requirements and standards [88].
The chart presented in Fig. 2.3 provides the ranking of cancer centers according
to their engagement in cancer research activities during the year 2021 [89].

Fig. 2.3 The ranking of 35

cancer centers based on 30 29.2

their cancer research
Number of Publications (%)

output in 2021 25

20 17.97

15
11.2
10.11
10 7.86
6.74
5.61
5 3.37
2.24 2.24
1.12 1.12 1.12
0
Affiliations

Burjeel Medical City, Abu Dhabi

University of Sharjah, Sharjah
Dubai Hospital, Dubai
Tawam Hospital, Al Ain
Mediclinic City Hospital, Dubai
Cleveland Clinic Abu Dhabi
College of Medicine and Health Sciences, United Arab Emirates University, Al Ain
American Hospital, Dubai
Gulf International Cancer Center, Abu Dhabi
Sheikh Khalifa Specialty Hospital, Ras Al-Khaimah
Sheikh Khalifa Medical City, Abu Dhabi
Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai
Alzahra Hospital, Dubai
2 Cancer Care in the UAE 41

2.26 Education and Training

At present, there is a lack of well-structured and comprehensive fellowship training

programs in oncology and hematology in the UAE. The only fellowship program
that has received accreditation from the Accreditation Council for Graduate Medical
Education-International (ACGME-I) in the UAE is the medical oncology fellow-
ship training program, which commenced in August 2019. Since its inception, three
fellows have joined the program, but there have been no graduates announced thus
far. The program has a duration of 3 years and focuses solely on medical oncology,
excluding hematology. As for hematology, the only fellowship training program in
this field was initiated in Dubai in 2020 and currently stands as the sole hematology
fellowship training program available in the UAE.
The National Institute for Health Specialties (NIHS) was established as a national
institution with the objective of organizing, regulating, and leading the professional
development of the healthcare workforce, particularly in advanced specialty train-
ing. It operates under the umbrella of the United Arab Emirates University, the
country’s primary national higher education institute, and is governed by a Board of
Directors chaired by the Ministry of Education in the UAE. The NIHS has formed
an oncology committee comprising 12 members, currently chaired by Professor
Humaid Al-Shamsi. This committee, established in May 2022, is tasked with devel-
oping the NIHS Program Requirements for Specialty Education in Hematology and
Medical Oncology, which will lead to the Emirati Board in Hematology and Medical
Oncology. Graduates of these programs will hold Tier I qualifications and serve as
consultants in the UAE.
At present, there is a lack of oncology residency training programs specifically
designed for nurses in the UAE. There is a pressing and unfulfilled requirement to
establish comprehensive and organized oncology training programs that cater to the
needs of both physicians and nurses, given the global scarcity of adequately trained
oncology nursing professionals [69].

2.27 Emirates Oncology Society

The Emirates Oncology Society (EOS) serves as the official governing entity that
represents oncology healthcare providers in the United Arab Emirates (UAE) [90].
The Emirates Oncology Society (EOS) operates as part of the Emirates Medical
Association (EMA), which was founded in 1981. The EMA is a non-profit organi-
zation that unites healthcare professionals from different specialties who fulfill the
membership requirements outlined in its regulations. Under the purview of the
Ministry of Social Affairs, the EMA is headquartered in Dubai and takes on the
responsibility of organizing and conducting scientific training programs, confer-
ences, and events. It also collaborates with various healthcare organizations to pro-
mote collaboration and advancement in the field of medicine.
The Emirates Oncology Society (EOS) was initially founded in 2016, but it
became fully operational in 2020. The society comprises over 80 physicians
42 H. O. Al-Shamsi and A. M. Abyad

specializing in various areas of oncology, including medical, surgical, and radiation

oncology. Membership in EOS requires physicians to hold an active UAE license in
the field of oncology.
In the past 3 years, the Emirates Oncology Society (EOS) has published over 50
scholarly articles, establishing itself as the most prolific scientific society in the
country. The society has also organized a wide range of scientific activities, deliver-
ing over 200 continuing medical education (CME) hours to healthcare professionals
and the general public. One of the notable events organized by EOS is the annual
conference held in September. Additionally, EOS has introduced the groundbreak-
ing EOS Annual Award, which recognizes individuals and organizations making
significant positive contributions at the national, regional, and global levels. This
includes prestigious accolades such as the EOS Lifetime Achievement Awards.
The Emirates Oncology Society (EOS) plays a crucial role as a trusted advisor to
healthcare regulatory bodies. Expert members of the society have been providing
valuable guidance and counsel to the Ministry of Health and Prevention, UAE, and
the Dubai Health Authorities. Their expertise and insights contribute to the develop-
ment of best practices aimed at improving the quality of cancer care. Furthermore,
selected members of EOS actively participate as members of the national committee
for cancer control, further enhancing their influence in shaping cancer control strat-
egies at the national level.

2.28 Oncology Continuing Medical Education (CME)

in the UAE

Numerous organizations, including the pharmaceutical industry, host a wide

range of oncology educational events throughout the UAE year-round. These
educational activities aim to enhance knowledge and expertise in the field of
oncology. Examples of such events include the International Oncology
Conference initiated by VPS Healthcare and the International Oncology
Conference at Tawam Hospital, both established in 2011. In Dubai, the
Excellence in Oncology Care event was launched in 2010, while the American
Hospital in Dubai organized the International Oncology Summit, which began
in 2019. As mentioned earlier, the Emirates Oncology Society annual confer-
ence was introduced in 2020, further contributing to the educational landscape.
Additionally, the pharmaceutical industry plays an active role in delivering con-
tinuing medical education (CME) programs, featuring renowned oncologists
from leading clinical and research institutions worldwide.

2.29 Cancer Medical Tourism in the UAE

The UAE is a sought-after healthcare destination, particularly for patients from

Africa and Iraq. According to the World Health Organization (WHO), the UAE’s
healthcare system is ranked 27th globally [81, 91]. The UAE government has intro-
duced medical tourism portals that enable international patients to access a
2 Cancer Care in the UAE 43

comprehensive range of tourism services and schedule medical procedures. These

portals provide various services, including visa issuance, appointment booking,
accommodation, transportation, and social and recreational activities [82].
The UAE’s prime geographical location is one of the key factors that contribute
to its appeal as a prominent destination for medical tourism. Additionally, the pres-
ence of internationally recognized centers and hospitals, healthcare professionals
with extensive training and experience in the US and Europe, and the availability of
cutting-edge cancer drugs and treatment approaches not widely accessible in many
countries make the UAE an attractive choice for numerous cancer patients. However,
the high cost of medical services in the UAE poses a significant challenge, as it
tends to be more expensive compared to other countries renowned for cancer medi-
cal tourism, such as India. Further endeavors are necessary to enhance the afford-
ability and allure of cancer medical tourism, particularly for specialized treatments
like bone marrow transplantations.

2.30 Government-Funded Cancer Care Medical Tourism

Outside the UAE

In 2013, the UAE government allocated a budget of more than $163 million US
dollars for various purposes, including government-funded cancer care, medical
tourism conducted outside the UAE, and medical treatment provided abroad [92].
There is no publicly available official data regarding the specific stages or types of
cancer cases treated abroad. The top five destinations for cancer care medical tour-
ism from the UAE are the United States of America, Germany, Singapore, South
Korea, and Thailand [93, 94]. A study analyzed administrative data from the Dubai
Health Authority (DHA) for UAE nationals who sought medical treatment abroad
between 2009 and 2016. The dataset included information from 6557 UAE nation-
als. The primary medical travel destinations were Germany (46%), the UK (19%),
and Thailand (14%). The most common intended medical specialties were orthope-
dic surgery (13%), oncology (13%), and neurosurgery (10%). After adjusting for
other factors, oncology had the highest expected number of patient trips, with an
incidence rate ratio (IRR) of 1.34 (95% CI: 1.24–1.44) [94].
Multiple entities, including health authorities such as the Department of Health
AD, Dubai Health Authority, and the Ministry of Health and Prevention, as well as
Presidential affairs offices, armed forces, police, and charitable organizations, pro-
vide sponsorship for cancer care abroad. These entities may offer financial support
or assistance for individuals seeking treatment outside of the UAE [2]. The specific
requirements and procedures for sponsorship vary among different agencies that
provide sponsorship for cancer treatment. One key requirement is that the individual
seeking sponsorship must be a UAE citizen. However, there may be exceptions in
certain cases for non-UAE citizens when the required treatment is not available in
the UAE. Despite the availability of cancer treatment options within the UAE, many
patients still choose to seek treatment abroad. Currently, there are no established
criteria or guidelines for these entities/agencies to determine the selection of patients
for treatment abroad [2].
44 H. O. Al-Shamsi and A. M. Abyad

During an internal evaluation conducted at an oncology center outside the UAE,

a review was conducted on 273 patients who sought to travel abroad for treatment
between January and September 2017. The findings revealed that 86% of these
referrals were deemed unnecessary from a clinical perspective, as comparable
oncology services were already accessible within the UAE [2]. This evaluation took
place prior to the establishment of multiple bone marrow transplantation programs,
which was a significant factor for these cases since many of them required such
treatment [6]. Based on our expertise, we believe that over 95% of cancer cases can
be appropriately managed and treated within the UAE.
As mentioned in the previous section discussing cancer care medical tourism in
the UAE, despite the presence of well-established cancer care centers, there are still
factors that drive individuals to seek treatment abroad [95]:

• Patients may reject the initial diagnosis and seek a second opinion to validate the
diagnosis.
• Patients and their families may believe that more advanced treatment options for
their cancer are available abroad, including new drugs, technologies, and exper-
tise that are not accessible locally.
• Patients and their families may receive generous government funding while
receiving treatment abroad, including full paid leave during sickness. In contrast,
patients receiving treatment within the UAE do not receive similar flexible sick
leave benefits. The same applies to family members, who may be granted com-
panion leave while accompanying the patient abroad, which is not the case if the
patient is treated within the UAE.

Seeking cancer care abroad is not a viable and sustainable solution in the long
run. It is crucial to conduct targeted research to understand the reasons behind the
preference for overseas treatment and identify the barriers that prevent patients
from receiving local treatment. By gaining this insight, we can provide recom-
mendations to reduce the unnecessary demand for cancer care abroad. As previ-
ously discussed in our earlier report, it is recommended to limit overseas treatment
to complex cancer cases that require advanced treatment options not available in
the UAE. Building public confidence in local cancer care is of utmost importance,
and it requires dedicated efforts such as national outreach programs and active
involvement from regulatory bodies and sponsoring agencies involved in facilitat-
ing medical travel abroad.

2.31 National Cancer Control Plan

The establishment of the National Cancer Control Committee took place in 2017,
accompanied by the launch of a National Cancer Control Plan that aligns with the
UAE National Agenda for 2021 and the WHO Cancer Control Plan. This compre-
hensive plan is built upon key pillars including leadership and governance, preven-
tion and awareness, early detection, capacity building, treatment, palliative care,
research, and surveillance. In 2022, the committee and plan were updated based on
2 Cancer Care in the UAE 45

reliable data obtained from the National Cancer Registry. The vision of the national
plan is to reduce cancer mortality and morbidity, while improving the survival rate
among the population of the UAE. The mission is focused on saving lives and alle-
viating suffering by prioritizing cancer prevention, early detection, and providing
the best possible curative and palliative care. Currently, efforts are underway to
develop a national surveillance monitoring framework in collaboration with the
World Health Organization (WHO).

2.32 Integrative Oncology

Integrative oncology refers to a patient-centered approach in cancer care that is sup-

ported by evidence and incorporates various mind-body practices, natural products,
and lifestyle modifications from diverse traditions alongside conventional cancer
treatments [96]. Integrative oncology is an emerging field in the UAE, and currently,
no cancer centers in the country offer this service as part of their practice. However,
despite the ongoing debates surrounding this approach, some cancer patients from
the UAE choose to seek integrative cancer treatment abroad. In the UAE, several
centers utilize complementary medicine, specifically hemopathy, in the treatment of
cancer patients. To ensure the appropriate use of integrative oncology and prevent
its misuse in cancer care, proper control and monitoring measures are necessary.
The addition of the integrative oncology specialty to the existing cancer care land-
scape in the UAE would be a significant development.

2.33 Major Recommendations for the Advancement

of Cancer Care in the UAE

In Fig. 2.4, we have highlighted the key recommendations to advance cancer care in
the UAE to a higher level.
These initiatives will encompass the following:

• Implementation of a National Cancer Control Plan (CCP): A well-executed and

comprehensive cancer control plan necessitates precise data collection and anal-
ysis, a dependable cancer registry, and regular monitoring and evaluation.
• Establishment of a National Cancer Care Agency: This agency will oversee all
aspects of cancer care, from prevention and screening to accurate diagnosis and
the establishment of clear management guidelines. Its aim is to ensure that can-
cer patients throughout the country receive appropriate, safe, evidence-based,
and effective care.
• Designation of central comprehensive tertiary oncology referral facilities as
Centers of Excellence
• Establishing Centers of Excellence for cancer care that meet rigorous criteria to
enhance the outcomes of cancer patients in the UAE.
• Enhancing and facilitating the availability of a comprehensive national cancer
registry and improving reporting mechanisms.
46 H. O. Al-Shamsi and A. M. Abyad

Fig. 2.4 Major recommendations for the advancement of cancer care in the UAE

• Promoting cancer research focused on the UAE’s population, including studies

on cancer epidemiology, therapeutic clinical trials, and international research
collaborations.
• Implementing a well-structured national screening program across the UAE,
which includes targeted research to identify barriers to screening and increase
public awareness.

2.34 Conclusion

In this review, our objective was to provide an overview of the current state of can-
cer care in the UAE. We highlighted the rapid advancements in cancer care within
the country, featuring cutting-edge cancer centers. However, to further improve can-
cer care, it is crucial to implement quality control measures under the guidance of
regulatory bodies throughout the UAE. The establishment of a federal cancer agency
2 Cancer Care in the UAE 47

is recommended to ensure specialized oversight and governance of cancer care. It is

imperative to enhance the national UAE cancer control program, focusing on refin-
ing early detection, cancer screening, and facilitating timely referrals to cancer net-
works. Education and training programs are necessary to address the global shortage
of oncology healthcare providers, particularly oncology nurses. Additionally, the
activation of survivorship programs that address onco-fertility, psycho-oncology,
and precision oncology and foster UAE-specific cancer research through regional
and international collaborations is essential for the next phase of cancer care in
the UAE.

Conflicts of Interest The authors have no conflict of interest to declare.

Appendix

 ppendix 1 Number of Cancer Cases Among the UAE Population

A
According to Primary Site, Gender, and Nationality in 2021

Non-Emirati Emirati Grand

Primary site ICD-10 Female Male Total Female Male Total Total
(C00-C96) All invasive cancers 2237 1944 4181 822 609 1431 5612
(malignant cases)
C00-C14 lip, oral cavity and 27 97 124 10 20 30 154
pharynx
C15 esophagus 3 15 18 5 4 9 27
C16 stomach 25 79 104 14 16 30 134
C17 small intestine 6 14 20 2 4 6 26
C18–C21 colorectal 132 240 372 81 79 160 532
C22 liver and intrahepatic bile 22 62 84 11 19 30 114
ducts
C23, C24 gallbladder, other and 15 19 34 8 4 12 46
unspecified part of biliary tract
C25 pancreas 29 50 79 12 19 31 110
C26 other and ill-defined digestive 1 5 6 1 1 2 8
organs
C30, C31 nasal cavity, middle ear, 2 9 11 1 1 12
accessory sinuses
C32 larynx 17 17 12 12 29
C34 bronchus and lung 53 118 171 17 43 60 231
C37 thymus 3 4 7 3 3 10
C38 heart, mediastinum, and pleura 6 6 6
C40–C41 bone and articular 2 20 22 5 7 12 34
cartilage
C43 skin melanoma 18 30 48 2 1 3 51
C44 skin (carcinoma) 94 155 249 15 9 24 273
C45 mesothelioma 4 1 5 1 1 6
C46 Kaposi sarcoma 2 2 1 1 3
C48 retroperitoneum and 5 7 12 5 1 6 18
peritoneum
48 H. O. Al-Shamsi and A. M. Abyad

Non-Emirati Emirati Grand

Primary site ICD-10 Female Male Total Female Male Total Total
C49 connective and soft tissue 7 23 30 9 8 17 47
C50 breast 915 6 921 213 5 218 1139
C51 vulva 2 2 1 1 3
C52 vagina 2 2 1 1 3
C53 cervix uteri 118 118 23 23 141
C54–C55 uterus 113 113 60 60 173
C56 ovary 85 85 23 23 108
C57 other and unspecified female 5 5 1 1 6
genital organs
C58 placenta 4 4 4
C61 prostate 180 180 71 71 251
C62 testis 45 45 15 15 60
C64–C65 kidney and renal pelvis 29 80 109 14 28 42 151
C66, C68 ureter and other urinary 1 2 3 2 2 5
organs
C67 urinary bladder 12 65 77 11 38 49 126
C69 eye 3 1 4 1 1 5
C70–C72 brain and CNS 28 77 105 22 22 44 149
C73 thyroid 266 136 402 155 38 193 595
C74–C75 other endocrine glands 4 5 9 1 1 2 11
C76–C80 unknown or unspecified 17 21 38 11 12 23 61
sites
C81 Hodgkin’s lymphoma 26 33 59 13 19 32 91
C82–C85, C96 Non-Hodgkin 53 98 151 32 45 77 228
lymphoma
C88, C90 multiple myeloma 22 45 67 13 9 22 89
C91–C95 leukemia 69 163 232 26 46 72 304
Other hematopoietic malignancies 15 13 28 3 5 8 36
Other malignancy 1 1 1 1 2
(D00-D09) Non-invasive cancers 107 49 156 44 18 62 218
(in-situ cases)
D01 carcinoma in situ of other and 2 3 5 3 1 4 9
unspecified digestive organs
D02 carcinoma in situ of middle are 1 1 1
and respiratory system
D03 melanoma in situ 3 4 7 7
D04 carcinoma in situ of skin 1 1 3 1 4 5
D05 carcinoma in situ of breast 45 3 48 20 20 68
D06 carcinoma in situ of cervix 51 51 17 17 68
uteri
D07 carcinoma in situ of other and 2 9 11 1 2 3 14
unspecified genital organs
D09 carcinoma in situ of other and 4 28 32 14 14 46
unspecified sites
Grand total—invasive and 2344 1993 4337 866 627 1493 5830
non-invasive
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021
 2

Appendix 2 Cancer Centers and Hospitals in the UAE in Alphabetical Order

Facility available
Medical Acute Bone marrow Nuclear
oncology and hematology transplantation Pediatric Surgical medicine / Palliative Research
Cancer center Location infusion unit service unit oncology Radiation oncology PET imaging care unit unit
Abu Dhabi Stem Cells Abu Dhabi No No Yes No No No No No No
Center
Cancer Care in the UAE

Advanced Care Oncology Dubai Yes No No No No No No No No

Center
American Hospital Dubai Dubai Yes Yes Yes Yes Yes Yes Yes Yes No
Al Zahra Hospital Dubai Dubai Yes No No No No Yes No No No
Aster Hospital Dubai Yes No No No No Yes No No No
Burjeel Hospital Abu Dhabi Yes No No No No Yes No No No

Burjeel Hospital for Dubai Yes No No No No Yes No No No

Advanced Surgery Dubai
Burjeel Medical City Abu Dhabi Yes Yes Yes Yes Yes Yes Yes Yes Yes

Burjeel Day Surgery Abu Dhabi Yes No No No No No No No No

Center, Al Reem Island
Burjeel Royal Hospital Alain Yes No No No No Yes No No No
Burjeel Specialty Hospital Sharjah Yes No No No No Yes No No No
Canadian Hospital Dubai Yes No No No No Yes No No No
Cleveland Clinic Abu Abu Dhabi Yes No No No No Yes Yesa No No
Dhabi (Off-site)
Clemenceau Medical Dubai Yes No No Yes No Yes Yes No Yes
Center
Dubai Hospital Dubai Yes Yes No Yes No Yes Yes No Yes
Gulf International Cancer Abu Dhabi Yes No No No Yes No Yes No No
49

Center
Lifeline Hospital VPS Abu Dhabi Yes No No No No No No No No
 50

Facility available
Medical Acute Bone marrow Nuclear
oncology and hematology transplantation Pediatric Surgical medicine / Palliative Research
Cancer center Location infusion unit service unit oncology Radiation oncology PET imaging care unit unit
King’s College Hospital Dubai Yes Yes No No No Yes No No No
London, Dubai
Medcare hospital Sharjah Yes No No No No Yes No No No
Mediclinic Airport Road Abu Dhabi Yes Yes No No Yes Yes No No No

Mediclinic City Hospital Dubai Yes Yes No Yes Yes Yes Yes Yes Yes
Neuro Spinal Hospital Dubai Yes No No No Yes Yes No No No
NMC Royal Hospital Sharjah Yes No No No No Yes No No No
Sharjah
NMC Specialty Hospital Abu Dhabi Yes No No Yes No Yes No No No

Saudi German Hospital Dubai Yes No No No Yes Yes No No No

Dubai
Saudi German Hospital Ajman Yes No No No No Yes No No No
Ajman
Sharjah University Sharjah Yes No No No No Yes No No Yes
Hospital
Sheikh Khalifa Specialty Rasal- Yes No No No Yes Yes Yes No No
Hospital Khaimah
Sheikh Shakhbout Medical Abu Dhabi Yes Yes No No No Yes No No No
City
Tawam Hospital Alain Yes Yes No Yes Yes Yes Noa Yes Yes
Yas Clinic Abu Dhabi Yes No No No No No No No No

Zulekha Hospital Sharjah Sharjah Yes No No No No Yes No No No

a
Cleveland Clinic Abu Dhabi’s (CCAD) Positron emission tomography (PET) scanner is located in Al Ain city (150 km away from CCAD main campus) near the
H. O. Al-Shamsi and A. M. Abyad

main building of Tawam Hospital

2 Cancer Care in the UAE 51

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2 Cancer Care in the UAE 55

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society,
Full Professor of Oncology at the Ras Al Khaimah Medical and
Health Sciences University, Ras Al Khaimah, UAE, and an
Adjunct Professor of Oncology at the College of Medicine,
University of Sharjah. He is the first Emirati to be promoted as a
professor in oncology in the UAE. He is also the Chairman for
Colorectal Cancer in the MENA region, appointed by the presti-
gious National Comprehensive Cancer Network®. He is also the
only member of Lung Cancer Policy Network in the MENA
region that aims to advance lung cancer research and screening
globally. He is the Chairman of the Oncology and Hematology
Fellowship Training Program for the National Institute for Health
Specialties in the United Arab Emirates. He is the only member in
GCC in the WIN Consortium which is comprised of organiza-
tions representing all stakeholders in personalized cancer medi-
cine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow)
in 2024. He is the only physician in the UAE with a subspecialty
fellowship certification and training in gastrointestinal oncology
and the first Emirati to train and complete a clinical post-doc-
toral fellowship in palliative care. He was an assistant professor
at the University of Texas MD Anderson Cancer Center between
2014 and 2017. He has published more than 140 peer-reviewed
articles in JAMA Oncology, Lancet Oncology, The Oncologist,
BMC Cancer, and many others. His area of expertise includes
precision oncology and cancer care in the UAE. In 2016, he
published with his group from MD Anderson the JCO paper
describing a new distinct subgroup of CRC, NON V600 BRAF-
mutated CRC. In 2022, he published the first book about cancer
research in the UAE and also the first book about cancer in the
Arab world, both of which were launched at Dubai Expo 2020.
Cancer in the Arab World has been downloaded more than
450,000 times in its first 18 months of publication and is the
ultimate source of cancer data in the Arab region. He also pub-
lished the first comprehensive book about cancer care in the
UAE which is the first book in UAE history to document the
cancer care in the UAE with many topics addressed for the first
time, e.g., neuroendocrine tumors in the UAE. He is passionate
about advancing cancer care in the UAE and the GCC and has
made significant contributions to cancer awareness and early
detection for the public using social media platforms. He is con-
sidered as the most followed oncologist in the world with over
300,000 subscribers across his social media platforms
(Instagram, Twitter, LinkedIn, and TikTok). In 2022, he was
awarded the prestigious Feigenbaum Leadership Excellence
Award from Sheikh Hamdan Smart University for his excep-
tional leadership and research and the Sharjah Award for
Volunteering. He was also named the Researcher of the Year in
the UAE in 2020 and 2021 by the Emirates Oncology Society.
56 H. O. Al-Shamsi and A. M. Abyad

In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice

President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
of research training for medical trainees to enhance their clinical
and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Dr. Amin M. Abyad earned his medical degree, Bachelor in

Medicine and Surgery (MBChB), from Beirut Arab University.
After completing his internship, he joined the Internal Medicine
Residency at Makassed Hospital in Beirut, Lebanon, which is affili-
ated with the American University of Beirut Medical Center
(AUBMC). Dr. Amin was appointed as Chief Resident of Internal
Medicine (2017–2018). Then Dr. Amin started his fellowship in
hematology and medical oncology at Makassed Hospital, where he
received intensive training in hematology and medical oncology.
Dr. Amin joined Burjeel Medical City in July 2021. Dr. Amin is
highly interested in malignant hematology and solid malignancies.
He has been highly involved in clinical research, being involved in
multiple research projects and publishing in multiple peer-reviewed
journals. Dr. Abyad believes in patient-centered care, trying to
enhance patient outcomes through the application of the latest evi-
dence-based practice and personalized medicine.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
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indicate if changes were made.
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Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
UAE National Cancer Registry
3
Alya Zaid Harbi, Buthaina Abdulla Bin Belaila,
Wael Shelpai, and Hira Abdul Razzak

3.1 Background

The United Arab Emirates (UAE), a member of the Gulf Cooperation Council
(GCC) and the Arab world, boasts an exceptional healthcare system, particularly
renowned for its oncology care. This includes unique integration and alliances with
the public and private healthcare sectors within the country.
Established with the objective of offering guidance and oversight in the field of
healthcare, the Ministry of Health and Prevention (MOHAP) serves as a govern-
mental entity. Our main focus is on fostering the overall health and prosperity of
individuals, aiming to facilitate a state of well-being for all. The Statistics and
Research Center houses the UAE National Cancer Registry (UAE-NCR), which
offers valuable tools and information for cancer surveillance systems. This crucial
initiative is dedicated to safeguarding our society from the detrimental impact of
cancer by monitoring and addressing its health risks.
Consequently, cancer registration and surveillance form the fundamental pillars
of the UAE National Cancer Registry’s mission. In this chapter, we provide a con-
cise overview of the UAE-NCR’s methodology for cancer registration and surveil-
lance, aimed at monitoring and analyzing cancer-related outcomes. The UAE
National Cancer Registry meticulously collects and ensures the quality of cancer
data in the United Arab Emirates. This endeavor is regarded as a valuable opportu-
nity to gain insights into the prevailing landscape and is anticipated to drive future
advancements and transformations.

A. Z. Harbi · H. A. Razzak
Statistic and Research Center, Dubai, United Arab Emirates
Ministry of Health and Prevention, Dubai, United Arab Emirates
e-mail: alya.harbi@mohap.gov.ae; Hira.AbdulRazzak@mohap.gov.ae
B. A. B. Belaila · W. Shelpai (*)
Ministry of Health and Prevention, Dubai, United Arab Emirates
e-mail: Buthaina.Abdulla@mohap.gov.ae; Wael.shelpai@mohap.gov.ae

© The Author(s) 2024 57

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_3
58 A. Z. Harbi et al.

The present chapter has been collaboratively developed by the UAE National
Cancer Registry Section, a division of the Statistics and Research Center under
the Ministry of Health and Prevention (MOHAP). The NCD and Mental Health
Sections have also provided valuable support throughout the process. The team
has actively engaged in discussions and continuous improvement efforts con-
cerning cancer registration activities undertaken by the Statistics and Research
Center—UAE National Cancer Registry Section. This collective endeavor aims
to prioritize the resolution of critical issues and ensure comprehensive coverage
of the pertinent aspects.

3.2 Introduction

Noncommunicable diseases (NCDs) are the primary cause of mortality world-

wide, resulting in 41 million fatalities annually, which corresponds to 74% of all
global deaths. Each year, approximately 17 million individuals die from NCDs
prior to reaching the age of 70, with 85% of these premature deaths taking place
in low- and middle-income nations. Among NCD-related deaths, cardiovascular
diseases claim the most lives, accounting for 17.9 million fatalities on an annual
basis, followed by cancer (9.3 million), chronic respiratory diseases (4.1 million),
and diabetes (2.0 million, such as kidney disease fatalities associated with diabe-
tes). Collectively, these four categories contribute to 80% of all premature deaths
attributed to NCDs.
The risk of NCD-related mortality is elevated by factors such as physical inactiv-
ity, tobacco use, excessive alcohol consumption, and unhealthy eating habits.
Essential elements in addressing NCDs include early detection, screening, treat-
ment, and the provision of palliative care [1].
In the fight against the burden imposed by NCDs, nations have pledged their
commitment to attain global NCD targets, including Sustainable Development Goal
3.4. This target aims to reduce premature mortality caused by noncommunicable
diseases by one-third by the year 2030 [2].
Accurate and up-to-date cancer incidence and mortality data play a critical
role in the development and evaluation of cancer control programs. To meet this
need, a population-based cancer registry systematically gathers comprehensive
cancer information. The collection of high-quality cancer data over time serves
as a catalyst for transforming healthcare services, leading to enhanced patient
outcomes.
An organization dedicated to storing, collecting, analyzing, and interpreting data
on individuals affected by cancer is known as a cancer registry. A population-based
cancer registry acquires data from various healthcare providers within a specific
geographic area and can be utilized to illustrate trends in cancer occurrence at a
variety of locations over time or among different population groups.
Cancer registry data holds the potential to provide valuable information for eval-
uating the long-term impact of various treatment methods and the effectiveness of
early detection initiatives like colorectal screening or mammography. Furthermore,
3 UAE National Cancer Registry 59

these data can be utilized in epidemiological research aimed at identifying the

underlying factors responsible for the development of cancer. Information on cancer
incidence and mortality, as well as changing trends, is a significant component in
the monitoring and planning of programs for early detection, prevention of cancer,
and treatment.
The UAE National Disease Registry (UAE-NDR) is central to public health and
healthcare in the UAE. The UAE-NDR at the Ministry of Health and Prevention
includes data on all diseases that have a high impact on society, as the UAE-National
Cancer Registry (UAE-NCR) is one of the largest, most advanced, and most com-
plex cancer data curation services.
The UAE National Cancer Registry (UAE-NCR) carries out a systematic process
of gathering, storing, summarizing, analyzing, and disseminating data concerning
individuals diagnosed with cancer and receiving treatment within the UAE. The
main objectives of the UAE-NCR are to ascertain cancer statistics on a national
level in the UAE, furnish decision-makers and researchers with trustworthy data,
monitor the effectiveness of cancer screening and early detection initiatives, and
plan for cancer services and cancer control.
The UAE National Cancer Registry (UAE-NCR) is an integral component of
the UAE National Disease Registries and operates under the supervision of the
Statistics and Research Center at the Ministry of Health and Prevention
(MOHAP). UAE-­NCR offers comprehensive and reliable data services that
encompass the entire cancer journey for all individuals diagnosed with cancer in
the UAE. These services ensure the provision of high-quality, carefully vali-
dated information.
MOHAP has a qualified cadre that has acquired the international accreditation to
register and manage the cancer data according to international standards, like
Certified Tumor Registrars (CTRs), clinical coders, biostatisticians, and epidemi-
ologists, as well as the registration data is utilized to generate various outputs, such
as official statistics and data tools.

3.3 UAE National Cancer Control Program

The UAE National Cancer Registry annual report relies on the incidence data and
cancer mortality statistical data provided by the UAE-NCR as the foundation for
all the cited cancer statistics. The crucial role of these surveillance activities, com-
bined with the data gathered through the screening program, the national health
survey, and other initiatives, cannot be overstated in the context of cancer control
programs.
The UAE National Cancer Control Committee comprises members from key
stakeholders involved in cancer control within the UAE. These members are indi-
viduals officially appointed through the minister’s decision. The committee meets
regularly with different stakeholders.
According to the World Health Organization (WHO) guidelines, the UAE
National Cancer Control Program supports a national agenda to lessen cancer
60 A. Z. Harbi et al.

mortality and incidence, increase the survival and quality of life of cancer patients,
and develop strategic methods to minimize or prevent the cancer impact in the UAE.
Utilize data to determine and track the extent of the cancer burden in the UAE,
prioritize effective strategies for cancer control, formulate cancer plans, and
implement them. Additionally, use this data, in conjunction with screening and
other cancer-related measures, to assess and monitor cancer programs. For
instance, information extracted from the UAE National Cancer Registry reveals
that breast, colorectal, and thyroid cancer are prevalent types of cancer in the
UAE, with cancer ranking as the third leading cause of mortality. The UAE
National Cancer Control Program has used this information to develop a plan, in
collaboration with local health authorities, to educate and empower UAE citizens
in the prevention and control of breast and colorectal cancer. As well as develop-
ing a UAE lung and prostate cancer screening plan, UAE National Cancer Registry
data have been utilized to demonstrate that breast, colorectal, thyroid, prostate,
and lung cancer are the most common cancers across the UAE. This information
has been used to develop a prostate and lung cancer screening plan in association
with local health authorities.
The UAE National Cancer Control Committee is currently reviewing and updat-
ing the National Strategy for Cancer Control and its Action Plan, which have existed
since 2017.

3.4 UAE National Cancer Registry (UAE-NCR)

Cancer poses a significant health challenge in both developed and developing

nations, with the UAE experiencing it as the third most common cause of death.
Cancer registration involves an ongoing, organized procedure that entails col-
lecting, storing, analyzing, interpreting, and reporting data related to the occurrence
and attributes of cancer.
Population-based cancer registries serve as a distinctive and invaluable informa-
tion resource for cancer control programs. These data aid in the provision of finan-
cial and human resources for efficient healthcare planning, in addition to the
development of prevention and early detection initiatives. Furthermore, cancer reg-
istries play a vital role in providing critical data to determine the occurrence and
frequency of cancers in a specific population.
The establishment of the Gulf Centre for Cancer Registration (GCCR) aimed to
establish a comprehensive database on cancer incidence for the GCC countries,
namely the United Arab Emirates (UAE), Bahrain, Saudi Arabia, Oman, Qatar, and
Kuwait. The GCCR commenced the collection and accumulation of data for this
purpose on January 1, 1998, where the Gulf Center for Cancer Registration is pro-
vided with the required data periodically. The main goal of the GCCR is to gather
and categorize data on all instances of cancer, enabling the production of statistical
information regarding cancer occurrence within a specific population. This initia-
tive serves to offer technical assistance for early detection and screening initiatives
as well as facilitate epidemiological research on cancer. Ultimately, the aim is to
3 UAE National Cancer Registry 61

establish a framework for evaluating and managing the impact of cancer on the
communities residing in the GCC states.
In 2012, the Department of Health (DOH) in the Emirate of Abu Dhabi initiated
the establishment of the Abu Dhabi Central Cancer Registry, a proficient and cen-
tralized cancer registry within the DOH. This registry serves as a comprehensive
database encompassing all cancer-related information in Abu Dhabi. Similarly, the
Emirate of Dubai has a Dubai Health Authority (DHA) cancer registry and various
hospital-based cancer registries.
In 2014, a comprehensive UAE National Cancer Registry (UAE-NCR) was
established by the Statistics and Research Center and works under the jurisdiction
of the Ministry of Health and Prevention (MOHAP). Its primary responsibilities
include assessing the population-based incidence of cancer in the UAE, gauging the
magnitude of the cancer burden, conducting epidemiological studies, promoting
early detection methods, and implementing cancer screening initiatives.
The UAE-NCR is responsible for collecting, processing, and analyzing com-
plex data on patients who are diagnosed with or treated for the condition of
cancer in the UAE. The data are systematically gathered from various sources
and entities throughout the UAE, including the Abu Dhabi Central Cancer
Registry at the Department of Health Registry, the cancer registry of the Dubai
Health Authority, cancer registries based on private hospitals in Dubai, medical
facilities in the Northern Emirates, certified records of malignancies from public
and private hospitals, pathology laboratory reports, and mortality data. This com-
prehensive approach ensures that individuals diagnosed with and/or receiving
cancer treatment within the UAE are included in the data collection process.
Consequently, the data compiled by the UAE-NCR encompasses all individuals
in the country who have undergone a cancer diagnosis or treatment. The col-
lected data encompasses various aspects, including demographic information,
diagnostic details, cancer type, staging, direct treatment methods, and follow-up
data. The UAE-NCR obtains this information through either the medical record
concept or electronic reporting at the level of the medical facility. All incident
cases from central registries, public and private hospitals, primary healthcare
centers (PHC), clinics, pathology laboratories, treatment facilities, and other
medical establishments are mandated to report to the UAE-NCR. The central
registry plays a vital role in consolidating the data from the cancer registry, creat-
ing a unified record for each individual cancer case, and providing a subset of
this data to the UAE-NCR on an annual basis. Collaborating with local health
authorities, the UAE-NCR works toward ensuring the coherence and compara-
bility of cancer incidence and mortality data.
The data obtained from the UAE-NCR plays a crucial role in shaping cancer care
service plans and oncology research programs, as well as the development of future
initiatives, including advancements in screening programs. Each year, a report is
published based on the data collected by the registry, focusing on in situ and inva-
sive neoplasms, and adhering to international standards. In 2013 and 2020, the
Prime Minister’s Office issued a circular to all health authorities and medical facili-
ties to report all cancer cases according to an updated form to be submitted to the
62 A. Z. Harbi et al.

UAE-NCR in MOHAP. The UAE-NCR is an associate member of the International

Association of Cancer Registries (IACR).

3.5 Coverage of the Cancer Registry

Data for the cancer registry is gathered from both public and private healthcare
facilities throughout the UAE, enabling the UAE-NCR to compile individual records
that encompass different levels of geographical coverage. This coverage spans from
Abu Dhabi to Dubai and extends to the Northern Emirates of the UAE.

3.6 Legal Framework for Cancer Registration

and Surveillance

The cancer is notifiable by law, and the notification of cancer cases is done by all
healthcare providers—public and private—and other related entities.
In 2013 and 2020, the UAE Prime Minister’s Office approved a cancer registra-
tion policy to obligate notification of cancer cases by all public and private facilities
across the UAE.

3.7 UAE-NCR Staff (Personnel)

At the level of technical expertise, the expertise and technical competence of the
registry staff significantly impact the quality of the cancer registry data. MOHAP
hired qualified cadres that had acquired international accreditation to register and
manage the cancer registry data according to international standards, like CTRs,
clinical coders, biostatisticians, data scientists, and epidemiologists.

3.8 Registry Data Linkages

The UAE-NCR also links data with national databases for the purpose of supple-
menting and improving the quality of the data, and it regularly links cancer data
with UAE death databases and other data sources, such as treatment abroad and
health insurance claim files.

3.9 Methodology and Standard Operating Procedures

The UAE National Cancer Registry (UAE-NCR) under MOHAP acquires compre-
hensive demographic, diagnostic, cancer, staging, treatment, and follow-up data for
all cancer cases diagnosed and/or treated within the UAE. The collection of this
information aligns with internationally recognized registration protocols, utilizing
3 UAE National Cancer Registry 63

ICD coding and TNM staging standards. Annually, all invasive and in situ cases
diagnosed in public or private medical facilities are notified and registered with the
UAE-NCR.
Two data collection methods are available:

3.9.1 Active Method

Representatives from public and private hospitals, as well as NGOs, serve as

key contacts responsible for gathering cancer data from patient medical records,
the Health Information Management System, and pathology reports. After
completing a standardized form, the collected information is submitted to the
UAE-NCR.
Meanwhile, the UAE-NCR staff conducts regular visits to the medical treatment
abroad department at MOHAP to collect and abstract registry data.

3.9.2 Passive Method

Designated representatives from various stakeholders and medical facilities through-

out the UAE gather cancer data from patient files, the Health Information
Management System, and pathology reports. They then proceed to fill out a stan-
dardized form and submit the collected information to the UAE-NCR.
The Department of Health in Abu Dhabi supplies mortality data specific to Abu
Dhabi, while MOHAP provides mortality data for the other Emirates.
In cases where TNM information is available in the patient’s medical file, infor-
mation on the extent of the disease is collected as part of the TNM staging system.
The SEER summary stage is abstracted.
The abstraction form (data collection form) is distributed to the main public hos-
pitals that have oncological services.
The unique identification (Emirates ID) number is available and used for the
deduplication procedures as well as by comparing the demographic information,
such as patient name and date of birth, through cancer registry software.

3.10 Reporting Sources and Data Processing

The UAE National Cancer Registry (UAE-NCR) includes the following reporting
sources: the DOH central cancer registry, the DHA cancer registry, public and pri-
vate hospitals, private physician clinics, public and private laboratories, death noti-
fications, and medical treatment abroad.
Ensuring the participation of all public and private hospitals, including both
inpatient and outpatient clinics, within the reporting region responsible for diagnos-
ing and/or treating cancer is crucial for maintaining comprehensive reporting. All
data provided for this report underwent coding according to ICD-10-CM and
64 A. Z. Harbi et al.

ICD-­O-­3, which was subsequently converted to ICD-10-CM for analysis and report
generation.
To maintain data comparability, all cases reported to the UAE-NCR must adhere
to the rules and recommendations set forth by the International Agency for Research
on Cancer (IARC).
A thorough examination of all pertinent details pertaining to new cases is con-
ducted to identify potential duplications using a master index. Subsequently, the
clinical data is verified by the Cancer Tumor Registrar (CTR) and a team of profi-
cient registry staff.
The collected data serve various purposes, including monitoring incidence
trends, facilitating research endeavors, supporting planning initiatives, and evaluat-
ing the quality of cancer care facilities.

3.11 Reportable List and International Standards

The registry encompasses all neoplasms classified in the International Classification

of Diseases for Oncology, Third Edition (ICD-O-3), specifically those with a behav-
ior code of 2 or 3, as well as malignant and in situ cases in the ICD-10 CM. It is
mandatory to report all diagnosed reportable tumors in individuals residing in the
UAE by the reference date specified by the registry.
If a term in ICD-O-3 with a behavior code of “0” or “1” is confirmed as in situ
(“2”) or malignant (“3”) by a pathologist, the case is considered reportable. The
multiple primary rules are employed to determine the number of primary tumors a
patient has, providing guidance and standardization in this process.
Additionally, the histology rules, which contain specific instructions for coding
histology, are applied to ensure consistent reporting among all participants.

3.12 Data Items, Data Management, and Quality

Control Procedures

Cancer has been designated as a mandatory notifiable disease through a ministerial

decree, guaranteeing the opportunity for inclusive data gathering. The UAE-NCR
endeavors to achieve unrestricted access to cancer data from all medical establish-
ments, both public and private, across the UAE.
A cancer registry or cancer surveillance system can gather numerous data items,
and the UAE-NCR determines the necessary elements for data collection. Each data
item on the sample data collection form, as displayed in Table 3.1, is accompanied
by a comprehensive description, specific codes, and definitions.
Every data item relating to the patient is collected and updated. The registry reg-
isters all new cases of cancer diagnosed in the UAE. Multiple data sources had aided
in optimizing collection completeness; however, this could lead to the problem of
multiple patient notifications. This problem was addressed by cross-checking the
Emirates ID number, names, age, gender, date of birth, and address, which is a good
3 UAE National Cancer Registry 65

Table 3.1 UAE National UAE-NCR data item

Cancer Registry Data Items Facility name
Facility license number
Facility referred from
Facility referred to
Date case reported
Case reported by
First name
Middle name
Last name
Date of birth
Gender
Nationality
Marital status
Occupation
Emirates ID
Medical record number
Address emirate—current
Address city—current
Smoking status
Alcohol status
Family history of cancer
Basis of diagnosis
Date of first contact
Date of initial diagnosis
Age at diagnosis
Comorbidities code
Comorbidities description
Primary site ICD10 code
Primary site ICD10 description
Primary site ICDO 3
Primary site ICDO 3 description
Histology ICDO-3 codes
Histology description
Behavior code
Behavior description
Sequence number
Grade
Grade description
Laterality code
Laterality description
Date of surgical diagnostic procedure
SEER summary stage
Clinical T
Clinical N
Clinical M
Clinical stage group
66 A. Z. Harbi et al.

Table 3.1 (continued) AJCC edition

Pathological T
Pathological N
Pathological M
Pathological group
Other staging system—name
Other staging system—value
Date of start of treatment
Surgery (Y/N)
Rx date—surgery
Rx FIN—surgery
Radiotherapy (Y/N)
Rx start date—radiotherapy
Chemotherapy (Y/N)
Rx start date—chemotherapy
Rx protocol—chemotherapy
Hormonal therapy (Y/N)
Rx start date—hormonal therapy
Rx FIN—hormone therapy
Immunotherapy (Y/N)
Rx start date—immunotherapy
Rx FIN—immunotherapy
Hematologic, transplant, and endocrine procedure
Hematologic, transplant, and endocrine procedure date
Rx FIN—hematologic, transplant, and endocrine
procedure
Hematologic, transplant, and endocrine procedure type
Systematic/surgery sequence
Other treatment
Other treatment—specify
Other treatment date
Palliative care
Palliative care date
Rx FIN—palliative care
Rx code—palliative
Date of last contact
Date of death
Vital status
Underlying cause of death
Cause of death
Source: Ministry of Health and Preventions (MOHAP),
Statistics and Research Center—UAE National Cancer
Registry
3 UAE National Cancer Registry 67

quality indicator as well as demonstrating good coverage along with the extensive-
ness of cancer cases in the UAE. The Emirates identification card number serves as
a distinct identifier assigned to both UAE citizens and non-UAE citizens
individually.
Following a thorough review and filtering of the received cancer data, updates
were made to ensure the exclusion of any duplicate or previously registered cases.
Every endeavor is made to ensure the completeness of all variables. In cases where
information is found to be incomplete, notification forms with insufficient details
are returned to the respective data providers for further clarification. Upon comple-
tion, the forms are returned to the registry.
All the revised information obtained in electronic format, whether through pas-
sive or active means, was entered into both the enterprise data warehouse (EDW)
and the disease registry databases. The electronic data preserved in the cancer reg-
istry databases is imperiled by ongoing quality control. Quality control procedures
and activities involving data checks for accuracy, completeness, consistency, valid-
ity, uniqueness, and timeliness are implemented.
Internal consistency and edit checks are performed during data entry into the
EDW and disease registry system.
Collaboration between the UAE-NCR and local health authorities is established
to guarantee the coherence and consistency of cancer incidence and mortality data.
As part of this effort, the annual cancer registry data is published on the MOHAP’s
website as open data [3]. The website serves as a platform for accessing the official
UAE cancer statistics as well as the annual reports of the UAE cancer registry.
Moreover, the UAE cancer registry data is designed to be comparable with that of
other GCC countries and their international counterparts.

3.13 Improving the Quality of Cancer Incidence

and Mortality Data

Several workshops and trainings have been done in collaboration with the WHO
Regional Office for the Eastern Mediterranean (WHO-EMRO), the International
Agency for Research on Cancer (IARC), and the Union for International Cancer
Control (UICC) to raise the quality of cancer incidence and mortality data collected
at the hospital level. For example:
The Statistics and Research Center—UAE National Cancer Registry, in the
UAE, conducted several workshops and trainings for cancer registrars and countries
about cancer registration, cancer data quality, and cancer staging. In addition to that,
the department conducted several trainings for physicians about the mechanism of
writing the causes of death according to international standards and provided
instructions on how to complete and file death certificates.
68 A. Z. Harbi et al.

3.14 UAE National Cancer Registry Software

To alleviate the challenges posed by a multifaceted system for data collection, the
UAE-NCR has implemented multiple surveillance and informatics initiatives.
These initiatives aim to automate developments and facilitate the electronic
exchange of data for cancer and other disease reporting. For example, the devel-
opment of an enterprise data warehouse (EDW), which is a web-based repository
to automate data collection and facilitate data cleaning, analytic data extraction,
and writing reports, will improve cancer registration and its quality on a short-
term basis.

3.15 Dissemination and Use of Data and Reports

from the UAE National Cancer Registry

Ensuring the confidentiality of data is a key priority for the UAE-NCR, as it plays a
central role in releasing data for clinical purposes, research, and healthcare plan-
ning. The registry has established robust procedures for data release that guarantee
the preservation of confidentiality.
Unless mandated by law or with the explicit written consent of the healthcare
provider or facility, no identifying information regarding an individual health-
care provider or facility will be disclosed. Furthermore, specific patient informa-
tion will not be furnished to individuals (patients) unless otherwise
stipulated by law.
All requests for data should be directed to the Statistics and Research
Director, the UAE-NCR manager, or another designated member of the registry
staff who is authorized to respond. The Statistics and Research Center has a data
request form available for researchers, registry staff, and other individuals to
utilize.
This form serves as internal documentation for data requests, ensuring the docu-
mentation of all information inquiries, aiding in staff effort monitoring, and facili-
tating the preparation of periodic summary reports on data requests.
To request the release of statistical cancer registry data, individuals can submit
formal requests via email to SARC.Request@mohap.gov.ae. The data will be pre-
pared for the statistical staff’s review. All correspondence and the cancer registry
data are carefully documented and filed for reference, facilitating the generation of
summary tabulations and routine reports.
The release of UAE-NCR data is contingent upon its utilization solely for medi-
cal purposes. These permissible medical purposes include surveillance, clinical
audit, cancer service evaluation, and ethically approved research.
It is important to note that any information that can potentially identify an indi-
vidual will not be disclosed. Comprehensive information regarding all the data
released by the registry is made available on MOHAP’s website through open data
3 UAE National Cancer Registry 69

initiatives. This website serves as a platform for hosting the official UAE cancer
statistics and annual reports from the UAE cancer registry.

3.16 Confidentiality Procedures and Data Security

Maintaining confidentiality is an obligation upheld by the UAE National Cancer

Registry, ensuring that any information that could potentially identify a patient,
healthcare professional, or medical facility remains confidential. Stringent confi-
dentiality procedures are implemented and upheld throughout all stages of registry
operations, aiming to:

• Safeguard the privacy of each individual patient.

• Ensure the confidentiality of the facilities that report the cases, ensuring their
privacy is protected.
• Offer public reassurance that the data will be handled responsibly and will not be
subject to misuse.

Access to identifiable data is strictly limited to a selected number of UAE-NCR

staff members, and such access is only granted when necessary to uphold data qual-
ity or investigate specific incidents. These registry specialists undergo certification,
possess extensive training, and work in secure environments to ensure the utmost
confidentiality and security of the data.
Whenever feasible, the tasks are conducted using de-identified data, wherein
any direct identifiers of individuals are removed. In cases where an analyst
necessitates access to patient-identifiable information, such as for record accu-
racy verification, they must provide a justifiable reason and obtain special
permission.
All data collected by UAE-NCR is stored on secure servers within the MOHAP
network, and MOHAP is legally obligated to ensure proper storage and usage of
information in accordance with the Data Protection Act. A daily backup of the
UAE-NCR database is required to be performed at the end of each day.

3.17 Cancer Statistics and Annual Reports in the UAE

The UAE-NCR serves as the sole means to monitor the incidence of cancer and
its various types. It provides valuable insights into the annual number of cancer
diagnoses, the prevalence of cancer within the population, and survival rates for
different types of cancer. By consistently tracking these statistics over time,
UAE-NCR helps determine whether the incidence of cancer is on the rise or
decline, as well as the overall progress in extending the lifespan of individuals
affected by cancer.
70 A. Z. Harbi et al.

UAE Burden of NCD (% of total deaths 2020)

Chronic respiratory disease 0.49%

Diabetes and endocrinology 1.59%

Cancer disease 9.30%

Cardiovascular disease 36.95%

Fig. 3.1 UAE’s burden of NCDs by MOHAP in 2020 (mortality rate) (Source: Ministry of Health
and Prevention (MOHAP), Statistics and Research Center)

All indicators related to cancer are calculated annually, such as age-standardized

mortality rates, crude mortality rates, crude and age-standardized incidence rates,
and other indicators.
MOHAP shows the UAE burden of NCDs (mortality ratio) in 2020, which shows
the percentage of total deaths in 2020 due to cancer was 9.3% (Fig. 3.1).
According to the recent UAE cancer registry annual report 2021, there were
a total of 5830 newly diagnosed cancer cases (malignant and in-situ) in the UAE
(total population 2020 = 9,282,410). Among these cases, 5612 (96%) were
malignant. There were 2553 (45%) males and 3059 (55%) females among them.
In males, the most common cancers were colorectal (12.5%), followed by pros-
tate (9.8%), leukemia (8.2%), thyroid (6.8%), and skin (carcinoma) (6.4%). In
females, the most common cancers were breast (36.9%), thyroid (13.8%),
colorectal (7.0%), uterus (5.7%), and cervix uteri (4.6%) (Table 3.2) [4].
Based on the latest data available from the UAE-NCR, covering the time-
frame of January 1 to December 31, 2021, a total of 5830 newly diagnosed
cancer cases (malignant and in-situ) were recorded in the UAE. Among these
cases, 5612 (96%) were classified as malignant, indicating active cancer, while
218 (4%) were categorized as in situ cases, representing early-stage cancer. The
data reveal that cancer was more prevalent among females, with 3210 cases
(55.1%) reported, compared to 2620 cases (44.9%) among males. For more
detailed information, please refer to Table 3.3 [4].
In the UAE citizens, there were 1493 newly diagnosed cases of cancer (malig-
nant and in-situ), with 1431 (95.8%) classified as malignant and 62 (4.2%) cat-
egorized as in situ cases. Among non-UAE citizens, a total of 4337 cancer cases
were newly diagnosed, with 4181 (96.4%) being malignant and 156 (3.6%)
3 UAE National Cancer Registry 71

Table 3.2 The top ten most prevalent malignant primary sites among both females and males
were determined as the highest occurrences in 2021 [4]
Primary site ICD-10 Female % Primary site ICD-10 Male %
C50 Breast 36.9 C18–C21 Colorectal 12.5
C73 Thyroid 13.8 C61 Prostate 9.8
C18–C21 Colorectal 7 C91-C95 Leukemia 8.2
C54–C55 Uterus 5.7 C73 Thyroid 6.8
C53 Cervix uteri 4.6 C44 Skin (Carcinoma) 6.4

C44 Skin (Carcinoma) 3.6 C34 Bronchus and Lung 6.3

C56 Ovary 3.5 C82-C85, C96 Non-Hodgkin 5.6
lymphoma
C91-C95 Leukemia 3.1 C00-C14 Lip, Oral cavity & 4.6
pharynx
C82-C85, C96 Non-Hodgkin 2.8 C64-C65 Kidney & Renal pelvis 4.2
lymphoma
C34 Bronchus and lung 2.3 C67 Urinary bladder 4
Source: Ministry of Health and Preventions (MOHAP), Statistics and Research Center, UAE
National Disease Registries—UAE National Cancer Registry Report 2021 [4]

categorized as in situ cases. For more detailed information, please refer to

Table 3.3 [4].
On the whole, the crude incidence rate of cancer for both genders in the UAE
was 60.5 per 100,000 individuals. The data clearly showed a higher incidence of
cancer among females, with a crude incidence rate of 108.7 per 100,000, compared
to males, with a rate of 39.5 per 100,000.
Furthermore, the overall age-standardized incidence rate (ASR) for both gen-
ders was calculated to be 107.8 per 100,000 individuals, for females 149.4 per
100,000 females, and for males 96.6 per 100,000 males.
Breast, thyroid, colorectal, leukemia, and skin (carcinoma) were identified as the
most common cancers among both genders in the UAE. Among males, the top-­
ranked cancers were colorectal, prostate, leukemia, thyroid, and skin (carcinoma).
The leading cancers among females were breast, thyroid, colorectal, uterus, and
cervix uteri.
According to IARC’s GLOBOCAN [5], in 2022, there were an estimated 5 526
new cancer cases (2 607 in males and 2 919 in females) and 2 283 cancer deaths
(1 283 in males and 1 000 in females) over a total population of approximately ten
million inhabitants. Females are more affected because of the high burden of breast
cancer (39.1%), which ranks first, followed by the thyroid (11.5%) and the colorec-
tum (7.0%). The three most frequent cancer sites for males are the colorectum
(13.3%), prostate (11.9%), and bladder (7.3%).
 72

Table 3.3 Number of cancer cases among the UAE population based on primary site, nationality, and gender in 2021
Non-Emirati Emirati
Primary site ICD-10 Female Male Total Female Male Total Grand total
(C00–C96) all invasive cancers (malignant cases) 2237 1944 4181 822 609 1431 5612
C00–C14 lip, oral cavity & pharynx 27 97 124 10 20 30 154
C15 esophagus 3 15 18 5 4 9 27
C16 stomach 25 79 104 14 16 30 134
C17 small intestine 6 14 20 2 4 6 26
C18–C21 colorectal 132 240 372 81 79 160 532
C22 liver and intrahepatic bile ducts 22 62 84 11 19 30 114
C23, C24 gallbladder, other and unspecified part of biliary tract 15 19 34 8 4 12 46
C25 pancreas 29 50 79 12 19 31 110
C26 other and ill-defined digestive organs 1 5 6 1 1 2 8
C30, C31 nasal cavity, middle ear, accessory sinuses 2 9 11 1 1 12
C32 larynx 17 17 12 12 29
C34 bronchus and Lung 53 118 171 17 43 60 231
C37 thymus 3 4 7 3 3 10
C38 heart, mediastinum, and pleura 6 6 6
C40–C41 bone and articular cartilage 2 20 22 5 7 12 34
C43 skin melanoma 18 30 48 2 1 3 51
C44 skin (Carcinoma) 94 155 249 15 9 24 273
C45 mesothelioma 4 1 5 1 1 6
C46 Kaposi sarcoma 2 2 1 1 3
C48 retroperitoneum and peritoneum 5 7 12 5 1 6 18
C49 connective and soft tissue 7 23 30 9 8 17 47
C50 breast 915 6 921 213 5 218 1139
C51 vulva 2 2 1 1 3
C52 vagina 2 2 1 1 3
A. Z. Harbi et al.
 3

Non-Emirati Emirati
Primary site ICD-10 Female Male Total Female Male Total Grand total
C53 cervix uteri 118 118 23 23 141
C54–C55 uterus 113 113 60 60 173
C56 ovary 85 85 23 23 108
C57 other and unspecified female genital organs 5 5 1 1 6
C58 placenta 4 4 4
C61 prostate 180 180 71 71 251
C62 testis 45 45 15 15 60
C64–C65 kidney & renal pelvis 29 80 109 14 28 42 151
UAE National Cancer Registry

C66, C68 ureter and other urinary organs 1 2 3 2 2 5

C67 urinary bladder 12 65 77 11 38 49 126
C69 eye 3 1 4 1 1 5
C70–C72 brain & CNS 28 77 105 22 22 44 149
C73 thyroid 266 136 402 155 38 193 595
C74–C75 other endocrine glands 4 5 9 1 1 2 11
C76-C80 unknown or unspecified sites 17 21 38 11 12 23 61
C81 Hodgkin’s lymphoma 26 33 59 13 19 32 91
C82–C85, C96 Non-Hodgkin lymphoma 53 98 151 32 45 77 228
C88, C90 Multiple myeloma 22 45 67 13 9 22 89
C91-C95 Leukemia 69 163 232 26 46 72 304
Other hematopoietic malignancies 15 13 28 3 5 8 36
Other Malignancy 1 1 1 1 2
(D00–D09) non-invasive cancers (in-situ cases) 107 49 156 44 18 62 218
D01 Carcinoma in situ of other and unspecified digestive organs 2 3 5 3 1 4 9
D02 Carcinoma in situ of middle are and respiratory system 1 1 1
D03 Melanoma in situ 3 4 7 7
D04 Carcinoma in situ of skin 1 1 3 1 4 5
D05 Carcinoma in situ of breast 45 3 48 20 20 68
73
 74

Table 3.3 (continued)

Non-Emirati Emirati
Primary site ICD-10 Female Male Total Female Male Total Grand total
D06 Carcinoma in situ of cervix uteri 51 51 17 17 68
D07 Carcinoma in situ of other and unspecified genital organs 2 9 11 1 2 3 14
D09 Carcinoma in situ of other and unspecified sites 4 28 32 14 14 46
Grand total—invasive and non-invasive 2344 1993 4337 866 627 1493 5830
Source: Ministry of Health and Preventions (MOHAP), Statistics and Research Center, UAE National Disease Registries—UAE National Cancer Registry
Report 2021
A. Z. Harbi et al.
3 UAE National Cancer Registry 75

3.18 Pediatric Cancer Cases

In 2021, there were 154 newly diagnosed cases of cancer in children aged 0–14 years
in the UAE, with 45% being females and 55% being males. These cases accounted
for roughly 2.7% of all malignant cases registered.
The most common cancers among pediatric patients were leukemia, brain and
CNS, non-Hodgkin lymphoma, kidney & renal pelvis, and bone and
articular cartilage.

3.19 Cancer Mortality

In 2021, cancer was identified as the fifth leading cause of death in the UAE.
The total number of cancer-related deaths was 975, with 506 in males and 469 in
females. These deaths represented 8.2% of all deaths, irrespective of nationality,
gender, or type of cancer.
The estimated age-standardized rate of mortality for both genders in 2021 was
29.6 deaths per 100,000 population. Among all cancer-related deaths, colon cancer
accounted for the highest percentage, with an average of 11.49% per year. Trachea,
bronchus & lung ranked as the second most common cause of cancer death in both
males and females. Breast cancer was the third-most common cause of cancer death.

3.20 Conclusion

In this chapter, we aim to give a full picture of cancer registration and surveillance
in the UAE, describe the UAE-NCR’s approach to cancer registration and surveil-
lance to monitor cancer-related outcomes, and give some examples of how the UAE
National Cancer Registry can improve cancer care in the UAE.
The UAE National Cancer Registry, as a population-based cancer registry, plays
an important role in the planning, operation, and evaluation of the UAE national
cancer prevention and control program, not only to articulate the disease burden,
trends, and geographical comparisons but also to evaluate the quality of cancer care.

Conflict of Interest The authors have no conflicts of interest to disclose.

References
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news-­room/fact-­sheets/detail/noncommunicable-­diseases.
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76 A. Z. Harbi et al.

4. UAE-NCR annual report 2021. https://mohap.gov.ae/assets/download/ab960117/

CANCER%20INCIDENCE%20IN%20UNITED%20ARAB%20EMIRATES%20
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populations/784-united-arab-emirates-fact-sheet.pdf

Dr. Alya Zaid Harbi is a director of statistics and research within

the Ministry of Health and Prevention-UAE and a PhD holder in
the field of computer science, specialized in data science. She plays
a critical role in illustrating the health of the UAE population
through the management of health data and information across the
country. She launched and completed one of the biggest health
studies in the UAE that is related to the National Health Survey,
where she worked in collaboration with different organizations and
stakeholders to make it successful. Moreover, she is leading the
first National Cancer Registry project in the UAE and is responsi-
ble for making the UAE a leader in that field. Dr. Alya is currently
establishing the enterprise data warehouse and nationwide disease
registries for all UAE health data, which is an integrated informa-
tion technology solution that will help MOHAP collect, aggregate,
analyze, and represent data to help in decision-making and refining
policies.

Dr. Buthaina Abdulla Bin Belaila is a consultant family physi-

cian and Head of Non-Communicable Disease and Mental Health
at MOHAP. A leader in the field of health care systems in the UAE
with extensive experience in non-communicable diseases. She is a
graduate of the UAE Faculty of Medicine and the UAE Women
Leadership Program. She played a critical role in implementing the
WHO ISH/CVD/risk assessment tool and integrating NCD ser-
vices in all PHCs in 2015. She has participated in multiple interna-
tional publications on NCD. Dr. Buthaina led the development of
the master national plan for NCDs in 2017 and the national action
plans for diabetes and obesity, cardiovascular disease, and cancer
control for 2023–2026, which have made a significant impact on
the health and well-being of the people of the UAE.

Wael Shelpai is a Certified Tumor Registrar (CTR®) and (ODS)

from NCRA, USA. He is the GICR—IARC/WHO Regional Expert
and Trainer in Cancer Registration and Cancer Registry Data
Quality for the MENA Region.
He is an expert on national disease registries, Ministry of Health
and Prevention, UAE. He has received training in disease-cancer
registration, epidemiology, and survival analysis from several inter-
national organizations, like IARC/WHO—France, WIA, India, etc.
He is affiliated with several professional committees and associa-
tions, and he has delivered international cancer registration and
cancer registry data quality trainings and workshops. He is the
author of several publications and has presented abstracts at
3 UAE National Cancer Registry 77

national and international conferences. Since 2006, he has been an

active member of the NCRA (National Cancer Registry Association)
in the USA.

Hira Abdul Razzak is an accomplished Health Research

Specialist at the Ministry of Health and Prevention in the UAE. With
an MSc in Genetics and a gold medal from the University of
Karachi, she has over 12 years of experience conducting scientific
research.
Previously serving as a Research Manager, she has engaged in
collaborative endeavors with renowned research networks and fac-
ulty members possessing diverse backgrounds at local, national,
and international levels. Through these collaborations, she has
showcased her proficiency in conducting systematic reviews and
national surveys, authoring books, extracting and monitoring data,
designing studies, analyzing and disseminating research findings,
and maintaining stringent quality control measures. Moreover, she
has played a crucial role in spearheading the digital transformation
of research services, recognizing the potential of technology to
revolutionize the field. She believes in utilizing the collective power
of her profession, passion, and knowledge to create meaningful
narratives and scholarly articles to benefit the people she serves.
She has embarked on a journey to engineer positive change in the
research culture as well as in the realms of human health, behavior,
and well-being.
Her research interests primarily revolve around non-communi-
cable and communicable diseases, mental disorders, and genetic
diseases, reflecting her dedication to advancing health care in the
country. Colleagues readily acknowledge her as an innovative spe-
cialist, renowned for her unwavering capability to consistently gen-
erate new and groundbreaking ideas that can be relied upon.
Overall, her academic achievements, extensive experience, and
contributions in the field position her as a respected figure in the
field of medical research.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Cancer Prevention, Screening, and Early
Detection in the UAE 4
Saeed Rafii and Humaid O. Al-Shamsi

4.1 Cancer Incidence in the UAE

The United Arab Emirates National Cancer Registry (UAE-NCR) 2021 has reported
that between January 1 and December 31, 2021, 5830 patients were diagnosed with
either malignant or in situ cancer, of which 5612 (96%) were malignant and 218
(4%) were in situ cases [1].
GLOBOCAN, the International Agency for Research on Cancer, predicts 4807
newly diagnosed cancers in the UAE by 2020 [2]. Cancer incidence in the UAE
has risen in the past decade. According to the World Health Organization (WHO),
the number of breast cancer cases has almost doubled between 2012 (568 cases)
and 2018 (1054 cases). It is estimated that the number of breast cancer cases will
almost triple and increase to 2993 by 2040. Additionally, WHO has forecasted a
steep and alarming increase in lung cancer, from 190 new cases in 2018 to 1020
new cases by 2040 (Fig. 4.1). Furthermore, the probability of premature death
from cancer per year in the UAE has increased from 3.29% in 2000 to 3.93% in

S. Rafii
Department of Oncology, Mediclinic City Hospital, Dubai, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
e-mail: saeed.rafii@mediclinic.ae
H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 79

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_4
80 S. Rafii and H. O. Al-Shamsi

Fig. 4.1 An estimated past and future trend in total breast and lung cancer cases per year [3].
(Used with permission from the World Health Organization)

Fig. 4.2 Probability of premature death from cancer per pear between 2000 and 2030 [3]. (Used
with permission from the World Health Organization)

2015 [3]. If the current trend continues, it is projected that by 2030 the probability
of premature death from cancer will have increased to 4.49% (Fig. 4.2). These
statistics highlight the importance of public awareness and a national cancer pre-
vention strategy.
4 Cancer Prevention, Screening, and Early Detection in the UAE 81

4.2 Cancer Risk Factors in the UAE

Identifiable and modifiable risk factors for developing cancer include obesity, smok-
ing, industrialism, sedentary life, and high-risk viral infections such as the human
papillomavirus (HPV). HPV and hepatitis are among the most common factors in
the UAE, similar to other parts of the world. However, some of the risk factors, such
as the increased risk of obesity, smoking, and sedentary life, are increasingly alarm-
ing. The most common population-attributable fractions are thought to be tobacco
use (11.6%), infections (11.9%), obesity (4.6%), UV-light (3.1%), alcohol (2.6%),
and occupational risks (1.6%) [3].

4.2.1 Obesity and Physical Exercises

The prevalence of obesity in the UAE is rising due to increased consumption of fast
food and reduced physical activity. The UAE climate, particularly in late spring and
summer, may limit outdoor activities, forcing many people to stay indoors or use
large shopping malls, which in turn encourages the consumption of fast food in
large food courts. In the past few years, initiatives such as 30 minutes of activities
for 30 days, led by His Highness Sheikh Hamdan, Crown Prince of Dubai, the
Dubai Marathon etc., have tried to encourage the public to have more outdoor activ-
ities and exercises. The high level of safety and security in the UAE encourages
women to take part in physical activities, yet female obesity remains a concerning
issue. The UAE government has initiated multiple programs for controlling cancer-­
risk factors, including obesity. The National Nutrition Strategy 2022–2030 has rec-
ommended the implementation of the specifications related to trans fatty acids and
the implementation of a reformulation program to reduce salt in processed foods. In
2017, an excise tax of 50% was applied to soft drinks and 100% to energy drinks [4].
In 2019, the excise tax was applied to 50% for sweetened beverages [5].

4.2.2 Smoking

Many forms of active smoking, including habitual or occasional smoking, are

increasingly observed in modern Arab culture and in the UAE. In particular, smok-
ing shisha with flavored tobacco has become popular among youth [6]. The UAE
Federal Law No. 15 of 2009 forbids the sale of tobacco products to those under 18,
smoking in private cars when a child under the age of 12 is present, smoking in
houses of worship, educational institutions (such as universities and schools), health
and sports facilities, the sale of sweets that resemble tobacco products, automatic
vending equipment and devices for tobacco distribution inside the country, tobacco
advertisement, and smoking in closed public spaces [7]. It is encouraging that many
restaurants and businesses have adopted the policy of allocating designated smok-
ing areas. Nonetheless, both active and passive smoking are of concern. The UAE
National Tobacco Control Committee intends to outlaw smoking in public places
entirely [8]. Excise tax was introduced across the UAE in 2017; in 2019, the tax for
tobacco products and electronic smoking devices increased from 50 to 100% [5].
82 S. Rafii and H. O. Al-Shamsi

4.2.3 HPV Infection and Cervical Cancer in the UAE

According to the UAE-NCR, cervix uteri is ranked the fifth-most common cancer
among females in the UAE in 2021, with 141(4.6%) malignant cases. This is also
the sixth most common cause of cancer death, with an estimated average of 13
(1.33%) [1]. Although there is a paucity of data regarding the rate of HPV infection
in the UAE, it is estimated that between 2.3 and 2.5% of the general female popula-
tion carry HPV 16 and 18 variants, which are the most common causes of invasive
cervical cancer [9]. Women aged 25–65 who are residing in the UAE are eligible for
cervical cancer screening that includes, according to the National Cancer Screening
Guidelines, a PAP smear and an HPV test as co-testing, and it is recommended that
the screening test be repeated every 3 years for women aged 25–29 years, every
5 years for women 30–65 years, and annually for women who are immune-­
compromised due to disease or medication [10].
In 2008, Abu Dhabi’s Health Authority (HAAD) launched an HPV vaccination
program for girls entering grades 11 and 12. Abu Dhabi is the first state within the
Middle East or Arab nations to introduce HPV vaccination in the public sector [11].
In 2018, the Department of Health (DOH) announced that the early detection of
cervical cancer campaign had resulted in a significant decrease in the late-stage
diagnosis of cervical cancer rate from 30.3% in 2012 to 14.8% in 2015. We have
previously recommended improving public, parental, and adolescent education
about HPV vaccination, specifically to address misconceptions and fears surround-
ing HPV vaccination [12].

4.2.4 Hepatitis Infection and Hepatocellular Cancer Risk

in the UAE

The UAE mandated hepatitis B vaccination in 1991 and introduced compulsory

hepatitis B and C testing for all new immigrants since 2006, followed by a manda-
tory HBV vaccination in cases of non-immunity [13, 14]. It is estimated that
the national prevalence is between 1.0 and 1.5% in the Emirati general population,
translating to 12,000 and 18,000 cases [13]. A study looking at the burden of virus-­
associated liver cancer in the Arab world from 1990 to 2010 reported in 2015 that
the age-standardized death rate for HBV-associated HCC in the UAE increased by
approximately 10% between 1990 and 2010 to 3.2 per 100,000 males and 1.2 per
100,000 females in 2010 [15].
Given that it takes decades to observe the effect of HBV vaccination on the
reduction of HCC, there is currently no data available in the UAE to compare the
prevalence of HCC before and after the HBV vaccination mandate.

4.3 Cancer Screening Programs in the UAE

The national cancer screening program is outlined in Table 4.1 [16].

4 Cancer Prevention, Screening, and Early Detection in the UAE 83

Table 4.1 Recommendations for regular cancer screening by the national cancer screen-
ing program
Cancer type Primary population group Screening test and frequency
Colon and rectum cancer Men and women Colonoscopy, every 10 years
Age: 40–75 years Or
Stool test, every 2 years
Breast cancer Women Mammogram
Age: 40 years and above Every 2 year
Cervical cancer Women PAP smear test
Age: 25–65 years Every 3–5 years
Source: The UAE government portal, updated 24 October 2018

4.4 Current Status of Cancer Screening in the UAE

Despite the existence of a cancer screening program and the technology needed to
deliver cancer screening, the rate and coverage of national cancer screening are cur-
rently suboptimal. No official published data on cancer screening uptake is avail-
able, although it is estimated that the uptake rate is generally low. One study reported
that of the 45,147 UAE nationals in the Emirates of Abu Dhabi eligible for screen-
ing in 2015–2016, only 23.5% were screened [17]. When applied to the general
eligible population, regardless of nationality, we estimate that cancer screening
uptake will be lower than this. Multiple factors are responsible for the current low
coverage and uptake of cancer screening in the UAE, which have been summarized
in Table 4.2 [12].
We have already proposed a UAE-wide national screening program that includes
breast, colorectal, cervical, lung, and prostate cancer based on a call-and-recall sys-
tem, and reformatory actions needed to improve nationwide cancer screening
[12, 18].

4.4.1 Available Screening Techniques in the UAE

There is a wide range of radiological and non-radiological screening tests available

both in the public and private sectors in the UAE.
According to a WHO report, in 2020, the following radiology equipment was
available in the UAE per 100,000 population: mammography (129.6), CT scanners
(422.8), MRI (373.9), and PET CT scanners (12.7) [3]. It is likely that this statistic
has improved as many more medical facilities have been established in the past
few years.
In addition to radiological screening, there are a few non-invasive and blood-­
based early cancer tests, such as those being introduced in the UAE commercially,
e.g., hPG80® and Epiprocolon®.
84 S. Rafii and H. O. Al-Shamsi

Table 4.2 Causes for low uptake of cancer screening and reformatory actions needed to improve
a nationwide cancer screening program in the UAE [12]
Cause/factor Root causes Reformatory actions
Access to the service • Difficulty in accessing • Mass education/campaign on
services screening and early detection
• Cost • Address the target groups at
• The location of examination educational institutes, media, etc.
centers • Launch mobile screening
• Health insurance does not services, such as mammograms,
include screening cervical examinations, stool
• Population growth and examinations (FIT test), and
change in the population medical advice
pyramid • Covering the cost through health
• Recommendations and insurance or delivering it for free
guidelines do not include the • Develop discounted rates for
younger population screening packages
• Creating a unified cost and
quality standard for cancer
screening
• Establish a specialized center for
cancer detection
Mechanisms and • The need for a unified • Activating a national program for
quality control of national program for cancer early detection of cancer that
cancer screening screening includes a central call system and
services • Poor compliance in the text messaging to call the target
application of the national high-risk groups
screening guidelines • Establishing a mechanism and
• The absence of a dedicated unified targets to measure the
team to monitor the quality coverage rate
of services • Linking the Emirates ID to the
• Lack of human resources for cancer screening record
auditing, and lack of audits to • Commit all service providers to
assess the quality of services achieve the target percentage
• Activating the national registry
for screening and early detection
• Integrating primary care and
screening
• Building capacity and logistical
resources
• Assigning coordinators for
quality assurance
• Establishing screening services
• Establishing a quality assurance
and monitoring department for
screening services
• Integrating screening and early
detection into insurance coverage
• Monitoring the impact of
screening on outcome mortality
4 Cancer Prevention, Screening, and Early Detection in the UAE 85

Table 4.2 (continued)

Cause/factor Root causes Reformatory actions
Community awareness • Lack of awareness • Conducting a cancer awareness
of the importance of campaigns measurement assessment by
early examination and • Lack of education and questionnaire in the community
detection of cancer understanding of cancer • Intensifying awareness
• Lack of integration of campaigns on the importance of
information about cancer into early detection
the educational curriculum • Information about the availability
• Lack of availability of smart and locations of services
awareness applications • Involving prominent and famous
• Lack of awareness about figures to disseminate awareness
early detection programs • Emphasize the importance of
• Lack of awareness of global early detection of cancer
awareness days for different • Develop a public information
types of cancer website
• Incorporating cancer information
End-user factors 1. Emotional factors into educational programs and
influencing the  • Fear campaigns in universities and
screening and  • Shyness schools
detection service  • Anxiety about the • Include representatives from the
outcome relevant authorities
 • Hospital admission • Conducting free campaigns to
2. Practical factors detect cancer during ambulatory
 • Absence from work care
 • Transportation • Smart awareness campaigns and
3. Understanding and applications to help community
education members make the right
 • Lack of knowledge decisions and get early detection
 • Misconceptions and tests
stigma
 • Confidentiality of the
information
 • Awareness of the
importance of
examination
4. Cultural differences in
society affect concepts of
prevention and early
detection
Capacity building in • Lack of competencies • Increasing the budget allocation
human resources and • Inadequate distribution of for early detection programs
logistic support human resources • Increasing the logistical and
• Lack of logistical resources human resources to increase the
and modern equipment coverage rate through training
and manpower
• Linking the annual performance
of general practitioners in
primary healthcare centers
• Hosting independent international
experts regularly to evaluate the
program and staff
• Raising the efficiency level of
employees through training
courses
86 S. Rafii and H. O. Al-Shamsi

4.5 Specific Cancer Screening Initiatives

4.5.1 Breast Cancer Screening

Breast cancer awareness and screening are more developed in the UAE compared
with other cancers. Most major hospitals offer mammograms and breast ultrasound
scans. Breast cancer screening is also accepted by many major insurance compa-
nies. In 2011, an initiative called “Pink Caravan” was established by Sheikha
Jawaher Bint Mohammed Al Qasimi to raise awareness about breast cancer screen-
ing. Since its foundation and until 2020, the caravan has travelled 1953 kilometers
and provided 20,794 free mammograms and 3584 US scans to women across the
UAE, leading to the diagnosis of 80 breast cancer cases [19].

4.5.2 Colon Cancer Screening

According to the national guidelines, all members of the public over the age of 40
are advised to have an annual stool fecal immunochemical test as well as a colonos-
copy every 10 years. At-risk populations, such as those with hereditary susceptibil-
ity genes, family history, and patients with inflammatory bowel disease, need to
undergo colonoscopies once a year or every 5 years, at the discretion of their physi-
cians [20, 21].
Data from the DOH indicates that between 2012 and 2019, 42% of the estimated
845 patients who were diagnosed with colorectal cancer in Abu Dhabi were detected
as a result of routine screening [20].
The UAE Ministry of Health and Prevention (MOHAP) has also issued a national
guideline for colorectal cancer screening and diagnosis [21]. However, there is no
official data on the coverage and uptake of colorectal cancer screening.

4.5.3 Prostate Cancer Screening

There is no official nationwide prostate cancer screening program in the

UAE. Most major hospitals offer prostate cancer screening to men as part of a
health package with reduced costs. In their most expensive insurance plans, some
insurance companies provide free annual prostate cancer screenings to all men
over the age of 45.

4.5.4 Lung Cancer Screening

There is no national lung cancer screening program in the UAE at the moment.
Despite the availability of low-dose CT scans, general awareness and lung cancer
screening are low throughout the UAE [22]. To the best of our knowledge, lung
cancer screening is not used routinely throughout the UAE, although the DOH in
Abu Dhabi has a published guideline for lung cancer screening [23].
4 Cancer Prevention, Screening, and Early Detection in the UAE 87

4.6 Challenges in Cancer Screening in the UAE

The UAE has experienced a rapid expansion in its economy and population in the past
20 years. Its unique population is comprised of a majority of immigrants from across the
globe with diverse backgrounds. Such a rapid expansion in the population has resulted
in an increase in non-communicable diseases, including cancer. Due to the historical
nature of short-term placement in the country, the UAE healthcare system has not fully
integrated non-UAE residents into cancer screening programs. Additionally, the cost of
cancer screening has not been fully covered by some insurance companies, and access
to cancer screening is not equally available to all at-risk groups. Even when structured
cancer screening is available (see Sects. 4.3 and 4.4), the uptake and compliance with
such programs may be unsatisfactorily low. Many factors, such as cultural barriers, edu-
cation and awareness, access to healthcare, and the unequal distribution of specialized
healthcare facilities, contribute to the lack of effective cancer screening in the country.
This may impact the late-stage diagnosis of cancer and, subsequently, the higher risk of
cancer-related death, despite the advanced healthcare system.

4.7 Conclusion and Recommendations

Much has been done in the past few years by the UAE government to reduce the
burden of cancer in the country, including raising public awareness, encouraging
physical activities, passing laws in order to reduce obesity, and reducing smoking.
However, more needs to be done in order to have effective cancer screening pro-
grams that are accessible and effective, result in early-stage cancer diagnosis, and
subsequently reduce cancer-related mortalities in the country.
We recommend focusing on educating the public and enhancing awareness about
cancer and its risk factors. It is important to address cultural misconceptions and
beliefs about cancer. In parallel, governmental legislation is imperative to target
known causes of cancer.
It is important to recognize that reducing cancer-related mortality is not possible
without an effective early cancer detection program. Therefore, we encourage leg-
islators and health authorities to plan and implement a nationwide call/recall cancer
screening program for the most common cancers, such as breast, colorectal, lung,
and prostate. Guidelines must take into account the young population of the UAE
and tailor screening recommendations that reflect the age of diagnosis of the most
common cancers in the country. Such a program should also address the referral
pathway by which patients are appropriately referred to highly specialized centers.
We have previously proposed an all-inclusive cancer control program to formu-
late strategy, implement prevention, and enforce comprehensive cancer manage-
ment through a collaborative process between government organizations, the
community, and non-government organizations [12]. Given the current increasing
trend in cancer incidence and cancer mortality rate, it is urgent to formulate an
action plan with an emphasis on preventing cancers or detecting cases early at a
curable stage in order to control the rising incidence rate at its current level or, ide-
ally, to reduce it. It takes a concerted effort from all stakeholder groups in order to
88 S. Rafii and H. O. Al-Shamsi

set a series of targets that result in significant risk reduction by increasing early
detection, improving treatment, and enhancing survivorship [12].

Conflict of Interest The authors have no conflict of interest to declare.

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Dr. Saeed Rafii is a board-­certified consultant medical oncologist.

After completion of his primary medical degree, he was trained in
internal medicine, followed by subspecialty training in medical
oncology in two of the most prestigious cancer hospitals in the UK,
Queen Elizabeth Hospital Birmingham and the Royal Marsden
Hospital, London. He then completed a clinical fellowship in early-
phase clinical trials at the Royal Marsden Hospital, London, and
received his CCT (certificate of completion of training) from the
UK General Medical Council. Dr. Rafii was subsequently appointed
as an associate professor and consultant in medical oncology at the
University of Manchester and the Christie Hospital, where he
helped to establish and expand the Experimental Cancer Medicine
Centre. He then moved to University College London Hospital and
the Oxford Cancer Network as a consultant medical oncologist.
He has extensive expertise in clinical trials and has been chief,
principal, or co-investigator on over 100 early and late-phase
oncology clinical trials. Dr. Rafii also holds a PhD and a postdoc-
toral fellowship in molecular cancer genetics. He is a member of
the Royal College of Physicians of the UK, the European Society
of Medical Oncology (ESMO), and the American Association for
Clinical Oncology (ASCO). In 2018, he was elected as Fellow of
the Royal College of Physicians of UK (FRCP) for his outstanding
medical and research activities.
Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer
of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
90 S. Rafii and H. O. Al-Shamsi

been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in

2024. He is the only physician in the UAE with a subspecialty fel-
lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fel-
lowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new dis-
tinct subgroup of CRC, NON V600 BRAF-mutated CRC. In 2022,
he published the first book about cancer research in the UAE and
also the first book about cancer in the Arab world, both of which
were launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to docu-
ment the cancer care in the UAE with many topics addressed for
the first time, e.g., neuroendocrine tumors in the UAE. He is pas-
sionate about advancing cancer care in the UAE and the GCC and
has made significant contributions to cancer awareness and early
detection for the public using social media platforms. He is consid-
ered as the most followed oncologist in the world with over
300,000 subscribers across his social media platforms (Instagram,
Twitter, LinkedIn, and TikTok). In 2022, he was awarded the pres-
tigious Feigenbaum Leadership Excellence Award from Sheikh
Hamdan Smart University for his exceptional leadership and
research and the Sharjah Award for Volunteering. He was also
named the Researcher of the Year in the UAE in 2020 and 2021 by
the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
of research training for medical trainees to enhance their clinical
and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
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A Proposal for Cancer Control Plan
in the UAE 5
Humaid O. Al-Shamsi and Amin M. Abyad

Abbreviations

EMRO Eastern Mediterranean Region Office

ICER Institute for Clinical and Economic Review
KPI Key performance indicators
MDT Multidisciplinary team
MENA Middle East and North Africa
NCD Noncommunicable diseases
NICE National Institute for Health and Care Excellence
UAE United Arab Emirates
WHO World Health Organization

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca
A. M. Abyad
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Burjeel Medical City, Abu Dhabi, United Arab Emirates

© The Author(s) 2024 91

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_5
92 H. O. Al-Shamsi and A. M. Abyad

5.1 Introduction

Cancer poses a significant worldwide health challenge, with nearly nine million
lives lost to malignant diseases across the globe in 2015. It stands as the second
most prevalent cause of death internationally, responsible for approximately one-­
sixth of all fatalities in present times [1]. The Eastern Mediterranean Region is
renowned for its notable occurrence of cardiovascular ailments [2].
Within the swiftly expanding population of the Middle East, despite significant
advancements in life expectancy, the occurrence of cancer is projected to double
over the next two decades, aligning with the global trend of rising cancer rates [3].
The transition toward a more westernized lifestyle plays a significant role in driving
this transformation. The adoption of westernized lifestyle choices is a major factor
contributing to this shift.
Based on the aforementioned information, the incidence of cancer in our region
is projected to experience a twofold increase within the next two decades, making it
the region with the highest expected rise among all World Health Organization
(WHO) regions. By the year 2030, it is expected that the number of cancer-related
deaths will reach 652,097, which is a significant rise from the 367,441 reported in
2012 [4]. These projections stem from the combined influence of population growth
and aging, the cumulative impact of heightened exposure to cancer risk factors such
as smoking, dietary shifts, lifestyle changes, and the exacerbation of environmental
pollution. These factors contribute to a substantial increase in the burden of cancer,
placing a significant strain on the healthcare system.
In the UAE population, cancer mortality has been the fifth leading cause of death
in 2021 [5].
In a significant number of cases, cancer can be prevented, making it a highly
preventable disease. Timely diagnosis plays a crucial role in successful treatment
outcomes. Even when diagnosed at later stages, it is possible to manage cancer-­
related symptoms, slow down disease progression, improve the quality of life, and
provide support to patients and their caregivers throughout their journey. It is
essential to develop and implement effective cancer control plans to address these
needs. Many countries have ongoing cancer control programs at different levels.
However, in several other countries, either no effective cancer control plan exists,
the existing plan is outdated, or it is not effectively implemented. Therefore, there
is a need for a comprehensive plan that is efficiently executed, regularly monitored,
and subject to necessary modifications and updates based on local needs and
requirements [1, 2, 4].
Cancer management now requires a comprehensive global approach that ensures
equal and uniform access to care. The UAE National Cancer Strategy is designed to
prioritize various initiatives aimed at reducing the impact of cancer in the UAE and
facilitating the provision of optimal cancer care for patients and their caregivers.
This strategy aims to enhance cancer care efforts in the UAE, aligning them with
5 A Proposal for Cancer Control Plan in the UAE 93

international guidelines and the most effective evidence-based practices while

adapting them to suit the country’s specific needs [3, 5, 7].

5.2 The Cancer Burden

During the previous century, the economy of the UAE experienced rapid growth,
positioning it as one of the world’s swiftest-growing economies [8, 9]. The remark-
able economic growth witnessed in the UAE resulted in various transformations in
the population’s economy, sociodemographics, and way of life. Concurrently, there
has been an epidemiological rise in the prevalence of noncommunicable diseases
(NCDs), with cancer being particularly noteworthy. Epidemiological studies con-
ducted in the UAE have linked this increase in cancer rates to various risk factors,
including reduced physical activity and sedentary lifestyles [10–12], the consump-
tion of high-calorie and low-nutrient meals [13], the obesity pandemic [12, 13], a rise
in the number of individuals who smoke [14], and higher levels of air pollution [15].
Cancer diagnostic tools and procedures have witnessed advancements, leading to
improved detection capabilities. In 2016, noncommunicable diseases (NCDs)
accounted for 77.3% of all reported deaths. The top two main causes of death
included cardiovascular diseases and malignancy. Approximately 6% of all deaths
are attributed to infectious, maternal, perinatal, and nutritional conditions, while
chronic respiratory diseases and diabetes account for approximately 5% each [9, 16].

5.2.1 Cancer Incidence Rate

In 2021, a total of 5830 cases were diagnosed in the UAE, with 218 cases (4%) clas-
sified as in situ cancer and 5612 cases (96%) classified as malignant. Among these
cases, there were 2620 (44.9%) male patients and 3210 (55.1%) female patients.
Due to the UAE’s diverse population, a significant proportion of the reported cancer
cases were individuals who had migrated to the country. The distribution of cancer
cases by nationality is not evenly distributed, with 866 female cases and 627 male
cases reported among UAE citizens, while non-­UAE citizens accounted for 2344
female cases and 1993 male cases [5] (Table 5.1).

5.2.2 The Most Common Cancer Types

From January 1 to December 31, 2021, the UAE National Cancer Registry (UAE-­
NCR) reported a total of 5830 newly diagnosed cancer cases, comprising both
malignant and in situ cases. Among these, 5612 cases (96%) were classified as
malignant, while 218 cases (4%) were in situ. Overall, cancer affected more
94 H. O. Al-Shamsi and A. M. Abyad

Table 5.1 The most common primary malignant tumors in the UAE for both genders in 2021

Primary site % Primary site %

Breast 36.9 Colorectal 12.5
Thyroid 13.8 Prostate 9.8
Colorectal 7.0 Leukemia 8.2
Uterus 5.7 Thyroid 6.8
Cervix uteri 4.6 Skin (Carcinoma) 6.4
Skin (Carcinoma) 3.6 Bronchus and Lung 6.3
Ovary 3.5 Non-Hodgkin 5.6
lymphoma
Leukemia 3.1 Lip, Oral cavity & 4.6
pharynx
Non-Hodgkin lymphoma 2.8 Kidney & Renal pelvis 4.2

Bronchus and Lung 2.3 Urinary bladder 4.0

Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021

women than men, with 3210 (55.1%) females and 2620 (44.9%) males being
diagnosed. Among UAE citizens, there were 1493 newly diagnosed cancer cases,
with 1431 cases (95.8%) being malignant and 62 cases (4.2%) being in situ.
Similarly, among non-UAE citizens, there were 4337 newly diagnosed cancer
cases, with 4181 cases (96.4%) being malignant and 156 cases (3.6%) being in
situ. The overall crude incidence rate for both genders was 60.5 per 100,000
population. The incidence rate was higher for females, with a rate of 108.7 per
100,000, compared to males at 39.5 per 100,000. The overall age-standardized
incidence rate (ASR) for both genders was 107.8 per 100,000. The most common
cancers among both genders were breast, thyroid, colorectal, leukemia, and skin.
Among males, colorectal, prostate, leukemia, thyroid, and skin were the top-
ranked cancers, while among females, breast, thyroid, colorectal, uterus, and
cervix uteri were the most prevalent. In 2021, there were 154 children between
the ages of 0–14 diagnosed with new cancer in the UAE, with 45% being females
and 55% being males. These cases constituted approximately 2.7% of all regis-
tered malignant cases. The most common cancers in boys and girls were leuke-
mia, brain and CNS, non-Hodgkin lymphoma, kidney & renal pelvis, and bone
and articular cancers [5].
5 A Proposal for Cancer Control Plan in the UAE 95

5.2.3 Cancer Mortality

In 2021, cancer was the cause of 975 deaths, accounting for 8.2% of all reported
fatalities. This corresponds to an estimated age-standardized mortality rate of 29.6
deaths per 100,000 population for both genders. Among the leading causes of
cancer-­related deaths, colon cancer ranked first, responsible for 11.49% of the
deaths, followed by trachea, bronchus, and lung cancer (9.85% deaths), and breast
(9.64% deaths) [5].

5.3 Cancer Prevention, Screening, and Early Detection

Around one-third of cancers can be prevented through lifestyle modifications,

genetic testing for high-risk individuals, and vaccination. Despite the relatively low
reported incidence of cancer in the UAE, it is crucial to prioritize enhancing out-
comes for diagnosed and treated cancer patients. Cancer screening and early detec-
tion have the most significant influence on patient outcomes. Early detection plays
a vital role in increasing the likelihood of successful treatment and positive results.
However, the 2017 data indicate that the global population coverage rate for early
cancer screening among the targeted age groups is lower (less than 70%) than the
targets set by the World Health Organization [1, 2, 4, 5, 17].
The factors contributing to the low rates of cancer screening in the UAE popula-
tion, as well as the suggested actions to enhance these rates, are outlined in
Table 5.2 [18].
96 H. O. Al-Shamsi and A. M. Abyad

Table 5.2 Root causes for low cancer screening and proposed actions [18]
Cause/factor Root causes Reformatory actions
Access to the • Nonaccessibility to service • Public education and media
service • Financial inability campaigns on early detection and
• Examination center location cancer screening
• Screening is not covered by • Utilizing media and other tools to
health insurance address specific target groups
• Demographic change and • Launch and use mobile screening
population growth/change in apps for services such as
the population pyramid mammography, pap smear, and
• Younger populations are not stool occult blood (FIT test)
addressed in recommendations • Free screening campaigns or
or local guidelines insurance coverage for screening
tools
• Creation of screening packages with
a discounted price
• Unifying the cost and quality of
screening tools
• Establishment of a specialized
cancer screening and detection
center
Quality control • Poor compliance with the • Using a national program for early
mechanisms for adopted national screening detection of cancer that utilizes
cancer screening guidelines and standards smart technology, such as an
services • The absence of a team automated system for text
dedicated to assessing the messaging, to notify the target
quality of services high-risk population
• Deficiency in human resources • Establishing a clear mechanism and
for monitoring and a lack of identifying targets to monitor
auditing to assess the quality of patients’ coverage rates
services • Cancer screening records are being
linked to Emirates ID
• Committing all service providers to
the achievement of the target
numbers
• Activation of the national cancer
registry for screening and early case
detection
• More integration of screening into
primary care
• Expanding logistical resources and
capacity
• Assigning coordinators for quality
improvement
• Establishing unified cancer
screening services
• Establishing a quality assurance
department for continuous
monitoring
• Inclusion of cancer screening and
early detection in mandatory
insurance coverage
• Monitoring the outcome of
screening on cancer mortality
5 A Proposal for Cancer Control Plan in the UAE 97

Table 5.2 (continued)

Cause/factor Root causes Reformatory actions
Community • Deficiency in awareness • Conducting community cancer
awareness campaigns awareness measurement
regarding the • Poor awareness of cancer questionnaire studies
importance of etiology, management, and • Highlighting the importance of
early detection outcomes early detection through awareness
and cancer • Improper integration of campaigns
screening cancer-related topics into the • Spreading information about the
educational curriculum availability and locations of
• Lack of utilization of smart screening services
applications for cancer • Involving famous personnel and
awareness public figures to disseminate
• Lack of public knowledge or awareness
awareness about early detection • Emphasize the significance of early
programs cancer detection
• Lack of publicity for global • Creation of a public information
awareness days, months, or website to facilitate public access to
events for different types of accurate information
cancer • Incorporating cancer-related topics
End-user factors 1. Emotional factors into educational curricula
influencing the  • Fear • Universities and school campaigns
screening and  • Shyness • Include educational authorities’
detection service  • Anxiety about the outcome representatives
 • Hospital admission • Utilization of ambulatory care
2. Practical factors services to conduct free campaigns
 • Absence from work to detect cancer
 • Transportation • Smart awareness campaigns and
3. Understanding and education applications to help community
 • Lack of knowledge members make the right decisions
 • Misconceptions and stigma and get early detection tests
 • Confidentiality of the
information
 • Awareness of the
importance of examination
4. Cultural differences in
society affect concepts of
prevention and early
detection
Capacity • Lack of competencies • Increasing the budget allocation for
building in • Inadequate distribution of early detection programs
human resources human resources • Increasing the logistical and human
and logistic • Lack of logistical resources and resources to increase the coverage
support modern equipment rate through training and manpower
• Linking the annual performance of
general practitioners in primary
healthcare centers
• Hosting independent international
experts regularly to monitor and
evaluate the staff and program
• Implementing continuous training
and education to raise the level of
efficiency of employees
98 H. O. Al-Shamsi and A. M. Abyad

5.4 Diagnostic Tools and Services

Achieving a clear and definitive diagnosis is crucial for prompt and successful treat-
ment. However, there is a lack of well-established and efficient pathways that ensure
the timely referral of patients to the appropriate physicians and centers for diagno-
sis. During this crucial period, patients should undergo a comprehensive clinical
and physical assessment, appropriate radiologic tests, and a biopsy with histopa-
thology for tissue diagnosis. The plan for further management, including assess-
ment and treatment, should be discussed and agreed upon at multidisciplinary team
(MDT) tumor board meetings involving various clinical specialties. Unfortunately,
not all diagnostic services are universally accessible or provided with the desired
equity. Therefore, there is a pressing need for tumor-site-specific diagnostic clinics
that offer access to supportive genetic testing. Quality certifications in line with
international standards and regulations are essential, often requiring accreditation
from recognized international organizations and societies. This process should align
with the development and implementation of regulations that adhere to internation-
ally established diagnostic standards [5, 19–23].

5.5 Cancer Management

The establishment, adaptation, integration, and oversight of various cancer-related

services are of utmost importance. These services encompass medical oncology,
surgical interventions, radiotherapy, pediatric cancer care, and palliative care. In
addition, emerging subspecialties such as gyne-oncology, uro-oncology, ortho-­
oncology, and neuro-oncology require dedicated development to meet the increas-
ing demand and need for specialized services. Currently, these services do not meet
the proposed standards. There is a notable deficiency in comprehensive supportive
services accessible to all patients, including clinical psychologists, certified dieti-
tians, social and community workers, and nursing care at all healthcare levels. We
still face challenges in establishing and implementing universally accepted practice
guidelines for physicians, radiologists, and pathologists in the treatment of each
specific type of cancer. These guidelines should be customized based on local data,
planned objectives, specific needs, disease biology within the local context, and
available resources. The role of multidisciplinary tumor boards in cancer institu-
tions is crucial, as they review and discuss new and complex cases to formulate
well-documented care plans for each patient involved [19–23].

5.6 The Cancer Control Plan of the UAE

In 2011 [11, 16, 24, 25], the World Health Organization (WHO) emphasized the
significant importance of establishing a standardized framework to track trends and
evaluate the efforts of individual countries in addressing the worldwide cancer
5 A Proposal for Cancer Control Plan in the UAE 99

crisis. A comprehensive cancer control plan necessitates the collection of accurate

data, the establishment of a reliable and evolving cancer registry, and the monitoring
and evaluation of initiatives to ensure effective prioritization and quality implemen-
tation [26]. The World Health Organization (WHO) recommended that health regu-
latory bodies integrate their health information systems with reliable and
evidence-based research indicators that have been well-established.
This plan embraces the principle of establishing a collaborative partnership with
relevant sectors, both governmental and nongovernmental organizations, to effec-
tively implement its goals. A unified policy has been developed to decrease cancer
mortality rates, and numerous initiatives have been undertaken by participating gov-
ernmental and nongovernmental agencies. The implementation of this plan signifies
a significant milestone in advancing policy execution, health initiatives, and ser-
vices aimed at reducing cancer prevalence and mortality, as well as controlling risk
factors in the UAE [2, 17].
The Ministry of Health and Prevention, along with its partners in the UAE, has
developed a national comprehensive plan to prevent and control cancer. We propose
implementing this plan in line with specific objectives and in alignment with the
National UAE Vision 2021. The national plan for cancer prevention and control
(2022–2026) has been carefully crafted, taking into consideration the global action
plan for cancer prevention and control by the World Health Organization (WHO), as
well as the regional executive framework for cancer prevention and control in the
Eastern Mediterranean Region Office (EMRO). The structure of this plan reflects
the national strategy to reduce cancer incidence, improve the cancer patient's jour-
ney, decrease mortality by at least 25%, enhance quality of life, and alleviate the
suffering of both cancer patients and caregivers. This approach is based on an inte-
grated model of comprehensive cancer care services. The plan is based on nine
strategic axes centered across the healthcare system:

1. Healthcare services
2. Cancer prevention
3. Sustainability
4. Innovation
5. Quality and patient safety
6. Health workforce
7. Research and development
8. Regulation and legislation
9. Strategic partnerships and collaborations

The plan encompasses various domains, such as governance, disease prevention,

early detection, treatment, palliative care, surveillance, and research [2, 6, 17].
In collaboration with relevant sectors and stakeholders, including both public
and private entities, a unified national plan for cancer prevention and control has
been established. The objective of this plan is to strengthen the commitment to
global and regional initiatives in combating and managing cancer. The strategic plan
100 H. O. Al-Shamsi and A. M. Abyad

provides a comprehensive framework for indicators and controls that guide the
development of policies, the formulation of regulations, and the evaluation of mate-
rial resources to support disease prevention, cancer care, and quality management
programs within the country. It also outlines appropriate measures for plan imple-
mentation, ongoing assessment, and a follow-up system. Key performance indica-
tors (KPIs) have been identified to assess the effectiveness of proposed and
implemented activities. This plan serves as a roadmap for the implementation of a
targeted strategy to prevent and control cancer. It is an integral part of the National
UAE Agenda for 2021, aiming to reduce cancer mortality rates and contribute to the
achievement of the agenda’s objectives, as outlined in the “one thousand people”
initiative in Table 5.3 [11, 16, 23, 25, 26].

5.6.1 The Principles and Strategic Directions of the National

Plan as per WHO and EMRO Guidelines

The national plan for cancer prevention and control draws inspiration from the stra-
tegic directives outlined by the World Health Organization for the Eastern
Mediterranean Region. It aligns with the executive framework established for the
action plan. The recommendations provided by both the Eastern Mediterranean
Region Office (EMRO) and the World Health Organization (WHO) are condensed
in Table 5.4 [4, 11, 17, 26].

Table 5.3 The vision, objectives, and strategy of the UAE cancer care plan [18]
Vision To reduce cancer mortality and morbidity and improve survival rate in the
UAE
Message Saving lives and reliving suffering across the UAE population through
cancer prevention, early detection, and best curative and palliative care
Objectives of 1. To strengthen the implementation and planning at the national level
the strategy aiming to combat cancer in the United Arab Emirates
2. To reduce preventable and early cancer deaths and the risk of developing
cancer by 30% by the year 2030
3. To optimize cancer prevention in the UAE society
4. To strengthen cancer prevention, early detection, and treatment
5. To ensure a sustainable and continuous development of cancer
prevention, control, and treatment plans and strategies
6. To improve the cancer patients’ quality of life
7. To ensure continuity of care through well-defined transition points in the
healthcare system
8. To develop a framework to enhance, integrate, and coordinate initiatives
to combat cancer and outline principles and regulations to supervise the
organization
9. To ensure consistency and standardization in practices and help unify
efforts in the fight against cancer.
10. To consolidate the efforts by providing a legal framework of applicable
governmental regulations and policies
5 A Proposal for Cancer Control Plan in the UAE 101

Table 5.4 Recommendations by EMRO and WHO [4, 11, 17, 26]
1. Governance: Focus on developing a strategy and establishing a multisectoral committee
for cancer prevention and control, while ensuring an available and sustained budget,
adequate, and well-identified national cancer rates, establishing unified and reasonable
costs for cancer care and management packages, and determining a mechanism to ensure
treatment expense coverage with equity
2. Prevention: Focus on implementing healthy lifestyle measures by combating smoking and
encouraging physical activity and healthy food habits in line with the noncommunicable
disease control framework and plan. This focus should also include vaccination strategies
against hepatitis and HPV infections
3. Early detection: The directions in this area focus on four main titles: raising public
awareness about the importance of early warning signs and symptoms of cancer, mass
education, and ongoing focused education for healthcare professionals on the early signs
and symptoms of common cancers, easy and accessible diagnosis and referral for patients,
effective screening programs, and continuous evaluation and monitoring of these programs.
The focus should also be on enhancing the accessibility and affordability of diagnostic
tools for suspected patients
4. Treatment: Focus on the development and implementation of protocols and clinical
practices based on evidence-based guidelines. Assess human resource availability and
focus on cancer care services that are accessible to all with affordable treatment pathways.
This also includes the development of an integrated, coordinated, and prompt referral
system to avoid delays in diagnosis and treatment
5. Palliative care: There is an unmet need to develop and integrate multidisciplinary
palliative care services, including but not limited to pain management and psychological
support, available in hospitals and primary healthcare centers. Developing and
implementing these standards for best evidence-based practice and comprehensive care,
and a smooth and early transition. Palliative care should be highlighted in medical
educational programs.
6. Research and surveillance: Developing a national cancer registry and hospital registries.
With continuous monitoring of these registries through an accredited quality insurance
program. The area includes focusing on the development and utilization of an integrated
plan for research according to the priorities of the country

5.6.2 Definitions of the Strategic Axes and Executive Framework

of the UAE Cancer Plan

The national cancer control plan of the UAE should encompass three main areas of
focus, which are elaborated upon through nine strategic axes (Table 5.5). The first
area of emphasis is cancer prevention, which encompasses education, understand-
ing of the disease, prevention strategies, and early detection through prompt and
efficient diagnosis. The second area centers around healthcare services, covering
continuous care and comprehensive cancer treatment. The third area pertains to
sustainability and innovation, which involves performance measurement, human
resources, and research. These aspects are further outlined and discussed in detail in
Table 5.6.
102 H. O. Al-Shamsi and A. M. Abyad

Table 5.5 Strategic axes of the UAE cancer plan [18]

First area
1. Education and understanding
Enhancing health awareness about the knowledge of cancer, risk factors leading to cancer, and
correction of misconceptions about the disease
2. Prevention
Launching awareness campaigns and prevention programs against cancer and known causes
3. Early detection
Detecting cancer in the early stages increases the patients’ survival and outcome. It involves
periodic clinical assessments and reduces the delays in appropriate treatment referrals to
receive treatment promptly
4. Rapid diagnosis
A healthcare center should assess the condition of the patient promptly in a systematic
integrated way and take appropriate medical decisions based on a developed pathway
Second area
5. Treatment
Provide appropriately validated clinical practices in line with international guidelines for
treating cancer according to disease stage to improve outcomes
6. Ongoing care
Provide timely transition to post-treatment and palliative care services for cancer patients and
educate them about the appropriate ways to live with the disease and directions to avoid
disease recurrence
Third area
7. Performance measurements
Establishing national records including all data sources in a central place and assembling
comprehensive data of high quality, accuracy, and to record information about a disease
8. Workforce capacity building
Providing a qualified and appropriately trained team to deliver prevention, treatment, and
continuity of care for patients; and provision of suitable training facilities for the workforce
9. Research
Cancer research improves the diagnosis, treatment, and outcome, and enhances quality of life
by translating quality research and clinical trials for improvements in personalized care
 5

Table 5.6 Detailed strategic and executive framework of the UAE cancer plan [18]
Strategic axis Education and understanding
Measurement
Main objectives Application mechanisms indicators The executing agency Follow-up
Raising health awareness Conducting a national survey Survey completion Ministry of Health and Ministry of Health and
about cancer and on awareness in society rate Prevention—Noncommunicable Prevention—Noncommunicable
associated risk factors and assessing knowledge of risk Disease and Mental Health Disease and Mental Health Section
correcting the factors and opinions about Section
misconceptions access to services and early
examination
Raising health awareness about Number of Stakeholders
cancer risk factors awareness
• Inclusion of cancer in campaigns
scientific curricula
• The initiative of the
researcher/young intellectual
A Proposal for Cancer Control Plan in the UAE

which aims and implements

cancer awareness campaigns
in school and university
Awareness campaigns Number of Stakeholders
synchronized with designated awareness
international days for each campaigns
cancer type
(continued)
103
Table 5.6 (continued)
104

Strategic axis II. Prevention

Main objectives Application mechanisms Measurement indicators The executing agency Follow-up
Monitoring of risk factors Physical activity The number of Ministry of Health and Prevention— Ministry of
between different groups • Inclusion and intensification of awareness programs Noncommunicable Disease and Mental Health and
in society and physical activity compulsory in Health Section Prevention
encouragement to adopt schools
healthy lifestyles • Campaigns to encourage exercise and
walk in the community
• Creation of more tracks for walking
and parks within reach of people
Healthy foods The number of
• Develop educational programs on a awareness programs
healthy diet
Assessment of the presence of The number of
carcinogenic factors in the environment awareness programs
and highlighting the environmental
pollution and exposure to radiation
Awareness campaigns about the harms The number of
of smoking and shisha in young people awareness programs
Monitor smoking rates
Providing preventive Hepatitis B vaccination for prevention Hepatitis C vaccination Ministry of Health and Prevention/ All
vaccinations of liver cancer for high-risk population coverage rate health authorities
Children and among
those who have major
risk
HPV vaccination in schools and society Coverage rate of the
for girls aged 13–26 years to prevent targeted category
cervical cancer
H. O. Al-Shamsi and A. M. Abyad
 5

Strategic axis III. Early detection

Main objectives Application mechanisms Measurement indicators The executing agency Follow-up
Create a national program for Development of a central public electronic • Completion rate Ministry of Health and Ministry of
early detection of cancer recall system for early detection services and • Population coverage Prevention/Statistics Health and
identification by e-mail rate in target groups Department and Prevention
Create a national platform or program for the Research The society
registration of cases that underwent early
examination for cancer
Increase the capacity of logistical and human
resources to increase population coverage
Health insurance and financial • Insurance coverage for early diagnostic Completion rate
coverage for early disclosure examinations
• Discounted packages for early detection and
uniform prices in the private and public
sectors
A Proposal for Cancer Control Plan in the UAE

(continued)
105
Table 5.6 (continued)
106

Strategic axis III. Early detection

Main objectives Application mechanisms Measurement indicators The executing agency Follow-up
Increase awareness about the • Awareness campaigns on the importance of • Number of Ministry of Health and Ministry of
importance of early detection early screening awareness campaign Prevention Health and
• Facilitate visitors to healthcare centers • Percentage of cases (community/ Prevention
• Target age and annual performance linked from categories of participants)
for health workers in early examination target age
centers transferred for early
• The rate of turnout to early examination examination
• Appointing clinical nurse specialists to • Number of
educate and support the team specialized
workforces that
were redundant
Establish a framework and • Develop a framework for standardization Percentage of policy Ministry of Health and
governance policy for quality and best practices completion and Prevention—
assurance and early screening • Clinical pathways for early cancer frameworks Noncommunicable
services in the health regions examination Disease and Mental
• For early screening of breast, cervical, and Health Section
colon cancer among the target age groups in
the population
Raising awareness of common Awareness campaigns about the symptoms of Number of awareness All participating
symptoms of cancer in society the most common cancers in the community campaigns parties
H. O. Al-Shamsi and A. M. Abyad
 5

Strategic axis IV. Rapid diagnosis

Main objectives Application mechanisms Measurement indicators The executing agency Follow-up
Establish an effective referral system 1. Implementing the service 1. Average waiting time from the Service providers, Ministry of
between different levels of care for access policy so that access time of onset to GP referred to early examination, Health and
cancer patients time is reduced to diagnostic the specialist and therapeutic Prevention
and therapeutic services every 2. Average waiting time from services Participating
year doctor’s appointment till the parties
diagnosis
3. Average waiting time from
diagnosis time until the start of
the treatment
4. Average waiting time from GP
appointment to time received
treatment
Rapid diagnostic initiative for lung Launch of rapid mobile Number of beneficiaries
cancer investigation clinics for early
A Proposal for Cancer Control Plan in the UAE

detection of lung cancer using

X-ray, CT scan, and breath
examination for people
susceptible to lung cancer
(continued)
107
Table 5.6 (continued)
108

Strategic axis V. Treatment

Measurement
Main objectives Application mechanisms indicators The executing agency Follow-up
Covering the cost of cancer Adopt a model pay for performance (personalized Number of Healthcare service Ministry of
treatment reimbursement model). Dubai Health Authority is beneficiaries providers Health and
providing therapeutic services where the treatment Prevention
is covered by insurance and pharmaceutical Participating
companies. The results are then evaluated on parties
treatment response/efficacy
Accreditation of centers of Preparing for specialized centers of excellence Number of Stakeholders
excellence for cancer treatment (third level) in cancer treatment and its accredited centers
complications and rehabilitation centers of excellence

Strategic axis VI. Ongoing care

The executing
Main objectives Application mechanisms Measurement indicators agency Follow-up
Development of palliative care • Studying the work on adding palliative service • Percentage of Ministry of Health Ministry of Health
services in health centers with easy access to services completion of the and Prevention and Prevention
and developing a guide for implementing a guide Stakeholders Participating
palliative care program parties
• Creation of teams to support cancer patients. • Team achievement Stakeholders
The team consists of patients who have percentage
recovered or are under treatment • Number of
• The team meets periodically for psychology beneficiaries
support among patients
H. O. Al-Shamsi and A. M. Abyad
 5

Strategic axis VII. Performance measurements

Main objectives Application mechanisms Measurement indicators The executing agency Follow-up
Annual evaluation for • Establishing a registry for early The percentage of Ministry of Health and Ministry of Health and
anticancer detection of cancer completion of the national Prevention Prevention
performance • Preparing and developing a registry registry, population Department of Research Department of Research and
indicators for early detection and development coverage for early cancer and Statistics Statistics
• Early detection data collection screening among the Participating parties
targeted age groups
• Create a unified national electronic The percentage of Ministry of Health and Ministry of Health and
registry for cancer completion of the National Prevention Prevention
Cancer Registry Society/Statistics Department of Research and
Department of Research Statistics
and Statistics
Participating parties
Measuring indications: Report completion Ministry of Health and Ministry of Health and
• The rate of detection of positive percentage rate of time Prevention Prevention
A Proposal for Cancer Control Plan in the UAE

cases by early cancer examination commitment to access the Participating parties Community/care
• Average number of cases detected in service management
late stages of cancer Specialty
• Waiting period, since the case was
referred before to the general
practitioner to complete the early
examinations
• Measurement of the KAP index Report completion rate Ministry of Health and Ministry of Health and
(knowledge, attitude, and practice— Prevention Prevention
to assess acceptance) for the Participating parties Community/care
community’s understanding of management
cancer screening Specialty

(continued)
109
Table 5.6 (continued)
110

Strategic axis VII. Research

Measurement
Main objectives Application mechanisms indicators The executing agency Follow-up
The priority for Research work to discover concepts, Research Ministry of Health and Ministry of Health and Prevention
epidemiological and knowledge, and opinions about cancer, completion rate Prevention Community/care management
clinical research of risk factors, and screening cancer in the Participating parties Specialization/management
cancer context of encouraging research related Statistics and research
to cancer
Develop a research agenda for the three Agenda Ministry of Health and
most common cancers (breast, colon, completion rate Prevention
and thyroid) Participating parties

Strategic axis IX. Workforce

Measurement
Main objectives Application mechanisms indicators The executing agency Follow-up
Providing qualified Complete medical team specialized in treating The percentage of Ministry of Health and Ministry of Health
human resources in the cancer in secondary and specialty care increase in the Prevention and Prevention
developing field of • Specialized doctors workforce Participating parties Community/care
cancer • Clinical nurse specialist management
• X-ray technicians Specialty
Raising the efficiency of Creation of training programs for healthcare The number of Ministry of Health and
employees, healthcare workers in the field of cancer and assess the training programs Prevention
professionals risk factors such as: Community/training center
• Awareness and health education and development
• Early detection Participating parties
• Palliative care
H. O. Al-Shamsi and A. M. Abyad
5 A Proposal for Cancer Control Plan in the UAE 111

5.7 Vistas in Cancer Care Plan

5.7.1 Expected Cancer Burden

The documented age-adjusted cancer incidence in the UAE population is lower

compared to the reported incidence in countries such as the United States and other
similar developed nations. However, it is anticipated that there will be an actual
increase of approximately 10–15% in the number of cancer cases annually, aligning
with the current trends in cancer occurrence [2, 3, 5, 7, 8, 16].

5.7.2 Cancer Control Program

It is crucial to establish a comprehensive National Cancer Control Program that

encompasses strategy development, the implementation of preventive measures,
and the execution of a comprehensive cancer management plan. This process
requires collaboration among various stakeholders, including government agencies,
nongovernmental organizations (NGOs), and the community. An effective and well-­
rounded plan should prioritize risk reduction, early detection of cancer, and
improved management to enhance survivorship and outcomes and ultimately reduce
the overall burden of cancer.
The cancer control program should not only simply aim to maintain the current
incidence rate of cancer but also strive to reduce it. A thorough national cancer pro-
gram assesses different approaches to cancer control and implements the most mod-
ern and cost-effective methods for the entire population. It emphasizes the
significance of cancer prevention and early detection at a treatable stage while also
aiming to provide optimal support to patients and their caregivers during the journey
of advanced disease. A well-established and effectively implemented cancer control
program is expected to lead to substantial risk reduction, improved early detection,
enhanced treatment approaches, and ultimately higher rates of survivorship.
In 2022, the National Cancer Committee underwent revisions and welcomed
experts from various healthcare sectors. It is crucial to adhere to the WHO Cancer
Control Strategy to establish a uniform, equitable, and consistent approach.
Strengthening collaboration with other ministries, including the Ministry of
Education, the Ministry of Religious Affairs, and the media, is strongly encouraged.
A well-defcO strategy to local requirements and existing data [8, 11, 24–26].

5.7.3 Cancer Registry

The cancer registry serves as a primary tool for the Cancer Control Program, pro-
viding essential functions. It plays a vital role in determining the extent of the can-
cer burden, identifying prevalent risk factors, and evaluating the effectiveness of the
cancer control program. By collecting and analyzing comprehensive epidemiologi-
cal data, such as cancer incidence, mortality, prevalence, stage at diagnosis, and
112 H. O. Al-Shamsi and A. M. Abyad

patient survival outcomes, the cancer registry enables the development and organi-
zation of standardized control plans. It provides valuable insights into cancer pat-
terns and trends over time, aiding in strategic planning and the implementation of
effective control measures.
In recent times, registry managers from 19 countries in the Middle East and
North Africa (MENA) region have reported the existence of 97 population-based
registries, 48 hospital-based registries, and 24 pathology-based registries. The
majority of population-based registries were either well-developed or partially
developed. However, significant challenges were identified, including the lack of
accurate death records, incomplete and unclear medical records, limited communi-
cation between various stakeholders, and a shortage of trained personnel. These
challenges were particularly pronounced in active conflict zones and neighboring
regions. Cancer registration faced additional obstacles, including inadequate health
infrastructure, the absence of regulations mandating cancer registration, and disrup-
tions caused by ongoing wars, conflicts, and financial constraints [27].
A fully developed national cancer registry consistently publishes an annual
report that provides details on cancer incidence and prevalence. It is essential for the
registry to collect extensive information, including disease staging, mortality rates,
disease demographics, and data on risk factors. However, the registry often faces
challenges such as a limited workforce, inadequate data on patients diagnosed and
treated overseas, difficulties in obtaining cooperation from nongovernmental insti-
tutions and medical personnel, and the mobility of the population [5, 27–29]. To
ensure accurate, consistent, reliable, comprehensive, and valuable data in the cancer
registry, the following actions need to be taken:

1. Establish the Cancer Registry Advisory Committee, which will be responsible

for planning cancer registry activities, providing feedback on data and reports,
and contributing to data dissemination and advocacy efforts.
2. Implement data quality indicators to monitor and improve the accuracy and reli-
ability of the collected data.
3. Collect complete data on cancer stage, mortality, risk factors, and prevalence to
enhance the comprehensiveness of the registry.
4. Increase the number of trained personnel in the registry by offering training to
new staff members and providing ongoing technical and financial support. This
will ensure the completeness of the cancer registration team and the sustainabil-
ity of the cancer registry.
5. Collect more comprehensive data on different types of cancers, including non-
morphological data, to capture a broader range of information.
6. Establish mandatory reporting requirements to ensure that healthcare providers
are legally obligated to notify cancer cases.
7. Make adjustments to the cancer notification form and electronic notification
forms to improve the efficiency and effectiveness of the reporting process.
8. Foster greater collaboration from healthcare providers to encourage their active
participation and contribution to the cancer registry efforts.
5 A Proposal for Cancer Control Plan in the UAE 113

5.7.4 Indicators for Monitoring

There are several widely recognized indicators used globally to monitor and assess
progress within a national cancer framework. Key performance indicators (KPIs)
are utilized, some of which are well-established, while others are specifically devel-
oped to suit local circumstances. Examples of these indicators include raising can-
cer awareness, reducing the number of active and passive smokers, increasing the
proportion of early-stage (1 and 2) colon and breast cancer cases, boosting the num-
ber of patients diagnosed through screening and/or urgent referral pathways, com-
paring 1-year and 5-year cancer survival rates to international benchmarks,
increasing the percentage of patients with comprehensive treatment plans across the
entire care pathway, and decreasing the number of patients with incomplete com-
prehensive treatment plans [3–5, 10, 16, 17, 23, 26].

5.7.5 Continuing on the Path to Progress and Excellence

While considerable advancements have been achieved, there is still a considerable

amount of work that lies ahead as we strive to realize our vision for the future of
cancer care, which remains a significant challenge. The UAE is committed to pursu-
ing excellence in health care, particularly in the field of cancer care, by enhancing
specialized services and implementing innovative treatment approaches. It is crucial
to continuously update and incorporate evidence-based, approved treatment modal-
ities and technologies that have demonstrated positive impacts on patient care into
our standardized management strategies. Moreover, there is a need for improve-
ments in the patient experience, with a particular emphasis on ensuring seamless
care pathways that align with the principles of the WHO Cancer Care Continuum
[24, 26, 27, 29].

5.7.6 Public Education and Understanding

It is imperative to invest in knowledge dissemination and educate the public about

the significance of prevention, enhance early detection initiatives, and facilitate
accurate cancer diagnoses. Efforts should be made to improve awareness campaigns
and debunk misconceptions surrounding cancer. These misconceptions include the
belief that cancer only manifests in advanced stages or specific locations, that it is
more prevalent in low-income countries, that it is invariably fatal, and that surgery
accelerates its spread. In addition, cancer carries numerous stigmas, leading to dis-
comfort and avoidance when discussing the topic. People may refrain from using
terms such as “cancer” or “tumor.” A diagnosis is often associated with vulnerabil-
ity, concerns about job security, and apprehension about the impact on sexual activ-
ity [2, 4, 28, 29].
114 H. O. Al-Shamsi and A. M. Abyad

5.7.7 Partnership Within the Cancer Community

There is a significant requirement to establish strong connections within the cancer

patient community, with the objective of promoting cancer awareness and preven-
tion; fostering public knowledge and comprehension of cancer; facilitating the shar-
ing of experiences; offering financial assistance to eligible cancer patients;
promoting collaboration with various stakeholders to organize gatherings, work-
shops, educational programs, and conferences; and supporting research endeavors
that raise awareness about the disease and its prevention methods [27, 29].

5.8 Prevention

Nearly one-third of cancer cases can be attributed to lifestyle and environmental

factors. The incidence of these preventable cancers will depend on the success of
preventive service initiatives in promoting healthy diets, physical activity, and envi-
ronmental well-being. By prioritizing public health through primary healthcare and
prevention services, we can reduce these risk factors and effectively lower the inci-
dence of cancer. A small proportion of cancer cases (10%) are associated with a
significant family history of cancer, potentially resulting from identifiable gene
mutations. Enhancing the capacity for genetic testing is necessary to identify these
cancer-linked genes. To address this, a comprehensive program for cancer preven-
tion and education should be developed, specifically targeting academic institu-
tions, and regular public education events should be scheduled [1].

5.8.1 Healthy Lifestyle Strategies

Adopting a healthy lifestyle, maintaining a nutritious diet, and engaging in suffi-

cient physical activity play a crucial role in reducing the risk of cancer. It is impor-
tant to enhance awareness regarding the positive impact of nutrition and regular
physical activity. To achieve this, it is necessary to establish and continuously moni-
tor culturally appropriate and sustainable policies and regulations that aim to pro-
mote food diversity, encourage healthy eating habits, and facilitate physical activity
across various settings, such as the general population, schools, universities, work-
places, and targeted communities. Primary healthcare teams have a vital role in
providing education, preventive guidance, and wellness services. The presence of
health coaches in primary healthcare centers is essential. Cancer prevention and
education messages should be disseminated through family physicians, primary
care providers, and community pharmacists, whenever possible, to support com-
munity education. These messages should be tailored to local needs and culture,
such as enhancing private exercise and recreation areas for women, providing access
to exercise facilities in the workplace, and regulating potentially harmful substances
used in food and its storage [10, 12, 13].
5 A Proposal for Cancer Control Plan in the UAE 115

5.8.2 Access to Genetic Testing

The breast and ovarian cancer screening clinic for individuals at high risk should
incorporate genetic testing and counseling services. Detecting individuals with a
heightened risk of hereditary cancer allows for prevention and early detection, lead-
ing to the potential reduction of cancer cases and related deaths. Consideration
should be given to making premarital screening mandatory, and the scope of ser-
vices can be expanded to encompass other hereditary diseases linked to cancer,
including gastrointestinal conditions. It is crucial to foster collaboration and estab-
lish an infrastructure for a national program focused on genetic testing, sequencing,
and research [26, 28, 29].

5.8.3 Vaccination

Human papillomavirus (HPV) infection is widely recognized as a major cause of

cervical cancer. Effective vaccination against the specific HPV strains that can lead
to cancer is possible. Many countries with high rates of cervical cancer have imple-
mented vaccination programs targeting preadolescent females. While the incidence
of cervical cancer is currently low in the UAE, further reductions can be achieved
through vaccination. Therefore, it is crucial to ensure that the HPV vaccine remains
accessible to families who choose to immunize their children. In addition, hepatitis
vaccination already plays a well-established role in preventing hepatocellular carci-
noma and should continue to be included in all national immunization programs
[27, 29].

5.8.4 Smoking

It is imperative to maintain our commitment to implementing a public health strat-

egy aimed at eliminating all forms of smoking. This strategy encompasses various
components, such as tobacco surveillance systems, warnings on cigarette packag-
ing, a regulatory framework for enforcement, tobacco cessation services, including
a national quit helpline and website, access to nicotine replacement therapy, support
through primary healthcare services, and a well-designed comprehensive tobacco
taxation model encompassing customs and excise taxes on all tobacco products [14,
26, 28, 29].

5.9 Early Detection

Evidence has shown that early detection of cancer significantly improves the likeli-
hood of successful treatment and better outcomes. For instance, in cases of colon
cancer diagnosed at the earliest stage, over 90% of individuals survive for at least
116 H. O. Al-Shamsi and A. M. Abyad

10 years. On the other hand, if the cancer is diagnosed at an advanced stage, the
10-year survival rate drops to below 5%.

5.9.1 Increase in Awareness

Ongoing efforts to raise awareness about the accessibility and significance of

screening and early detection should persist and be enhanced throughout the entire
healthcare system, encompassing public and private primary, secondary, and ter-
tiary healthcare providers. Engaging public figures as advocates for promoting
screening as a means of early disease detection can have a substantial impact. It is
essential for each country to determine the appropriate age and frequency of screen-
ing based on its own national data [29].

5.9.2 Enhancing Cancer Detection Services

Despite having a relatively low incidence of cancer, our priority remains enhanc-
ing the treatment outcomes for cancer patients. Early detection plays a critical
role in improving cancer survival rates. Given that breast cancer tends to occur at
a younger age in the United States compared to other developed nations, it is
essential to consider initiating breast screening for women at a younger age [30].
Continuing the implementation of comprehensive national screening programs
and establishing effective systems for screening recall are crucial to screening
services. By thoroughly examining baseline data, we can assess the advantages
and challenges of lowering the age for initial screening and implementing screen-
ing for the young adult population. Cervical screening operates on an opportu-
nistic basis due to the relatively low prevalence. A situational analysis is needed
to assess the evidence for the adoption of a national population-based cervical
cancer screening program. Early detection of lung cancer can significantly
improve outcomes, and it is worth considering the evaluation of low-dose com-
puted tomography scanning for lung cancer in older males and smokers.
Moreover, given the increasing incidence of thyroid cases, population-based thy-
roid screening should also be taken into consideration. It is crucial that the guide-
lines are fully embraced and uniformly implemented by all healthcare providers.
These guidelines should be formally adopted and established as national policy
while also being utilized for reimbursement by the National Health Insurance. To
stay up-to-date with evolving practices and technological advancements in diag-
nostics, it is necessary to periodically review and update clinical management
guidelines and screening protocols through peer review. Implementation of con-
tinuous improvement initiatives and the use of performance indicators are essen-
tial for effective monitoring and surveillance. Operational standards for all
cancer screening programs need to be updated on a regular basis [6, 19–
22, 27–29].
5 A Proposal for Cancer Control Plan in the UAE 117

5.10 Diagnosis

Ensuring a prompt and accurate diagnosis is crucial when cancer is suspected to

enable timely treatment. It is necessary to establish efficient referral pathways to
ensure that patients referred to specialists for suspected cancer undergo diagnostic
procedures within a predetermined timeframe. During this period, a comprehensive
evaluation, including physical examinations, imaging, and pathology testing, should
be conducted to establish a diagnosis, which can then be discussed and approved in
multidisciplinary team (MDT) meetings. The investment in advanced imaging sys-
tems has yielded positive results, enabling clinicians to plan targeted therapies and
monitor treatment responses. It is important to have a connected system where diag-
nostic images can be accessed by all healthcare providers. Centralized pathology
laboratories, PET scans, nuclear medicine units, and other support services can
enhance diagnostic capabilities. Streamlining the patient experience along the entire
care pathway is crucial, with breast clinics following international best practices to
offer mammography, ultrasound, core biopsy, and clinical examination in a single
visit. In the coming years, site-specific diagnostic clinics will be established,
equipped to provide site-specific genetic testing. While considering the pros and
cons of centralization, the principle of “localize where possible, centralize where
necessary” should guide the planning and development of cancer diagnostic ser-
vices [3, 8, 19, 20, 26].
We need to ensure our dedication to meeting the highest international standards
and adhering to quality control regulations, which often necessitate accreditation
from internationally recognized organizations. It is important to establish a steering
committee that will be responsible for overseeing the regulation, development, and
implementation of diagnostic standards.

5.10.1 Monitoring and Measuring Success

Regular and periodic monitoring of diagnostic pathways is essential to ensure sus-

tained progress. The number of cancer patients seeking healthcare services world-
wide is steadily increasing, leading to greater demands on diagnostic services such
as pathology and imaging. Meeting targets becomes challenging due to these
increasing demands. The implementation of electronic medical records systems in
public healthcare providers has improved data exchange capabilities within the sys-
tem. Prioritizing the recruitment of specialized personnel in pathology and imaging,
the continuous development of patient pathways, the adoption of precision diagnos-
tic techniques, the incorporation of precision medicine, and the integration of
molecular pathology and molecular genetics are crucial. Gradual decentralization of
diagnostic tests and training in cancer diagnosis can help meet timelines for cancer
treatment pathways and increase the rate of patient referrals in a cost-effective man-
ner. Providing training for primary care physicians in procedures like colonoscopy,
ultrasound, and radiology can support the diagnostic pathway. It is necessary to
initiate a communication skills training program as well [28, 31].
118 H. O. Al-Shamsi and A. M. Abyad

Regularly gathering feedback from patients and primary care physicians is

important for the ongoing review, development, and enhancement of the training
program. This feedback should be consistently communicated across all levels of
the healthcare system to ensure uniformity and enable patients to make well-­
informed decisions about their treatment. It is necessary to create tools that facilitate
shared decision-making. Key performance indicators can be established in collabo-
ration with healthcare professionals and the broader public to monitor progress and
effectiveness [27, 29].

5.11 Treatment

Following the establishment of up-to-date diagnostic services, it is essential to

develop and maintain comprehensive treatment services, which encompass surgical
oncology, medical oncology, radiation oncology, and palliative care. Surgical oncol-
ogy has undergone continuous advancement, and a proficient surgical oncologist
collaborates closely with other subspecialties in oncology to provide improved can-
cer treatment. This collaboration helps reduce the occurrence of unnecessary sur-
geries, such as those with involved margins, inadequate surgeries, or unplanned
procedures. Furthermore, surgical oncologists are skilled in reconstruction surger-
ies, aiming to enhance the quality of life for patients. Integrating surgical oncology
within oncology services and ensuring structured training and fellowship programs
for surgeons are crucial. In addition, the introduction of new supportive services like
clinical psychologists, clinical dietitians, social workers, and community nursing
services is necessary [7, 28].
We should establish and enforce guidelines for referring physicians and radiolo-
gists to ensure standardized practices for each type of cancer. Strengthening the
tumor boards in cancer institutes is crucial, and all new and complex cases should
be reviewed and discussed by a multidisciplinary team (MDT). This collaborative
approach will result in a well-documented care plan tailored to each patient's needs.
In addition, there should be a mechanism in place to evaluate and incorporate new
treatment options based on randomized controlled trials, international approvals,
and guidance, ensuring that the most up-to-date and effective treatments are avail-
able [23, 27, 31].

5.12 Palliative Care

Palliative care is a crucial and specialized aspect of cancer care services that centers
around alleviating symptoms, preventing patient distress, and enhancing overall
quality of life [8, 17, 29]. Palliative care encompasses all stages of illness, including
those receiving treatment for curable conditions, those living with the disease, and
those nearing the end of life. It can be provided in various settings, such as hospitals,
homes, or hospices. Palliative care adopts a multidisciplinary approach, involving a
team of healthcare professionals including physicians, pharmacists, specialized and
5 A Proposal for Cancer Control Plan in the UAE 119

community nurses, chaplains, social workers, psychologists, dietitians, and other

allied health professionals. Together, they collaborate to create a comprehensive
care plan that addresses the physical, emotional, spiritual, financial, and social
needs of the patient and their family, aiming to alleviate suffering in all aspects of
their lives [24, 28]. We need to identify and address gaps and needs in palliative care
and utilize all available resources effectively. Our focus should be on promoting the
establishment of palliative care services across different levels of health care,
including the community. This entails engaging in advocacy, providing education
and training, and raising awareness about palliative care. We should also advocate
for the availability and accessibility of essential opioids and other medications used
in palliative care for all cancer patients. In addition, we should explore potential
legislative and regulatory changes to support and improve palliative care services.

5.13 Services

There will be a growing need to expand services and optimize medical oncology
services in terms of human resources and infrastructure to ensure the effective deliv-
ery of systemic anticancer therapy. Early diagnosis plays a crucial role in improving
cure rates and is both simple and cost-effective. Achieving early diagnosis relies on
raising awareness among the general public and healthcare professionals about the
early signs and symptoms of cancer. This includes recognizing potential warning
signs and taking prompt action. It is important to disseminate knowledge to the
public to enhance cancer awareness and provide training to healthcare professionals
to improve their understanding and skills in identifying early signs and symptoms
of common cancers. Furthermore, it emphasizes the importance of accessible,
affordable, and timely access to diagnostic tests, staging investigations, treatment
services, and follow-up care within public healthcare services. Screening is a
method of identifying individuals who are apparently healthy and asymptomatic but
at higher risk of having early-stage disease that may not be detectable clinically.
Screening tests can be offered to the general population at regular intervals
(population-­based screening) or recommended to asymptomatic individuals by
healthcare providers during routine healthcare visits (opportunistic or spontaneous
screening).
Cancer control and prevention can be accomplished through several crucial mea-
sures. Implementing an effective screening program can lead to a decrease in the
incidence of new cancer cases, improved outcomes, and reduced mortality rates.
Globally recommended screening programs for breast, cervical, and colorectal can-
cers aim to prevent these diseases by identifying and treating pre-cancerous lesions
that may increase the risk of developing malignancies. These screening initiatives
play a vital role in detecting and managing these conditions in an effective and
timely manner [19–22]. Furthermore, early detection of these diseases, often at a
stage where treatment is possible, is facilitated. To effectively plan and address the
situation, it is necessary to conduct a comprehensive analysis, evaluating the current
status and identifying the need for capacity building. This includes developing
120 H. O. Al-Shamsi and A. M. Abyad

training programs for healthcare providers and ensuring readiness and accessibility
to timely diagnostic investigations, appropriate treatment options, and follow-up
care. Collaboration with the community and the utilization of mass media platforms
can help disseminate accurate information to the public. Standardized plans for
early cancer diagnosis and screening in primary care facilities should be developed,
establishing reliable screening infrastructure tailored to specific cancers and adher-
ing to unified selection criteria for cancer screening [17].
We should provide training to volunteers from nongovernmental organizations
(NGOs) to enhance their ability to effectively communicate scientifically based
information to the public. In addition, efforts should be made to establish a well-
structured screening registry to ensure organized and systematic screening processes.
It is important to initiate women’s health programs at the age of 40, focusing on
regular clinical breast examinations, educating women about breast self-­examination,
and providing mammograms as necessary and upon request. We should also priori-
tize adherence to the Extended Program of Immunization and the National Tobacco
Control Program.
In numerous developed nations, well-organized medical oncology services exist,
accompanied by comprehensive guidelines for the safe and efficient administration
of chemotherapy medications. These services are conveniently located near patients’
residences, ensuring easier access to effective treatment and enhancing patient
adherence and outcomes. Therefore, there is a continuous requirement to establish
models that enable simplified and secure delivery of systemic therapy, including
chemotherapy, to eligible patients in the UAE, integrating it as an essential element
of a National Cancer Control Program [3, 9, 16, 26, 29].
The implementation of a comprehensive plan to enhance oncology services at
the secondary and tertiary healthcare levels will contribute to ensuring equal access
to standardized treatment, and delivering safe and optimal therapy in proximity to
patients’ residences. This involves establishing guidelines for the procurement, stor-
age, and administration of drugs, monitoring treatment outcomes, establishing
referral pathways, and creating a network of oncology services within the public
healthcare system to facilitate training. To meet the growing demand for cancer
care, it is essential to establish satellite or secondary oncology centers that can pro-
vide services in close proximity to patients, alleviating the need for extensive travel.
These centers should operate under the supervision of the main oncology services,
maintaining affiliation and collaboration.

5.14 Resource Allocation and Cost-Effectiveness

Proper allocation of resources is crucial for the development and success of any
cancer control plan. It requires strong commitment, dedication, and vision from
decision-makers. The rising costs of cancer treatment, driven by advancements in
diagnostics and therapies, have made it increasingly unaffordable. In the United
States, private insurers rely on the Institute for Clinical and Economic Review
(ICER) to assess costs and determine reimbursement decisions. Meanwhile, in
5 A Proposal for Cancer Control Plan in the UAE 121

England, the National Institute for Health and Care Excellence (NICE) makes cov-
erage decisions for the publicly funded National Health Service. Many newly
developed cancer drugs are found to be lacking cost-effectiveness in evaluations
conducted by NICE. However, NICE’s ability to negotiate price discounts and
implement patient access schemes has helped reduce costs significantly. The chal-
lenges in proving the clinical effectiveness of new cancer drugs, including reliance
on inadequately validated surrogate measures, contribute to variations in cost-­
effectiveness. The adoption of ICER assessments by private insurers in the US has
provided a standard for measuring the comparative value of new cancer treatments.
NICE employs various policy tools, such as value-based pricing, direct price nego-
tiations, and patient access schemes, to inform its recommendations, considering a
range of cost-effectiveness values. Spending on expensive new cancer therapeutics
is increasing for payers and health systems. Both ICER and NICE have indicated
that most new cancer drugs do not offer good value for money at their current
prices [28, 31–33]. Hence, it is essential to establish an evaluation system for all
treatments, engage in negotiations with suppliers, and develop patient support sys-
tems. We need to allocate our existing resources in a fair and reasonable manner to
provide patients with equitable access, affordability, and proven therapeutic
benefits.

5.14.1 Workforce

There will be a requirement to invest in capacity development by recruiting and

nurturing a skilled workforce, providing training opportunities, and establishing
local institutions. It will be necessary to enhance the potential and capabilities of the
workforce through ongoing training, education, and the implementation of personal
development programs for each individual.
We should establish training programs and fellowships in specialized areas of
cancer care to strengthen our cancer services by training and incorporating a local
workforce. It is essential to ensure quality by implementing accreditation, certifica-
tion, audits, and regular evaluations [2, 4, 9, 11, 19, 20].

5.15 Research

In 2011, the United Nations highlighted the importance of research to guide action
against NCDs at regional and global levels [24, 26, 29] as NCDs, including cancer,
are now considered global crises. Every country, culture, and society are different in
terms of cancer incidence, cancer types, cancer biology, economy, access, and
affordability. Differences in cultural beliefs, customs, and misconceptions about
cancer contribute to variations in the acceptance of certain treatments across differ-
ent societies. Therefore, there is a growing need to develop guidelines, pathways,
and practices that are tailored to local factors and take into account the specific
cultural contexts.
122 H. O. Al-Shamsi and A. M. Abyad

5.16 Conclusion

Countries in the WHO Eastern Mediterranean Region must prioritize national can-
cer control planning, as it is crucial to address the rising incidence of cancer in this
region. The increasing rates of cancer pose significant challenges, including a high
disease burden, premature mortality, and escalating healthcare expenses [4, 17].
Cancer control planning and implementation exhibit significant disparities both
between countries and within countries. Over half of the countries (12 out of 22)
have individual comprehensive national cancer control plans, while six (27%) have
noncommunicable disease plans that encompass cancer [27, 29]. The effective exe-
cution of cancer plans has faced obstacles due to inadequate governance structures,
limited coordination mechanisms, and insufficient human and financial resources.
In the majority of countries (20 out of 22, or 91%), the plan receives either full or
partial funding, yet this is often hindered by political instability and conflicts,
greatly impacting the planning and implementation of cancer control measures [32].
The UAE, as a growing economy, is facing a significant burden of cancer that is
expected to increase, leading to higher rates of illness and death. However, the cur-
rent efforts in screening and early detection are falling short of reaching the desired
coverage among the target population. To effectively combat cancer, it is crucial to
implement a comprehensive, well-structured, and efficient national cancer control
plan. This plan should involve accurate data collection, the establishment of an
organized and efficient cancer registry, and regular monitoring and evaluation of the
plan’s activities. The UAE’s cancer control plan aligns with the cancer control ini-
tiatives and frameworks set by the WHO and EMRO, incorporating well-defined
objectives and clear targets. These objectives aim to combat cancer, reduce its inci-
dence, minimize cancer-related morbidity and mortality, improve patient outcomes,
and enhance the quality of life for individuals affected by cancer [2, 8, 9, 17].
Continual commitment to progress and excellence is essential to our journey.
Expanding the cancer registry and providing it with the necessary legal framework
is imperative. We must prioritize preventive oncology by integrating the latest
knowledge, advancements in technology, and approved medications based on solid
evidence from international data and guidelines. Developing clinical pathways and
guidelines and implementing them, along with using key performance indicators
(KPIs), will enable us to monitor our cancer services effectively. Collaboration with
all stakeholders is crucial in enhancing cancer care initiatives and ensuring equita-
ble and affordable services while considering cost-effectiveness. Retaining a skilled
workforce and continuously enhancing their expertise through training and ongoing
education is vital. Regular monitoring and evaluation of their performance is essen-
tial. Seeking international accreditations from reputable organizations will ensure
that we remain on the path of progress and excellence [34].
Cancer care services should be easily accessible, consistent, and affordable for
everyone. By optimizing resource utilization, we can improve the delivery of cancer
care, ensuring that it reaches patients conveniently. It is important to establish connec-
tions and collaborations between primary health care, secondary care hospitals, tertiary
care centers, and private cancer care facilities equipped with advanced technologies. A
significant emphasis should be placed on investing in preventive oncology through
5 A Proposal for Cancer Control Plan in the UAE 123

Fig. 5.1 General structure of the plan

enhanced education, screening, and early detection approaches. The patient’s path
from identifying symptoms to receiving definitive treatment should be well-organized,
following both local regulations and international guidelines and protocols.
The primary emphasis should be on enhancing public awareness, enhancing
coordination of prevention efforts, expanding initiatives for early detection, ensur-
ing timely diagnosis, expediting treatment processes, and ensuring seamless conti-
nuity of care. These collective and integrated efforts should undergo regular
evaluation based on predetermined targets and key performance indicators (KPIs),
with a strong emphasis on workforce training and research. By addressing all
aspects of service and care, we can enhance the delivery of high-quality care and
improve patient outcomes (Fig. 5.1).

Conflict of Interest The authors have no conflict of interest to declare.

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Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer of

Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty fel-
lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fel-
lowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new dis-
tinct subgroup of CRC, NON V600 BRAF-mutated CRC. In 2022,
he published the first book about cancer research in the UAE and
also the first book about cancer in the Arab world, both of which
were launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to
126 H. O. Al-Shamsi and A. M. Abyad

document the cancer care in the UAE with many topics addressed
for the first time, e.g., neuroendocrine tumors in the UAE. He is
passionate about advancing cancer care in the UAE and the GCC
and has made significant contributions to cancer awareness and
early detection for the public using social media platforms. He is
considered as the most followed oncologist in the world with over
300,000 subscribers across his social media platforms (Instagram,
Twitter, LinkedIn, and TikTok). In 2022, he was awarded the pres-
tigious Feigenbaum Leadership Excellence Award from Sheikh
Hamdan Smart University for his exceptional leadership and
research and the Sharjah Award for Volunteering. He was also
named the Researcher of the Year in the UAE in 2020 and 2021 by
the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various lev-
els of research training for medical trainees to enhance their clini-
cal and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Dr. Amin M. Abyad earned his medical degree, Bachelor in

Medicine and Surgery (MBChB), from Beirut Arab University.
After completing his internship, he joined the Internal Medicine
Residency at Makassed Hospital in Beirut, Lebanon, which is affili-
ated with the American University of Beirut Medical Center
(AUBMC). Dr. Amin was appointed as Chief Resident of Internal
Medicine (2017–2018). Then, Dr. Amin started his fellowship in
hematology and medical oncology at Makassed Hospital, where he
received intensive training in hematology and medical oncology. Dr.
Amin joined Burjeel Medical City in July 2021. Dr. Amin is highly
interested in malignant hematology and solid malignancies. He has
been highly involved in clinical research, being involved in multiple
research projects and publishing in multiple peer-reviewed journals.
Dr. Abyad believes in patient-centered care, trying to enhance
patient outcomes through the application of the latest evidence-
based practice and personalized medicine.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Comprehensive Cancer Centers
in the UAE 6
Humaid O. Al-Shamsi and Amin M. Abyad

6.1 Introduction

The UAE is home to more than 30 oncology centers and clinics. In previous discus-
sions, we have provided an overview of the historical context surrounding the prom-
inent cancer centers in the UAE [1]. In the UAE, a specific definition for a
comprehensive cancer center (CCC) does not exist officially. The Department of
Health (DOH) has issued general criteria for centers of excellence in Abu Dhabi,
which are not tailored specifically to oncology [2].

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca
A. M. Abyad
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Burjeel Medical City, Abu Dhabi, United Arab Emirates

© The Author(s) 2024 127

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_6
128 H. O. Al-Shamsi and A. M. Abyad

6.2 Comprehensive Cancer Centers in the UAE

The comprehensive cancer center (CCC) should serve as a single destination cater-
ing to all requirements related to cancer treatment [3]. According to our perspective,
for a facility to be recognized as a comprehensive cancer center (CCC), it must offer
the following services: medical oncology and hematology for both adults and chil-
dren, surgical oncology, radiation oncology, nuclear medicine, and palliative care
[3]. At present, there are four centers that meet the criteria for being classified as
comprehensive cancer centers (CCCs) (Table 6.1). The cancer centers and hospitals
in the UAE are listed in Table 6.2 in alphabetical order.
The Al Jalila Foundation, a member of Sheikh Mohammed Bin Rashid Al
Maktoum Global Initiatives, has plans to establish the inaugural comprehensive
cancer charity hospital in Dubai, known as the “Hamdan Bin Rashid Cancer
Hospital.” This initiative aims to bring together renowned experts in order to pro-
vide integrated services for cancer prevention, diagnosis, and treatment within a
single facility. The hospital, named after the late Sheikh Hamdan Bin Rashid Al
Maktoum, will offer a range of services, including outpatient, ambulatory, and diag-
nostic services, as well as inpatient and surgical care, all delivered in a nurturing
environment that prioritizes individualized patient attention. Patients from all parts
of the UAE will be accepted, and the medical services provided will be either free
or significantly subsidized to alleviate the financial burden on individuals who are
unable to afford high-quality healthcare. The Al Jalila Foundation is investing AED
1.2 billion in constructing the region’s first fully modular-built hospital. Opening its
doors in 2026, the hospital aims to serve as a comprehensive hub for cancer care,
offering prevention, diagnosis, and treatment services with a capacity to accommo-
date 30,000 patients annually [4].
 6

Table 6.1 Established comprehensive cancer centers in the UAEa (alphabetical orders)
Services not
Hospital Location Established Oncology International Accreditation Unique services offered
American Dubai 2010 • N/A • Only acute hematology in private sector and Research Unit/
Hospital BMT unit in Dubai Publication,
Dubai • Palliative care unit Genetic
• Pediatric oncology Counseling
Burjeel Abu 2020 • The European Society for Medical • BMT unit and only pediatric BMT in the Genetic counseling
Medical Dhabi Oncology (ESMO) Designated Centres UAE
City of Oncology and Palliative Care, the • Only palliative care service in Abu Dhabi
only center accredited by ESMO in the city
UAE • Only acute hematology in private sector in
Abu Dhabi
• Cancer research unit
• Only Brain lab in the UAE
Comprehensive Cancer Centers in the UAE

• Pediatric oncology
Mediclinic Dubai 2016 • JCI accredited breast cancer unit • Brachytherapy Acute hematology
City • Palliative care unit and BMT unit,
Hospital • Pediatric oncology genetic counseling
Tawam Alain 1979 • JCI-­accredited breast cancer unit • Palliative service • Hepatobiliary
Hospitalb • JCI Clinical Care Program • Genetic counseling surgery
Certification in 2017 • Pediatric oncology • BMT unit
• National Accreditation Program for • Research and
Breast Centers (NAPBC) in 2015 publications
a
The following services must be available at the facility to be considered as a comprehensive cancer center: medical adult and pediatric oncology and hematol-
ogy; surgical oncology; radiation oncology; nuclear medicine and palliative care
b
The positron emission tomography (PET) scanner which is located near the main building of Tawam hospital is affiliated with Cleveland Clinic Abu
Dhabi (CCAD)
129
Table 6.2 Cancer centers and hospitals in the UAE in alphabetical order
130

Facility available
Medical Acute Bone marrow Nuclear
oncology and hematology transplantation Pediatric Surgical medicine/ Palliative Research
Cancer center Location infusion unit service unit oncology Radiation oncology PET imaging care unit unit
Abu Dhabi Stem Abu No No Yes No No No No No No
Cells Center Dhabi
Advanced Care Dubai Yes No No No No No No No No
Oncology Center
American Hospital Dubai Yes Yes Yes Yes Yes Yes Yes Yes No
Dubai
Al Zahra Hospital Dubai Yes No No No No Yes No No No
Dubai
Aster Hospital Dubai Yes No No No No Yes No No No
Burjeel Hospital Abu Yes No No No No Yes No No No
Dhabi
Burjeel Hospital Dubai Yes No No No No Yes No No No
for Advanced
Surgery Dubai
Burjeel Medical Abu Yes Yes Yes Yes Yes Yes Yes Yes Yes
City Dhabi
Burjeel Day Abu Yes No No No No No No No No
Surgery Center, Al Dhabi
Reem Island
Burjeel Royal Alain Yes No No No No Yes No No No
Hospital
Burjeel Specialty Sharjah Yes No No No No Yes No No No
Hospital
Canadian Hospital Dubai Yes No No No No Yes No No No
H. O. Al-Shamsi and A. M. Abyad
 Facility available
Medical Acute Bone marrow Nuclear
oncology and hematology transplantation Pediatric Surgical medicine/ Palliative Research
6
Cancer center Location infusion unit service unit oncology Radiation oncology PET imaging care unit unit
Cleveland Clinic Abu Yes No No No No Yes Yesa No No
Abu Dhabi Dhabi (off-site)
Clemenceau Dubai Yes No No Yes No Yes Yes No Yes
Medical Center
Dubai Hospital Dubai Yes Yes No Yes No Yes Yes No Yes
Gulf International Abu Yes No No No Yes No Yes No No
Cancer Center Dhabi
Lifeline Hospital Abu Yes No No No No No No No No
VPS Dhabi
King’s College Dubai Yes Yes No No No Yes No No No
Hospital London,
Dubai
Medcare Hospital Sharjah Yes No No No No Yes No No No
Mediclinic Airport Abu Yes Yes No No Yes Yes No No No
Comprehensive Cancer Centers in the UAE

Road Dhabi
Mediclinic City Dubai Yes Yes No Yes Yes Yes Yes Yes Yes
Hospital
Neuro Spinal Dubai Yes No No No Yes Yes No No No
Hospital
NMC Royal Sharjah Yes No No No No Yes No No No
Hospital Sharjah
NMC Specialty Abu Yes No No Yes No Yes No No No
Hospital Dhabi
Saudi German Dubai Yes No No No Yes Yes No No No
Hospital Dubai
Saudi German Ajman Yes No No No No Yes No No No
Hospital Ajman
Sharjah University Sharjah Yes No No No No Yes No No Yes
Hospital
(continued)
131
Table 6.2 (continued)
132

Facility available
Medical Acute Bone marrow Nuclear
oncology and hematology transplantation Pediatric Surgical medicine/ Palliative Research
Cancer center Location infusion unit service unit oncology Radiation oncology PET imaging care unit unit
Sheikh Khalifa Rasal-­ Yes No No No Yes Yes Yes No No
Specialty Hospital Khaimah
Sheikh Shakhbout Abu Yes Yes No No No Yes No No No
Medical City Dhabi
Tawam Hospital Alain Yes Yes No Yes Yes Yes Noa Yes Yes
Yas Clinic Abu Yes No No No No No No No No
Dhabi
Zulekha Hospital Sharjah Yes No No No No Yes No No No
Sharjah
a
Cleveland Clinic Abu Dhabi’s (CCAD) positron emission tomography (PET) scanner is located in Al Ain city (150 km away from CCAD main campus) near
the main building of Tawam Hospital
H. O. Al-Shamsi and A. M. Abyad
6 Comprehensive Cancer Centers in the UAE 133

6.3 Conclusion

In the UAE, there are over 30 cancer centers, with four of them meeting the criteria
to be classified as comprehensive cancer centers. These comprehensive centers offer
a range of services, including medical oncology and hematology for both adults and
children, surgical oncology, radiation oncology, nuclear medicine, and palliative
care. While there are several other cancer centers in the UAE providing various
aspects of cancer care, they may lack certain essential modalities such as radiation
and palliative care. However, there are ongoing efforts by additional centers to
establish themselves as comprehensive cancer centers in the UAE. It is crucial to
prioritize quality to ensure that cancer patients in the UAE receive high-quality care.

Conflict of Interest The authors have no conflict of interest to declare.

References
1. Al-Shamsi H, Darr H, Abu-Gheida I, et al. The state of cancer care in the United Arab Emirates
in 2020: challenges and recommendations, a report by the United Arab Emirates oncology task
force. Gulf J Oncolog. 2020;1:71–87.
2. https://www.doh.gov.ae/-­/media/F27DED3FBBA340A58EA4FD891EE39215.ashx. Accessed
9 Aug 2022.
3. Grosso D, Aljurf M, Gergis U. Building a comprehensive cancer center: overall structure. In:
Aljurf M, Majhail NS, Koh MBC, et al., editors. The comprehensive cancer center: d­ evelopment,
integration, and implementation. Cham: Springer International Publishing; 2022. p. 3–13.
4. https://www.aljalilafoundation.ae/what-we-do/treatment/hamdan-bin-rashid-cancer-hospital/.
Accessed on 7 Jun 2024.

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty
134 H. O. Al-Shamsi and A. M. Abyad

fellowship certification and training in gastrointestinal oncology and

the first Emirati to train and complete a clinical post-doctoral fellow-
ship in palliative care. He was an assistant professor at the University
of Texas MD Anderson Cancer Center between 2014 and 2017. He
has published more than 140 peer-reviewed articles in JAMA
Oncology, Lancet Oncology, The Oncologist, BMC Cancer, and
many others. His area of expertise includes precision oncology and
cancer care in the UAE. In 2016, he published with his group from
MD Anderson the JCO paper describing a new distinct subgroup of
CRC, NON V600 BRAF-mutated CRC. In 2022, he published the
first book about cancer research in the UAE and also the first book
about cancer in the Arab world, both of which were launched at
Dubai Expo 2020. Cancer in the Arab World has been downloaded
more than 450,000 times in its first 18 months of publication and is
the ultimate source of cancer data in the Arab region. He also pub-
lished the first comprehensive book about cancer care in the UAE
which is the first book in UAE history to document the cancer care
in the UAE with many topics addressed for the first time, e.g., neu-
roendocrine tumors in the UAE. He is passionate about advancing
cancer care in the UAE and the GCC and has made significant con-
tributions to cancer awareness and early detection for the public
using social media platforms. He is considered as the most followed
oncologist in the world with over 300,000 subscribers across his
social media platforms (Instagram, Twitter, LinkedIn, and
TikTok). In 2022, he was awarded the prestigious Feigenbaum
Leadership Excellence Award from Sheikh Hamdan Smart
University for his exceptional leadership and research and the
Sharjah Award for Volunteering. He was also named the Researcher
of the Year in the UAE in 2020 and 2021 by the Emirates Oncology
Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various lev-
els of research training for medical trainees to enhance their clini-
cal and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.
Dr. Amin M. Abyad earned his medical degree, Bachelor in
Medicine and Surgery (MBChB), from Beirut Arab University.
After completing his internship, he joined the Internal Medicine
Residency at Makassed Hospital in Beirut, Lebanon, which is affili-
ated with the American University of Beirut Medical Center
(AUBMC). Dr. Amin was appointed as Chief Resident of Internal
Medicine (2017–2018). Then Dr. Amin started his fellowship in
hematology and medical oncology at Makassed Hospital, where he
received intensive training in hematology and medical oncology. Dr.
Amin joined Burjeel Medical City in July 2021. Dr. Amin is highly
interested in malignant hematology and solid malignancies. He has
been highly involved in clinical research, being involved in multiple
research projects and publishing in multiple peer-­reviewed journals.
Dr. Abyad believes in patient-centered care, trying to enhance
patient outcomes through the application of the latest evidence-
based practice and personalized medicine.
6 Comprehensive Cancer Centers in the UAE 135

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Emirates Oncology Society
7
Humaid O. Al-Shamsi and Amin M. Abyad

7.1 Emirates Medical Association

Emirates Medical Association (EMA) is the mother organization of the Emirates

Oncology Society. EMA was established in 1981 as a nonprofit organization under
the United Arab Emirates’ Ministry of Community Development by a ministerial
decree number (24) dated May 9, 1981. The EMA is composed of healthcare pro-
viders that are members of the EMA as defined by its established bylaws. EMA is
responsible for supervising and establishing subsocieties, scientific training, confer-
ences, and events, as well as collaborating with healthcare organizations. EMA
launched its work through its competent executive, supervisory, and specialist
elected boards and committee members. The election happens every three years,
and all members are eligible to nominate themselves. The last election was in 2021,
and the next election will be in 2024. EMA is a scientific organization that has legal
personality, and its headquarters are in Dubai.

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca
A. M. Abyad
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Burjeel Medical City, Abu Dhabi, United Arab Emirates

© The Author(s) 2024 137

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_7
138 H. O. Al-Shamsi and A. M. Abyad

EMA aims to improve and enhance professional performance, develop, advance,

and encourage skills, and enrich scientific publications and practice in all health
fields, by:

1. Developing and advancing professional health-related programs and developing

sustained medical education programs for healthcare specialties, in line with the
general educational framework.
2. Coordinating and planning with other professional health entities, associations,
and authorities, inside and outside the United Arab Emirates (UAE).
3. Encouraging and supporting scientific research, publishing scientific publica-
tions, and issuing its own journal, Emirates Medical Journal (EMJ), established
in 2019.
4. Recommending and planning general plans to develop and qualify human
resources in health fields, e.g., physicians, nurses, and technicians.
5. Organizing scientific meetings, seminars, workshops, campaigns, and confer-
ences to discuss national health challenges and provide solutions and recom-
mendations to regulators and decision-makers.
6. Proposing research topics and encouraging health-related scientific research.
7. Approving the establishment of scientific societies or clubs for health specialties
under the umbrella of the EMA. EMA has 48 societies and 30 scientific clubs as
of September 2022.
8. The establishment of Emirates Medical Day was celebrated on May 9th annu-
ally. The day is dedicated to all healthcare workers in the UAE.

7.2 EMA Vision, Mission, and Core Values

The EMA vision is “to play a vital role in the continuous improvement in the quality
of health care in the UAE by being an integral part of the professional life of every
physician” [1].
To keep the EMA members up-to-date with the global changes and advance-
ments in practice within the medical field.

• Leadership
• Commitment
• Quality
• Integrity
• Ethics

7.3 Emirates Oncology Society Mission and Logo

The Emirates Oncology Society (EOS) was established in 2016. It is dedicated to

promoting and enhancing the comprehensive care of cancer patients across the UAE
by bringing together all of the practicing cancer specialists and healthcare workers
from different backgrounds in the field of oncology.
7 Emirates Oncology Society 139

To help our cancer patients through their treatment journey against different
challenges until recovery, this requires their treating team, including medical oncol-
ogists, surgeons, radiation oncologists, oncology nurses, pharmacists, cancer
researchers, social workers, and dietitians, to gain easy access to the latest scientific
knowledge, technology, and treatment protocols at hand. The EOS aims to provide
the members with state-of-the-art evidence-based information in order to unify and
enhance their practice and achieve this goal for all of their patients. The EOS is also
dedicated to cancer research and scientific publications.
The EOS logo highlights the core values and mission: Innovation, Research, and
Education.

7.4 Board of Directors

The EOS board of directors is elected every three years; the last election was in
November 2021. The following were elected (Fig. 7.1):
President (second term): Professor Humaid Al Shamsi
Vice President (second term): Dr. Falah Al khatib
General Secretary: Dr. Saeed Rafii
Scientific committee Chairperson: Dr. Aydah Alawadi
Cultural committee Chairperson: Dr. Syed Hammad Tirmazy
140 H. O. Al-Shamsi and A. M. Abyad

Fig. 7.1 The EOS board of directors (2022)

7.5 EOS Membership

For a candidate to be eligible for membership, he or she must be a physician licensed

to practice oncology or hematology in the UAE. There are 80 active members in
EOS as of September 2022.

7.6 Continuing Medical Education (CME) Activities

and Conferences

The EOS is dedicated to advancing cancer care in the UAE by updating all health-
care providers in the cancer field with the latest advances in cancer. The EOS holds
the largest number of accredited conferences and CMEs in the UAE. The EOS
7 Emirates Oncology Society 141

delivered more than 200 accredited CME hours in 2020 and 2021. The EOS holds
many events and activities as stand-alone activities or in collaboration with interna-
tional cancer societies and organizations like the European Society of Medical
Oncology (ESMO), the International Association for the Study of Lung Cancer
(IASLC), and the Union for International Cancer Control (UICC) [2].
The EOS annual conference is held every year in September. The last annual
conference was held in September 2022, with over 2000 attendees, both in person
and virtually from across the globe. The faculty were highly selected from the UAE,
Gulf Cooperation Council (GCC) countries, the Middle East and North Africa
(MENA) region, and also internationally, e.g., the USA, Spain, the UK, and Canada.
The EOS is also the official organizer of Best of ESMO© in the UAE and Best
of WCLC© in the UAE. There are also many local oncology CME activities orga-
nized locally and across the GCC.
Besides the scientific activities, the EOS is dedicated to increasing community
awareness about cancer. It publishes and organizes awareness campaigns through-
out the year. It also posts articles in Arabic and English about cancer dedicated to
the public [3].

7.7 Cancer Care Quality Improvement

The ESO works closely with the regulators in the UAE to identify gaps and improve
the quality of cancer care by implementing quality checks and KPIs. The EOS is part
of the UAE national committee for cancer care under the Ministry of Health and
Prevention (MOHAP). The EOS has also worked closely with the Dubai Health
Authority (DHA) as an advisor on a cancer quality improvement project in Dubai. The
EOS provides professional consultations to national, regional, and international bodies
interested in learning about cancer care in the UAE and quality improvement measures.

7.8 Research and Publications

In 2021, the EOS was named by the EMA as the most scientific publishing society
among all the 48 members of the EMA. The EOS has published more than 25 pub-
lications in 2021.

7.8.1 Books

1. Cancer in the Arab World

Al-Shamsi, Humaid O., Ibrahim H. Abu-Gheida, Faryal Iqbal, and Aydah
Al-Awadhi. [4]
This book contains up-to-date data on cancer rates across the Arab region,
discussing the present state of cancer treatment and potential future develop-
ments. It features dedicated sections on breast cancer, colon cancer, and pallia-
142 H. O. Al-Shamsi and A. M. Abyad

tive care specific to the Arab world. Expert authors from various Arab countries
contributed to each chapter.
The book has been downloaded more than 300,000 times within 1 year of its
launch, making it the most downloaded medical book in the MENA region
in 2022.

7.8.2 Book Chapters

1. Abu-Gheida, I.H., Nijhawan, N., Al-Awadhi, A., Al-Shamsi, H.O. (2022).

General Oncology Care in the UAE. In: Al-Shamsi, H.O., Abu-Gheida, I.H.,
Iqbal, F., Al-Awadhi, A. (eds) Cancer in the Arab World. Springer, Singapore.
https://doi.org/10.1007/978-­981-­16-­7945-­2_19
2. Al-Shamsi, H.O., Iqbal, F. (2022). General Oncology Care in Qatar, Comoros,
and Djibouti. In: Al-Shamsi, H.O., Abu-Gheida, I.H., Iqbal, F., Al-Awadhi,
A. (eds) Cancer in the Arab World. Springer, Singapore. https://doi.
org/10.1007/978-­981-­16-­7945-­2_21
3. Al-Shamsi, H.O., Iqbal, F., Abu-Gheida, I.H. (2022). Introduction. In: Al-­
Shamsi, H.O., Abu-Gheida, I.H., Iqbal, F., Al-Awadhi, A. (eds) Cancer in the
Arab World. Springer, Singapore. https://doi.org/10.1007/978-­981-­16-­7945-­2_1
4. Humaid Al-Shamsi, Siefker-Radtke A, Czerniak B, Dinney C, Millikan
RE. Uncommon Cancers of the Bladder. In: Textbook of Uncommon Cancer, 5th
ed. Ed(s) Raghavan D, Brecher ML, Johnson DH, Meropol NJ, Moots PL, Rose
PG, Mayer IA. John Wiley and Son, 2016.
5. Nijhawan N.A., Al-Shamsi H.O. (2021) Palliative Care in the United Arab
Emirates (UAE). In: Laher I. (eds) Handbook of Healthcare in the Arab World.
Springer, Cham. https://doi.org/10.1007/978-­3-­319-­74365-­3_102-­1
6. Abu-Gheida I., Nijwahan N., Al-Shamsi H.O. (2020) Oncology Care in the
UAE. In: Laher I. (eds) Handbook of Healthcare in the Arab World. Springer,
Cham. https://doi.org/10.1007/978-­3-­319-­74365-­3_183-­1

7.8.3 Peer-Reviewed Publications

1. Abboud K, Umoru G, Esmail A, Abudayyeh A, Murakami N, Al-Shamsi HO,

Javle M, Saharia A, Connor AA, Kodali S, Ghobrial RM. Immune Checkpoint
Inhibitors for Solid Tumors in the Adjuvant Setting: Current Progress, Future
Directions, and Role in Transplant Oncology. Cancers. 2023 Feb 23;15(5):1433.
2. Park, S. H., Hong, S. H., Kim, K., Lee, S. W., Yon, D. K., Jung, S. J., … & Smith,
L. (2023). Nonpharmaceutical interventions reduce the incidence and mortality
of COVID-19: A study based on the survey from the International COVID-19
Research Network (ICRN). Journal of medical virology, 95(2), e28354.
3. Bernstein E, Lev-Ari S, Shapira S, Leshno A, Sommer U, Al-Shamsi H, Shaked
M, Segal O, Galazan L, Hay-Levy M, Sror M. Data From a One-Stop-Shop
Comprehensive Cancer Screening Center. Journal of Clinical Oncology. 2023
Jan:JCO-22.
7 Emirates Oncology Society 143

4. Al-Shamsi HO, Abdelwahed N, Al-Awadhi A, Albashir M, Abyad AM, Rafii S,

Afrit M, Al Lababidi B, Abu-Gheida I, Sonawane YP, Nijhawan NA. Breast
Cancer in the United Arab Emirates. JCO Global Oncology. 2023
Jan;9:e2200247.
5. Al-Shamsi, Humaid O., Ibrahim H. Abu-Gheida, Faryal Iqbal, and Aydah Al-­
Awadhi. “Cancer in the Arab World.” https://link.springer.com/
book/10.1007/978-­981-­16-­7945-­2
6. AlZaabi A, AlHarrasi A, AlMusalami A, AlMahyijari N, Al Hinai K, ALAdawi
H, Al-Shamsi HO. Early onset colorectal cancer: Challenges across the cancer
care continuum. Annals of Medicine and Surgery. 2022 Aug 22:104453.
7. Nijhawan NA, Al-Shamsi HO. Experiences and challenges of a new palliative
care service in the United Arab Emirates. Palliat Med Hosp Care Open J. 2022;
8(2):30–34. doi: 10.17140/PMHCOJ-8-150.
8. Al-Shamsi HO. The State of Cancer Care in the United Arab Emirates in 2022.
Clinics and Practice. 2022 Nov 23;12(6):955–85.
9. Al-Shamsi HO. Barriers and Facilitators to Conducting Oncology Clinical
Trials in the UAE. Clinics and Practice. 2022 Nov 7;12(6):885–96.
10. Ennab, F., Tsagkaris, C., Babar, M. S., Tazyeen, S., Kokash, D., Nawaz, F. A., &
Al-Shamsi, H. O. (2022). A potential rise of breast cancer risk in the UAE post-­
COVID-­19 lockdown: A call for action. Annals of Medicine and Surgery, 103976.
11. Aoude M; Mousallem M; Abdo M; Youssef B; Kourie HR; Al-Shamsi
HO. Gastric cancer in the Arab World: a systematic review. East Mediterr
Health J. 2022;28(7):521–531. https://doi.org/10.26719/emhj.22.051
12. Abou Ghayda, R., Lee, K. H., Han, Y. J., Ryu, S., Hong, S. H., Yoon, S., … &
Shin, J. I. (2022). The global case fatality rate of coronavirus disease 2019 by
continents and national income: A meta-analysis. Journal of Medical Virology,
94(6), 2402–2413.
13. Al Ashour, B. H., Azam, F., Ibnshamsah, F., Alrowais, F., Al-Garni, A., Al-­
Shamsi, H. O., & Bukhari, N. (2022). Metastatic Type II Papillary Renal Cell
Carcinoma With Recurrent Complete Responses to Sunitinib: A Case Report
With a Literature Review. Cureus, 14(5).
14. Mula-Hussain, Layth, Hala Mahdi, Zhian Salah Ramzi, Marwan Tolba,
Mohamad Saad Zaghloul, Zineb Benbrahim, Atlal Abusanad, Humaid
Al-Shamsi, Adda Bounedjar, and Abdul-Rahman Jazieh. “Cancer Burden
Among Arab World Males in 2020: The Need for a Better Approach to Improve
Outcome.” JCO Global Oncology 8 (2022): e2100407.
15. Abu-Gheida, I.H., Nijhawan, N., Al-Awadhi, A., Al-Shamsi, H.O. (2022).
General Oncology Care in the UAE. In: Al-Shamsi, H.O., Abu-Gheida, I.H.,
Iqbal, F., Al-Awadhi, A. (eds) Cancer in the Arab World. Springer, Singapore.
https://doi.org/10.1007/978-­981-­16-­7945-­2_19
16. Al-Shamsi, H.O., Iqbal, F. (2022). General Oncology Care in Qatar, Comoros,
and Djibouti. In: Al-Shamsi, H.O., Abu-Gheida, I.H., Iqbal, F., Al-Awadhi,
A. (eds) Cancer in the Arab World. Springer, Singapore. https://doi.
org/10.1007/978-­981-­16-­7945-­2_21
144 H. O. Al-Shamsi and A. M. Abyad

17. Al-Shamsi, H.O., Iqbal, F., Abu-Gheida, I.H. (2022). Introduction. In: Al-­
Shamsi, H.O., Abu-Gheida, I.H., Iqbal, F., Al-Awadhi, A. (eds) Cancer in the
Arab World. Springer, Singapore. https://doi.org/10.1007/978-­981-­16-­7945-­2_1
18. Mula-Hussain L, Mahdi H, Ramzi ZS, Tolba M, Zaghloul MS, Benbrahim Z,
Abusanad A, Al-Shamsi H, Bounedjar A, Jazieh AR. Cancer Burden Among
Arab World Males in 2020: The Need for a Better Approach to Improve
Outcome. JCO Global Oncology. 2022 Mar;8:e2100407.
19. Allehebi A, Kattan KA, Rujaib MA, Dayel FA, Black E, Mahrous M, AlNassar
M, Hussaini HA, Twairgi AA, Abdelhafeiz N, Omair AA, Shehri SA, Al-Shamsi
HO, Jazieh AR. Management of Early-Stage Resected Non-Small Cell Lung
Cancer: Consensus Statement of the Lung cancer Consortium. Cancer Treat
Res Commun. 2022 Feb 22;31:100538. doi: 10.1016/j.ctarc.2022.100538.
Epub ahead of print. PMID: 35220069.
20. Al-Shamsi, H.O., Abyad, A.M. and Rafii, S., 2022. A Proposal for a National
Cancer Control Plan for the UAE: 2022–2026. Clinics and Practice, 12(1),
pp.118–132.
21. Rafii, S., Tashkandi, E., Bukhari, N. and Al-Shamsi, H.O., 2022. Current Status
of CRISPR/Cas9 Application in Clinical Cancer Research: Opportunities and
Challenges. Cancers, 14(4), p.947.
22. Al-Shamsi, H. O., Abyad, A., Kaloyannidis, P., El-Saddik, A., Alrustamani, A.,
Abu Gheida, I., … & Mheidly, K. (2022). Establishment of the First
Comprehensive Adult and Pediatric Hematopoietic Stem Cell Transplant Unit
in the United Arab Emirates: Rising to the Challenge. Clinics and Practice,
12(1), 84–90.
23. Ramia P, Bodgi L, Mahmoud D, Mohammad MA, Youssef B, Kopek N, Al-­
Shamsi H, Dagher M, Abu-Gheida I. Radiation-Induced Fibrosis in Patients
with Head and Neck Cancer: A Review of Pathogenesis and Clinical Outcomes.
Clinical Medicine Insights: Oncology. 2022 Jan;16:11795549211036898.
24. Elsamany, Shereef, Mohamed Elbaiomy, Ahmed Zeeneldin, Emad Tashkandi,
Fayza Hassanin, Nafisa Abdelhafeez, Humaid O. Al-Shamsi, Nedal Bukhari,
and Omima Elemam. “Suggested Modifications to the Management of Patients
With Breast Cancer During the COVID-19 Pandemic: Web-Based Survey
Study.” JMIR cancer 7, no. 4 (2021): e27073.
25. M.H. Hodroj, G. El Hasbani, Humaid O. Al Shamsi, et al., clinical burden of
hemophilia in older adults: Beyond bleeding risk, Blood Reviews (2021) https://
doi.org/10.1016/j.blre.2021.100912
26. Al-Shamsi, H.O., Jaffar, H., Mahboub, B., Khan, F., Albastaki, U., Hammad,
S. and Zaabi, A.A., 2021. Early Diagnosis of Lung Cancer in the United Arab
Emirates: Challenges and Strategic Recommendations. Clinics and Practice,
11(3), pp.671–678.
27. Al-Shamsi, H.O., Abu-Gheida, I., Abdulsamad, A.S., AlAwadhi, A., Alrawi, S.,
Musallam, K.M., Arun, B. and Ibrahim, N.K., 2021. Molecular Spectra and
Frequency Patterns of Somatic Mutations in Arab Women with Breast Cancer.
The oncologist.
7 Emirates Oncology Society 145

28. Humaid, O. Al-Shamsi, Eric A Coomes (2021) Successful Vaccination of

Patients with History of Severe Anaphylactic Reaction with Pfizer-Biotech
COVID-19 Vaccine. Journal of Oncology Research Review & Reports. SRC/
JONRR-125. occur up to, 20.
29. Al-Shamsi, H. O., Alzaabi, A. A., Afrit, M., Abu-Gheida, I., & Musallam,
K. M. (2021). Clinicopathological Features of Gastric Cancer in a Cohort of
Gulf Council Countries’ Patients: A Cross-Sectional Study of 96 Cases. Journal
of Oncology Research Review & Reports. SRC/JONRR-133, 3.
30. Al-Shamsi, H., Azribi, F., Abu-Gheida, I., Jaafar, H., & Razek, A. A. (2021).
The Emirates Oncology Task Force Clinical Practice Guideline on Screening
for SARS-CoV-2 in Asymptomatic Adult Cancer Patients Prior to Anti-Cancer
Therapy. Journal of Oncology Research Review & Reports. SRC/JONRR-137, 3.
31. Humaid O Al-Shamsi, Faryal Iqbal, Mohd Subhi Al Saad, Priyanka Ashish
Dhemre, Fady Georges Hachem, et al (2021) The Burden of Gynecologic
Cancers in the UAE. Journal of Oncology Research Review & Reports. ­SRC/
JONRR-147.
32. Bukhari N, Alshangiti A, Tashkandi E, Algarni M, Al-Shamsi HO, Al-Khallaf
H. Fluoropyrimidine-Induced Severe Toxicities Associated with Rare DPYD
Polymorphisms: Case Series from Saudi Arabia and a Review of the Literature.
Clinics and Practice. 2021; 11(3):467–471. https://doi.org/10.3390/
clinpract11030062
33. Azhar, Malik, Faisal Aziz, Salama Almuhairi, Mohammad Alfelasi, Ali Elhouni,
Rizwan Syed, Humaid O. Al-Shamsi, and Khaled M. Aldahmani. “Decline in
radioiodine use but not total thyroidectomy in thyroid cancer patients treated in
the United Arab Emirates-A retrospective study.” Annals of Medicine and
Surgery 64 (2021): 102203.
34. Humaid, O. Al-Shamsi, Eric A Coomes (2021) Higher and Increasing Incidence
of Cancer between the Age of 20–49 Years in the UAE Population; A focus
Analysis of the UAE National Cancer Registry Data 2015–2017. Journal of
Oncology Research Review & Reports. SRC/JONRR-127, 3.
35. Humaid, O. Al-Shamsi, Sadir Alrawi, Ahmed S. Abdulsamad, Nuhad K. Ibrahim
(2021) AStrong Beliefs and Soft Evidence Underlying Mammography
Surveillance Recommendations in Breast Cancer Survivors: A Study in Reflexive
Science and Decision-Making. Journal of Oncology Research Review &
Reports. SRC/JONRR-131, 3.
36. Bernstein, Ezra, Shiran Shapira, Shahar Lev-Ari, Ari Leshno, Udi A. Sommer,
Lior Galazan, Humaid O. Al-Shamsi et al. “One-stop-shop for cancer screen-
ing: A model for the future.” (2021): 10554–10554.
37. Latif, M.F., Azam, F., Tirmazy, S.H., Bashir, S., Ibnshamsah, F., Al Selwi, W.M.,
Bukhari, N., Alwbari, A., Alshangiti, A., Gabsi, A. and Al-Shamsi, H.O., 2021.
Impact of COVID 19 pandemic on psychological wellbeing of oncology clini-
cians in MENA (Middle East and North Africa) region.
146 H. O. Al-Shamsi and A. M. Abyad

38. Al-Shamsi, H., Darr, H., Abu-Gheida, I., Ansari, J., McManus, M. C., Jaafar,
H., ... & Al-Khatib, F. (2020). The State of Cancer Care in the United Arab
Emirates in 2020: Challenges and Recommendations, A report by the United
Arab Emirates Oncology Task Force. The Gulf journal of oncology, 1(32), 71–87.
39. Al-Shamsi, H. O., Coomes, E. A., & Alrawi, S. (2020). Screening for
COVID-19 in asymptomatic patients with cancer in a hospital in the United
Arab Emirates. JAMA oncology, 6(10), 1627–1628.
40. Al-Shamsi, H. O., Coomes, E. A., Aldhaheri, K., & Alrawi, S. (2020). Serial
Screening for COVID-19 in Asymptomatic Patients Receiving Anticancer
Therapy in the United Arab Emirates. JAMA oncology. doi:10.1001/
jamaoncol.2020.5745.
41. Humaid O. Al-Shamsi (2020) Rethinking Cancer Screening and Diagnosis
During the Covid-19 Pandemic. Journal of Oncology Research Review &
Reports. SRC/JORRR/110.
42. Humaid O. Al-Shamsi., et al. “Early Onset Colorectal Cancer in the United
Arab Emirates, Where do we Stand?”. Acta Scientific Cancer Biology 4.11
(2020): 24–27.
43. Abdel-Wahab, R., Hassan, M.M., George, B., Pestana, R.C., Xiao, L., Lacin, S.,
Yalcin, S., Shalaby, A.S., Al-Shamsi, H.O., Raghav, K. and Wolff, R.A., 2020.
Impact of Integrating Insulin-Like Growth Factor 1 Levels into Model for End-­
Stage Liver Disease Score for Survival Prediction in Hepatocellular Carcinoma
Patients. Oncology, 98(12), pp.836–846.
44. Al-Shamsi, H. O., Abu-Gheida, I., Rana, S. K., Nijhawan, N., Abdulsamad,
A. S., Alrawi, S., … & McManus, M. C. (2020). Challenges for cancer patients
returning home during SARS-COV-19 pandemic after medical tourism-a con-
sensus report by the emirates oncology task force. BMC cancer, 20(1), 1–10.
45. Al-Shamsi HO, Alhazzani W, Alhuraiji A, Coomes EA, Chemaly RF, Almuhanna
M, Wolff RA, Ibrahim NK, Chua MLK, Hotte SJ, Meyers BM, Elfiki T, Curigliano
G, Eng C, Grothey A, Xie C. A Practical Approach to the Management of
Cancer Patients During the Novel Coronavirus Disease 2019 (COVID-19)
Pandemic: An International Collaborative Group. Oncologist. 2020
Jun;25(6):e936-e945. doi: 10.1634/theoncologist.2020-0213. Epub 2020 Apr
27. PMID: 32243668; PMCID: PMC7288661.
46. Al Shamsi, H., R. Iskanderian, R., Karmstaji, A., Kamal Mohamed, B.,
Alahmed, S., H. Masri, M., …, R. Grobmyer, S. (2020). Outcomes and Impact of
a Universal COVID-19 Screening Protocol for Asymptomatic Oncology
Patients. The Gulf Journal of Oncology, (34), 162–167.
47. Coomes, E. A., Al-Shamsi, H. O., Meyers, B. M., Alhazzani, W., Alhuraiji, A.,
Chemaly, R. F., … & Xie, C. (2020). Evolution of Cancer Care in Response to
the COVID-19 Pandemic. The oncologist, 25(9), e1426–e1427.
48. Al-Shamsi HO et al, Authors Reply: Oncological surgery during COVID-19
pandemic: The need for deep and lasting measures. https://doi.org/10.1634/
theoncologist.2020-­0451
7 Emirates Oncology Society 147

49. Jain, A., Borad, M.J., Kelley, R.K., Wang, Y., Abdel-Wahab, R., Meric-Bernstam,
F., Baggerly, K.A., Kaseb, A.O., Al-Shamsi, H.O., Ahn, D.H. and DeLeon, T.,
2018. Cholangiocarcinoma with FGFR genetic aberrations: a unique clinical
phenotype. JCO Precision Oncology, 2, pp.1–12.
50. Ehab Abdou, Ravi M Pedapenki, Mohamed Abouagour, Abdul R Zar, Emad
Anwar, Dalia Elshourbagy, Humaid Al-Shamsi & Enrique Grande (2020)
Patient selection and risk factors in the changing treatment landscape of meta-
static renal cell carcinoma, Expert Review of Anticancer Therapy, 2020. https://
doi.org/10.1080/14737140.2020.1810572.
51. Al-Shamsi HO et al, Authors Reply: How to manage febrile neutropenia during
the COVID pandemic? In response to, “A Practical Approach to the Management
of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID-19)
Pandemic.” 2020 https://doi.org/10.1634/theoncologist.2020-­0329
52. Tashkandi, E., Zeeneldin, A., AlAbdulwahab, A., Elemam, O., Elsamany, S.,
Jastaniah, W., … & Al-Shamsi, H. (2020). Virtual management of cancer
patients in the era of COVID-19 pandemic. J Med Internet Res [Internet].
53. Al-Shamsi, H. O. (2020). Mammography screening for breast cancer—the UK
Age trial. The Lancet Oncology, 21(11), e505.
54. Humaid O. Al-Shamsi (2020) COVID-19 Vaccination for Cancer Patients,
What Oncologists and Cancer Patients Need to Know? Journal of Oncology.
Research Review & Reports. SRC/JONRR-114.
55. Humaid O. Al-Shamsi (2020) Anterior Mediastinal Mass: A Rare Presentation
of Thyroid Mass Compressing Mediastinal Structures. Journal of Oncology.
Research Review & Reports. SRC/JORRR-113.
56. Atlal M. Abusanad and Humaid O. Al-Shamsi*, “Tele-Oncology: An Emerging
Technology in Developing Countries during the COVID-19 Pandemic,” New
Emirates Medical Journal (2020) 1: 1. https://doi.org/10.217
4/0250688201999201109160857
57. Benbrahim, Z., Al Asiri, M., Al Bahrani, B., AlNassar, M. A. M. A., Al-Shamsi,
H. O., Bounedjar, A., … & Labidi, S. (2020). 1737P National approaches to
managing cancer care: Responses of countries in the MENA region to
COVID-19 pandemic. Annals of Oncology, 31, S1016.
58. Abdulsamad, A. S., Inam, A., Oner, M., Darr, H., Madi, T., Alrawi, S. J., & Al-­
shamsi, H. O. (2019). Malignant Peritoneal Mesothelioma Following
Wilms’ Tumor in a Horse-Shoe Kidney, A Case Report and Review of
Literature. Cancer Therapy & Oncology International Journal, 13(2), 66–71.

7.9 EOS Annual Awards

The EOS annual awards are dedicated to researchers, clinicians, healthcare workers,
nurses, and other healthcare providers who have made a significant impact on can-
cer care in the UAE, GCC, MENA region, and globally. The list of award recipients
in 2022 is shown in Table 7.1.
148 H. O. Al-Shamsi and A. M. Abyad

Table 7.1 The list of EOS award recipients in 2022

Award title Award recipients
EOS Lifetime Achievement Global Oncology Prof. Toni Choueiri
EOS Lifetime Achievement MENA Oncology Prof. Nagi El Saghir
EOS Lifetime Achievement GCC Oncology Prof. Bassim Al Bahrani
EOS Lifetime Achievement UAE Oncology Dr. Hassan Jaafar
EOS Women in Oncology Award MENA Dr. Omalkhair Abulkhair
EOS Women in Oncology Award UAE Dr. Aydah Al-Awadhi
EOS Researcher of the Year Dr. Deborah Mukherji
EOS Publication of the Year Dr. Ibrahim Abu-Gheida
EOS Industry Researcher of the Year Amgen Inc
EOS Member of the Year Dr. Hassan Ghazal
EOS Outstanding Oncology Nursing Award Mr. Khaled Al Qawasmeh
EOS Cancer Awareness Advocate of the Year Abu Dhabi Public Health Center
EOS Cancer Awareness Advocate of the Year Ministry of health and prevention
EOS Cancer Awareness Partner of the Year MSD Inc
EOS Cancer Awareness Partner of the Year Ipsen Inc
EOS Patient Advocate of the Year Emirates Cancer Society
EOS Media Cancer Awareness Award of the Year Ms. Mona Alhmoudi/Etehad
EOS Media Cancer Awareness Award of the Year Mr. Wagih El Sebaei/Emarate
EOS Media Cancer Awareness Award of the Year Ms. Jameelah Ismail/Albayan
EOS Hope Award Ms. Sumaia Saif Alkaabi
EOS Hope Award Dr. Hamad Alghamdi/KSA
Appreciation Award Dr. Mouza AlSharhan/EMA
EOS Special Recognition Award Prof. Nuhad Ibrahim
EOS Special Recognition Award Prof. Robert Wolff

7.10 EOS’ Achievements

1. Cancer in the Arab World was named the most downloaded medical book
in the MENA region in 2021 [4]. The book has been downloaded more than
190,000 times within the 4 months of publication as of September 2022.
The book has been downloaded more than 300,000 times within 1 year of its
launch, making it the most downloaded medical book in the MENA region
in 2022.
2. The publication of the year 2020—July 2020, by the Oncologist Journal
“Editor-­in-Chief Bruce A. Chabner Massachusetts General Hospital Harvard
Medical School Boston, MA” for the publication of “A Practical Approach to the
Management of Cancer Patients During the Novel Coronavirus Disease 2019
(COVID-19) Pandemic: An International Collaborative Group” [5].
3. Guinness World record for the largest cancer awareness ribbon, on Nov 9,
2021, on neuroendocrine tumor day [6].
4. Guinness World record for the largest number of cancer awareness ribbons,
Guinness World record on February 4, 2022 [7].
7 Emirates Oncology Society 149

The most publishing scientific society in the UAE among all 48 EMA societies
with over 25 publications in 2021.

7.11 Future Outlook

The EOS continues to work closely with the regulators in the UAE as an advisor to
advance cancer care quality in the UAE. The EOS is participating in the Ministry of
Health and Prevention Committee to reduce the cancer mortality rate in the UAE,
according to the UAE government’s agenda.
Upcoming book projects from the EOS include this book, “Cancer Care in the
UAE,” and “Healthcare in the UAE,” both of which are planned for publication by
Springer in the first quarter of 2023. The EOS is also planning to bid on interna-
tional oncology conferences to be held in the UAE.
The EOS is also supporting the initiative to establish accredited oncology and
hematology fellowship training programs.

7.12 Conclusion

The Emirates Oncology Society’s mission is to promote and improve the complete
care of cancer patients throughout the United Arab Emirates (UAE) by bringing
together all practicing oncologists and healthcare workers from various back-
grounds. It is the professional organization in the UAE that represents medical
oncologists, radiation specialists, and palliative care physicians. The EOS is also
working with the UAE to establish accredited oncology and hematology fellowship
training programs. The EOS collaborates closely with UAE regulators to improve
cancer care quality through the application of quality measures.

Conflict of Interest The authors have no conflict of interest to declare.

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4. https://link.springer.com/book/10.1007/978-­981-­16-­7945-­2. Accessed 9 Sept 2022.
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spective. Accessed 8 Sept 2022.
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guinness-­world-­record-­for-­largest-­awareness-­ribbon-­grtn1tcx.
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150 H. O. Al-Shamsi and A. M. Abyad

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty fel-
lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fel-
lowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new dis-
tinct subgroup of CRC, NON V600 BRAF-mutated CRC. In 2022,
he published the first book about cancer research in the UAE and
also the first book about cancer in the Arab world, both of which
were launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to docu-
ment the cancer care in the UAE with many topics addressed for
the first time, e.g., neuroendocrine tumors in the UAE. He is pas-
sionate about advancing cancer care in the UAE and the GCC and
has made significant contributions to cancer awareness and early
detection for the public using social media platforms. He is consid-
ered as the most followed oncologist in the world with over
300,000 subscribers across his social media platforms (Instagram,
Twitter, LinkedIn, and TikTok). In 2022, he was awarded the pres-
tigious Feigenbaum Leadership Excellence Award from Sheikh
Hamdan Smart University for his exceptional leadership and
research and the Sharjah Award for Volunteering. He was also
named the Researcher of the Year in the UAE in 2020 and 2021 by
the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
7 Emirates Oncology Society 151

of research training for medical trainees to enhance their clinical

and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Dr. Amin M. Abyad earned his medical degree, Bachelor in

Medicine and Surgery (MBChB), from Beirut Arab University.
After completing his internship, he joined the Internal Medicine
Residency at Makassed Hospital in Beirut, Lebanon, which is affili-
ated with the American University of Beirut Medical Center
(AUBMC). Dr. Amin was appointed as Chief Resident of Internal
Medicine (2017–2018). Then Dr. Amin started his fellowship in
hematology and medical oncology at Makassed Hospital, where he
received intensive training in hematology and medical oncology.
Dr. Amin joined Burjeel Medical City in July 2021. Dr. Amin is
highly interested in malignant hematology and solid malignancies.
He has been highly involved in clinical research, being involved in
multiple research projects and publishing in multiple peer-reviewed
journals. Dr. Abyad believes in patient-centered care, trying to
enhance patient outcomes through the application of the latest evi-
dence-based practice and personalized medicine.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
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Factors Influencing Seeking Cancer Care
Abroad for UAE Citizens 8
Humaid O. Al-Shamsi

8.1 Introduction

Despite notable progress in healthcare and oncology in the United Arab Emirates
(UAE), a considerable proportion of cancer patients still opt for treatment in other
countries. According to a report, in 2013, the UAE allocated approximately $163 mil-
lion US dollars toward government-funded cancer care overseas and medical tourism
beyond its borders [1]. There is currently no publicly available official data regarding
the specific types and stages of cancer cases treated outside the United Arab Emirates
(UAE). However, the most popular destinations for cancer medical tourism from the
UAE are the United States of America, Germany, Singapore, South Korea, and
Thailand [2, 3]. A study conducted using administrative data obtained from the Dubai
Health Authorities focused on UAE nationals who received medical treatment abroad
from 2009 to 2016. The study analyzed information from a total of 6557 UAE nation-
als. The primary destinations for treatment were Germany (46%), the United Kingdom
(UK) (19%), and Thailand (14%). The most prevalent medical specialties sought were
oncology (13%), orthopedic surgery (13%), and neurosurgery (10%). After account-
ing for various factors, the study found that oncology had the highest anticipated num-
ber of trips, with an incidence rate ratio (IRR) of 1.34 (95% CI: 1.24–1.44) [4, 5].

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 153

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_8
154 H. O. Al-Shamsi

In the UAE, cancer care abroad is supported by various distinct sponsoring agen-
cies. These include presidential affairs offices, the armed forces, the police, all
health authorities (such as the Department of Health, the Dubai Health Authority,
and the Ministry of Health and Prevention), as well as charitable organizations that
cover the costs themselves [2]. The sponsoring requirements and procedures differ
among the various sponsoring agencies in the UAE, and this is an important crite-
rion alongside being a UAE citizen. However, exceptions are occasionally made for
non-UAE citizens if they can provide evidence that the necessary treatment is not
available within the UAE. Nonetheless, despite the existence of cancer treatment
options in the UAE, a significant number of patients are granted exemptions to seek
treatment overseas. These entities and agencies lack standardized guidelines or cri-
teria for selecting patients to receive treatment abroad [2, 5].
During an internal assessment conducted at a tertiary referral oncology center in
the UAE, a review of 273 patients who sought permission to travel abroad between
January and September 2017 revealed that 86% of the referrals were deemed unnec-
essary from a clinical standpoint. This assessment was based on the fact that the
required oncology services were already available in the UAE [1]. This assessment
was conducted prior to the introduction of bone marrow transplantation services,
and a significant number of these cases involved such treatments [6]. Based on our
expertise, we estimate that over 95% of cancer cases can now be effectively treated
within the UAE [6].
The UAE has very well-established cancer care centers, with over 30 cancer
centers and at least five comprehensive cancer centers, yet there are various factors
for seeking treatment abroad [5] (Fig. 8.1).

Fig. 8.1 Factors causing Emirati patients to travel abroad for cancer care
8 Factors Influencing Seeking Cancer Care Abroad for UAE Citizens 155

8.2 Factors Leading Emirati Patients to Travel Abroad

for Cancer Care

8.2.1 Family and Societal Pressure

Family and societal pressure emerged as one of the primary driving factors behind
Emirati cancer patients’ decision to seek cancer care outside their country [7, 8].
This can be attributed to the familial setup prevalent in the UAE, characterized by
extensive and interconnected family units. In such structures, family members play
a significant role not only in everyday decision-making but also in matters concern-
ing an individual’s health, particularly when it comes to cancer. A study conducted
on a diverse patient population in critical care settings revealed that families in the
UAE perceived it as their duty to ensure that the patient received appropriate medi-
cal care. Therefore, they sought second opinions to confirm whether the provided
treatment was suitable or not [8]. In the Australian study conducted by Philip, it was
revealed that 70% of the patients received encouragement from their family and
friends to seek a second opinion. This was one of several reasons identified in the
study [7].

8.2.2 Perception of Patients with Cancer in Cancer Care

in the UAE

During the early days of the UAE after the establishment of the UAE as an indepen-
dent country, as expected, the UAE health system was in its infancy, many health-
care services were not available, and it was depending on some countries like
Kuwait to support the health system [9]. During that time, the concept of traveling
abroad for medical care started to evolve, and with the generous support of Sheikh
Zayed, the founder of the UAE, the sponsorship programs for UAE nationals to seek
medical care abroad started the culture of treatment abroad for various medical
conditions, from simple to very complex cases. Again, due to the limited healthcare
resources and healthcare providers’ manpower, the sponsorship programs supported
hundreds of thousands of Emirati patients over the last five decades to seek medical
treatment in Europe, North America, and Asia. The culture of traveling abroad for
medical care continued to evolve and persist despite the advances in the UAE’s
health system. This culture caused distrust in the health system, and the oncology
sector in the UAE health system may be affected the most, in our opinion, as oncol-
ogy care lagged behind in the development of the UAE health system for various
reasons, including the lack of specialized cancer care until around 1979, when
Tawam Hospital opened its doors, which was 8 years after the establishment of the
UAE in 1971.
From our ongoing discussion with patients during clinical care for cancer patients
who expressed their wishes to travel abroad after being diagnosed with a malig-
nancy in the UAE, common themes for reasons why they decline treatment locally
include: lack of trust in oncologists and other healthcare providers in the UAE; lack
156 H. O. Al-Shamsi

of trust in accurate pathological diagnosis; rumors of errors in diagnosis in the UAE

among the members of the UAE community; social media false information and
stories about errors in the diagnosis and management of cancer in the UAE; and the
wrong belief that patients treated locally tend to die and ones treated abroad tend to
survive.
These common misconceptions and the need to gain trust in the health system
should be addressed by highlighting the success stories in both traditional and social
media and by launching awareness campaigns to highlight the expertise and facili-
ties that are specialized in cancer care in the UAE. Accredited comprehensive can-
cer centers by the regulators to guide the public to the center of excellence in cancer
care. Utilization of virtual consultation with major cancer centers abroad with con-
firmation of the locally proposed treatment plan may help in establishing trust and
acceptance of cancer care locally among Emirati patients. This will also reduce the
financial burden on the government from the cost of cancer care abroad.

8.2.3 False Belief in Better Cancer Treatment Abroad

While better cancer care and outcomes would have certainly been true abroad in
more advanced health systems between the 1970s and early 2000s in the UAE, this
does not hold true nowadays. While survival and outcome data are generally lacking
except for a few reports [10], in our experience and that of other colleagues who
trained and practiced in the USA, Canada, and the UK, treatment modalities and
outcomes are similar for major cancer centers in the UAE. Certainly, patients being
treated in nonspecialized cancer centers, either in the UAE or anywhere else, have a
lower cure and survival rate [11].
Another common belief among cancer patients and their families is that more
effective and reliable anticancer therapies and technologies are available abroad
than in the UAE. Again, historically, this was true, but with fast advances in the
oncology landscape in the UAE [1, 12], fast-track approvals for anticancer therapies
in the UAE, the availability of state-of-the-art centers and technologies, including
the latest radiation machines, AI-powered applications used in cancer screening and
chemotherapy preparations, and advanced robotic surgical equipment, the cancer
treatment technologies in the UAE are very advanced [13].
As mentioned earlier, these advances must be highlighted to the public to change
these common misconceptions [14, 15].
There are very generous support programs for Emirati patients to travel to world-­
class facilities in Europe, Asia, and North America, with the cost of medical treat-
ment completely covered by the UAE government. There are many sponsoring
governmental entities that support Emirati patients traveling abroad for medical
care. There are various criteria for patients to travel abroad, but all sponsoring enti-
ties request medical reports from healthcare providers to confirm the patient’s medi-
cal condition [1]. All treatment costs are completely covered, with no co-payment
by the patients. The support is part of the government’s support of UAE nationals,
8 Factors Influencing Seeking Cancer Care Abroad for UAE Citizens 157

in addition to many other initiatives like free housing schemes, financial support for
youth, the “Marriage Grant,” and many others [14, 15].
There have been no official reports on the cost of medical treatment abroad over
the years, but with the increasing cost of cancer care worldwide, the cost of treat-
ment abroad must be significant.
Another important yet overlooked factor for patients to consider when traveling
abroad for cancer care is the travel distance for patients with cancer and their fami-
lies while being treated in the UAE, as the cost of travel and accommodation can be
significant, and this is not covered by the healthcare providers or any governmental
organizations. This cost is completely covered for patients and their caregivers
while being treated abroad. This is a major issue for many patients with limited
budgets, and the choice between staying in the UAE and paying out of pocket or
traveling abroad and getting all costs completely covered makes the latter choice
more appealing and attractive.
Supporting patients’ travel and lodging costs who live far from cancer centers
will increase their acceptance of being treated locally rather than abroad.

8.2.4 Extended Sick Leave for Cancer Patients

and Their Companions

Patients and one or two family members get extended paid sick leave and compan-
ion sick leave. This leave could be for months or years, as long as the medical condi-
tion is approved to continue treatment abroad. These sick leaves are not guaranteed,
either for patients with cancer or their family members who have to take sick leave,
which can be exhausted in a matter of a couple of weeks.
In order to encourage Emirati patients with cancer to get treatment locally, new
rules and regulations grant a similar advantage of extended work hours for patients
and their caregivers. Studies have shown that patients with cancer have a significant
negative impact on their work and finances [16].
Emirati patients’ and caregivers’ jobs and financial security will be critical in
changing the mindset about traveling abroad for cancer treatment.

8.2.5 International Institutions Promotion for Cancer

Care Abroad

Many major cancer centers in the USA, for example, have dedicated offices in their
centers to facilitate and attract cancer patients from Gulf countries. The usual
approach is direct communication with the sponsoring agencies in the UAE, hold-
ing scientific meetings to attract oncologists and create referral pathways from the
local oncologists to the cancer centers abroad, and having dedicated Arabic web-
sites to attract patients for treatment at their centers [17–19].
158 H. O. Al-Shamsi

8.2.6 Government Financial Incentive for Patients and Their

Companions While Abroad

The UAE government has a very generous program to cover the expenses for
patients and their families while being treated abroad; this covers the accommoda-
tion, food, pocket money, etc. Depending on where the patient and their companion
are being treated, the daily allowance can reach a few hundred dollars.

8.2.7 Physicians’ Attitude Influencing Patients’ Decisions

for Traveling Abroad

One of the major setbacks for cancer care in the UAE is the attitude of some oncolo-
gists and hematologists, who encourage patients to travel abroad, especially in more
complex cases, in order to avoid clinical work and complications and potential med-
icolegal complaints, which is not an uncommon practice by patients and their care-
givers. The direct recommendations in the medical reports to travel abroad, e.g., for
advanced, noncurable stage malignancies with limited survival and the availability
of the same treatment modalities in the UAE, are not uncommon for the abovemen-
tioned reasons. Auditing physicians with a high rate of recommendations adjusted
to their volume of patients is a potential solution to address this issue.

8.3 Negative Implications for Cancer Care Abroad

• Treatment postponement as a result of arranging travel and scheduling

appointments.
• Language barriers may negatively affect communication and adherence to
treatment.
• Patients receiving treatment abroad typically have limited time with their doc-
tors, leading to a lack of follow-up care and a potential failure to identify compli-
cations or treatment side effects. It is crucial for patients to be knowledgeable
about specialized centers that excel in treating specific types of cancer in order to
obtain accurate opinions. Without proper guidance, patients may select a loca-
tion for a second opinion that lacks the necessary facilities and expertise, which
can have adverse effects on their health.
• Significant cost to the health system, which can be utilized to support and
improve the UAE health system.
• Abuse of the traveling abroad program by cancer centers abroad: for example,
some centers abroad charge the UAE government for clinical trial participation,
despite the fact that these trials are already sponsored by pharmaceutical
companies.
8 Factors Influencing Seeking Cancer Care Abroad for UAE Citizens 159

8.4 Conclusion

The long-term sustainability and exorbitant costs associated with traveling abroad
for cancer treatment make it an impractical option. It is recommended that treatment
overseas be limited to complex cancer cases requiring specialized care that is not
available within the UAE. This decision should be made after a thorough evaluation
by an accredited comprehensive cancer center, following a consensus review. To
establish public confidence in cancer care within the UAE, it is essential to prioritize
outreach programs at the national level, involving regulatory bodies and sponsoring
agencies responsible for facilitating treatment abroad. Focused research efforts are
necessary to understand the factors motivating Emirati patients and their families to
seek treatment overseas as well as the barriers preventing them from receiving treat-
ment locally in the UAE. Such research will ultimately help reduce the demand for
and dependence on foreign cancer care.

Conflict of Interest The author has no conflict of interest to declare.

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Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer of

Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
8 Factors Influencing Seeking Cancer Care Abroad for UAE Citizens 161

2024. He is the only physician in the UAE with a subspecialty fel-

lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fel-
lowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles in
JAMA Oncology, Lancet Oncology, The Oncologist, BMC Cancer,
and many others. His area of expertise includes precision oncology
and cancer care in the UAE. In 2016, he published with his group
from MD Anderson the JCO paper describing a new distinct sub-
group of CRC, NON V600 BRAF-mutated CRC. In 2022, he pub-
lished the first book about cancer research in the UAE and also the
first book about cancer in the Arab world, both of which were
launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to docu-
ment the cancer care in the UAE with many topics addressed for the
first time, e.g., neuroendocrine tumors in the UAE. He is passionate
about advancing cancer care in the UAE and the GCC and has made
significant contributions to cancer awareness and early detection
for the public using social media platforms. He is considered as the
most followed oncologist in the world with over 300,000 subscrib-
ers across his social media platforms (Instagram, Twitter, LinkedIn,
and TikTok). In 2022, he was awarded the prestigious Feigenbaum
Leadership Excellence Award from Sheikh Hamdan Smart
University for his exceptional leadership and research and the
Sharjah Award for Volunteering. He was also named the Researcher
of the Year in the UAE in 2020 and 2021 by the Emirates Oncology
Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
of research training for medical trainees to enhance their clinical
and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
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adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
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Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Nongovernmental Organizations’ (NGO)
Role in Cancer Care in the UAE: Friends 9
of Cancer Patients as an Example

Aisha Al Mulla and Majed Mohamed

9.1 Cancer Care and the Role of FOCP in the UAE

Cancer care receives vital attention in the United Arab Emirates (UAE), with Friends
of Cancer Patients (FOCP) leading this frontier as an organization exclusively
focused on cancer patients and awareness. The nongovernmental organization was
founded in 1999 under the patronage of Her Highness Sheikha Jawaher Bint
Mohammed Al Qasimi, Wife of the Ruler of Sharjah, and has the vision of a world
where cancer no longer holds power over our lives. With the objective of providing
financial and emotional support to cancer patients and their families in the UAE, the
organization was also established to raise awareness, particularly about the cancers
with the highest rates of early detection.
For more than two decades, FOCP has been successful in offering hope and sup-
port to cancer patients during their journey toward recovery, as well as assisting
families in coming together again. The organization supports both UAE citizens as
well as residents and provides crucial guidance on the latest advancements in cancer
treatment. Fundraising efforts, either in the physical or digital realm, contribute
largely to the financial aid targeting the medical treatment of cancer patients. It also
provides donors with the opportunity to make a lasting impact and contribute to the
well-being of society through its focus on cancer care. The firm engages with the
community through initiatives like cancer walks, awareness campaigns, and involve-
ment in seminars and conferences.
FOCP emphasizes early screening and detection methods in addition to focusing
on pediatric cancers and cancers with high incidence rates in the UAE, such as
breast, colorectal, lung, thyroid, skin, and leukemia. Cancer screening projects are
in place for the early diagnosis of high-risk cancers like breast and cervical cancer.
The organization is also involved in discussions and advocacy efforts related to

A. Al Mulla · M. Mohamed (*)

Friends of Cancer Patients, Sharjah, United Arab Emirates
e-mail: Aisha@focp.ae; Majed@focp.ae

© The Author(s) 2024 163

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_9
164 A. Al Mulla and M. Mohamed

policy change, promotion of healthy lifestyles, tobacco control, and vaccination in

order to create a healthier society in the UAE.
In addition to collaborating with international and regional organizations such as
the Union for International Cancer Control (UICC), the American Cancer Society,
the NCD Alliance, and the Gulf Federation for Cancer Control, FOCP has also part-
nered with local health bodies such as the UAE Ministry of Health, the Abu Dhabi
Health Authority, the Sharjah Health Authority, and the Dubai Health Authority.
The organization has received widespread recognition and awards from leading
institutions, both locally and internationally, for its efforts in supporting cancer
patients and increasing awareness about the disease.

9.2 Beneficiary Support in the UAE

FOCP, the UAE-based cancer-focused society, provides services to all residents of

the country without discrimination based on nationality, gender, age, or religion.
Since its establishment in 1999, a total of 6217 patients have received various levels
of support from the FOCP. The NGO provides annual care to hundreds of cancer
patients, with the number reflected in Tables 9.1 and 9.2 based on months of diag-
nosis and gender for 2020 and 2021, respectively.
For the current year of 2022, the data in the table include analysis based on gen-
der and nationality until November (Table 9.3).
The FOCP is dedicated to providing comprehensive care to cancer patients in the
UAE, including early detection and screening, financial and moral support, and
awareness campaigns. The organization works with both nonprofits and private sec-
tor companies to ensure that patients have access to the resources they need to com-
bat their illness and recover. To receive assistance from the FOCP, cancer patients
must provide documents, including data on their social and economic status. In

Table 9.1 Number of FOCP beneficiaries (cancer patients) in 2020

Male Female Children Total number of patients per month
January 9 25 2 36
February 9 21 2 32
March 11 24 1 36
April 8 26 1 35
May 7 21 3 31
June 7 22 2 31
July 8 26 1 35
August 6 24 2 32
September 7 24 2 33
October 11 22 2 35
November 9 21 1 31
December 9 20 3 32
Total 101 276 22 399
9 Nongovernmental Organizations’ (NGO) Role in Cancer Care in the UAE: Friends… 165

Table 9.2 Number of FOCP beneficiaries (cancer patients) in 2021

Male Female Children Total number of patients per month
January 7 20 1 28
February 5 24 1 30
March 7 20 1 28
April 3 27 1 31
May 6 19 4 29
June 4 24 1 29
July 3 24 1 28
August 5 24 1 30
September 5 23 1 29
October 5 21 1 27
November 5 23 1 29
December 7 28 2 37
Total 62 277 16 355

Table 9.3 Number of FOCP beneficiaries (cancer patients) in 2022

Male Female Children Total number of patients per month
January 2 16 1 19
February 5 17 3 25
March 2 18 1 21
April 2 15 1 18
May 6 13 2 21
June 3 18 1 22
July 3 16 2 21
August 1 20 1 22
September 3 17 1 21
October 3 18 1 22
November 2 19 1 22
December 2 21 1 24
Total 34 208 16 258

response to the COVID-19 pandemic, the FOCP created an online portal for patients
to submit their applications and continue receiving support.
To ensure the sustainability of patient access to care, the FOCP works with non-
profit organizations and private sector companies to provide access programs with
free additional packages, including long-term medication support during the recov-
ery process. Over the past 3 years, 3392 patients have received psychological and
moral support from the FOCP. On the other hand, the Locks of Hope campaign,
which aims to help restore their self-esteem and their confidence, enabling them to
face the world with a positive outlook by providing wigs to cancer patients, has
received 3244 hair donations, and the Ramadan campaign, which has supported
2047 cancer patients since 2013, are two of the most effective community-focused
campaigns run by the FOCP. These campaigns aim to raise awareness about cancer
and its treatment, as well as provide support for those affected by the disease.
166 A. Al Mulla and M. Mohamed

9.3 Global Sustainable Aid Initiatives

The Ameera Fund is an initiative of the FOCP that aims to address cancer care on a
global scale through collaborative projects in the fields of cancer research, capacity
building, prevention, and treatment. Established in partnership with The Big Heart
Foundation, the Ameera Fund has a vision of a world where everyone has access to
cancer care and a mission to improve understanding of cancer through various ini-
tiatives and partnerships.
The Ameera Fund is committed to its vision of a world where everyone has
access to cancer care and its mission to improve understanding of cancer through a
range of initiatives and partnerships. By increasing access to cancer care, strength-
ening cancer monitoring systems, enhancing capacity building, and supporting can-
cer research and treatment, the Fund is working toward its goals of improving the
lives of cancer patients and their families around the world.
Since its establishment in 2018, the Ameera Fund has spent a total of USD
5,186,421 on cancer care and capacity building, with a total spending of USD
2,863,447 on 222,499 beneficiaries globally (Table 9.4).
One of the main objectives of the Ameera Fund is to increase access to cancer
care, particularly for underserved and disadvantaged communities. To achieve this
goal, the fund has initiated a number of projects in collaboration with various orga-
nizations around the world. For example, in partnership with Tumiani La Maisha in
Tanzania, the Ameera Fund helped to construct a pediatric intensive care unit and a
neonatal intensive care unit at Muhimbil National Hospital, the largest government
hospital in the country. This project aimed to give young patients greater access to
cancer care, allowing them to receive treatment closer to home and in a more sup-
portive environment.
In addition to increasing access to cancer care, the Ameera Fund also focuses on
capacity building and the strengthening of cancer surveillance systems. To this end,
the Fund has collaborated with the UICC in Geneva, Switzerland, on a project
aimed at strengthening cancer monitoring through cancer registries and supporting
the “Treatment for All” campaign, which advocates for universal access to cancer
treatment. The Ameera Fund has also joined forces with Access to Child Cancer
Essentials (ACCESS) in Eastern Africa to amplify cancer care facilities and conduct
research into the barriers to the availability and accessibility of cancer care resources
in the region.

Table 9.4 Ameera fund Year Total funding

global funding support 2018 22,95,155
(2018–2022)
2019 18,67,000
2020 2,40,892
2021–2022 7,83,374
9 Nongovernmental Organizations’ (NGO) Role in Cancer Care in the UAE: Friends… 167

Working on increasing access to cancer care and strengthening cancer monitor-

ing systems, the Ameera Fund also supports cancer research and treatment in vari-
ous ways. One notable highlight is the collaboration with the King Hussein Cancer
Foundation in Jordan, where the Fund supported the treatment and medical costs of
refugee cancer patients. Additionally, the Ameera Fund has partnered with BIO
Ventures for Global Health in Côte d’Ivoire-Abidjan to ensure access to oncology
medicines and build research and healthcare capacity.
The Ameera Fund has also responded to the needs of cancer patients affected by
natural disasters and other crises. For instance, in partnership with the Cancer
Warriors Foundation—Philippines Childhood Cancer International, the Fund
launched a project to support children with cancer who were affected by the Typhoon
Goni Hurricane in the Philippines, providing them with treatment, maintenance
medications, and food aid for themselves and their families. The Ameera Fund has
also provided support to cancer patients in Lebanon affected by the catastrophic
explosion in Beirut [1, 2].
The Fund, in partnership with the Bangladesh Ministry of Health and Family
Welfare, also organized a conference in Bangladesh, where cancer is the leading
cause of death among women of reproductive age. The conference brought together
various stakeholders to share evidence-based best practices for noncommunicable
diseases (NCDs) and advocate for policy changes to increase investment in preven-
tion, care, and treatment for disadvantaged communities. Additionally, the confer-
ence provided an opportunity to establish partnerships for research and
community-level model development.
Taking up various initiatives and partnerships, the Ameera Fund has also estab-
lished projects not only globally but also provided support to cancer treatment and
facilities within the UAE. The Fund has joined forces with the American University
of Sharjah to improve the effectiveness and efficiency of chemotherapy treatment
protocols in the country.

9.4 Advocacy for International Collaboration

The FOCP engages in international collaboration with similar organizations to

share knowledge and expertise in cancer screening, diagnosis, treatment, and
research. These collaborations take the form of forums, conferences, and roundta-
bles, some of which are pioneering events in the region. The FOCP seeks to ensure
that individuals in the region have access to the most advanced cancer treatments in
order to improve survival rates and reduce the incidence of the disease.
One example of this collaboration is the Sharjah PORTAGE (Pediatric Oncology
Roundtable to Transform Access to Global Essentials), which works to combat
pediatric cancer and support efforts to eliminate the disease. The forum has also
helped to identify funding sources and partners to implement priority initiatives and
develop strategies for effective communication between medical institutions and
relevant authorities in order to coordinate efforts to fight pediatric cancer.
168 A. Al Mulla and M. Mohamed

The First Childhood Noncommunicable Diseases (NCD) Forum, held in partner-

ship with the Global NCD Alliance, also focused on global efforts to address NCDs,
including cancer. The forum featured 110 delegates and 25 speakers from over 20
countries.
The Global NCD Alliance Forum, first held in 2015, provides a platform to advo-
cate for action to implement global pledges and meet the globally agreed NCD tar-
gets by 2025. The 2020 forum attracted more than 400 delegates from 80 countries,
with 53 national and regional alliances and over 20 youth leaders in attendance. In
addition to 20 individuals sharing their experiences living with NCDs, the event
featured 140 speakers from 32 countries, as well as five plenary sessions and 18
workshops.
The Cervical Cancer Forum, held in 2019 and 2021, has provided programmatic
guidance to the Ministry of Health and other agencies for the development and revi-
sion of cervical cancer prevention and control programs. The forum featured best
practices from the UAE and introduced the “Sharjah Declaration on Cervical
Cancer,” developed in partnership with the United Nations Population Fund
(UNFPA) and the MENA Coalition for Human Papillomavirus (HPV) Elimination.
The declaration outlines the actions and collaborations needed to address cervical
cancer and save lives in the region.
The forum advocates for regional and national cervical cancer strategies that
align with global initiatives, taking into account national capacities in order to
ensure their implementation in each country. It also aims to enhance cooperation in
order to improve countries’ and organizations’ capacity for cervical cancer control
and nationwide HPV vaccine program implementation, particularly in the context
of current and future health emergencies. The forum also seeks to improve data col-
lection, analysis, and utilization for evidence-based decision-making and to address
inequities in access to the HPV vaccine and cervical cancer detection and treatment.
The conference has also led to the establishment of a framework for monitoring the
progress of HPV vaccine implementation and cervical cancer elimination.
The fifth annual Combined Gulf Cancer Conference in 2022, hosted by the
FOCP in Sharjah in collaboration with the Gulf Federation for Cancer Control and
the Gulf Center for Cancer Control and Prevention, brought together over 50 inter-
national speakers and 500 delegates, including scientists, researchers, cancer pre-
vention advocates, and representatives of leading cancer nonprofit organizations in
the region. The conference focused on analyzing the current state of cancer care in
the region and discussing best practices to improve the standard of care across the
cancer control continuum. It also addressed the potential for creating medical
frameworks to improve access to healthcare and facilities for cancer patients during
treatment and beyond. Apart from being a networking platform for global cancer
experts, the conference also featured interactive panel discussions and presentations
by young scientists who presented their research abstracts and hypotheses.
The conference featured six tracks with a variety of panel sessions, dialogues,
and keynote speeches. The discussions addressed long-term issues in the sector,
such as cultural and socioeconomic barriers to cancer awareness and prevention, as
well as the importance of early detection and screening in cancer care and control.
9 Nongovernmental Organizations’ (NGO) Role in Cancer Care in the UAE: Friends… 169

The conference also focused on current issues such as the use of social media and
mobile health technology for health promotion and behavior change, the influence
of media on behavior, how to build better by learning from the COVID-19 pan-
demic, and the impact of advanced technology and innovation on cancer screening
programs in the region.

9.5 Cancer Awareness Initiatives

The FOCP places a significant emphasis on raising public awareness about the
importance of early detection in the fight against cancer. This focus is in line with
findings from the World Health Organization, which suggest that approximately
30–50% of cancers can be prevented through the adoption of healthy behaviors,
such as maintaining a healthy diet and weight and engaging in regular physical
activity [3]. Additionally, the World Health Organization (WHO) reports that
another 40% of cancers are curable if diagnosed in their early stages and treated
promptly [4].
Conversely, a large percentage of cancer cases that are diagnosed at later stages
are difficult to cure. Late detection is often attributed to a lack of knowledge about
cancer symptoms and the failure to undergo regular cancer screenings.
To address these issues, the FOCP works with local government organizations to
provide educational lectures and workshops, free medical examinations, and sup-
port programs for cancer patients and their families. One of the organization’s most
successful campaigns, the “Pink Caravan,” is a UAE-wide initiative focused on rais-
ing awareness about breast cancer and promoting early detection and screening
methods [1, 2] (Table 9.5).
Cancer awareness is at the heart of FOCP’s mission, which involves creating
awareness around the six early detectable cancers: breast cancer, cervical cancer,
prostate cancer, testicular cancer, colorectal cancer, and skin cancer under the

Table 9.5 Number of detected cancer cases since the launch of the Pink Caravan initiative
(2011–2022)

*
Detected cancer cases are currently under going treatment adopted by Friends of Cancer Patients
170 A. Al Mulla and M. Mohamed

“KASHF” umbrella initiative for early detection. In this regard, FOCP has launched
numerous cancer-focused awareness initiatives with a regional and international tar-
get scope, including the Pink Caravan for breast cancer, “Ana” for childhood cancer,
“Shanab” for men’s cancer, and “Mole Talk” for skin cancer.

9.6 Challenges in the UAE for Cancer Care

There are several challenges that cancer awareness initiatives in the UAE must over-
come, including misdiagnoses and expensive treatment costs. Much like the global
health diagnosis scenario, especially when it comes to cancer. Some patients’
tumors may not be identified correctly, and they do not receive the right treatment at
the right time, leading to undesired treatment complications or even death.
The cost of treatment can also pose a significant burden for patients, even if they
have health insurance or their employer covers some medical expenses. Certain
insurance companies may not cover treatments for previously diagnosed cases or
for those who have lived with the disease for an extended period without diagnosis
or treatment. Also, some insurance providers may not cover treatment costs for indi-
viduals over a certain age.
Access to comprehensive cancer care facilities is also a challenge in the UAE, as
patients may need to visit multiple hospitals to complete their treatment journey.
Specialized cancer facilities such as Tawam Hospital may also be difficult to reach
for those living in other emirates.
The societal stigma surrounding cancer can also negatively impact the psycho-
logical well-being of patients. Cancer patients may be reluctant to share their expe-
riences for fear of rejection, preventing them from receiving necessary psychological
and emotional support during the early stages of diagnosis. A cancer diagnosis may
also have economic consequences, as individuals may lose their jobs.

9.7 Strategies to Tackle Cancer Care Challenges

Cancer care is a complex and multifaceted issue that requires the implementation of
strategies that address the needs of patients and caregivers, as well as the training
and support of healthcare professionals. One key aspect of cancer care is ensuring
access to accurate assessment and diagnostic services, as well as reliable informa-
tion about the condition and available treatment options. This is crucial for empow-
ering patients to make informed decisions about their care and for helping them
maintain as normal a lifestyle as possible while minimizing the risk of further
complications.
By providing access to information and services, NGOs can support patients in
understanding the potential long-term effects of treatment and the possibility of
relapse. This can be achieved through the provision of information about new
research and the availability of resources for managing the disease.
9 Nongovernmental Organizations’ (NGO) Role in Cancer Care in the UAE: Friends… 171

To further improve cancer care, it is necessary to train healthcare professionals in

the delivery of high-quality care and to provide them with access to the latest tech-
nologies. This includes the development of frameworks that are tailored to the needs
of individual patients and the implementation of strategies to optimize the use of
time and resources.
To increase cancer survival rates and bring care up to par with countries with the
most advanced cancer care systems, it is necessary for health policymakers to
implement strategies that address the unique challenges faced by cancer patients in
different regions. This may include the creation of a registry that tracks the experi-
ences and outcomes of cancer patients, allowing for the exchange of best practices
and the identification of areas for improvement.
Enhancing cancer care requires the implementation of strategies that address the
needs of patients and caregivers, as well as the training and support of healthcare
professionals. By working toward a more inclusive and comprehensive approach to
cancer prevention, control, and care, we can create a brighter future for those
affected by the disease.

9.8 Conclusion

In summary, organizations like the Sharjah-based FOCP play a crucial role in pro-
viding aid, raising awareness about cancer, and enhancing cancer care facilities.
FOCP focuses on early screening and detection methods as well as pediatric cancers
and cancers with high incidence rates in the UAE. The organization also aims to
advocate for health, call for better policy change efforts, and promote healthy
lifestyles.
FOCP has been successful in offering hope and support to cancer patients and
their families, as well as collaborating with international and local organizations to
increase awareness about the disease. The organization provides services to all resi-
dents of the UAE without discrimination and has helped over 6000 patients since its
establishment in 1999. In 2020 and 2021 alone, FOCP provided annual care to
hundreds of cancer patients, with the majority being female and receiving support
within the first 6 months of their diagnosis.
Apart from providing medical financial aid and social support, FOCP also con-
ducts fundraising events and awareness workshops to increase public knowledge
and address misunderstandings about cancer care. By raising awareness and provid-
ing support to cancer patients, FOCP is making a positive impact on the lives of
individuals affected by the disease and the overall health of UAE society. It is
important for organizations like FOCP to continue their efforts in cancer care and
for individuals to prioritize their health and seek out early screening and detection
methods.

Conflicts of Interest The authors have no conflict of interest to declare.

172 A. Al Mulla and M. Mohamed

References
1. FOCP. Ameera fund. Advocacy. Our programs. Friends of Cancer Patients. 2022. https://www.
focp.ae/our-­programs/ameera-­fund/.
2. FOCP. Pink Caravan. Women’s health. Our programs. Friends of Cancer Patients. 2022. https://
www.focp.ae/our-­programs/womens-­health/.
3. WHO. Preventing cancer. Activities. World Health Organization. 2022. https://www.who.int/
activities/preventing-­cancer.
4. UN News. New WHO platform promotes global cancer prevention. Health. United Nations.
2022. https://news.un.org/en/story/2022/02/1111312. Accessed 10 Feb 2023.

Aisha Al Mulla is a leader who possesses a strong commitment to

creating a positive impact within her community. Her academic
achievements demonstrate her aptitude for finance and her drive for
self-improvement.
With a wealth of experience garnered from various roles and
organizations, Aisha began her career as a Senior Finance
Coordinator at Salam Ya Seghar, where she effectively managed
projects for Palestine and Syrian refugees and oversaw the depart-
ment’s yearly and monthly budget and expenses. In September
2015, she assumed the position of Head of Programs at The Big
Heart Foundation, where she expertly coordinated with existing
and potential partners, and implemented projects for all the initia-
tives under the foundation. In July 2022, Aisha was promoted to the
role of Deputy Director of Friends of Cancer Patients before
becoming Director in October 2022.
Throughout her career, Aisha has achieved numerous notable
accomplishments. In 2020, she received a Diploma in Humanitarian
Assistance from the Ministry of Foreign Affairs x UAE University.
In 2019, she completed the Sharjah Leadership Program from
Sharjah Capability Development. In 2015, she received a certificate
in the Advanced Management Development Program as well as a
certificate in Business Etiquette from a course given by Mohamed
AlMarzouqi.

Majed Mohamed is the Advocacy and Scientific Affairs Manager

at the Friends of Cancer Patients (FOCP) organization in the
UAE. Educational background includes a Master of Science in
Public Health from Hamdan Bin Mohammed Smart University and
a Bachelor of Science in Medical Sciences from the United Arab
Emirates University.
Focused on reducing the impact of cancer, Majed leads local
and international advocacy efforts, amplifying the voices of cancer
patients for impactful change. With an extensive local, regional,
and global network, Majed actively contributes to esteemed com-
mittees, including the WHO NCD Labs Steering Committee, NCD
Child Young Leader, CCI Asia Regional Committee (ASRC), and
MOHAP National Policy Healthy Lifestyle Committee.
He is recognized for his efforts in advancing cancer awareness,
prevention, and treatment through local and international advocacy
efforts to ensure that cancer patients’ voices are heard and valued to
drive better change.
9 Nongovernmental Organizations’ (NGO) Role in Cancer Care in the UAE: Friends… 173

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Clinical Cancer Research in the UAE
10
Subhashini Ganesan , Humaid O. Al-Shamsi ,
Mohamed Mostafa, and Walid Abbas Zaher

10.1 Need for Cancer Research in the UAE

The worldwide cancer incidence is on the rise, and according to the World Health
Organization (WHO), cancer is the first or second leading cause of death in about
112 countries [1]. In the United Arab Emirates (UAE), according to the UAE

S. Ganesan
G42 Healthcare, Abu Dhabi, United Arab Emirates
IROS (Insights Research Organization and Solutions), Abu Dhabi, United Arab Emirates
e-mail: subhashini.g@iros.ai
H. O. Al-Shamsi
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca
M. Mostafa
Science Park, Dubai, United Arab Emirates
e-mail: mohamed.mostafa@pdc-cro.com
W. A. Zaher (*)
Science Park, Dubai, United Arab Emirates
College of Medicine and Health Sciences, Khalifa University,
Abu Dhabi, United Arab Emirates
College of Medicine and Health Sciences, United Arab Emirates University,
Abu Dhabi, United Arab Emirates
e-mail: walid.zaher@carexso.com

© The Author(s) 2024 175

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_10
176 S. Ganesan et al.

National Cancer Registry annual report 2021, cancer is the fifth leading cause of
death in the United Arab Emirates. The report showed that breast, thyroid, colorec-
tal, leukemia, and skin (carcinoma) were the top-ranked cancers among all new
cancer cases in both genders. Colorectal, prostate, leukemia, and thyroid were the
top-ranked cancers among the males. Among females, breast, thyroid, colorectal,
uterus, and cervix uteri were the top-ranked cancers. The overall age-standardized
incidence rate was 107.8 per 100,000 and an overall crude incidence rate of
60.5/100,000 for both genders. Among females, the crude incidence rate was
reported to be 108.7 per 100,000 females and 39.5/100,000 for males [2]. These
numbers distinctly suggest that the UAE population differs from the west in their
ethnicity and genetic makeup, which, to a large extent, can affect the diagnosis,
treatment, and prognosis of this population. There is a difference in genomic struc-
ture between ethnic groups, and they differ in the strength of their association with
cancer risk. As a result, some research findings may not be validated in ethnic
groups other than the study cohort, affecting the study’s reproducibility in another
ethnic group [3]. Moreover, the sociocultural aspects of ethnicity and race, like food
habits, lifestyle, and environment, contribute to cancer risk and make a significant
contribution to cancer research [4]. As a result, robust cancer research among the
Emirati population is required to improve our understanding of such differences and
their impact on diagnostic and treatment strategies.

10.2 Clinical Trials in Oncology

The first clinical trial for the evaluation of cancer treatments was conducted in the
mid-1950s by the National Cancer Institute of NIH [5]. Since then, hundreds of
studies have been conducted and have provided substantial data, improving the
knowledge base and thereby providing supporting evidence for newer cancer treat-
ments or changes in regimens. In the hierarchy of evidence, randomized control
trials (RCTs) are the most robust designs, and clinical trials produce evidence that
can inform treatment policies and support changes [6]. Clinical trials have grown
and evolved significantly over time, both in terms of their scientific impact and the
regulations that govern them. However, clinical trials have their critics regarding the
external validity of the trials as they are conducted in a highly controlled environ-
ment and the challenges such as globalization of trials, operational complexities like
long time periods, regulatory and ethical approvals, recruiting and retaining the par-
ticipants in the study, and the increasing cost of conducting clinical trials [7, 8].
In this chapter, we will discuss the clinical trials and the randomized controlled
trials conducted in the UAE specific to oncology and their characteristics.

10.3 Clinical Trials in Oncology in the UAE

10.3.1 Search Criteria

A PubMed search was performed to find all cancer-related articles published in the
United Arab Emirates (UAE) in the last ten years, from 2012 to 2022. The database
10 Clinical Cancer Research in the UAE 177

was searched using the key words with Boolean operators as “OR” and “AND.” The
keywords used were “cancer,” “oncology,” “tumor,” “tumor,” “United Arab
Emirates,” and “UAE.” The search was filtered by article type, which included only
clinical trials and randomized controlled trials, and an additional filter on publica-
tion date, focusing on the last 10 years, was used to refine the search.
The search strategy included the following keywords: (Cancer) OR (TUMOR)
OR (TUMOUR) AND (United Arab Emirates), which resulted in 28 studies. The
abstracts of all 28 studies were screened by two coauthors, and studies that did not
specifically relate to cancer were excluded. Following this exclusion, 11 studies
were considered that were either conducted among the UAE population or had one
of the authors affiliated with a UAE-based institute (Fig. 10.1).
Among these 11 studies, 3 (27.3%) focused on breast cancer, followed by 2
(18%) on leukemia. Ten of these 11 studies were based on therapy for cancer, and
one was based on cancer screening. Out of the 11 studies, 6 (55%) were interven-
tional trials, 2 (18%) were observational, 2 (18%) were phase III trials, and 1 (9%)
was a phase II trial.
About 6 (55%) of these 11 studies were published in journals with an impact
factor of 3.0 or higher, while 2 (18%) were published in journals with an impact
factor of 10 or higher. About 7 out of 11 (64%) studies have gotten more than or
equal to 15 citations (Table 10.1).

Fig. 10.1 Clinical research in oncology in the UAE

Table 10.1 Characteristics of clinical trials registered in oncology in the UAE
178

Study
Title NCT Type of cancer Study type Year UAE-­based Status results
1. Epidemiological Study to Describe NCT01562665 Lung cancer Observational 2012 No Completed No
Non-small Cell Lung Cancer Clinical results
Management Patterns in MENA. Lung-­
EPICLIN/Gulf
2. A Study of Trastuzumab Emtansine in NCT01702571 Breast cancer Interventional 2012 No Completed Has
Participants with Human Epidermal Growth results
Factor Receptor 2 (HER2)-Positive Breast
Cancer Who Have Received Prior Anti-­
HER2 And Chemotherapy-based Treatment
3. A Study of Pertuzumab in Combination With NCT01572038 Breast cancer Interventional 2012 No Completed Has
Trastuzumab (Herceptin) and a Taxane in results
First-Line Treatment in Participants With
Human Epidermal Growth Factor 2
(HER2)-Positive Advanced Breast Cancer
4. A Safety and Tolerability Study of Assisted NCT01566721 Breast cancer Interventional 2012 No Completed Has
and Self-Administered Subcutaneous (SC) results
Herceptin (Trastuzumab) as Adjuvant
Therapy in Early Human Epidermal Growth
Factor Receptor 2 (HER2)-Positive Breast
Cancer
5. Study of Efficacy and Safety in NCT02278120 Breast cancer Interventional 2014 No Active, not Has
Premenopausal Women With Hormone recruiting results
Receptor-Positive, HER2-negative Advanced
Breast Cancer
6. Retrospective Epidemiology Study Of ALK NCT02304406 Lung cancer Observational 2015 No Completed Has
Rearrangement In Non-Small Cell Lung results
Cancer Patients In The Middle East & North
Africa
S. Ganesan et al.
 Study
Title NCT Type of cancer Study type Year UAE-­based Status results
7. Multicenter Registry of Treatments and NCT02273856 Lymphoma Observational 2015 No Terminated No
Outcomes in Patients With Chronic leukemia results
Lymphocytic Leukemia (CLL) Or Indolent
Non-Hodgkin’s Lymphoma (iNHL)
8. Prevalence of BRCA1 and BRCA2 NCT03082976 Ovarian cancer Observational 2017 No Completed No
Mutations in Ovarian Cancer Patients in the results
Gulf Region
9. Fulvestrant Versus Fulvestrant Plus NCT03447132 Breast cancer Interventional 2017 Yes Completed No
Palbociclib in Operable Breast Cancer results
Responding to Fulvestrant
10. A Study of Atezolizumab (Tecentriq) to NCT03285763 Lung cancer Interventional 2017 No Completed No
Investigate Long-term Safety and Efficacy in results
Previously treated Participants With Locally
10 Clinical Cancer Research in the UAE

Advanced or Metastatic Non-Small Cell

Lung Cancer (NSCLC)
11. Pembrolizumab And Tamoxifen Among NCT03879174 Breast cancer Interventional 2019 Yes Unknown No
Women With Advanced Hormone Receptor-­ status results
Positive Breast Cancer And Esr1 Mutation
12. A Study Investigating the Outcomes and NCT03782207 Urothelial Observational 2019 No Recruiting No
Safety of Atezolizumab Under Real-World carcinoma/ results
Conditions in Patients Treated in Routine non-small cell
Clinical Practice lung cancer/small
cell lung cancer/
hepatocellular
carcinoma
13. Prevention of Colorectal Cancer Through NCT04369053 Colorectal cancer Observational 2020 No Active, not No
Multiomics Blood Testing recruiting results
(continued)
179
Table 10.1 (continued)
180

Study
Title NCT Type of cancer Study type Year UAE-­based Status results
14. Retrospective Study to Describe the NCT04801186 Prostate cancer Observational 2021 No Recruiting No
Real-world Treatment Patterns and results
Associated Clinical Outcomes in Patients
With Metastatic Castration-resistant Prostate
Cancer
15. Study to Determine the Prevalence of NCT04991051 Fallopian tube Observational 2021 No Completed No
Homologous Recombination Deficiency cancer results
Among Women With Newly Diagnosed,
High-grade, Serous or Endometrioid
Ovarian, Primary Peritoneal, and/or Fallopian
Tube Cancer
16. An Observational Study to Evaluate the NCT04764188 Lung cancer Observational 2021 No Recruiting No
Real-World Clinical Management and results
Outcomes of ALK-Positive Advanced
NSCLC Participants Treated With Alectinib
S. Ganesan et al.
10 Clinical Cancer Research in the UAE 181

10.3.2 General Characteristics of the Clinical Trials

The clinical trials on cancer conducted or ongoing in the UAE were gathered from
the clinicaltrials.gov site, and the search keywords were “tumor,” “cancer,” and
“United Arab Emirates.” The search resulted in 25 studies. When restricting the
search to studies initiated in the last 10 years, only 16 clinical trials were identified.
Only 2 of the 16 trials were initiated and sponsored by an institute or hospital in the
UAE. The rest were sponsored by non-UAE-based organizations, of which the UAE
was one of the study sites. Of these 16 trials, 5 were active or recruiting, 9 were
completed, 1 study was terminated, and the status of one of the trials was unknown.
Among the completed trials, results were available for only four studies (Fig. 10.1;
Table 10.2).
About 6 (38%) of the cancer therapeutic trials were on breast cancer, 5 (31%)
were on non-small cell lung cancer (NSCLC), and the others were on leukemia,
colorectal, ovarian, prostate, and fallopian tube cancer. Regarding the study types, 7
(44%) were interventional trials, and the other 9 (56%) studies were observational.
About 15 of 16 studies (94%) were solely sponsored by the pharmaceutical indus-
try, and one was sponsored by Mediclinic in collaboration with AstraZeneca, Pfizer,
and Genomic Health. The main pharmaceutical industry sponsors were Hoffmann-La
Roche, which sponsored 6 (38%) of these trials, followed by AstraZeneca, which
sponsored 4 (25%) of the trials; the other sponsors were Astellas Pharma
International, Novartis, Pfizer, and Freenome Holdings (a biotechnology company).
Ten of these 16 (63%) trials were registered between 2012 and 2017, and 6 (37%)
were registered between 2018 and 2022 (Fig. 10.2).
Table 10.2 Characteristics of studies published in PubMed on cancer in the UAE
182

Title Cancer type Study type Year Journal Impact factor

1. Reinduction chemotherapy using FLAG-mitoxantrone for adult Leukemia Interventional 2018 International Journal 2.31
patients with relapsed acute leukemia: a single-­center experience clinical trial of Hematology
from United Arab Emirates
2. Response to Induction Neoadjuvant Hormonal Therapy Using Breast Phase III 2021 JCO Global 4.33
Upfront 21-Gene Breast Recurrence Score Assay-Results From cancer Oncology
the SAFIA Phase III Trial
3. Parts greater than their sum: randomized controlled trial testing Colorectal Interventional 2019 Annals of the 6.49
partitioned incentives to increase cancer screening cancer clinical trial New York Academy
of Sciences
4. Safety and tolerability of subcutaneous trastuzumab for the Breast Phase III 2017 European Journal of 10.00
adjuvant treatment of human epidermal growth factor receptor cancer Cancer
2-positive early breast cancer: SafeHer phase III study’s primary
analysis of 2573 patients
5. Autologous Bone Marrow Concentrates and Concentrated Growth Oral cancer Interventional 2018 Journal of 0.92
Factors Accelerate Bone Regeneration After Enucleation of clinical trial Craniofacial Surgery
Mandibular Pathologic Lesions
6. Standard triple therapy versus sequential therapy for eradication of Stomach Interventional 2016 Arab Journal of 1.80
Helicobacter pylori in treatment naïve and retreat patients cancer clinical trial Gastroenterology
7. Outcome of pregnancy in chronic myeloid leukemia patients Leukemia Observational 2015 Leukemia Research 3.71
treated with tyrosine kinase inhibitors: short report from a single clinical trial
center
8. Association of AXL and PD-L1 Expression with Clinical Renal Observational 2021 Clinical Cancer 13.80
Outcomes in Patients with Advanced Renal Cell Carcinoma cancer clinical trial Research
Treated with PD-1 Blockade
S. Ganesan et al.
 Title Cancer type Study type Year Journal Impact factor
9. A multicenter prospective phase II trial of neoadjuvant epirubicin, Breast Phase II 2015 Cancer 3.28
cyclophosphamide, and 5-fluorouracil (FEC100) followed by cancer Chemotherapy and
cisplatin-docetaxel with or without trastuzumab in locally Pharmacology
advanced breast cancer
10. Monopolar vs. bipolar transurethral resection for non-muscle Bladder Interventional 2018 Urologic Oncology: 2.95
invasive bladder carcinoma: A post-hoc analysis from a cancer clinical trial Seminars and
randomized controlled trial Original
Investigations
11. Efficacy of Spirulina 500 mg vs. Triamcinolone Acetonide 0.1% Oral cancer Interventional 2022 The Journal of 1.01
for the Treatment of Oral Lichen Planus: A Randomized Clinical clinical trial Contemporary
Trial Dental Practice
10 Clinical Cancer Research in the UAE
183
184 S. Ganesan et al.

Fig. 10.2 Clinical trials in oncology in the UAE

10.4 Data Utilization

Clinical trial data that were analyzed included the trial start date, study type, study
participants (including inclusion and exclusion criteria), intervention or treatment
details, type of cancer studied, research site, research institute, phase of the trial,
outcome measures, and availability of results.

10.4.1 Characteristics of Inclusion Criteria

The common inclusion criteria across all interventional trials included the ability to
give signed informed consent, being over 18 years old, being willing to be randomly
assigned to any treatment arms, and agreeing not to participate in any other trial
until the completion of the follow-up period. Other criteria included histologically
confirmed cancers by tests like immunohistochemistry (IHC), fluorescent in situ
hybridization (FISH), next-generation sequencing (NGS), or other nonspecified
sequencing methods depending on the type of cancer. Most trials limited the inclu-
sion criteria to subjects who were newly diagnosed or who were in the early stages
of cancer. However, few studies included patients with severe or advanced cancer
stages. To avoid pregnancy during the study period, most studies required the use of
highly effective contraception as defined by the protocol.
10 Clinical Cancer Research in the UAE 185

10.4.2 Characteristics of Exclusion Criteria

The most common exclusion criteria across most studies were patients diagnosed
with any severe acute or chronic medical or psychiatric conditions that might
increase the risk associated with study participation or interfere with the interpreta-
tion of the study result. Additionally, history of any investigational drug or device
use within 4 weeks of recruitment and chronic medical conditions like uncontrolled
diabetes, progressive neurological disorders, and any other medical condition that,
in the opinion of the investigator, should preclude enrollment in the study were
considered as exclusion criteria.

10.4.3 Study Type

Among the 16 studies registered, 9 (56%) were observational and 7 (44%) were
interventional, and the main outcomes were to study the safety and efficacy of the
treatment drug. Among the interventional studies, Pembrolizumab, Tamoxifen,
Trastuzumab Emtansine, Letrozole, Anastrozole, Goserelin, LEE011, Fulvestrant,
Palbociclib, Goserelin, Docetaxel, Nab-paclitaxel, Paclitaxel, Pertuzumab,
Trastuzumab, and Herceptin were the drugs studied among the breast cancer disease
patients. Alectinib and Atezolizumab were studied among non-small cell lung can-
cer (NSCLC) patients. The main routes of administration of the drugs included oral,
intravenous, and subcutaneous injections. One of the studies was to validate a diag-
nostic test (the Freenome test), a blood-based test for the early detection of colorec-
tal cancer.
Seven out of 16 (44%) studies focused on breast cancer, 5 (31%) focused on
NSCLC, and the remaining included colorectal cancer, ovarian, prostate, fallopian
tube cancer, and non-Hodgkin’s lymphoma (NHL). Among the 7 interventional
studies, 6 (86%) focused on breast cancer, and one was on NSCLC. In four of these
trials, a combination of drugs was used.

10.4.4 Outcomes Measured

The outcomes of the trials included the progression of the disease, overall survival,
and adverse effects. The parameters used for assessing the disease progression were
radiological findings, grading of the tumor, duration of response, clinical evaluation
of the tumor, and molecular responses. The follow-up period for interventional stud-
ies ranged from 1 year to 7 years, depending on the nature of the study. In real-world
safety assessment studies, observational studies had follow-up periods ranging from
3 months to 6 years.
186 S. Ganesan et al.

10.5 Discussion

Scientific studies producing high-quality evidence are essential for advancement in

medical practices and thereby influencing policy changes and guidelines for the
treatment and management of diseases. Cancer epidemiology varies among differ-
ent ethnic groups, and a variety of sociocultural factors play a significant role in
cancer detection and treatment; therefore, it is necessary to conduct studies and
gather evidence among the local population.
The PubMed search on clinical trials or randomized control trials in oncology
conducted in the UAE showed that there were only 11 studies published in the past
10 years. The majority of them were published in the last 5 years. However, out of
these 11 studies, three of them focused on breast cancer, which is the most common
cancer among women in the UAE, followed by two studies on leukemia. The major-
ity (38%) of clinical trials registered on clinicaltrials.gov focused on breast cancer,
followed by 31% on non-small cell lung cancers. This indicates that a higher num-
ber of oncology trials were conducted on conditions like breast cancer and lung
cancer, which are the most common cancers documented among women and men in
the Emirati population, respectively. However, no trials were registered on other
common cancers among this population, like cervical, thyroid, and gastric cancers.
This results in a lack of sufficient evidence for the other common cancers in this
population. It is a well-established fact that the external validity of clinical trials is
often questionable as they do not adequately represent real-world patient popula-
tions, where a variety of patient characteristics can interfere [7]. The validity of
these study results is challenged when the treatment protocols are based on research
conducted in other ethnic groups. Therefore, studying these cancer characteristics in
the local population is highly critical, as the application of trial findings conducted
on other populations might not help us completely understand the disease character-
istics and the treatment effects specific to this ethnic group.
Only 2 of the 16 clinical trials were based in the UAE, and the rest had the UAE
as one of the trial sites where the study was conducted. This is primarily due to the
increasing trend toward conducting trials outside of western countries like the
United States. Most pharmaceutical companies from the west now conduct trials
outside the country, as this costs less than running the trial in their country [9]. The
cost of conducting a trial is huge, depending on the number of participants needed,
the number of research sites, the country in which the site is located, the complexity
of the trial protocol, and the incentives provided to investigators and reimburse-
ments for patients. This globalization of clinical trials has also increased the effi-
ciency of clinical drug development, which can support the marketing authorization
of new drugs globally [7].
Exploration of the inclusion and exclusion criteria of the clinical trials showed
that all studies except for one epidemiological study on NSCLC were conducted
among the adult population. Further, most of the studies excluded participants with
comorbid conditions like diabetes, hypertension, severe kidney diseases, and preg-
nancy, which led to a lack of evidence in such groups. In the UAE, where diabetes
and hypertension are major noncommunicable diseases, excluding people with
10 Clinical Cancer Research in the UAE 187

these comorbid conditions can result in understudying of a significant percentage of

the population and a lack of supportive evidence in this most vulnerable group of
population [10–12].
Further, the majority of the interventional trials were in phase III, which was
mainly to test the safety and effectiveness of the new treatment against the current
standard treatment. Phase I and II studies were very limited; they were primarily to
study the pharmacokinetics and pharmacodynamics and to test whether a new treat-
ment worked for a certain type of cancer [13]. This indicates that we need more
resources and funding for the development of new molecules for cancer, which are
concerning and more specific to the Emirati population, to improve cancer treat-
ment and care.
Among the nine completed trials, results were available for only four trials on the
clinicaltrials.gov site; one more study result, though not available at this site, was
published in PubMed with a ClinicalTrials.gov identifier (NCT number). This
shows that only about 50% of the trial results are published.
The number of registered clinical trials in oncology has decreased in the last
5 years when compared to the 2012–2017 time period; this could be because the
recent pandemic has diverted grants and research capabilities into COVID-19
research, decelerating research and development in other critical diseases [14, 15].
In the context of oncology-based clinical trials, there are several barriers and facili-
tators to conducting clinical trials. Healthcare providers face barriers such as a lack of
time and research experience; institutional barriers such as a lack of research and clini-
cal trial units, and so on; and patient and community barriers such as a lack of under-
standing, unawareness, mistrust, and fear of clinical trials. Apart from these, there are
challenges from the global community, which include a lack of trust in research capa-
bilities in developing countries, the exclusion of researchers from developing countries
from research networks, and a lack of support for the publication of research from
non-Western countries. Finally, the barriers from the pharmaceutical industry include
concerns about research capabilities and regulatory delays, a lack of accredited centers
of excellence, and gaps in global and local pharmaceutical funding [16].

10.6 Way Forward for Clinical Trials in Oncology in the UAE

Overcoming the barriers of clinical research in oncology is of paramount impor-

tance and a critical step in improving cancer care in the UAE. To overcome these
barriers in clinical research, there is a need for all stakeholders and policymakers to
come together to improve local research capabilities. There is a need to establish a
research consortium specially dedicated to oncology research, which will work to
expand research infrastructure. Recently, the Emirates Oncology Society estab-
lished an oncology research program to advance cancer research in the UAE [17].
These initiatives should focus on training physicians in conducting clinical trials,
incentives for physicians, and awareness and training of investigators in clinical trial
protocols and procedures, along with regulatory aspects that can improve participa-
tion in clinical trials.
188 S. Ganesan et al.

Implementing a successful clinical trial requires a team of multidisciplinary sup-

port staff that includes skilled technicians, epidemiologists, biostatisticians, admin-
istrative support staff, hospital staff to handle patients, a data monitoring committee,
etc. This again reiterates the fact that training is not only needed for investigators but
for the whole team, which needs to be knowledgeable as well as trained in all
aspects of clinical trials.
Apart from training physicians and their teams, training patients also becomes
essential, as patient participation is key to clinical trials. The patient must be made
aware of their rights, their autonomy, and the opportunities to participate in clinical
trials. This could help to dispel widespread skepticism about industry-sponsored
trials among the general public [18].
Organizing research grants specific to research on common cancers among the
Emirati population can improve scientific output on these cancers. Collaboration
with international organizations and partnerships with established research organi-
zations would go a long way toward including the UAE in clinical trials and provide
an exceptional opportunity for knowledge sharing and transfer among
collaborators.

10.7 Limitations

The limitations of this study are that some studies might have been missed due to
the restriction of searches to PubMed and clinicaltrial.gov and limiting the search to
only English-language publications.

10.8 Conclusion

There are a limited number of clinical trials in oncology, where cancer is the third
leading cause of death among people in the UAE. More so, UAE-based trials are
fewer in number, which indicates the necessity to initiate specific cancer-based
research in the UAE. The country needs to allocate adequate funds and establish a
research unit pertaining to cancer research to increase the evidence bank for cancer
diagnosis and treatment that is precise for the Emirati population.

Conflict of Interest The authors have no conflict of interest to declare.

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Dr. Subhashini Ganesan is a researcher at G42 Healthcare. She

has contributed efficiently to research on various aspects of the
COVID-19 pandemic and published her findings in well-reputed
journals, supporting the company’s efforts in fighting the COVID-19
pandemic. She also works as a Senior Researcher at IROS, a clini-
cal research organization, where she consults on research studies
and clinical trials. Before joining G42 Healthcare, Dr. Subhashini
was working as an assistant professor at the PSG Institute of
Medical Sciences and Research, India, and has been an active
member of the Research and Ethics committee. She has more than
25 scientific publications in peer-reviewed journals, including
Nature. She has worked as a consultant on various community-
based research projects in India. She is trained at the World Health
Organization (WHO), Geneva, in adolescent and reproductive
health research. She graduated with a Bachelor of Medicine and
Surgery (MBBS) and an MD in Public Health from the PSG
Institute of Medical Sciences and Research, India. She also has a
PG Diploma in Research and Bioethics.
190 S. Ganesan et al.

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty fel-
lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fel-
lowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new dis-
tinct subgroup of CRC, NON V600 BRAF-mutated CRC. In 2022,
he published the first book about cancer research in the UAE and
also the first book about cancer in the Arab world, both of which
were launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to docu-
ment the cancer care in the UAE with many topics addressed for
the first time, e.g., neuroendocrine tumors in the UAE. He is pas-
sionate about advancing cancer care in the UAE and the GCC and
has made significant contributions to cancer awareness and early
detection for the public using social media platforms. He is consid-
ered as the most followed oncologist in the world with over 300,000
subscribers across his social media platforms (Instagram, Twitter,
LinkedIn, and TikTok). In 2022, he was awarded the prestigious
Feigenbaum Leadership Excellence Award from Sheikh Hamdan
Smart University for his exceptional leadership and research and
the Sharjah Award for Volunteering. He was also named the
Researcher of the Year in the UAE in 2020 and 2021 by the
Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
10 Clinical Cancer Research in the UAE 191

of research training for medical trainees to enhance their clinical

and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Mohamed Mostafa is Chief Executive Officer at PDC CRO from

2020; as such, he is responsible for overall management and strate-
gic initiatives within the organization. Mohamed holds a bachelor’s
degree in Pharmaceutical Science with more than 15 years’ experi-
ence in the Pharma/CRO industry in the MEA region. Mohamed
was responsible for various scientific initiatives with local and
international partners and worked closely with regulatory agencies
across the region on various guidelines and strategic plans.
Mohamed has a solid understanding of the MEA region’s pharma,
biotech, and healthcare markets and continues to work closely with
colleagues to further develop the clinical research capabilities
within the MEA region.

Dr. Walid Abbas Zaher is a highly awarded scientist, medical

doctor, and businessman from the Kingdom of Saudi Arabia. He is
the current CEO of Carexso, the MENA region’s first site manage-
ment organization for biotech and medical research. He previously
founded and was CEO of the UAE’s first contract research organi-
zation, as well as CRO of G42 Healthcare, and, before that, was
Corporate Group R&D Director of SEHA in Abu Dhabi. He was
instrumental in revamping the clinical and R&D ecosystem in Abu
Dhabi, as exemplified by his leadership of 4Humanity, the Middle
East’s largest clinical trial, the empowerment of COVID-19 vac-
cine manufacturing, and spearheaded the Emirati Genome Program,
one of the most ambitious population genomics and precision med-
icine programs to date. He also helped achieve over 100x company
growth in 2 years. He drove innovative health technology plat-
forms, regenerative medicine, and longevity initiatives. He has over
78 publications in peer-reviewed journals and book chapters,
including papers in Nature and JAMA. Dr. Walid Zaher has a
degree in medicine from King Saud University with a residency in
Obstetrics & Gynecology, followed by two MScs and a PhD in
Regenerative medicine from Odense University Hospital in
Denmark, with a visiting research period at Harvard Medical
School. He is known for his work in transformative genomics, pio-
neering health and longevity, and next-generation implementation
of research and innovation.
192 S. Ganesan et al.

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Basic Cancer Research in the UAE
11
Ibrahim Yaseen Hachim , Saba Al Heialy ,
and Mahmood Yaseen Hachim

11.1 Introduction

In the last few decades, there has been a significant improvement in our understand-
ing of cancer’s etiology, pathogenesis, and progression [1, 2]. Basic cancer research
breakthroughs were critical in determining the genetic, molecular, and clinical het-
erogeneity of cancer’s various cancers and their interactions with the tumor micro-
environment [3]. Indeed, such discoveries were essential for the personalized cancer
medicine concept, which focuses mainly on tailoring drugs to specifically target the
driver mutations in cancer patients according to their genetic and molecular finger-
print [4]. Therefore, better allocation of resources for basic cancer research that
might help improve patient stratification will be essential for accelerating discover-
ies in cancer management and care to improve patient outcomes and reduce side
effects. This might be achieved through collaboration between laboratories and hos-
pitals to incorporate their discoveries into routine practice [5].

I. Y. Hachim
Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
Clinical Sciences Department, College of Medicine, University of Sharjah,
Sharjah, United Arab Emirates
e-mail: ibrahim.hachim@sharjah.ac.ae
S. Al Heialy
Immunology, College of Medicine, Mohammed bin Rashid University of Medicine and
Health Sciences, Dubai, United Arab Emirates
Division of Respiratory Diseases, Department of Medicine, McGill University,
Montreal, QC, Canada
e-mail: saba.alheialy@mbru.ac.ae
M. Y. Hachim (*)
Molecular Medicine, College of Medicine, Mohammed bin Rashid University of Medicine
and Health Sciences, Dubai, United Arab Emirates
e-mail: mahmood.almashhadani@mbru.ac.ae

© The Author(s) 2024 193

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_11
194 I. Y. Hachim et al.

11.2 Why Basic Cancer Research Is Needed in the United

Arab Emirates (UAE)

In the last few decades, there has been rapid and significant progress in understand-
ing cancer etiology and tumorigenesis. This was achieved through advancements in
basic cancer research that implement new technologies that allow high-resolution
genetic mapping of thousands of cancers and tumors [2, 6]. This has led to the dis-
covery of specific mutations and aberrations that can be specifically targeted by
novel drugs [2]. Indeed, identifying patients with those mutations helps tailor
patients’ care to be more personalized. For that reason, basic cancer research in the
UAE is essential not only for the validation of results obtained from the Western
population but also for the discovery of distinct UAE population-specific genetic,
molecular, and biological variations that might lead to the discovery of novel molec-
ular markers and targets that are associated with cancer risk and response to therapy
unique to the UAE population [7, 8]. For example, researchers discovered a distinct
molecular profile of breast cancer in women from Arab countries, including the
UAE, compared to the Western population. This includes a high tumor grade, fewer
luminal subtypes of tumor, and a higher rate of HER-2 positivity and triple-negative
breast cancer (TNBC) tumors in breast cancer patients [9–12]. A study done by
Al-Shamsi et al. revealed that evaluation of the molecular characteristics of colorec-
tal cancer in patients from the Arab Gulf region showed a similarity in the frequency
of KRAS, BRAF, NRAS, TP53, and APC as well as PIK3CA mutations between Arab
and Western populations; however, the SMAD4 and FBXW7 mutation frequencies
were distinct [13].

11.3 State of Cancer Research in the United Arab Emirates

In the past decades, there has been a significant advancement in cancer research in
the United Arab Emirates. Therefore, an in-depth analysis of the cancer research
activity might be essential not only to understand the trends of cancer research but
also to highlight the advances, achievements, gaps, and obstacles in this field and
provide information for scientific, funding, and governmental institutions that might
help in strengthening the research productivity [14].
One of the significant sources to investigate the state of cancer research activity
in the UAE is through an analysis of the number of cancer-related articles in the
UAE using the National Library of Medicine (NLM) database MEDLINE and its
search engine PubMed (https://www.ncbi.nlm.nih.gov/pubmed), which includes
more than 34 million citations for biomedical literature [15]. Globally, the propor-
tion of cancer-related entries per year significantly increased from 6% in 1950 to
around 16% in 2016 [15]. Similarly, a recent study showed that 26,656 cancer-­
related studies published in the Arab world represent around 13.4% of the entire
Arab world’s biomedical research manuscripts between 2005 and 2019 [16].
Using a similar methodology [16], we investigated the number of cancer-related
publications in the UAE from 1987 to 2021 using the Boolean operator in the
11 Basic Cancer Research in the UAE 195

PubMed search engine (Fig. 11.1a). In the advanced article search, we used the fol-
lowing MeSH terms and formula: cancer, malignant, oncology, tumor, tumour, neo-
plasm, carcinoma, adenocarcinoma, sarcoma, leukemia, lymphoma, metastasis,
oncogene, chemotherapy. The affiliation, country, or territory should be the United
Arab Emirates.
Our results showed an exponential increment in cancer-related publications in
the last decade, from only 66 publications in 2011 to around 865 in 2021. Using the

b
LRQV
3 XEOLFDW

<HDU
V

Fig. 11.1 (a) Number of cancer-related publications in the United Arab Emirates generated from
PubMed between 1987 and 2021. (b) Number of cancer-related publications in the United Arab
Emirates generated using Scopus database
196 I. Y. Hachim et al.

same MeSH terms used above, we also investigated the number of cancer-related
publications in the UAE during the same period using the Scopus database (Fig.
11.1b). Our results revealed 746 cancer-related documents in 2021, compared to
only one publication in 1980. This goes with a recent report that showed a 16-fold
increase in research publications in the last two decades in the UAE [17]. An inter-
esting finding is that in 1998, around 50% of the UAE-based publications were in
medicine and life sciences [17]. Since then, the research output growth has become
more diverse, and the contribution of other disciplines has started to increase. An
analysis of the research publications according to significant research disciplines in
the UAE revealed that in 2017, medicine and life sciences represented around 20%
of the research productivity, preceded by engineering, energy, and environmental
sciences [17].

11.4 Research Infrastructure in the United Arab Emirates

Previously, the lack of research infrastructure and the limited number of researchers
and funding opportunities represented a significant challenge for conducting
research in Middle Eastern and North African countries [18]. However, some coun-
tries, like the United Arab Emirates, showed a ground-breaking improvement in
their biomedical research productivity due to their investment in educational insti-
tutes, foundations, and multidisciplinary medical research centers.
Moreover, several actions were taken as part of the country’s efforts to strengthen
the research capacity within the UAE. This includes the investment in state-of-the-­
art research infrastructure and facilities, the recruitment of experienced researchers,
the establishment of various training programs, and the encouragement of interna-
tional collaboration. This was reflected by the exponential increase in higher educa-
tion and research institutions [17]. For example, a report published in 2007 showed
that while in 1998 there were only 29 institutions with biomedical publications, this
number increased to 103 institutions (including hospitals, universities, and research
centers) after 8 years [19].

11.5 Cancer Research Centers and Institutes in the United

Arab Emirates

In recent years, there have been significant initiatives for the establishment of sev-
eral multidisciplinary medical research centers that aim to find solutions to several
health challenges and diseases, including cancer, through innovation, providing an
interactive environment for scientists and clinicians to work together, and encourag-
ing local, regional, as well as international scientists’ collaboration.
11 Basic Cancer Research in the UAE 197

11.5.1 Zayed Bin Sultan Al Nahyan Center for Health

Sciences (ZCHS)

This center was established as part of UAE University’s efforts to become a world-­
class center for applied health research. This center supports researchers from a
wide range of backgrounds, including medicine, biology, engineering, chemistry,
information technology, and nutrition, to advance innovation, discovery, and
improve health practices. ZCHS has established more than 15 programs in various
fields, including cancer, molecular genetics and genomic medicine, immunoregula-
tion and infection, artificial intelligence, robotics applications in health, and
nanotechnology.

11.5.2 Research Institute of Medical and Health Sciences (RIMHS)

at the University of Sharjah

Since its establishment in 2015, this institute has been one of the top research and
innovation centers in the UAE and the region. This was achieved by supporting
more than 170 distinguished faculties and young researchers and providing them
with a supportive research environment, including state-of-the-art lab facilities and
top-notch research equipment. The institute includes 27 research groups led by dis-
tinguished scientists from different disciplines and colleges, including medicine,
dentistry, pharmacy, health sciences, and arts and sciences. These focus groups are
directed toward providing solutions for health problems, including cancer, inflam-
matory diseases, immunological disorders, and genetic disorders, in addition to
drug discovery.

11.5.3 Mohammed Bin Rashid Medical Research Institute

This world-class biomedical research institute is an initiative of the Al Jalila

Foundation. The center aims to encourage local and international scientists to col-
laborate to provide solutions for many human diseases, including cancer. The Al
Jalila Foundation fully funds this life sciences research center, and it is equipped
with the latest research technology. Furthermore, it recruits scientists and postdoc-
toral fellows who graduated from leading institutions across the globe. The collabo-
ration between this center, the Mohammed Bin Rashid University of Medicine and
Health Sciences (MBRU), and the Al Jalila Foundation resulted in significant scien-
tific discoveries translated into landmark publications in well-known and highly
reputed scientific journals.
198 I. Y. Hachim et al.

11.6 Top Institutional Affiliation and Internal Funding

Sources in the United Arab Emirates

To improve our understanding of the currently available cancer research institutes

and infrastructures, we investigated the affiliations and funding bodies of cancer-­
related manuscripts within the UAE between 1978 and 2021. Our analysis revealed
that United Arab Emirates University is the first UAE-affiliated research institute,
followed by the University of Sharjah, Tawam Hospital, Dubai Hospital, Khalifa
University of Science and Technology, Cleveland Clinic Abu Dhabi, Gulf Medical
University, New York University (NYU) Abu Dhabi, American University of
Sharjah, Ajman University, Rashid Hospital, and Mohammed Bin Rashid University
of Medicine and Health Sciences (MBRU) (Fig. 11.2a). Most institutions include
state-of-the-art specialized research centers and research groups that aim to enrich
the research environment and facilitate integration and collaboration between col-
leges, hospitals, and healthcare providers.
Analysis of the top funding local sponsors of the cancer research publication,
which is one of the main outputs of funding in the UAE, showed United Arab
Emirates University to have the largest number of funded research publications, fol-
lowed by the University of Sharjah, Al Jalila Foundation, American University of
Sharjah, NYU Abu Dhabi, Sheikh Hamdan Bin Rashid Al Maktoum Award for
Medical Sciences, and Khalifa University of Science and Technology (Fig. 11.2b).
The presence of this large number and various types of internal funding institutions
reflects the UAE strategy to support cancer research as a step to provide novel solu-
tions to improve cancer patients’ management and care.

a b

Document
Document

Fig. 11.2 Bibliometric analysis was extracted from the Scopus database to investigate the affilia-
tion, funding, sponsors, and output of cancer-related publications in the United Arab Emirates. (a)
The top affiliation of cancer-related publications in the United Arab Emirates using the Scopus
database between 1978 and 2021. (b) The top internal funding institutions of cancer-related publi-
cations in the United Arab Emirates using the Scopus database between 1978 and 2021. (c) The top
external funding institutions of cancer-related publications in the United Arab Emirates using the
Scopus database between 1978 and 2021. (d) Publication types of cancer-related publications in
the United Arab Emirates using the Scopus database between 1978 and 2021. (e) Subject-wise
distribution of cancer-related publications in the United Arab Emirates using the Scopus database
between 1978 and 2021
11 Basic Cancer Research in the UAE 199

Document

d
Book Chapter (1.7%%) Short Survey (0.2%) ,Erratum (0.2% , Book (0.2%)
Letter (2.4%) Editorial (0.8%) , Note (0.7%)
Conference Paper (6.8%)

Review (16.7%%)

Article (69.9%%)

e
Chemical engineering (2.3%) Multidisciplinary (2.1%)
Agricultural and Biological Sciences(2.3%)
Immunology & Microbiology (3.2%)
Computer Science (4.1%)
Medicine
Engineering (4.1%) (34.8%)

Chemistry (5.1%)

Pharmacology, Toxicology and

Pharmaceutics (8.5%)

Biochemistry, Genetics and

Molecular Biology (19.5%)

Fig. 11.2 (continued)

200 I. Y. Hachim et al.

11.7 External Collaboration and External Funds

for Cancer-­Related Research in the United
Arab Emirates

The number of cancer-related research projects in the UAE that include interna-
tional collaboration and external funding has significantly increased in the last
decade. Our analysis revealed a wide spectrum of highly recognized funding bodies
involved in cancer-related research projects, including UAE-based scientists. This
includes the National Institutes of Health, the National Cancer Institute, the Medical
Research Council (MRC), the US Department of Health and Human Services,
the Seventh Framework Program, the Terry Fox Foundation, and others. This indi-
cates the trust of well-known international funding bodies and collaborators in
UAE-based cancer research and the attempt of UAE scientists and institutes to pro-
duce high-quality scientific research projects (Fig. 11.2c).

11.8 Type and Subject-Wise Distribution of Cancer-Related

Research in the United Arab Emirates

Our results showed that most of the cancer-related publications in the UAE were
research articles (69.9%), followed by reviews (16.7%), conference papers (6.8%),
letters (2.4%), and book chapters (1.7%). Most of the published manuscripts in the
cancer-related field indicate that UAE scientists and institutes focus mainly on inno-
vative primary research projects to improve our understanding of cancer and dis-
cover new solutions to treat this disease (Fig. 11.2d).
Subject-wise distribution of cancer-related manuscripts revealed that 34.8% of
manuscripts fall into the medicine subject area, followed by biochemistry, genetics,
and molecular biology (19.5%), pharmacology, toxicology, and pharmaceutics (8.5%),
chemistry (5.1%), computer sciences (4.1%), engineering (4.1%), immunology and
microbiology (3.2%), and agricultural and biological sciences (2.3%) (Fig. 11.2e).

11.9 Top Journals in Which Cancer-Related Manuscript

from the UAE Was Published

As seen in Fig. 11.3, the local Emirates Medical Journal was the dominant journal
for cancer-related manuscripts between 1980 and 2006. Since then, the diversity
and ranking of UAE-based cancer-related manuscript publishing journals have sig-
nificantly improved (Table 11.1). This includes PLOS One (CiteScore = 5.6),
Scientific Reports (CiteScore = 6.9), Molecules (CiteScore = 5.9), Asian Pacific
Journal of Cancer Prevention (CiteScore = 3.1), International Journal of Molecular
Sciences (CiteScore = 6.9), Annals of the New York Academy of Sciences
(CiteScore = 10), and Lancet (CiteScore = 115). This clearly indicates that the
increase in cancer research productivity was coupled with an improvement in the
quality of research output.
11 Basic Cancer Research in the UAE 201

Fig. 11.3 The top publishing journals of cancer-related publications in the United Arab Emirates
using the Scopus database in the period between 1978 and 2021

Table 11.1 The top 15 No. of

journals that published Journal publications
cancer-­related publications PLOS One 64
in the UAE
Scientific Reports 53
Molecules 51
Asian Pacific Journal of Cancer 45
Prevention
Emirates Medical Journal 38
International Journal of Molecular 34
Sciences
Annals of the New York Academy of 25
Sciences
Lancet 24
Frontiers in Immunology 23
BMJ Case Reports 22
Cancers 20
Saudi Medical Journal 20
Cellular Physiology and Biochemistry 19
European Journal of Medicinal 19
Chemistry
Frontiers in Pharmacology 18
202 I. Y. Hachim et al.

Table 11.2 Classification of Cancer type/keywords Number of publications

cancer-related manuscripts Breast, mammary 370
according to cancer type
Liver, hepatocellular 181
carcinoma
Colorectal, colon, rectum 137
Gastrointestine, stomach 98
Lung 98
Renal, kidney 78
Skin, melanoma 71
Prostate 67
Cervix, cervical 67
Leukemia 45
Lymphoma 49
Brain, CNS 49
Thyroid 44
Bladder 31
Ovary 24
Uterine, endometrial 17
Total 1426

11.10 Cancer-Related Manuscript Distribution According

to Cancer Type in the UAE

We also tracked the distribution of cancer-related publications based on their cancer

type. To achieve this, we used the anatomical site and common keywords for each
cancer type (Table 11.2). Breast cancer research output was the highest investigated
cancer type with 370 publications, followed by liver (181), colorectal (137), gastro-
intestinal (98), lung (98), kidney (78), skin (71), prostate (67), and cervix (67). This
distribution of cancer-related manuscripts according to cancer types showed simi-
larity with the incidence of various cancers in the UAE population. For example, a
recent study investigating the epidemiology of cancers in the UAE population found
breast, cervical, and thyroid cancer to be the most common cancers in Emirati
females, compared to lung, gastric, and prostate cancers in male patients [20, 21].

11.11 Common Scientific Outline (CSO) of Cancer Research

in the UAE

To understand the focus of cancer research groups in the UAE, we stratified cancer-­
related articles according to the Common Scientific Outline (CSO) implemented by
the International Cancer Research Partnership (ICRP) coding system [14, 22]. This
classification subdivides cancer research projects into six broad areas including:

1. Cancer biology
2. Cancer etiology
11 Basic Cancer Research in the UAE 203

3. Prevention
4. Early detection, diagnosis, and prognosis
5. Treatment
6. Cancer control survivorship and outcomes

11.11.1 Cancer Biology and Etiology Research in the UAE

To extract the research articles related to cancer biology and etiology, we used fur-
ther filtration of our cancer-related articles using the keywords (biology OR initia-
tion OR progression OR metastasis) as additional MeSH terms. Our results showed
538 documents that fulfilled those criteria. The top active institutes in this category
were the United Arab Emirates University and the University of Sharjah.
International Journal of Molecular Sciences, Scientific Reports, Seminars in Cancer
Biology, PLOS One, and Frontiers in Oncology and Cancers were the top journals
that publish manuscripts in this category. Research projects in this category were
comprehensive and included different aspects of cancer biology, including genetic
[23–25] and epigenetic studies [26, 27]. They investigate factors involved in differ-
ent stages of cancer development, including tumor initiation, progression, and
metastasis [28–32]. Many of the research projects include the use of new advanced
and state-of-the-art techniques and technologies like next-generation sequencing,
which allows whole genome, exome, and transcriptome sequencing [13, 33]. Many
projects also introduced multiomics approaches to investigate tumor heterogeneity,
complex biological derangements, and tumor subtyping [34, 35].

11.11.2 Cancer Prevention Research in the UAE

A better understanding of the risk factors involved in cancer development is essential

to cancer prevention. For that reason, many research projects focused on understand-
ing cancer risk factors and raising awareness among community members and patients
of those factors to reduce cancer risk by avoiding exposure to carcinogens and adopt-
ing a healthier lifestyle. Our analysis revealed that more than 300 cancer-­related man-
uscripts were related to risk factor assessment or cancer prevention. Some of those
manuscripts include collaborative work with other international and regional collabo-
rators to evaluate risk factors and the status of cancer prevention [36, 37]. Other manu-
scripts try to investigate the awareness and knowledge of some community groups on
the role of lifestyle and diet in preventing different cancer types [38–40].

11.11.3 Early Detection, Diagnosis, Prognosis, and Outcome

Prediction-Related Cancer Research in the UAE

Early detection, diagnosis, and prognosis represent a significant research area in the
UAE; this was evident by the number of cancer-related articles related to this
204 I. Y. Hachim et al.

category. Our results showed more than 200 cancer-related manuscripts related to
early detection, diagnosis, and prognosis for various cancers. This includes using
genetic, molecular, clinical, and novel algorithms to improve the early detection,
diagnosis, and prognostication of cancers [41–43]. In addition, artificial intelli-
gence, machine learning, bioinformatics, and computer-aided techniques were also
introduced to enhance and refine the diagnostic, predictive, and prognostic value of
various markers and techniques in different cancers [34, 42, 44–46].

11.11.4 Cancer Treatment and Anticancer Drug Discoveries

in the UAE

In recent years, there has been a significant shift in cancer research trends from funda-
mental basic cancer research into more translational research. The first step in the trans-
lational cancer research paradigm and new drug creation is the discovery of molecules,
components, and compounds that specifically target specific biological processes that
are deranged in malignant cells compared to healthy cells [47]. Implementing such an
approach is essential to increasing the efficacy of anticancer drugs and minimizing
the toxicity usually observed in conventional anticancer drugs [47].
In the last decades, there has been an exponential increase in the number of
research projects aiming to discover novel targets, molecules, and compounds that
might have anticancer activity. We performed a bibliometric analysis of the Scopus
database to investigate the drug discovery-related articles among the cancer-related
manuscripts within the UAE. In addition to the MeSH terms we used for investigat-
ing cancer-related articles in the UAE, we further filtrated our data to be limited to
articles that contain (drug OR compound OR anticancer) in their title or abstract.
Our analysis revealed that 723 cancer research articles (excluding reviews, confer-
ence papers, and book chapters) investigated molecules, compounds, and drugs with
anticancer activity, including around 139 articles in 2021 alone. The University of
Sharjah was the top UAE institute in compounds and anticancer drug discovery-­
related articles, followed by the United Arab Emirates University, the American
University of Sharjah, Ajman University, and NYU Abu Dhabi. Some of those reports
include nanoparticles used as a drug delivery system in cancer therapeutics [48–53].
Interestingly, our analysis revealed the presence of 42 patents from UAE-based
researchers related to the discovery of molecules, compounds, and drugs with
potential use in the treatment of various cancers. This includes 33 patents from the
United States Patent and Trademark Office, 5 from the Japan Patent Office, 2 from
the World Intellectual Property Organization, 1 from the European Patent Office,
and another from the United Kingdom Intellectual Property Office.

11.12 Conclusion

In conclusion, our analysis revealed a significant improvement in the quantity and

quality of cancer-related projects and manuscripts. This was also associated with
more diverse cancer research and an exponential increase in cancer research
11 Basic Cancer Research in the UAE 205

productivity, coupled with improvements in the quality and impact of those research
activities. The cancer research activities were distributed among a wide range of
cancer types, subjects, and scientific outlines covering all aspects of cancer biology.
This was achieved through investment in research infrastructure, recruitment of
experienced researchers, and the establishment of various training programs.

Conflict of Interest The authors have no conflict of interest to declare.

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Dr. Ibrahim Yaseen Hachim is an Assistant Professor in Pathology,

the Department of Clinical Sciences, College of Medicine, University
of Sharjah. Dr. Ibrahim is a medical doctor with an M.Sc. in histopa-
thology. He obtained his Ph.D. from the Cancer Research Program,
College of Medicine, McGill University, Montreal, Canada.
Dr. Hachim is known for his research work in the fields of
molecular pathology and cancer biology. His research interests
include molecular pathology, cancer biology, molecular subtyping
of cancers, biomarkers, cancer progression, and metastasis.
Dr. Ibrahim had more than 60 publications in different presti-
gious journals. During his career, Dr. Ibrahim received several
awards, including the George G. Harris Fellowship in Cancer, McGill
University, Montreal, Canada, and the Pauline Blinder Krupp Award
for the most promising clinical researchers in Montreal, Canada.

Dr. Saba Al Heialy is an Associate Professor of Immunology at

Mohammed bin Rashid University of Medicine, Dubai, UAE and
Health Sciences, and an Adjunct Professor at McGill University,
Montreal, Canada. Her research revolves around immune dysregula-
tion in various respiratory diseases. She has a particular interest in
asthma and its association with other diseases such as obesity and
lung cancer. Asthma is a heterogeneous disease of the airways charac-
terized by airway hyperresponsiveness and inflammation. Therefore,
she has been interested in exploring its association with lung cancer,
which has shown conflicting data in the past. Through funding from
the Al Jalila Foundation, her group has been able to investigate this
association in the UAE and identify candidate biomarkers that may
guide us in better understanding the progression of lung cancer.
208 I. Y. Hachim et al.

Dr. Mahmood Hachim ’s multidisciplinary background shaped

his medical degree and research career. With two Ph.D.s in molecu-
lar medicine and translation research from the University of Sharjah
and Lubeck University in Germany, a master of research in cancer
biology from the University of Dundee, and a master of science in
medical microbiology and immunology from Al Nahrain University
in Iraq, Dr. Mahmood made a research track and experience in sys-
tems biology to apply its advances to decipher complex diseases
like breast cancer, diabetes, and asthma, as well as an understand-
ing of the human microbiome by applying novel bioinformatics
approaches and a state-of-the-art omics approach. His goal is to
understand the molecular basis of such diseases to identify novel
diagnostic and predictive clinically proven biomarkers. Specifically,
to understand the exact role of host immune response and microbi-
ome interaction in susceptibility and the development of clinical
heterogeneity in such chronic diseases, Dr. Mahmood had more
than 75 Scopus-­indexed publications.

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Oncology and Hematology Fellowship
Training in the UAE 12
Humaid O. Al-Shamsi

12.1 Introduction

The United Arab Emirates (UAE) lacks systematized and well-structured advanced
fellowship training programs in hematology and oncology. The medical oncology
fellowship training program at Tawam Hospital, which was launched in August
2019, is the UAE’s sole approved program by the Accreditation Council for Graduate
Medical Education-International (ACGME-I). The program consists of 3 years of
medical oncology fellowship training (with no hematology training). Three fellows
were admitted at that time; however, the first graduate of the medical oncology pro-
gram was Dr. Ali Yousif, a Sudanese doctor who completed his training in December
2022 and obtained the Jordanian Board of Medical Oncology Certification in August
2022. The UAE has only one hematology fellowship training program, which
started in the Emirate of Dubai in 2020 [1].

12.2 Current Status

The establishment of the National Institute for Health Specialties (NIHS) was autho-
rized through Cabinet Decree No. 28 of 2014. Its primary objective is to lead,

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 209

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_12
210 H. O. Al-Shamsi

regulate, and coordinate the professional development of the healthcare workforce,

with a specific focus on specialized training. Affiliated with the United Arab Emirates
University, the country’s leading institution of higher education, the NIHS operates
under the guidance of a prominent Board of Directors led by H.E., the Minister of
Education. In May 2022, the NIHS formed a fellowship committee dedicated to
oncology and hematology for the Emirati Board of Medical Oncology and Hematology.
Professor Humaid Al-Shamsi was appointed as the committee’s chairman [2].
According to the NIHS, the Emirati Board in Oncology is responsible for defining its
program objectives in alignment with the sponsoring institution’s overall mission, the
community’s needs, the intended beneficiaries of its graduates, and the unique skills
required of physicians. The program is expected to demonstrate substantial adherence
to both general and specialty-specific program requirements. The committee com-
prises specialists from major cancer centers across the UAE, encompassing medical
oncology for adults, hematology for adults, and pediatric hematology and oncology.
Together, they have established four distinct pathways for fellowship training:

1. Adult medical oncology for 3 years.

2. Adult hematology for 2 years.
3. Adult combined medical oncology and hematology for 4 years.
4. Pediatric hematology and oncology for 3 years.

According to the NIHS, the eligibility requirements for the fellowship training
are [3]:

–– Completion of Clinical Education: To qualify for enrollment in an NIHS-­

accredited fellowship program, applicants must have successfully completed all
clinical education requirements within an NIHS-accredited residency program, a
program with ACGME-International (ACGME-I) Advanced Specialty
Accreditation, or any other structured residency program that has been approved
by the Central Accreditation Committee.
–– Completion of Internal Medicine Program: Prior to joining the fellowship, can-
didates should have fulfilled the requirements of an internal medicine program.
–– Compliance with NIHS Criteria: It is essential to refer to the NIHS criteria out-
lined in the Training Bylaw for additional details and specific requirements.
–– Fellow Eligibility Exception: Certain exceptions to the eligibility requirements
may be considered for prospective fellows, subject to further evaluation and
assessment.

The Central Accreditation Committee for Internal Medicine will allow the fol-
lowing exception to the fellowship eligibility requirements:
*In exceptional cases, an NIHS-accredited fellowship program has the option to
consider an international graduate applicant who does not meet the standard eligi-
bility requirements. However, the applicant must fulfill the following additional
qualifications and conditions:
12 Oncology and Hematology Fellowship Training in the UAE 211

1. Eligibility for Specialist License: The applicant should be eligible for a specialist
license in internal medicine as per the Professional Qualification Requirement
(PQR) set by the UAE Health Authority.
2. Evaluation by Program Director and Selection Committee: The program director
and fellowship selection committee will assess the applicant’s prior training and
review summative evaluations of their training in the core specialty.
3. Approval by the Graduate Medical Education Committee (GMEC): The excep-
tional qualifications of the applicant will be thoroughly reviewed and approved
by the Graduate Medical Education Committee (GMEC).

It is important to note that this provision is reserved for highly qualified interna-
tional applicants who possess exceptional qualifications and meet the specified con-
ditions. The final decision to accept such applicants rests with the NIHS-accredited
fellowship program.
*Applicants accepted through this exception must have an evaluation of their
performance by the Clinical Competency Committee within 12 weeks of matricula-
tion [3].

• All prerequisite postgraduate clinical education necessary for admission or trans-

fer into NIHS-accredited fellowship programs must be completed within a
NIHS-accredited program authorized by the NIHS.
• Prior to joining the program, fellows must satisfy the eligibility criteria estab-
lished by the NIHS.
• Collaborations with prominent international cancer centers offer UAE fellow-
ship trainees valuable opportunities to gain specialized experience in oncology
and hematology rotations, including advanced treatments like CAR-T cell ther-
apy that are currently unavailable within the UAE.
• The interest in medical oncology and hematology as subspecialties is relatively
uncommon, resulting in a limited number of UAE trainees pursuing these areas.
It is crucial to enhance awareness and attraction toward these subspecialties. This
can be accomplished by incorporating mandatory oncology rotations during
medical school and internal medicine training, as well as conducting informative
lectures for trainees to emphasize the benefits of these subspecialties.
• Presently, there are no fellowship training programs in surgical oncology, pallia-
tive care, or radiation therapy available within the UAE. Establishing fellowship
training in these subspecialties is essential to meeting the healthcare needs in the
field of oncology.
• The UAE currently lacks residency training programs in oncology for nurses. It
is imperative to develop robust oncology training programs that encompass both
physicians and nurses, particularly considering the global shortage of oncology-­
trained nurses [1, 4].
212 H. O. Al-Shamsi

12.3 Conclusion

Advanced oncology and hematology fellowship training in the UAE is still evolv-
ing. In Tawam Hospital, there is one oncology fellowship, and there is one hematol-
ogy fellowship program in Dubai. The medical oncology fellowship training
program at Tawam Hospital, which was launched in August 2019, is the UAE’s sole
approved program by the Accreditation Council for Graduate Medical Education-­
International (ACGME-I) and has graduated only one fellow as of December 2022.
In May 2022, the NIHS established an oncology and hematology fellowship com-
mittee for the Emirati Board of Medical Oncology and Hematology, and Prof.
Humaid Al-Shamsi was named the chairman of this committee. The hematology
fellowship and medical oncology fellowship were both approved by the NIHS in
November 2022 and December 2022, respectively, and as of December 2022, no
program has been accredited by the NIHS in these two programs, yet it is expected
that multiple hospitals will apply for accreditation in 2023. The interest in medical
oncology and hematology as subspecialties is not common, and only a limited num-
ber of UAE trainees are joining these subspecialties. There is a need to increase
awareness of and attraction to this subspecialty.

Conflict of Interest The author has no conflict of interest to declare.

References
1. Al-Shamsi HO. The state of cancer care in the United Arab Emirates in 2022. Clin Pract.
2022;12(6):955–85.
2. Adopting criteria for evaluating national programs for training physicians in the field of can-
cer and oncology in the country. https://www.wam.ae/ar/details/1395303106331. Accessed 6
Dec 2022.
3. https://nihs.uaeu.ac.ae/en/docs/hematology.pdf (Accessed on 08 Apr 2024).
4. Young A, Samadi M. The global power of oncology nurses in low- and middle-income coun-
tries. Asia-Pac J Oncol Nurs. 2022;9:131–2.

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society,
Full Professor of Oncology at the Ras Al Khaimah Medical and
Health Sciences University, Ras Al Khaimah, UAE, and an
Adjunct Professor of Oncology at the College of Medicine,
University of Sharjah. He is the first Emirati to be promoted as
a professor in oncology in the UAE. He is also the Chairman for
Colorectal Cancer in the MENA region, appointed by the pres-
tigious National Comprehensive Cancer Network®. He is also
the only member of Lung Cancer Policy Network in the MENA
region that aims to advance lung cancer research and screening
globally. He is the Chairman of the Oncology and Hematology
Fellowship Training Program for the National Institute for
Health Specialties in the United Arab Emirates. He is the only
member in GCC in the WIN Consortium which is comprised of
12 Oncology and Hematology Fellowship Training in the UAE 213

organizations representing all stakeholders in personalized can-

cer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow)
in 2024. He is the only physician in the UAE with a subspe-
cialty fellowship certification and training in gastrointestinal
oncology and the first Emirati to train and complete a clinical
post-doctoral fellowship in palliative care. He was an assistant
professor at the University of Texas MD Anderson Cancer
Center between 2014 and 2017. He has published more than
140 peer-reviewed articles in JAMA Oncology, Lancet
Oncology, The Oncologist, BMC Cancer, and many others. His
area of expertise includes precision oncology and cancer care in
the UAE. In 2016, he published with his group from MD
Anderson the JCO paper describing a new distinct subgroup of
CRC, NON V600 BRAF-mutated CRC. In 2022, he published
the first book about cancer research in the UAE and also the first
book about cancer in the Arab world, both of which were
launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months
of publication and is the ultimate source of cancer data in the
Arab region. He also published the first comprehensive book
about cancer care in the UAE which is the first book in UAE
history to document the cancer care in the UAE with many top-
ics addressed for the first time, e.g., neuroendocrine tumors in
the UAE. He is passionate about advancing cancer care in the
UAE and the GCC and has made significant contributions to
cancer awareness and early detection for the public using social
media platforms. He is considered as the most followed oncolo-
gist in the world with over 300,000 subscribers across his social
media platforms (Instagram, Twitter, LinkedIn, and TikTok). In
2022, he was awarded the prestigious Feigenbaum Leadership
Excellence Award from Sheikh Hamdan Smart University for
his exceptional leadership and research and the Sharjah Award
for Volunteering. He was also named the Researcher of the Year
in the UAE in 2020 and 2021 by the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan,
Vice President of the United Arab Emirates, awarded him the
first place in UAE Nafis program for outstanding leadership in
private sector across all business and medical disciplines. Beside
his clinical and administrative duties, he is engaged in educa-
tion and various levels of research training for medical trainees
to enhance their clinical and research skills. His mission is to
advance cancer care in the UAE and the MENA region and
make cancer care accessible to everyone in need around
the globe.
214 H. O. Al-Shamsi

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Oncology Nursing in the UAE
13
Lois Nyakotyo

13.1 Introduction

13.1.1 History of Oncology Nursing

The cancer care continuum spans prevention, early detection and screening, diagno-
sis and treatment, living with and beyond cancer, palliative care, and the end of life.
A cancer or oncology nurse is a qualified nurse who has the knowledge, skills, and
complete responsibility to provide critical nursing care to cancer patients and their
families based on evidence-based, specialized, ethical, knowledge and skills [1].
Globally, the development of medical oncology as a medical specialty created
the need for the development of nursing through academic education and the prac-
tice of oncology with a foundation in research-based evidence. Before oncology
nursing existed as a specialty; cancer patients received care from general nurses
who provided bedside care without specialist knowledge, skills, or practice [2].
However, the introduction of chemotherapy in the early 1970s and 1980s created the
need for nurses to be educated in the administration and management of the side
effects it posed for patients and the hazards it posed for staff. Thus, more focus
emerged on cancer as a specialty, which further developed into the delivery of che-
motherapy in specialized oncology centers [3].
Since then, oncology nursing has evolved significantly from physician-led inpa-
tient care to oncology nurse practitioner-led outpatient care. Oncology nursing pro-
fessional organizations have emerged, bringing with them the development of
standards and guidelines for practice that outline responsibilities and expectations
for the specialty role of nurses in cancer care, illustrating a complete transformation
from general, basic nursing care to advanced practice [4]. Oncology nurses are
responsible for everything from performing invasive procedures to diagnostic

L. Nyakotyo (*)
Mediclinic Middle East, Dubai, United Arab Emirates
e-mail: Lois.nyakotyo@mediclinic.ae

© The Author(s) 2024 215

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_13
216 L. Nyakotyo

interpretation and screening for cancer prevention. In contrast to the preceding illus-
tration of the oncology nursing role, oncology nursing in the United Arab Emirates
(UAE) is in its infancy, faced with the challenges of a transient workforce, a lack of
a defined oncology nurse role, a lack of licensure as a specialist in oncology, and
wage-related benefits in recognition of specialist skills [5]. This chapter explores
oncology nursing in the UAE, with a particular focus on the role of the oncology
nurse and the training required to develop specialist oncology nursing practice in
the UAE.

13.2 Impact of the Healthcare System on the Development

of Oncology Nursing in the UAE

The UAE has an outstanding government-funded health service that delivers timely,
effective, and safe care for Emirati nationals and expats in emergency cases as
needed. So, the private healthcare sector is rapidly expanding [6]. In the UAE, there
are 157 hospitals and 5369 health centers in private care that continuously develop
services in response to the economy, health policy, and advancements by competi-
tors [7]. Health care in the UAE’s public and private sectors delivers efficient, effec-
tive, and safe care that is closely monitored and regulated by government agencies.
However, there is a lack of government agency-led drive for collaboration in train-
ing and development or sharing best practices among oncology nurses.
Nurses are critical to achieving the goal of safe health care for all globally, and
the current staffing shortages are echoed in the oncology nursing setting [8]. The
pandemic has magnified and exacerbated the global nursing shortage issues, which
has led to changes in immigration laws in the United Kingdom (UK), Australia, and
the USA regarding nurses [9]. In the UAE, it has manifested in a significant number
of experienced expat oncology nurses of Indian and Filipino descent migrating from
the UAE to the UK, the USA, or Australia, where there is recognition of specialist
skills, increased wages, and the prospects of citizenship over a length of time [10].
To attract more nurses, the UAE government has removed the pre-requisite of 2
years of experience before registering as a nurse in the UAE. Therefore, no experi-
ence is required for nurses to get a license in the UAE if they have a current active
registration in Canada, the USA, the UK, Ireland, South Africa, New Zealand, or
Australia [11].
Training and further professional development opportunities for oncology nurses
in the UAE vary between employers, making it difficult to benchmark practice. In
addition, the competitive private care setting in the UAE does not promote sharing
best nursing practices across healthcare facilities through an agreed-upon and stan-
dardized framework for training and developing oncology nurses. As a result, newly
qualified nurses (NQN) who join the nursing workforce in the UAE will receive a
non-standardized orientation from their employee, which does not necessarily
ensure appropriate experience and exposure to develop the good communication
and practice skills required for cancer care. This lack of recognized standards of
practice creates a barrier to developing experienced and well-trained specialist
13 Oncology Nursing in the UAE 217

oncology nurses, as there is a pool of varying abilities and levels of training and
development across the private healthcare sector’s oncology services [12].
Nursing training worldwide aims to produce qualified nurses who employ
evidence-­based practice, work as part of a multidisciplinary team, continuously
apply quality improvement principles, and utilize informatics to inform innovation
in practice [12]. Therefore, there must be an agreed-upon framework for NQN
oncology orientation, development, and training to ensure that the UAE maintains a
well-defined, high level of oncology nursing practice. NQN in the UK joins the
workforce in an oncology nursing preceptorship capacity. The goal of preceptorship
is for the NQN to develop their confidence and autonomy. In organizations with
well-established preceptorship as part of the culture, there are significant benefits
for newly registered nurses, patients, and wider teams. Particularly in terms of
retention, recruitment, and staff engagement [7].
National guidance from the National Health Service (NHS) Executive and
Innovation recommends 2 weeks or 75 h of supernumerary time, not including
induction or orientation time. After this supernumerary period, the newly quali-
fied nurse undergoes a preceptorship period [12]. Only once one has completed a
year of preceptorship can they consider starting a career path as a junior oncology
nurse, focusing on outpatient chemotherapy, hematology inpatients, oncology
inpatients, oncology home care, or palliative care. Newly registered nurses
become accountable as soon as they are registered, and this transition from stu-
dent to responsible practitioner is known to be challenging [13]. The purpose of
the preceptorship is to provide support during this transition. Preceptorship pro-
grams may include classroom teaching and the attainment of role-specific compe-
tencies. However, the essential element is the individualized support provided in
practice by the preceptor [14].

13.3 Role of Oncology Nurses

Cancer is a life-threatening disease that is reported to cause 1 in 6 deaths per year

across the world [15]. Research shows that cancer patients interact with nurses more
than other members of the multidisciplinary team. Cancer patients have frequent
hospital visits due to the nature of cancer treatment management plans, and such
patients experience most of their time in the healthcare setting under the care and
guidance of a cancer nurse [16]. The cancer nurse’s role is pivotal in delivering
cancer care. A cancer nurse’s role is to coordinate, facilitate, and provide care at all
critical points in a patient’s cancer journey [2]. Cancer care aims to effectively advo-
cate for prevention, early diagnosis, effective treatment, survivorship, and providing
end-of-­life care that incorporates the patients’ priorities of care. This approach to
cancer care promotes quality of life throughout the cancer journey.
To provide the best evidence-based cancer care investment in training and devel-
oping oncology nurses [13], specific job descriptions for oncology nurses differ
between healthcare organizations in the UAE. Still, it is widely reflected in the job
218 L. Nyakotyo

descriptions that oncology nurses provide nursing care for cancer patients, but the
level of responsibility varies depending on the employer’s vision and priorities for
cancer care. A well-established oncology service, as shown in the UK guidelines
2020 [13], should have well-defined oncology nursing roles, and the nurses should
perform the following duties:

• History taking.
• Physical and psychological assessment.
• Monitoring and reviewing test results.
• Administration of systemic anti-cancer treatments.
• Key point of contact for the patient and a key member of the multidisci-
plinary team.
• Facilitating patient education across the clinical pathway.
• Patient advocate.
• Promoting self-management.

The UAE healthcare system is essentially physician-led; insurance charges are

largely related to physician activity; and service users value the input of a specialist
physician rather than a nurse. Furthermore, insurance approval is required before
delivering oncology services, except in an emergency. This results in oncology ser-
vices being facilitated with the involvement of nurses carrying out extensive admin-
istrative tasks, including liaising with the internal insurance department to ensure
that the proper clinical updates are given to meet requests from insurance compa-
nies. This further influences the perception patients have of the role of an oncology
nurse, which limits the engagement that patients have with nurses as they perceive
the physician to be the critical healthcare professional throughout their cancer jour-
ney and do not get to fully experience the full extent of care that a skilled oncology
nurse can deliver through assessment, management of side effects, care planning,
education, and psychological support. In addition, the revenue margins for health-
care organizations are directly linked to physical activity, and as such, organizations
invest in physicians rather than nurses. Therefore, there is a need for a culture shift
in practice; this involves educating healthcare leaders on the value of oncology
nurses and patients on the role of an oncology nurse and the benefits for patients.

13.4 Oncology Nurse Training and Development

Nurses who provide specialist cancer nursing are encouraged to undertake post-
graduate courses that enhance their research and evidence-based practice. However,
there are different levels of academic qualifications that range across certificate,
master’s, and doctorate levels. This enables nurses to practice as oncology-certified
nurses, specialist nurses, or advanced nurse practitioners or nurse consultants. To
this end, several organizations have established well-defined competencies that are
required for a cancer nurse to practice effectively, including EONS and the Oncology
Nursing Society (ONS) [17].
13 Oncology Nursing in the UAE 219

Cancer nursing in the UAE is a relatively new concept supported by the Emirates
Oncology Nursing Society, founded in 2017. The Emirates Oncology Nursing
Society (EOHNS) focuses on promoting oncology nursing and sharing advance-
ments in nursing practice among different oncology nurses within the UAE. EOHNS
is in its infancy; there is a need for solid nursing leadership across the UAE to form
a working group in pursuit of developing well-defined oncology nurse specialist
roles and pre-requisite education, training, and development frameworks with sup-
port from a government healthcare agency to address the barriers to collaboration
across healthcare organizations.
NHS England 2017 [12] illustrates the four components of advanced specialist
nursing:

1. Providing specialist clinical practice

2. Clinical leadership within a multidisciplinary setting
3. Continuous improvement of quality of cancer nursing care through professional
development
4. Continuing professional development and sharing best practices to develop others

An educational program for cancer nurses aims to provide evidence-based

research that develops good cancer nursing practice using a wide range of skills and
knowledge in pediatric or adult cancer services. The level of competency is defined
by the varying depth and complexity of training and practice. This separates the
novice from the expert in terms of a cancer nurse providing routine ward care, a
clinical nurse specialist, or an advanced nurse practitioner. The key principle is to
create a program that enables both employers and employees to understand the can-
cer nursing career pathway. This will ensure that cancer nurses with the right skillset
are employed in the relevant cancer nursing positions to ensure the provision of
quality cancer care [17]. Research shows that cancer nurses contribute substantially
to the quality of cancer services across the clinical pathway, from diagnosis, treat-
ment, survivorship, and palliative care, at all levels of health care, from primary to
tertiary care [18].
As educational programs develop, it is essential to simultaneously have a struc-
ture that reflects job roles, titles, and the required competence level that is related to
academic qualifications that include assessment in practice. This is particularly
important in terms of the consistency of the standard of cancer care delivery.
Policymakers, regulators, healthcare professionals, and the wider public will have
the same expectation of care provided by cancer nurses according to their title,
which inherently indicates a well-defined level of competence. In addition, cancer
nurses will be more accountable for their practices or omissions. Particularly, as
there are currently significant inconsistencies in relation to titles and competence
across the UK. For example, the title specialist nurse is used in different settings for
nurses with varying skillsets [17]. Therefore, the introduction and establishment of
a well-defined education program, clear role definitions, and skillset requirements
for every level of practice to address the gap of certified cancer nurses in the UAE
are imperative to further develop the quality of cancer nursing care.
220 L. Nyakotyo

13.5 Assessment and Care Plan Development

Cancer nursing practice provides patient care in all healthcare settings. The
scope of cancer nursing practice includes screening, diagnosis, all treatment
modalities, survivorship, and palliative care. Cancer nurses are an instrumen-
tal part of the multidisciplinary team [19]. They coordinate and facilitate the
delivery of cancer through effective communication with other healthcare pro-
fessionals, patients, and their families to ensure the delivery of the best evi-
dence-based cancer care.
Cancer nurses need to have a good understanding of all treatment modalities,
management of side effects, psychological and emotional impact of the disease, or
treatment on individual patients [19]. This enables them to formulate effective can-
cer nursing plans that address the patients’ health needs effectively with appropriate
and timely referrals to members of the wider multidisciplinary team. The aim is to
minimize the impact of side effects of treatment and to manage disease-related
symptoms effectively. The role of the cancer nurse has become pivotal in cancer
care as more complex protocols emerge. The key is to have cancer nurses who pro-
vide robust individualized education, cancer care, and monitoring at all points
throughout the cancer journey [20].

13.5.1 Components of Assessment and Management

• Management plan for common side effects of treatment and disease-related

symptoms
• Strategies for self-management of symptoms such as shortness, pain, or periph-
eral neuropathy
• Promotes evidence-based supportive care such as acupuncture
• Prioritizes facilitating a seamless pathway to living beyond cancer
• Facilitates follow-up and after care
• Facilitates individualized, high-quality clinical pathways that are affordable and
easy to access
• Good knowledge of ongoing clinic research studies and referring patients appro-
priately [2]

The peer-review process requires healthcare providers to share evidence of the

quality and outcomes of their service against agreed-upon measures. Their peers
then review these to monitor adherence and effectiveness [17]. However, the UAE
does not currently have peer reviews across healthcare organizations for oncology
nursing. Peer review would be beneficial in establishing good oncology nursing
practice in assessment and care plan development.
13 Oncology Nursing in the UAE 221

13.5.2 Cancer Nursing Development in the UAE

There is a need for further development of cancer nursing in the UAE. There are
varied levels of training across the healthcare system. The level of commitment to
developing oncology nursing is dependent on each healthcare facility’s priorities.
The nature of the private healthcare system is to be profitable. In an economy where
the nursing workforce is as transient as the patients, healthcare organizations lack
the appetite to invest in cancer nursing practice as the return on investment is not
guaranteed.
Specialist cancer nursing practice delivers expert cancer with the ability to rec-
ognize and manage complications independently according to the level of compe-
tence. This approach enables quality improvement in cancer nursing through setting
good standards of practice, clinical audits, and supervised practice to ensure quality
nursing practice and leadership [16].
Nursing research across the world has made a significant contribution to the can-
cer care provided to patients and has also improved patient outcomes. Particularly in
relation to patient self-management, reducing the time patients spend in hospital
beds, and improving the overall patient experience [18]. As healthcare systems con-
tinue to adjust to innovations, so too will cancer nursing evolve to meet the changing
demands [21]. The healthcare landscape for cancer services is rapidly transforming,
and it is key that cancer nursing care be encouraged to keep up with this transforma-
tion. The UAE has exceptional technological advances that would support innovation
in oncology nursing practice, but this would require support from government agen-
cies and collaboration between private healthcare organizations.

13.6 Conclusion

The UAE healthcare system delivers a high standard of care to oncology patients
through a sound, coordinated care pathway facilitated by well-trained and experi-
enced surgeons, radiologists, and pathologists. The vast majority of people in the
UAE prefer to be treated by a specialist consultant physician. The key to developing
oncology nurse practice at the international level in the well-researched and recog-
nized role of specialist or advanced nurses is engagement, investment, and commit-
ment from the health governing bodies and private and public healthcare
organizations. It is a role that will address patients’ complex physical, social, and
psychological needs and provide additional support for their families. There is a
need for nursing leaders at the executive level to drive this forward. This will be a
significant challenge, but the benefits of a good oncology nursing framework, train-
ing, and development supported by recognized licensure and remuneration for spe-
cialist oncology nursing skills are well-researched. This would be the new frontier
of oncology services and care delivered to cancer patients across the UAE in an
inpatient or outpatient setting and at the patient’s home.

Conflict of Interest The author has no conflict of interest to declare.

222 L. Nyakotyo

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17. Institute of Medicine. The future of nursing: leading change, advancing health. Washington,
DC: National Academies Press; 2018.
18. Lubejko BG, Wilson BJ. Oncology nursing: scope and standards of practice. 2019.
19. Gaguski ME, George K, Bruce SD, Brucker E, Leija C, LeFebvre KB, Mackey H. Oncology.
Nurse generalist competencies: oncology nursing society’s initiative to establish best practice.
Clin J Oncol Nurse. 2017;21(6):679–87.
20. Coolbrandt M, Wildiers H, Aertgeerts B. Systematic development of chemotherapy support a
nursing intervention to support adult patients with cancer in dealing with chemotherapy related
symptoms. BMC Nurs J. 2018;17:28.
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fact-­sheets/detail/cancer.
13 Oncology Nursing in the UAE 223

Lois Nyakotyo gained her nursing degree from Nottingham

University, her postgraduate oncology degree from Anglia Ruskin
University, and her MSc in healthcare management from
Westminster University, London, United Kingdom. She is the
Regional Cancer Programme Manager for Mediclinic Middle East.
She is registered with the DHA in the UAE and the Nursing and
Midwifery Council, UK. She is a member of the UK Oncology
Nursing Society. She has over 20 years of experience in specialist
oncology nursing, operational healthcare leadership, and manage-
ment. She has worked in the National Health Service, Private care
in the UK and the UAE. This included roles at Cambridge
University Hospitals, Imperial Healthcare College NHS Trust, The
Royal Marsden NHS Trust, King’s College London Hospital UAE,
and Mediclinic Middle East. Her achievements include being the
chairperson of the lung cancer nurses’ committee for the East of
England, member of the advisory panel for Roche and advisory
panel for the Roy Castle Foundation. She has a passion for facilitat-
ing learning in practice and has previously worked as a link lecturer
for Anglia Ruskin University in Cambridge, currently coordinates
the oncology rotation for MBRU students at Mediclinic Middle
East. She has a particular interest in developing innovative opera-
tional efficiency that delivers excellence in all aspects of can-
cer care.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Genomic Medicine in Cancer Care
in the UAE 14
Faraz A. Khan and Maroun El Khoury

14.1 Introduction

The importance of genomics in cancer dates back over 100 years. Theodor Boveri,
a German zoologist, made the initial proposition about the potential role of altera-
tions in the genetic material and the development of cancer. His publication was
later translated and published by Henry Harris, where he made the observation that
malignant tumor cells develop from normal tissue and postulated the potential role
of abnormal genetic material and chromosomes in tumorigenesis. He partly sup-
ported the observations made earlier by Von Hansemann, who is regarded as one of
the pioneers in human cancer genetics [1].
However, only later in the last century did we witness some key developments,
not only in the understanding of the role of genomic alterations in the development
of cancer but also in the concept of driver mutations and the development of drugs
as a therapeutic strategy.

14.2 Milestones in Cancer Genomics and Therapeutics

In 1959, David Hungerford and Peter Nowell first discovered the Philadelphia chro-
mosome in patients with chronic myeloid leukemia [2]. It took more than 30 years,
and only in the 1990s did Brian Drucker and his colleagues start working on poten-
tial drugs that could block the BCR-ABL pathway, as they hypothesized that block-
ing the BCR-ABL pathway may halt the progression of the leukemia, considering
that the mutation is not present in normal cells. In 1998, 40 years after the discovery
of the Philadelphia chromosome, the data of the first phase 1 clinical trial utilizing
STI-571, a compound known as imatinib, was reported, which changed the

F. A. Khan (*) · M. El Khoury

American Hospital, Dubai, United Arab Emirates
e-mail: fkhan@ahdubai.com; mkhoury@ahdubai.com

© The Author(s) 2024 225

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_14
226 F. A. Khan and M. El Khoury

prognosis and dynamics of a disease that, in the absence of a bone marrow trans-
plant, carried a poor prognosis. The Food and Drug Administration (FDA) approved
imatinib for the treatment of chronic myeloid leukemia in 2001 [3].
In 1984, the oncogene “neu” was discovered in rat cells, and the human “neu”
oncogene coding for the epidermal growth factor receptor was reported in 1985 [4].
More than a decade later, after confirming its role in the biological behavior of
breast cancer, trastuzumab was first approved by the FDA for the treatment of meta-
static breast cancer in 1998 [5].
In 1994 and 1995, the BRCA1 and BRCA2 tumor suppressor genes were identi-
fied, and their association with familial breast and ovarian cancer was established.
The discovery led to additional research, and using the mutation as a predictor to
guide therapy in patients with ovarian cancer harboring the BRCA mutation with a
PARP inhibitor, olaparib, came only in 2014 [6, 7].
Similar is the story of the identification of epidermal growth factor receptor
(EGFR) and anti-EGFR inhibitors like gefitinib in non-small cell lung cancer [8].
However, what really transformed the landscape was the start of a landmark
program in 2006 known as the Human Cancer Genome Atlas program, a joint
effort between the National Cancer Institute and the National Human Genome
Research Institute. The collaborative work of researchers from various disciplines
and institutions was successful in generating an enormous amount of genomic and
molecular data, which has played a pivotal role in the understanding of cancer
genetics and paved the way for the development of new drugs. The analysis of
over 11,000 tumors with over 33 different subtypes of cancer created a vital
resource that has become the key to the development of new treatments based on
genomic data [9].

14.3 The Era of Precision Medicine

In the last two decades, we have witnessed revolutionary advancements in biotech-

nology utilizing sequencing platforms and bioinformatics. In the field of medicine,
the most significant impact of progress in genomics and proteomics is seen in can-
cer medicine. The identification of new molecular targets and their significance in
tumorigenesis has led to the approval of many new classes of drugs with unique
mechanisms of action. However, this required changes at the regulatory level to
allow the incorporation and approval of new clinical trial designs like master proto-
cols and basket trials. The passage of the twenty-first Century Cures Act by the US
Congress in 2016 enabled the FDA to approve such modern clinical trial designs
that have facilitated rapid and fast-track drug development and approval [10].
In 2017, researchers from Memorial Sloan Kettering (MSK) published their data
from a next-generation sequencing test called MSK-IMPACT using over 10,000
patient tumor specimens and identified that 37% had relevant mutations and altera-
tions, which allowed 11% of the first 5009 patients to enroll in a relevant clinical
trial, which also led to the approval of the test as the first comprehensive next-­
generation sequencing panel testing 468 genes [11]. A few days later, the FDA
14 Genomic Medicine in Cancer Care in the UAE 227

approved the FoundationOne CDx panel as well as the 324-gene next-generation

sequencing assay [12].
In the last decade, at least 52 drugs for hematologic malignancies were approved,
including small molecules like Bruton’s tyrosine kinase (BTK) inhibitors, monoclo-
nal antibodies, bispecific T-cell engager antibodies, antibody-drug conjugates, and
CAR T-cell products. All this is possible only due to an improved understanding of
cancer genomics and tumorogenesis [13]. In 2020 alone, half of the 53 new small
molecules approved were for oncology [14]. Every year, we see hundreds of new
drugs with novel mechanisms of action based on genomic data, which has acceler-
ated and transformed drug development, clinical trials, and approval.

14.4 Cancer Care in the UAE

Al-Shamsi et al. published a narrative description of the development of cancer care

facilities, programs, manpower resources, and access to modern cancer treatments
and technology in the United Arab Emirates (UAE) over the last decade with his-
torical timelines in 2020 [15].
In this chapter, we reflect on the development and progress in cancer genomics
and molecular diagnostics, including the utilization of comprehensive tumor profil-
ing in the UAE, with their limitations and challenges.

14.5 Genomic Testing Facilities and Resources

Even though access to commercial genomic tests has been available for several
years, only a few centers have developed the facilities and expertise for in-house
testing, particularly with reference to the genomic analysis of cancer cases.
Nevertheless, in the UAE, major milestones have been achieved. In 1995, the
first of its kind in the region, the Dubai Genetics Center, was inaugurated under the
patronage of HH Sheikh Hamdan bin Rashid Al-Maktoum. Since its inception, the
center has reported genomic data on various hereditary disorders like thalassemia,
sickle cell disease, and other hemoglobinopathies. For cancer genomics, the center
has developed facilities offering molecular testing, utilizing fluorescence in situ
hybridization (FISH), polymerase chain reaction (PCR), and lately next-generation
sequencing (NGS), and is CAP accredited. The center is offering analysis for diag-
nosis and monitoring response to therapies in various hematologic malignancies,
including acute and chronic myeloid and lymphoid leukemias and multiple
myeloma [16].
In 2020, Sheikh Khalifa Specialty Hospital in Ras Al Khaimah was the first cen-
ter to start in-house next-generation sequencing analysis for solid tumors that
includes a 52-gene solid tumor panel test; however, testing is limited to patients
seen at the hospital [17].
The government in Abu Dhabi has also started an ambitious national project
called the Emirati Genome Program with the aim of profiling and completing the
228 F. A. Khan and M. El Khoury

Genomics in UAE timeline

Population 0.28m 4.1m 8.2 m* 8.6 m* 9.5m* 12.4m

Incidence of
First UAE 1st cancer in Gulf The state of cancer
1st Research Cancer documentation Cooperation care in the UAE in
of UAE cancer
Research paper Congress
History
Council
countries,
2020: A report by
published from and Cancer the UAE Oncology
Publications UAE14 Week published 14 1998–2001 task force Published
published

1971 1979 1981 1983 1985 ------ 2002 2004 2005 2007 2010 2011 2013 2014 2015 2016 2017 2019 2020 2021 2022 2024 - 2040

Genomic
testing UAE was Dubai Abu Dhabi Central MOHAP established 1st UAE National cancer Khalifa 1st precision
Established
UAE
Genetics Cancer Registry UAE national cancer registry data published University 1st medicine
(ADCCR) established for the year 2014 program in
1st unofficial digital center 1995
registry
Sheikh Khalifa WGS of
Tumor Registry at oncology
Tawam hospital by Utilization of genomic assays in oncology practice speciality Emiratis
Mr. Antony D. R. Beal
The first official cancer
hospital 1st in 1st public
Cancer incidence report from house NGS policy on
Tawam was published solid tumor genomics by
data in 2002 by the MOHAP
DOH
registry

NGS ; next generation sequencing, WGS ; whole genome sequencing, MOHAP ; Ministry of Health and Prevention , DOH ; deperment of health, UAE ; United Arab Emirates
* Source: Federal Competitiveness and Statistics Centre

Fig. 14.1 Timeline of genomics in the UAE

gene sequencing of UAE nationals to aid in the prevention and treatment of chronic
diseases. In 2019, Al-Safar and her colleagues from Khalifa University in Abu
Dhabi reported the whole-genome sequencing data of the first two Emiratis [18]. It
is expected that this program will facilitate the identification of local populations at
genetic risk for cancer and help develop preventative strategies. Initiatives are
expected to further research and the development of more comprehensive programs
in cancer genomics within the UAE (Fig. 14.1).

14.6 Utilization of Genomic Assays in Cancer Care

and Research

Despite the limited number of centers performing in-house genomic testing, oncol-
ogists and hematologists in the UAE have been able to have access to many of the
commercial assays, like the Molecular Intelligence Profile by Caris and
FoundationOne CDx for solid tumors and FoundationOne Heme for hematologic
malignancies offered by Roche. There are a number of other commercial companies
that offer both germline (hereditary cancer panels offered by Centogene and Myriad)
and somatic mutation testing, or more precise genomic signatures, to determine and
guide therapy based on the risk of cancer recurrence, like Oncotype Dx in breast
cancer, which is routinely used. There are also a number of commercial companies
offering liquid biopsy as an alternative to tissue in cases where tissue quantity is
inadequate or follow-up serial monitoring of the mutational landscape is desired
(FoundationOne Liquid, Guardant 360). There are also other well-reputed interna-
tional laboratories, like the Mayo Clinic, that offer cancer-specific gene panel tests
for both germline and somatic mutations.
Most of the institutions providing cancer care in the UAE have access to these
tests. In many cases, these are covered and reimbursed by some local health
14 Genomic Medicine in Cancer Care in the UAE 229

authorities and insurance providers. Many drug companies have also chipped in
with third-party support programs to cover the cost of limited genomic testing for
their partner drugs. However, there are still barriers and challenges with coverage
and reimbursement in many cases. Some insurance providers refuse to cover
genomic testing and consider it a genetic test for hereditary diseases. There is no
one central genomic laboratory in any of the emirates that can offer a more compre-
hensive scope of testing for solid tumors and hematologic malignancies. Most of the
centers have developed institutional relationships with international laboratories
and institutions for sample testing. However, in spite of the barriers, utilization of
genomic testing in cancer care in the UAE has steadily increased over the last
decade, and some have reported the data, which remains mostly retrospective and
observational.
In patients with breast cancer, Dawood et al. reported the data of 363 patients
tested in the UAE using an NGS-based panel and found that 32 (8.8%) had a patho-
genic variant identified in the BRCA1, BRCA2, or CHEK2 genes. In 89 patients that
were tested using a 33-gene panel, they found additional pathogenic variants in 7
(7.8%) of the MUTYH, RAD51C, RAD50, and PALB2 genes. The data was used to
enroll patients in the pilot phase of the tele-genetics program, where patients were
offered genetic counseling using either a telephone or an online Skype platform [19].
Al-Shamsi recently published a study that used an AmpliSeq 50-gene panel to
look at the pattern of somatic mutations in Arab women with breast cancer [20].
Earlier, they also reported the frequency of somatic mutations in colorectal cancer
using next-generation sequencing and reported a similar prevalence of common
mutations like KRAS, NRAS, and BRAF [21].
We have also reported retrospective data from 25 patients with advanced and
refractory solid tumors using a combination of next-generation sequencing (NGS),
protein expression (IHC), gene amplification (CISH or FISH), and RNA fusion
analysis, showing an overall disease control rate of 73% and a median duration of
response of 7 months when treated according to the genomic profile data [22].

14.7 Challenges, Limitations, and Recommendations

However, there are many challenges that limit the optimal utilization of genomics in
cancer care in the UAE, both in clinical practice and research. Some of the difficul-
ties stem from the diverse configurations of healthcare delivery systems in each
emirate, as well as the lack of a broader, unified national policy on healthcare deliv-
ery systems.
Over the years, health care has been moving from government-funded to private
in many emirates. The private hospitals operate on a commercial basis with limited
interest in investment in research and a lack of private (not-for-profit) institutions.
There is no national cancer care body, such as the National Cancer Institute (NCI)
in the United States, to facilitate regulation, support, and fund clinical research.
Hence, most of the effort is individual-driven, and there is an absence of structured
utilization of genomics in cancer in the context of clinical trials.
230 F. A. Khan and M. El Khoury

There is currently no single, central facility, either in the public or private sector,
that can offer more comprehensive genome sequencing for patients with both hema-
tologic and solid tumors. This limits the availability of a reliable genomic database
of the local population, which is quite diverse. This also allows many small or less-
known genomic laboratories to commercially operate and market their tests with no
real oversight on quality, reproducibility, or reliability.
In 2018, the European Society of Medical Oncology provided the framework for
the optimal utilization and categorization of alterations and mutations, paving the
way for recommendations on the utilization of genomic tumor profiling both in
clinical practice and research [23]. There is no centralized body in the UAE that is
able to oversee optimal utilization, particularly in clinical practice. More recently,
the Department of Health (DOH) in Abu Dhabi, after the initiative of the National
Genome Project, has published a policy on genomics. However, currently there is
no specific document or policy on genomics in cancer [24].
There is also a need for local consensus guidelines on the utilization and inter-
pretation of these assays.
Even though tumor profiling is increasingly used in clinical practice, there is a
lack of precision medicine clinics with a trained workforce. Considering that the
field is relatively new, most practicing oncologists lack training in molecular diag-
nostics and genomics and rely on the interpretation of the genomic report to make
therapeutic decisions, which at times can be misleading. Most of the time, molecu-
lar data is discussed in multidisciplinary tumor boards (MDTs) and therapeutic
decisions are made, but most MDTs may lack experts in the genomic field, which
can limit the strength of recommendations [25].
There are individual efforts to develop molecular tumor boards, but most lack
structure and expertise. International and institutional collaboration within the
region and abroad can address the issue in the short term by using virtual platforms
and seeking input from tertiary centers and precision clinics. We and others have
shown that utilizing virtual platforms and MDTs with international collaboration
can improve patient care and decision-making, and this approach can be extended
to genomic medicine in the form of well-structured molecular tumor boards [26,
27]. Long term, there is a need for dedicated training and education for trainees and
practicing oncologists. Khalifa University in Abu Dhabi and Mohammed Bin
Rashid University in Dubai (MBRU) have started to offer similar programs, but
training the treating oncologist and developing precision medicine clinics manned
by trained professionals are important.
Recently, DOH Abu Dhabi announced the launch of the first Precision Medicine
Program for Oncology in the region, in collaboration with Mubadala Health,
Cleveland Clinic Abu Dhabi, NYU Abu Dhabi, Mohamed bin Zayed University of
Artificial Intelligence, and G42 Healthcare [28].
However, to further the progress of genomic medicine in cancer in the UAE, it
will require setting up a clinical trial network where, based on their genomic pro-
files, patients could enroll in clinical trials.
14 Genomic Medicine in Cancer Care in the UAE 231

Table 14.1 Recommendations to advance genomics in cancer care in the UAE

Recommendations to advance genomics in cancer care in UAE
Formulation of a national policy on genomics in cancer care
Development of a national cancer institute to enhance collaboration and coordination among
different emirates for cancer care and research
Regulation and legislation to develop national tumor banks
Development of clinical trial networks
Local consensus guidelines on the utilization of genomic assays in cancer care
Education and training to incorporate molecular tumor boards and precision medicine
programs as part of comprehensive cancer care in the UAE
Regulation for payers to ensure uniform access to genomic testing, both in the private and
public sectors

There is a need to create tumor banks at the regional or national level, which will
be essential for any meaningful research in genomics and cancer in the UAE and the
region in the future [29, 30].
Perhaps the formation of a national subcommittee of genomic medicine in can-
cer care, operating under the auspices of the Ministry of Health and other health
regulatory bodies such as the Department of Health (DOH), could develop a frame-
work for advancing standards of practice and research in the field (Table 14.1).
In summary, even though there has been an increase in the utilization of genom-
ics in clinical practice in cancer care over the last several years, utilization remains
sporadic, and the challenges outlined above remain barriers to the optimal utiliza-
tion of genomics in cancer care in the UAE.
With recent initiatives such as the development of the first genomic policy and
the launch of a precision medicine program, there is hope that the era of genomic
and precision medicine in cancer care in the UAE has begun. However, the success
of these initiatives will depend on the development of robust research and clinical
trial networks.

14.8 Conclusion

Genomics is reshaping the treatment paradigm in cancer medicine in the modern

era. The outcomes of various cancers continue to improve with the utilization of
genomic medicine in cancer care. The UAE has also joined the evolving healthcare
system in the utilization of genomics in cancer treatment. It is hoped that new initia-
tives and regulatory frameworks will transform the practice from utilization to
research and clinical trial development.

Conflict of Interest The authors have no conflict of interest to declare.

232 F. A. Khan and M. El Khoury

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Ahmed Y, Kantawala K, Hamza M, Sonal A, Ahmed S, Yang C, Abdelrahman D, AHD-MDT
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234 F. A. Khan and M. El Khoury

Dr. Faraz Khan is US board-certified in internal medicine, hema-

tology, and medical oncology. He is a consultant medical oncolo-
gist and hematologist, head of the hematology program at the
American Hospital Dubai, and an assistant professor at Sharjah
Medical University. He is currently also serving as secretary gen-
eral of the Emirates Society of Haematology.

Dr. Maroun El Khoury is US board certified in internal medi-

cine, hematology, and medical oncology. He is a consultant medical
oncologist and hematologist, director of the cancer program at the
American Hospital Dubai, and an assistant professor at Sharjah
Medical University. He is also a member of the Emirates Oncology
Society Research Council.
Dr. Maroun El Khoury is US board-certified in internal medi-
cine, hematology, and medical oncology. He is a consultant medical
oncologist and hematologist, director of the cancer program at the
American Hospital Dubai, and an assistant professor at Sharjah
Medical University. He is also a member of the Emirates Oncology
Society Research Council.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Genetic Testing for Cancer Risk
in the UAE 15
Rita A. Sakr and Hassan Ghazal

15.1 Introduction

Hereditary cancers account for around 10% of all cancers. Of all cancer patients,
15–20% are estimated to have a positive family history, and mutations in highly
penetrant genes were identified in 20% of high-risk families [1]. For example,
hereditary breast and ovarian cancers originate from specific gene mutations
called BRCA1 and/or BRCA2 (Table 15.1). Multiple studies into hereditary can-
cer genes were performed in Asian and European populations, but very few
were completed in Arab countries [2]. Furthermore, consanguineous marriages

Table 15.1 Clinical features of hereditary breast cancer genes

Gene Syndrome Breast cancer risk Other
BRCA1 Hereditary breast and BRCA1 60% by age 70 Ovarian cancer
BRCA2 ovarian cancers BRCA2 55% by age 70 Pancreatic cancer
Prostate cancer
TP53 Li-Fraumeni syndrome High Sarcoma
Brain tumors
Adrenocortical carcinomas
PTEN Cowden syndrome 77% by age 70 Thyroid cancer
Endometrial cancer
Gastrointestinal cancer
Renal cell cancer
CDH1 Hereditary diffuse 39% by age 80 Gastric cancer
gastric cancer

R. A. Sakr (*) · H. Ghazal

Emirates Oncology Society, Dubai, United Arab Emirates
King’s College Hospital London, Dubai, United Arab Emirates

© The Author(s) 2024 235

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_15
236 R. A. Sakr and H. Ghazal

can increase the risk of inheriting a gene mutation, with, for example, 21–28%
of all Emirati marriages happening between cousins, according to current
research by the Centre for Arab Genomic Studies based in Dubai [3]. Therefore,
it can be of great value to better understand targetable familial cancer genes in
the United Arab Emirates (UAE) and the Arab region.

15.2 Oncogenesis

Cancer can develop after multiple damages to cellular DNA. By consequence,

the cell will not follow the normal process for cell proliferation, and it will
engage in dysregulated cell division. In oncogenesis, the tumor will initiate
with damage to DNA, which will cause a mutation in a critical gene. Following
that, the tumor cell is exposed to stimuli that will promote clonal proliferation
and genetic instability. New mutations will provide a selective advantage for
tumor cells to grow. Somatic mutations can happen in cells throughout their
lifetime, with a number of them being cancer-causing mutations, whereas in
hereditary cases, cancer occurs due to a constitutional mutation in a gene [4, 5]
(Figs. 15.1 and 15.2).

Fig. 15.1 The cell accumulates somatic mutations. DNA damage can be repaired by a cell. In
cases of deficient DNA damage repair, the mutations will accumulate and the cell will become
malignant
15 Genetic Testing for Cancer Risk in the UAE 237

a b

Fig. 15.2 (a) When cancer is non-hereditary, the somatic mutations will occur later, and the can-
cer is happening at a later age. (b) When cancer is hereditary, the mutations are already present in
the cells. The tumor will initiate with only one somatic mutation, and thus, the cancer is happening
at an earlier age

15.3 Genetic Counseling

In cases of a risk of hereditary cancer predisposition syndrome, we should have the

risk assessed through a three-generation family. It should be done as part of the
regular doctor’s family history assessment, followed by the assessment with a clin-
ical genetic specialist. The guidelines for whom to refer to clinical genetic services
in cases of suspected hereditary cancer are publicly available (National Institute
for Health and Care Excellence, National Comprehensive Cancer Network) [6, 7].
Many prediction scoring tools and many computerized models were also identified
as being helpful in the clinical setting (e.g., the MSS scoring system, Gail model,
Claus model, Tyrer-Cuzick model, or IBIS model in breast cancer) [8, 9] in order
to identify the necessity for a genetic test. However, they tend to be less accessible
because of the need to collect information, which can be time-consuming and less
accurate [10]. Genetic testing can be either diagnostic or predictive. The diagnostic
testing is performed on an individual with cancer to help guide further treatment
options. The predictive testing is performed on any individual with a high familial
risk of carrying a gene mutation. As genetic testing technology expands, it is
becoming easier to test a large panel of genes involved in a higher risk for cancer.
In breast cancer, for example, it allows for the identification of patients who have
a specific constitutional gene mutation, thus enabling more personalized manage-
ment. As access to technology is widely increasing, the tests are likely to be pro-
vided by more specialties outside of clinical genetics with respect to the guidelines
and recommendations.
238 R. A. Sakr and H. Ghazal

15.4 BRCA1/2 Mutation

BRCA gene mutations can increase an individual’s risk of developing cancers like
breast cancer (up to 87% lifetime risk), ovarian cancer (45%), prostate cancer
(20%), pancreatic cancer (7%), and male breast cancer (8% lifetime risk). There are
two genes, BRCA1 and BRCA2, that make proteins to help repair damaged
DNA. Every one of us has two copies of each of these genes, called tumor suppres-
sor genes, and any defect in them will usually lead to cancer development at a
younger age. In contrast to acquired or somatic mutations, germline mutations are
inherited and carried by one of the parents at a 50% risk and have been present
since birth.
So, in breast cancer, about 13% of women will develop it, and that risk goes up
to 55–72% in BRCA1 carriers and 45–69% in BRCA2 carriers. Furthermore, contra-
lateral breast cancer may develop in 25% of women after 10 years and up to 40–50%
by year 20. Ovarian cancer risk is up to 45% in BRCA1 carriers and 12–18% in
BRCA2 carriers. Prostate cancer may occur in BRCA2 carriers mostly, while pan-
creas cancer can occur in both BRCA1 and BRCA2 carriers.
Other mutations that can increase one’s risk for cancer are: PALB2, ATM, the
CHECK2 mutation, and TP53.
Ways to reduce this high lifetime risk include:

–– Surgery, like risk-reducing mastectomies and bilateral

salpingo-oophorectomies.
–– Chemoprevention by taking drugs like tamoxifen can reduce breast cancer inci-
dence by nearly 50%.
–– Intense screening with breast MRI, ultrasound of both breasts and ovaries, and
still mammograms.

In the UAE, the most common gene causing breast cancer is BRCA2 (19%), fol-
lowed by BRCA1 (17%), as per a Tawam Hospital study [11, 12], but it can vary
from one Arab country to the next: in Lebanon, up to 6%; in Oman, about 7%; and
probably a little higher in the UAE [13–16].

15.5 Lynch Syndrome

Another important inherited mutation is along the Lynch syndrome family of genes,
like MLH1, MSH2, MSH6, PMS2, and EPCAM. These could be due to a germline
mutation, an inherited form, or a somatically acquired one. Patients with those
mutations are more at risk of developing colorectal cancer, endometrial cancer,
breast cancer, stomach cancer, and even skin cancer and urinary malignancies at a
young age.
So, taking family history into account is critical in this regard. Among colon
cancer patients, only about 4–5% can be attributed to Lynch syndrome, and some
strategies to decrease that risk include:
15 Genetic Testing for Cancer Risk in the UAE 239

–– Surgical intervention, to remove the whole colon or uterus, or to do frequent

surveillance like a colonoscopy annually, as well as endometrial surveillance
with ultrasound and biopsies.

Testing for this can be done in two ways:

1. Immunohistochemistry, or IHC, checks for the above proteins, like MLH1,

MSH2, and MSH6, to see if a person is proficient in or deficient in MMR, or
mismatch repair.
2. MSI, or microsatellite instability DNA testing, so if the result is MSI-H high,
that means that person has Lynch syndrome [17].

15.6 Available Genetic Testing in the UAE

Technologies for gene sequencing have advanced dramatically. The diagnostic

testing is a complete gene screen performed on a cancer patient. It can help guide
future therapeutic options and identify family members who are at risk of devel-
oping cancer. The predictive testing is typically performed on an individual with-
out cancer but with a high family risk of carrying a gene mutation that was
previously identified in a family member. It can help identify high-risk people
before they get cancer, therefore allowing proper surveillance and prophylactic
treatment before cancer can occur. However, cancer will not happen to every
individual who is a mutation carrier. Therefore, pre-test counseling is recom-
mended in order to identify the candidates for genetic testing and to reduce
unnecessary adverse psychological effects on the candidate and his family. Gene
testing was highly revolutionized by the introduction of next-generation sequenc-
ing (NGS), but still, good, detailed clinical information is highly required for a
good interpretation of the results and the proper advice of the candidate [18]. The
more genetic testing technology expands, the easier it becomes for clinicians to
test much larger panels of genes [19]. As a consequence, this large gene panel
testing will probably not only increase the detection rate of pathogenic mutations
but also the detection rate of variants of uncertain significance (VUS). This
detection of VUS can induce confusion among families and patients; therefore,
the NCCN highlighted that proper evaluation for clinical suspicion of hereditary
cancer susceptibility genes should be considered before the multigene testing
(Table 15.2). In the UAE, a multitude of panels testing for mutations in cancer
genes are available. They are employed to confirm large deletions or duplications
in the number of genes and are thus able to report pathogenic variants (Table 15.3).
By consequence, it allows the clinician to provide proper counseling, surveil-
lance management, and prophylactic management (medical or surgical).
240 R. A. Sakr and H. Ghazal

Table 15.2 Representation of guidelines for genetic testing in breast cancer

Personal history of breast cancer
Age at diagnosis <45
Age at diagnosis 46–50
 – Another primary breast cancer
 – One or more close relative(s) with breast, pancreatic, or prostate cancer
 – Unknown family history
Age at diagnosis <60
 – Triple-negative breast cancer
Diagnoses at any age
 – One or more close relative(s)—breast cancer diagnosed at <50
 – Two or more close relatives—breast cancer at any age
 – One or more close relative(s)—invasive ovarian cancer
 – Two or more relatives—pancreatic cancer
 – Male relative—breast cancer
 – Ashkenazi Jewish ancestry
Personal history of invasive ovarian cancer
Personal history of male breast cancer
Personal history of high-grade prostate cancer—one or more close relative(s) with breast,
ovarian, pancreatic, or prostate cancer

Table 15.3 List of mostly analyzed genes

APC CTNNA1 NBN SDHA
ATM DICER1 NF1 SDHB
AXIN2 EPCAM NTHL1 SDHC
BARD1 GREM1 PALB2 SDHD
BMPR1A HOXB13 PDGFRA SMAD4
BRCA1 KIT PMS2 SMARCA4
BRCA2 MEN1 POLD1 STK11
BRIP1 MLH1 POLE TP53
CDH1 MSH2 PTEN TSC1
CDK4 MSH3 RAD50 TSC2
CDKN2A MSH6 RAD51C VHL
CHEK2 MUTYH RAD51D

15.7 Challenges in the UAE

So far, when required, genetic testing has been performed by oncologists on patients
with cancer. Extending genetic testing to individuals with a strong family history of
cancer is still limited, even if they do fall into the category of recommended genetic
testing as per the international guidelines. Challenging reasons are multiple. Doctors
need to be encouraged to ask their patients about their cancer family history, and
patients need to be encouraged to mention their cancer family history to the doctor.
Thus, individuals with a family history of cancer can be identified and referred for
genetic clinical counseling, if available, or to the specialized doctor in the team who
15 Genetic Testing for Cancer Risk in the UAE 241

is able to deliver proper genetic counseling. Another significant challenge is the lack
of insurance coverage for genetic testing, even for people who have a strong family
history of cancer or those with a family member already carrying the cancerogenic
mutation. Many of whom are at high risk for cancer and are potential carriers of
carcinogenic mutations will find themselves postponing the test that could allow
them to decide on prophylactic measures to avoid cancer.

15.8 Conclusion

The care of familial breast cancer was revolutionized in the 1990s by the genes
BRCA1 and BRCA2. However, the major challenge is how to translate the advances
in our understanding of genetic susceptibility into improving patient outcomes in
cancer care. With increasing access to technology, the threshold for cancer suscep-
tibility testing falls. As a consequence, it allows for the identification of patients
with a specific gene mutation earlier, thus enabling personalized management. The
actual model of delivered genetic testing will surely need to follow changing needs,
and clinical genetics might not be the only specialty providing the genetic testing.
The development of those services would certainly require close communication
between all involved clinicians, who need to appreciate the challenges in the inter-
pretation of genetic test results because of the serious potential psychosocial conse-
quences for both individuals and families.

Conflict of Interest The authors have no conflict of interest to declare.

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Dr. Rita A. Sakr (MD, PhD, associate professor) is a French/

European board-certified, American fellow, consultant breast onco-
plastic surgeon, and obstetrician-­gynecologist with over 20 years of
surgical, clinical, academic, and research experience in the field.
After training in both France and the USA, Dr. Rita Sakr was
appointed consultant breast oncoplastic surgeon and obstetrician-­
gynecologist in several institutions, including the Institut Curie,
Paris, the Memorial Sloan Kettering Cancer Centre, New York, and
Assistance Publique—Hôpitaux de Paris. She also held the position
of associate professor and co-head of the Breast and Gynecology
Care Unit for high-risk patients at Pierre & Marie Curie/Sorbonne
University, France. She later relocated to Dubai as a consultant
breast surgeon and obstetrician-gynecologist at the Dr. Sulaiman Al
Habib Hospital and then the American Hospital.
Dr. Rita Sakr is a member of various clinical societies such as
the American Society of Clinical Oncology, the American
Association for Cancer Research, the Lebanese Society of
Obstetrics and Gynecology, the Collège National des Gynécologues
et Obstétriciens Français, Société Française de Sénologie et
Pathologie Mammaire, the New York Academy of Sciences, the
European Society of Surgical Oncology, the Emirates Oncology
Society, and the Europa Donna. Dr. Rita Sakr has more than 100
publications and abstracts in peer-reviewed journals and interna-
tional conferences, and has been awarded many international rec-
ognitions, such as the American Association for Cancer Research
Award and the San Antonio Breast Cancer Symposium Award.
In addition to her wide surgical, clinical, and academic experi-
ence, Dr. Rita Sakr has a passion for patient advocacy and has been
actively involved in multiple associations for breast cancer survi-
vorship in Europe, the USA, and the UAE.
15 Genetic Testing for Cancer Risk in the UAE 243

Dr. Hassan Ghazal is an American board-certified consultant

medical oncologist and a consultant clinical hematologist, offering
more than three decades of clinical experience.
Dr. Hassan Ghazal, after completing his basic medical educa-
tion at the American University of Beirut, moved to the USA for his
residency program in internal medicine at the Sinai Hospital of
Baltimore, MD. In 1992, after completing the residency program,
Dr. Hassan Ghazal joined the George Washington University
Medical Center for his fellowship in medical oncology and com-
pleted the same in 1995. He stayed at George Washington
University Medical Center for another 2 years, earning a senior fel-
lowship in bone marrow transplantation in 1997. He got his US
board certification in internal medicine, medical oncology, and
hematology in 1992, 1995, and 1996, respectively.
Except for his association with CMC for the preceding 3 years,
all his clinical practices were in the USA in various capacities,
including director, Kentucky Cancer Clinic, and staff oncologist/
hematologist at Hazard Appalachian Regional Medical Center.
Dr. Hassan Ghazal is a member of various clinical societies,
such as the American College of Physicians, the American Society
of Haematology, the American Society of Clinical Oncology, and
the European Society of Medical Oncology. Dr. Hassan Ghazal has
many publications and abstracts to his credit in peer-reviewed jour-
nals, and there are many international recognitions and accolades to
his name.
He has been involved in numerous clinical trials—nearly 100 in
the USA—serving as the principal investigator for over 25 years
and enrolling hundreds of patients in these trials.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Fertility Preservation and Oncofertility
in the UAE 16
Nahla Kazim

16.1 Introduction

Cancer burden has risen worldwide by 26.3% in the past decade, concurrently with
the rise in the number of new cancer cases that have increased globally from 18.7
million in 2010 to 23.6 million in 2019. Global age-standardized incidence remained
at a similar rate of −1.1% (95% UI, −5.8% to 3.5%), while mortality rates decreased
by −5.9% (95% UI, −11.0% to −0.9%) [1]. Higher numbers of cases and deaths
occurred in the low to middle sociodemographic index (SDI) groups (Tables 16.1
and 16.2) [1].

Table 16.1 Cancer type distribution (United Arab Emirates (UAE) and global) in females [1, 2]
Rank in the UAE Global rank, 2019 Female cancer in the UAE, 2021
1 1 Breast
2 21 Thyroid
3 3 Colorectal
4 13 Uterine
5 4 Cervical
6 24 (non-melanoma) Skin
7 6 Ovarian
8 8 Leukemia
9 12 Non-Hodgkin lymphoma
10 2 Tracheal, bronchus, and lung (TBL)
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021

N. Kazim (*)
Bourn Hall Fertility Center, Mediclinic Hospital, Al Ain, United Arab Emirates
Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, UAE
University, Al Ain, United Arab Emirates

© The Author(s) 2024 245

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_16
246 N. Kazim

Table 16.2 Cancer type distribution (UAE and global) in males [1, 2]
Rank in the UAE Global rank, 2019 Male cancer in the UAE, 2021
1 3 Colorectal
2 6 Prostate
3 7 Leukemia
4 23 Thyroid
5 20 (non-melanoma) Skin
6 1 Bronchus and lung
7 10 Non-Hodgkin lymphoma
8 11 Lip, oral cavity, and pharynx
9 14 Kidney and renal pelvis
10 12 Bladder
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021

In 2021, the UAE National Cancer Registry (UAE-NCR) (MOHAP, 2021)

reported 5830 newly diagnosed cancer cases, of which 96% were malignant and 4%
were in situ cases. Comparatively, cancer was more common among women (55.1%)
than men (44.9%), while the incidence of cancer increases with advancing age.
There were 154 pediatric malignancies reported, with leukemia being the most
common (42.9%). Notably, boys had a higher cancer frequency (55%) than girls
(45%), and 27.9% of cases were seen in children aged 10–14 years, making this
group unique because it represents children in a transitional phase between child-
hood and adulthood and may not fit perfectly into either category depending on
pubertal status (Table 16.1) [2].
The differences in cancer burden worldwide may reflect several factors, includ-
ing population demography, shifting population age structures, the infrastructure of
the healthcare system, improved capacity for diagnosis and registration of cancer
cases and deaths, and other influences modifying cancer risk such as metabolic,
diet, lifestyle, environmental, and occupational exposures.
Modern anticancer treatments have resulted in higher survival rates (up to 90%
in young women when diagnosed early), but at the expense of fertility damage due
to unwanted side effects (Dolmans et al. 2019; Oktay et al. 2018) [3, 4]. Irreversible
damage occurs when reproductive organs are subjected to aggressive chemotherapy
and radiotherapy, resulting in a reduced or permanent loss of fertility. The likeli-
hood of conception is reduced by 30–50% in female cancer survivors following
radiotherapy or chemotherapy, with an apparent increase in the risk of obstetric and
neonatal complications [3, 4]. Preconception counseling and appropriate obstetric
monitoring are recommended for women intending to become pregnant after
gonadotoxic treatments. Large reports based on cancer registry data, including the
Scottish, Finnish, and North Carolina Central Cancer Registry, concluded that
women who have had cancer have higher rates of postpartum hemorrhage, operative
or assisted delivery, preterm labor, and a variety of other maternal and fetal compli-
cations if they conceive within a year of starting treatment. Similar adverse maternal
and fetal outcomes are also found post-radiotherapy [5].
16 Fertility Preservation and Oncofertility in the UAE 247

Cancer treatments, including chemotherapy using alkylating agents such as

cyclophosphamide, ifosfamide, and busulfan, in addition to ionizing radiotherapy to
the abdomen and pelvis or total body irradiation, are all gonadotoxic, causing dose-­
dependent impairment to the ovaries and uterus [3, 4]. Aside from the dose, the site,
the fractionation of the chemotherapy and radiotherapy, and the patient’s age at the
start of treatment, all contribute to the degree of ovarian and uterine damage. Other
benign medical conditions that include autoimmune diseases like systemic lupus
erythematosus (SLE) and hematological diseases such as sickle cell anemia and
thalassemia may require chemotherapy, radiotherapy, or a combination of both,
with some cases requiring bone marrow transplantation. All such interventions may
result in an early loss of fertility [6]. Severe ovarian damage can increase the likeli-
hood of diminished ovarian reserve and premature ovarian failure due to the exhaus-
tion of primordial follicles and oocytes. Similarly, severe uterine damage can lead
to complications such as pelvic synechia, recurrent miscarriage, pregnancy loss,
preterm delivery, and low birthweight due to uterine vasculature disruption.
Chemotherapeutic agents can directly damage the DNA of the mature follicle, sub-
sequently causing apoptosis and temporary amenorrhea. Ovarian function in terms
of folliculogenesis and resumption of menstruation may occur post-completion of
cancer treatment if the primordial follicle pool is unaffected. However, the resump-
tion of menses does not provide evidence of a complete recovery of ovarian function
or predict reproductive outcomes. While some metals are considered highly gonado-
toxic, causing acute ovarian failure, regimens containing cisplatin, carboplatin, and
adriamycin are considered to have a moderate risk for gonadotoxicity, while patients
receiving bleomycin, actinomycin D, vincristine, methotrexate, or 5-fluorouracil are
considered to have a low risk for gonadotoxicity [7].
Similar to chemotherapy, a high risk of gonadotoxicity is noted post-­radiotherapy
among women receiving pelvic or whole abdominal radiation doses >6 Gy or total
body irradiation (prior to stem cell or bone marrow transplantation) and pelvic or
whole abdominal radiation doses >10 Gy among post-pubertal girls. Craniospinal
irradiation alone, without additional treatment, is not considered to pose a high
gonadotoxicity risk.
Risk-based assessment of cancer patients and survivors depending on chemo-
therapy and radiation allows appropriate patient counseling based on the degree of
gonadotoxicity as well as discussion of fertility preservation options, with early
referral of patients planned to undergo a gonadotoxic, high-moderate-risk regimen
for freezing options and fertility treatment that is most appropriate for their situation.
International guidelines recommend that physicians discuss with all patients of
reproductive age their risk of infertility from cancer and its treatment and streamline
fertility preservation options by referring them to a fertility specialist at the earliest
possible time to discuss their interest in having children after cancer and the avail-
able options [5, 8, 9]. Improved quality of life in survivorship remains the collective
goal through a multidisciplinary approach.
As recommended by the American Society of Clinical Oncology [8] and the
European Society for Medical Oncology [5], sperm cryopreservation for males and
embryo/oocyte cryopreservation for females are standard strategies for fertility
248 N. Kazim

Table 16.3 Female fertility preservation options and current status in the UAE [5, 8, 9]
Characteristics Option 1 Option 2 Option 3 Option 4
Methods Embryo Egg freezing Ovarian Ovarian tissue
freezing following protection cryopreservation and
following ovarian techniques autotransplantation of
ovarian stimulation GnRH analog, frozen-thawed tissue
stimulation and egg ovarian
and egg retrieval by transposition,
retrieval by TVS/TRUS/ pelvic shielding,
TVS/TRUS/ TAS and
TAS chemotherapy
and radiotherapy
fractionated dose
Status Established Established Debatable Established
Availability in Yes Yes Yes No reports
the UAE
Contraindication Single Prepubertal Oophoropexy Frozen-thawed
women and girls and pelvic ovarian tissue
unmarried shielding not autotransplantation in
girls useful in ovarian cancer and
chemotherapy malignancies with risk
Hormonal GnRH of metastasis into
analog not useful ovaries
in radiotherapy

preservation. Other strategies, such as pharmacological protection of the gonads

and gonadal tissue cryopreservation, are either yet considered experimental or
require further investigation and validation (Table 16.3).

16.2 Fertility Preservation Methods in Females

16.2.1 Ovarian Stimulation

Fertility preservation (FP) is an option to store oocytes or embryos prior to cancer

therapy; both require controlled ovarian stimulation (COS), commonly using an
antagonist protocol [10]. In brief, daily subcutaneous injections of gonadotropins
such as recombinant follicular-stimulating hormone (rFSH) (follitropin alpha,
Gonal-F, Merck, Germany; follitropin beta, Puregon, Organon, USA; corifollitropin
alpha, Elonva, Organon, USA) or urinary human menopausal gonadotropin (HMG)
(Ferring Pharmaceuticals, USA) start from the second to the fourth day of the men-
strual cycle. When the leading follicle measures more than 12 mm, 0.25 mg of GnRH
antagonist cetrorelix (Cetrotide, Merck, Germany) or ganirelix (Orgalutran, Organon,
USA) is added daily to prevent premature LH surge. Finally, recombinant hCG
(Ovitrelle, Merck, Germany) and/or a GnRH agonist (Ferring Pharmaceuticals,
USA) are given subcutaneously for final oocyte maturation when three or more
follicles reach 17 mm in diameter and after assessing the risk of ovarian
­
16 Fertility Preservation and Oncofertility in the UAE 249

hyperstimulation syndrome (OHSS). Oocyte retrieval under general anesthesia is

performed 36 hours later as a day procedure. Routinely, egg collection is done under
transvaginal scan guidance, but other routes such as transrectal, transabdominal, and
laparoscopic recovery may be considered for unmarried females, adolescents, and
children who have reached puberty. An oocyte is cryopreserved by rapid vitrification
or fertilized with her husband’s sperm to proceed with embryo cryopreservation.
Other non-conventional ovarian stimulation protocols, such as random start, dual
stimulation (DUOSTIM), and luteal phase stimulation, have shown similar out-
comes to the conventional cycles, potentially optimizing the number of oocytes
retrieved within the shortest possible timeframe while providing tailored care man-
agement for cancer patients [11].

16.2.2 Special Considerations

The age of a patient undergoing fertility preservation strongly impacts the outcome
of freezing in regard to the number of retrieved mature oocytes, the survival rate of
oocytes during the thawing process, and the fertilization rate when injected with
sperm, with higher chances of pregnancy, including a live birth rate per patient, seen
among women aged <35 years. Outcomes of 137 women returning to use their vitri-
fied oocytes for non-oncologic reasons showed cumulative live birth rates (CLBRs)
of 15.4% when five oocytes were used, 40.8% when eight eggs were used, and
60.5% when 10 eggs were used among patients below <35 years of age. In women
aged >35 years, lower CLBRs were noted, showing 5.1% (5 eggs), 19.9% (8 eggs),
and 29.7% (10 eggs), respectively [12].
While several studies have confirmed an association between older age and lower
retrieved oocyte yields and pregnancy chances, such data should be interpreted with
caution because the majority of these studies are retrospective and report outcomes
on healthy women undergoing elective oocyte freezing. Reduced live birth rates
(LBR) were observed in women attempting pregnancy who had undergone FP for
malignant indications versus women who had FP for benign indications [11, 12].
The aim of gonadotropin injections for fertility preservation is to produce multi-­
follicular development in a short time; this may increase the risk of ovarian hyper-
stimulation syndrome (OHSS), particularly in young lean patients with high
ovarian reserve. OHSS is an iatrogenic complication associated with ovarian
gonadotropin stimulation that is followed by the hCG trigger given for final oocyte
maturation. The etiopathogenesis of OHSS includes ovarian enlargement, secre-
tion of vasoactive substances, ascites, hypovolemia resulting from an acute extrav-
asation of fluid into the interstitial space, hemoconcentration, hypercoagulation,
and electrolyte imbalances, all leading to life-threatening cascades. The incidence
of moderate-to-­severe OHSS is approximately 1–5% of cycles, and many strate-
gies are used effectively to prevent or reduce OHSS incidence during the early
stages, including using an antagonist protocol with a GnRH agonist for triggering
ovulation instead of hCG [13].
250 N. Kazim

Other less common complications of ovarian stimulation with oocyte retrieval

include vaginal bleeding, pelvic infection or abscess, injury to pelvic structures, and
ovarian torsion [14].
An increased frequency of venous thromboembolism (VTE) is noted with
assisted reproduction, complicating 0.1% of cycles, although the exact mechanism
remains unknown. High estrogen levels following ovarian stimulation may exhibit
a procoagulant effect by increasing levels of von Willebrand factor, factor V, factor
VIII, and fibrinogen while decreasing levels of the anticoagulants protein S and
antithrombin. The clinical implication of these changes in healthy females is unclear
since most variables remain within normal limits. Low-molecular-weight heparin
(LMWH) prophylaxis may be considered during ovarian stimulation for patients
with an increased risk of VTE, including thrombophilia, OHSS, obesity, prior VTE,
or a strong family history of venous thrombosis [15].
To prevent venous thromboembolism and estrogenic symptoms in estrogen-­
sensitive cancers, an antagonist protocol with the addition of letrozole or tamoxifen
may also be added during stimulation [16].
Ovarian gonadotrophic stimulation among females with possible steroid-­
sensitive tumors requires concurrent use of an aromatase inhibitor to minimize the
abnormal iatrogenic rise in estradiol that may accompany COS, thereby reducing
the potential risk of exacerbating malignant breast disease [17].
While available data in the literature is reassuring, a theoretical link to disease
progression or a high risk of cancer recurrence exists due to a lack of publications
on the long-term effect of COS on the prognosis of breast cancer [5, 9, 17].
A cohort analysis of 155 cycles evaluating the effect of different hormonal recep-
tor profiles on stimulation cycle parameters among women with breast cancer found
that patients with a triple-negative breast cancer profile (TNBC) had a significantly
lower number of mature oocytes when compared to the ER + PR+ and non-TNBC
groups [18]. Multivariate analysis using a threshold of 10 mature oocytes revealed
a high cumulative live birth rate of 50% among 18–38 years of age. The study con-
cluded that the TNBC subtype, with an average number of 7 mature oocytes col-
lected, had a negative effect on fertility preservation outcomes. While such studies
are useful in the fertility preservation decision-making process before deciding on
stimulation protocol or gonadotropin dose for women with different breast cancer
subtypes, further studies should explore other factors in cancer, such as BRCA
mutations, that may hinder the ovarian response to stimulation, reducing the prob-
ability of having offspring in the future.
There is a lack of data on oocyte quality in women with cancer. A retrospective
case-control study using univariate and multivariate analyses among 105 women
with breast cancer and 189 healthy women in the control group, both undergoing
controlled ovarian stimulation cycles for fertility preservation, found a fourfold
increased risk of retrieving dysmorphic and poor-quality oocytes among breast can-
cer women with no effect on the ovarian reserve or its response to stimulation [19].
A retrospective, observational multicenter study comparing the success of IVF
cycles after elective fertility preservation (EFP) for age-related fertility decline and
oncofertility preservation (OFP) prior to cancer treatment showed lower live birth
16 Fertility Preservation and Oncofertility in the UAE 251

rates after oocyte vitrification among cancer patients. However, after controlling for
age and ovarian stimulation (COS) regime, there was no statistically significant
association between malignant disease and reproductive outcome. The limitation in
statistical power to compare IVF outcomes was attributed to fewer women returning
to use their oocytes in the Onco-FP group, and the lower implantation rate failed to
prove the impact of cancer disease or the type of cancer treatment as a causative
factor per se. While encouraging data is available for donor oocyte vitrification,
however, the evidence cannot be applied to oocyte vitrification for infertile patients
or women with pre-existing medical or oncological conditions, as different oocyte
sources from different conditions may vary in their inherent qualities that may affect
vitrification outcomes. Nevertheless, there is an ample amount of data in the litera-
ture confirming a significantly higher cumulative probability of live birth in patients
<35 years of age versus >35 in the EFP, with improved outcomes when more oocytes
were available for IVF [11, 20].
Pregnancy is considered safe in women who have survived breast cancer, inde-
pendent of the estrogen receptor status of the tumor (strong ESHRE recommenda-
tion). Women may be advised to stop tamoxifen treatment due to the risk of abnormal
fetal development and wait at least 3 months before attempting conception to allow
an appropriate washout period from the drug [5].
Knowledge of the overall risks associated with ART cycles is important for can-
cer patients to avoid further delays in their treatment or adding to their disease’s
health burden. Gonadotropin cycles should be managed by a clinician with the req-
uisite training and experience and, in the UAE, by licensed reproductive medicine
specialists or consultants.

16.3 Embryo Freezing

Embryo cryopreservation is an effective fertility preservation technique that is the

first choice for married women whose mature oocytes can be collected after
10–14 days of ovarian stimulation and injected with their husband’s sperm in an
embryology laboratory. This technique is not appropriate for unmarried females or
children who have not reached puberty, according to the UAE’s fertility legislation.
The proportion of cryopreserved embryo transfer cycles compared with fresh cycles
has grown worldwide. In Europe, it was estimated that cryopreserved cycles con-
tributed to 32% of the transfers in 2011, while around 50% of all ART transfers are
now FET. Current UAE fertility legislation that allows embryo and egg cryopreser-
vation has resulted in an increase in the proportion of cryopreserved cycles per-
formed, exceeding 80% of ART transfers.
Data available from cohort studies, large RCTs, and meta-analysis show that the
newer rapid vitrification and warming technique is superior to the slower freezing
and thawing methods that were used earlier in terms of improved clinical outcomes
as well as better cryosurvival rates for oocytes, cleavage-stage embryos, and blasto-
cysts. The longest frozen embryos resulting in a live birth on record were twins born
in October 2022 in the USA from embryos frozen 30 years ago. Generally, it is
252 N. Kazim

difficult to track pregnancies resulting from older frozen embryos, as the US Centers
for Disease Control and Prevention (also the Department of Health in the UAE)
track data and success rates around reproductive technologies but do not track how
long the embryos have been frozen.
Embryo cryopreservation showed excellent success rates and emerging long-­
term data supporting the safety of the procedure. The post-thaw survival rates of
embryos are up to 90%, the implantation rate is 80%, and the cumulative pregnancy
rates are over 50% [21].
The majority of fertility centers in the UAE have adopted preimplantation genetic
testing for aneuploidies (PGT-A) in their laboratories, often using ICSI as the fertil-
ization method of choice. PGT-A provides some confidence before embryo transfer
for choosing the best embryos that are chromosomally normal with high implanta-
tion potential but also reduces the time to achieve pregnancy [22].
Women at risk for or confirmed carriers of hereditary cancers can use both
PGT-A and PGT-M, allowing identification of embryos that are both euploid and
unaffected/non-pathogenic carriers, thereby reducing the risk of transmission in off-
spring. However, proper patient counseling is warranted, as this increases the pos-
sibility of having fewer euploid and non-affected embryos (or none) that are
available for transfer than expected [22, 23].
Although embryos and oocyte vitrification procedures are well-established
worldwide, as well as in the UAE, long-term follow-up studies of children are man-
dated. Data in the literature is conflicting, with some suggesting that pregnancies
obtained from a cryopreserved oocyte and/or embryo transfer are associated with
increased perinatal and obstetrical risks, while larger systematic reviews and cohort
studies mostly show reassuring results and lower obstetric and perinatal complica-
tions such as antepartum hemorrhage, preterm delivery, low birthweight, and peri-
natal mortality with frozen embryo transfer, irrespective of their cleavage stage,
compared to fresh embryo transfer [24, 25].
Once again, emphasis is placed on the importance of careful counseling of
women with cancer desiring offspring in the future, and case-by-case selection of
suitable candidates is recommended. Women should be informed of accurate,
center-­specific ART performance indicators and live birth rates. Women with a part-
ner may be offered a combination of options for embryo and oocyte cryopreserva-
tion [5].

16.4 Oocyte Freezing

Oocyte freezing is no longer considered an experimental method by the American

Society for Reproductive Medicine and has merged as a successful technique among
unmarried females, provided they attained menarche, in countries where embryo
freezing is legally restricted or when sperm is unavailable on the day of oocyte
retrieval [5, 8, 9].
Post-pubertal patients can delay chemotherapy by 2 weeks, allowing the retrieval
of mature oocytes following ovarian stimulation and eventually being vitrified.
16 Fertility Preservation and Oncofertility in the UAE 253

Later on, the oocytes may be thawed, injected with the woman’s husband’s sperm,
forming embryos, and then transferred to the uterine cavity for pregnancy.
In addition to infertility and medical and oncological indications, the trend in the
UAE in recent years has been elective fertility preservation for women (married and
single) who are conscious of the decline in oocyte quality and quantity with advanc-
ing maternal age with the intention of postponing pregnancy for a later age.
The combined technique may also be applied, involving ovarian tissue cryo-
preservation, IVM, and mature oocyte vitrification following controlled ovarian
stimulation. This combined technique theoretically yields more than a 50% chance
of achieving a live birth [26, 27].
Patients pursuing oocyte cryopreservation need to be informed about the dura-
tion of oocyte cryopreservation as per the law and counseled regarding their likeli-
hood of live birth with autologous thawed oocytes after cancer treatment and if the
duration of freezing has any impact on the outcome. A study by Whiteley et al. of
530 IVF cycles using autologous vitrified or thawed oocytes from 2010 to 2020
found no impact of the duration of oocyte vitrification on the live birth rate follow-
ing fresh or frozen embryo transfer [28].
Most studies have shown that the number of live births obtained from oocyte
cryopreservation decreases with advancing age due to low ovarian reserve and poor-­
quality eggs, with a resultantly high rate of aneuploidy. Doyle et al. [29] estimated
that to achieve a 70% chance of one live birth in their cohort, i.e., for women aged
30–34 years, 14 oocytes would need to be frozen, 35–37-year-olds would need 15
oocytes, and 38–40-year-olds would need 26 mature oocytes in their cohort of 128
autologous thawed or warmed treatment cycles. Cobo et al. demonstrated cumula-
tive live birth rates of 43% and 70% when 10 and 15 oocytes were vitrified, respec-
tively, in women aged <35 years, confirming that every 15 cryopreserved oocytes
can result in a live birth [11]. Women aged 36–40 years would need to freeze 16–25
oocytes to increase their chances of having one live birth, whereas women aged
≥41 years would need to freeze more than 40 eggs. It is extremely challenging to
have similar oocyte yields in older women and in cancer patients due to multiple
reasons, including poor ovarian reserve and a time constraint before starting gonado-
toxic treatment. Women need to be informed that success rates after cryopreserva-
tion of oocytes at the time of a cancer diagnosis may be lower than in women
without cancer [5].

16.5 IVM

This technique involves harvesting immature oocytes from unstimulated or mini-

mally stimulated ovaries. While oocytes at the diplotene stage of prophase I, or
germinal vesicle (GV) stage, have been shown to survive cryopreservation better
than those frozen at the mature stage, a lower blastulation rate with lower implanta-
tion and pregnancy rates has been reported when compared to conventional IVF due
to suboptimal nuclear and cytoplasmic maturation. IVM gained popularity as an
alternative treatment protocol in certain cases, such as women who are at risk of
254 N. Kazim

OHSS or women who have a limited time to begin fertility preservation prior to
gonadotoxic cancer treatment. It may also reduce patient burden due to shorter stim-
ulation cycles, fewer injections, and associated reduced drug and monitoring costs.
According to ASRM, this technology is no longer considered experimental, and
the procedure should always be performed by experts with specific training and
accompanied by appropriate counseling about expected outcomes and informed
consent [9].
So far, a relatively small number of children are born worldwide with IVM, with
no available long-term studies assessing the safety of IVM with regard to fetal mal-
formations and developmental outcomes [30].
In the UAE, any attempted in vitro gamete maturation from immature sperm or
eggs followed by cryopreservation has only been reported in the internal communi-
cation of the embryology laboratories of some of the private clinics or is used as a
marketing strategy on their websites with no published data on its efficiency or suc-
cess. An observational study was performed at ART Fertility Clinics, Abu Dhabi,
UAE, between January 2019 and June 2021, wherein a total of 5454 cumulus-oocyte
complexes (COC) were retrieved from 469 ovarian stimulation cycles, showing no
difference in the blastocyst euploidy rates in embryos resulting from mature oocytes
at the time of retrieval compared to immature eggs undergoing IVM. The humble
data identified a group of patients’ populations that may benefit from rescue IVM
within a routine ART scenario. Patients with ≤59% mature oocytes at retrieval and/
or anti-Mullerian hormone (AMH) >2.52 ng/mL have increased chances of obtain-
ing an euploid embryo from immature eggs progressing to matured oocytes without
adhering to unnecessary costs and workload [31].

16.6 Ovarian Tissue Cryopreservation (OTC)

and Autotransplantation (OTT)

Due to the increasing success rates of ovarian cryopreservation and autologous

transplantation, this technique is no longer considered experimental by the ASRM
[9]. Nonetheless, a recent 20-year prospective study found no reduction in repro-
ductive lifespan or effect on the natural age of menopause when one-fifth of ovarian
tissue cortex was harvested among 48 women undergoing benign non-ovarian
OBGYN procedures for the purpose of fertility cryopreservation to delay reproduc-
tive aging when compared to controls who had declined an ovarian biopsy but
underwent similar benign surgeries. The study highlighted the scope of ovarian tis-
sue cryopreservation in providing a natural form of hormone replacement therapy
[32]. The same should be investigated as an option for OFP and improving repro-
ductive outcomes following cancer treatment.
OTC is recommended for patients undergoing moderate- or high-risk gonado-
toxic treatment when oocyte or embryo cryopreservation is not possible or at the
patient’s preference [5].
Over 100 successful live births have been reported following ovarian tissue replace-
ment. So far, no official report of ovarian tissue cryopreservation and
16 Fertility Preservation and Oncofertility in the UAE 255

autotransplantation in the UAE is available. A multidisciplinary team should carefully

select cases with a focused effort to appropriately select the fertility preservation pro-
cedure based on the patient’s profile, avoiding harm to the patient by delaying cancer
treatment, and ensuring that all attempts are made to provide information on access to
such services in the UAE or abroad. Patients of advanced age or with poor ovarian
reserve with an AMH <0.5 ng/mL and an AFC <5 may not be suitable for OTC as the
risks of the procedure may outweigh the benefits, with experts suggesting alternative
FP methods [5]. Furthermore, the OTC method is not suitable for all patients, as there
is a theoretical risk of transplanting cancer cells into disease-free patients [5, 9, 33].
Slow freezing protocol for OTC is well-established and commonly used, but
setbacks include the lack of FDA-approved media for transportation or cryopreser-
vation of ovarian tissue, and there is no formal system for tracking the outcomes,
nationally or internationally. It is recommended to limit tissue harvesting to ≤ one-­
third of the cortex of one ovary to minimize the risk of inducing early menopause.
A superficial cortical biopsy is preferred over performing a wedge resection to mini-
mize adhesion risks.
Ovarian tissue replacement, or autotransplantation, is considered a safe proce-
dure that can be done laparoscopically. Orthotopic sites, such as the placement of
thawed slices into a peritoneal pocket, are recommended to restore fertility and
natural conception, whereas heterotopic transplantation requires ART. The full
potential of subcutaneous heterotopic transplantation techniques in restoring ovar-
ian endocrine function remains unclear; however, they may be considered a natural
source of autologous HRT in cases where synthetic hormonal replacement therapy
is contraindicated [33].
It is highly recommended to assess the risks of cancer recurrence and the safety
of pregnancy after a complete remission of the disease. The decision to perform
OTT on oncological patients necessitates a multidisciplinary approach once again.
Parents of patients under the age of 18 should be provided with all available
information and future prospects regarding ovarian tissue cryopreservation.
Candidates should be informed about the uncertainty of benefits, risks, and alterna-
tives and perform the procedure, preferably under an Institutional Review Board
(IRB)-approved protocol.

16.7 GnRH Agonist

GnRH agonists are the only medical strategy available for clinical use during che-
motherapy as an option for ovarian function protection in premenopausal cancer
patients [5, 8, 9]. A pituitary gonadotropin flare-up is observed after an intramuscu-
lar or subcutaneous injection of a GnRH agonist, followed by a prolonged down-
regulation and ovarian suppression. However, the benefit of this flare-up is unclear,
as the primordial follicles are not gonadotropin-sensitive. Some of the proposed
mechanisms by which GnRH agonists exert a follicle protective effect are by reduc-
ing primordial follicle recruitment and differentiation along with lowering gonadal
vascularity, hence reducing levels of gonadotoxic agents in the targeted organs [34].
256 N. Kazim

GnRH agonist depot may be administered at a monthly or 3-monthly interval,

with downregulation lasting 1–3 months and about 1–2 weeks beyond the end of the
last chemotherapy cycle. The major adverse effects involve climacteric symptoms
such as hot flushes, vasomotor symptoms, and sexual problems [5].
Data on the protective effect of GnRH agonists on ovarian reserve is heteroge-
neous and has an unproven role in future pregnancies. A potential protective effect
was demonstrated when GnRH analogs were administered during gonadotoxic che-
motherapy with the intention of preserving ovarian function in a large systematic
review and meta-analysis of 12 RCTs and 7 cohort studies published between 1987
and 2015, as measured by the resumption of menstruation [35].
While high-quality evidence shows concurrent use of GnRH agonists during
chemotherapy significantly reduces the risk of developing chemotherapy-induced
POI with no negative impact on survival, concerns exist about possible irreversible
loss of bone density if GnRHa is administered for >6 months, cardiovascular health,
and overall quality of life, with no large, randomized control data validating such
concerns [36].
It is noteworthy to mention that most of the data from randomized trials assess-
ing the use of GnRHa during chemotherapy have been conducted in breast cancer
patients, with limited and mostly negative evidence in women with other malignan-
cies such as ovarian cancer and Hodgkin’s and non-Hodgkin’s lymphoma [37].
GnRH agonists should be applied in addition to other FP interventions, such as
oocyte or embryo cryopreservation. It may be used as a single FP option where
oocyte or embryo cryopreservation is not feasible [5].
GnRH agonists should not be routinely prescribed in malignancies such as lym-
phomas or other than breast cancer without first discussing with the patient the
unproven benefit of ovarian function protection or post-treatment pregnancy.
Furthermore, a small trial showed the potential benefit of GnRHa for the protection
of ovarian function in cases of ovarian cancer, adding to uncertainty about its benefit
in the absence of large data [5].

16.8 Oophoropexy

Women may be offered surgical ovarian transposition using either lateral or medial
transposition approaches with the aim of preventing premature ovarian insufficiency
when pelvic radiotherapy without chemotherapy is planned [5]. The ovaries are
mobilized and affixed to a location in the abdomen free of radiation, which is car-
ried out shortly before radiotherapy to prevent the ovaries from returning to their
original position. The preservation of ovarian function assessed by the absence of
amenorrhea is noted in 71% of cases [38].
Radiation therapy is indicated for the treatment of pelvic malignancies, including
cervical, endometrial, rectal, and bladder cancers, as well as sarcomas and lympho-
mas involving the pelvic region.
The recommendation to offer ovarian transposition as a fertility preservation
option to women prior to pelvic radiotherapy is in line with recommendations from
16 Fertility Preservation and Oncofertility in the UAE 257

the American Society of Reproductive Medicine, the American Society of Clinical

Oncology, and the National Comprehensive Cancer Network. While well-designed
clinical trials on the efficacy and safety of ovarian transposition are lacking, small
observational studies show it is an effective method for preserving ovarian function.
Reproductive and pregnancy outcomes are rarely reported as a whole cohort. In the
context of safety, an overall complication rate of 12.8% has been reported, mainly
ovarian cysts, with no additional intervention or treatment necessary [10]. Again,
GDG advises against ovarian transposition for women with reduced ovarian reserve,
again highlighting the importance of effective fertility preservation methods to pro-
tect ovarian function, which is dependent on patient characteristics, including her
age [5]. The risks of ovarian transposition may outweigh the benefits for women of
advanced age with poor ovarian reserve, as high chances of ovarian failure exist.
Also, women who are at risk of having ovarian metastases are inappropriate candi-
dates for ovarian transposition [5].

16.9 Male Fertility Preservation

Male fertility preservation options are less complex and faster than female fertility
preservation options, requiring sperm collection via masturbation, electroejacula-
tion, or testicular biopsy, followed by cryopreservation of semen and testis tissue.

16.9.1 Sperm Cryopreservation Through Ejaculation

Sperm cryopreservation has been used worldwide since the 1970s and in the UAE
since the early 1990s to treat couples with infertility.
There is no recommended medical treatment to protect spermatogenesis in males
undergoing gonadotoxic treatment as opposed to their female counterparts. Studies
to date have failed to confirm the significant benefit of hormonal suppression of
testicular function and spermatogenesis with the use of GnRH agonists, testoster-
one, androgenic progestogens, or anti-androgens [39, 40].
Masturbation-based sperm collection is feasible and successful for the majority
of adult and post-pubertal male cancer patients.
As per the AUA/ASRM Guideline (2020), males should be counseled about the
negative impact of cancer treatment on their reproductive potential, and early refer-
ral to a reproductive specialist or urologist is recommended for options of fertility
preservation prior to the initiation of gonadotoxic therapies such as chemotherapy
or radiotherapy [40]. To ensure successful sperm oncofertility freezing, ejaculated
samples should be obtained twice or thrice to yield several vials for cryopreserva-
tion [40, 41].
Sperm can be used successfully during fertility therapy, even after 40 years of
cryopreservation. The recent birth of a baby boy in October 2022, in the USA, from
sperm frozen in 1996 when his father (21 years old at the time) was diagnosed with
Hodgkin’s lymphoma made headlines while sparking scientific and ethical debate
258 N. Kazim

about the legal limit for the allowed number of years of sperm cryostorage versus
sperm shelf-life (news). The duration of sperm freezing in clinical practice world-
wide varies depending on local legislation, governing authorities, clinical require-
ments, and funding. While the Human Fertilisation and Embryology Authority
(HFEA) allows patients with persistent infertility to consent for sperm freezing for
up to 55 years, National Health Service (NHS) funding for sperm freezing may be
limited to 5–10 years per patient, depending on the region of the UK.
In the UAE, males who consent and proceed with sperm cryopreservation are
counseled about the quality and quantity of their cryopreserved sample, the number
of years of cryostorage allowed under UAE fertility legislation (up to 5 years,
extendable further for onco cases and severe male factor infertility), and how to
renew their cryostorage consent on a yearly basis with rights for future use within
the same fertility center or after transporting it to another center within the UAE.
Semen parameters prior to cryopreservation have been shown to be an accurate
predictor of post-thaw sperm motility and viability, and spermatogenesis recovery
rate is dependent on cancer type, treatment modality, type of chemotherapy regi-
men, radiation dose, and underlying testicular function [42].
As is the case with women, advanced paternal age has been linked to an increas-
ing number of defects in sperm DNA integrity and genomes, influencing assisted
conception outcomes and offspring health [43].
Despite this, patients with testicular cancer can experience spontaneous sper-
matogenesis recovery in up to 50% of cases 2 years after gonadotoxic treatment,
with rates of long-term azoospermia (more than 2 years) ranging from 5 to 18% in
patients who have undergone orchiectomy and radiotherapy [40]. The rates of long-­
term azoospermia post-chemotherapy range from 0 to 82% for men with Hodgkin’s
lymphoma and 19–55% among men with leukemia [40].
Both radiotherapy and chemotherapy affect the differentiating spermatogenic
cells, including the spermatocytes and the spermatids, but do not kill the spermato-
gonial stem cells in the testis, thus causing a temporary decline or cessation of
spermatogenesis followed by a gradual recovery of sperm production after complet-
ing gonadotoxic therapy. Furthermore, a man can produce an increased proportion
of genetically abnormal spermatozoa for a specific period of time following radia-
tion and/or chemotherapy exposure, which can significantly increase the risk of
genetic mutations in the offspring if the spouse conceives during this time. As per
ample data given in the literature, AUA/ASRM recommends that clinicians inform
patients undergoing chemotherapy and/or radiation therapy to avoid pregnancy for
a period of at least 12 months after completion of treatment [40]. It is recommended
that clinicians advise patients to delay SA for assessing sperm recovery after
gonadotoxic therapies, which should be done at least 12 months (and preferably
24 months) after treatment completion [40].
Concerns over the years have been raised about the freeze-thawing technique
that may lead to a reduction in the number of normally functional sperm as a result
of osmotic and oxidative stress, toxicity from the cryoprotectant, and the formation
of intracellular ice crystals [41]. In recent years, cryopreservation has been improved
16 Fertility Preservation and Oncofertility in the UAE 259

to reduce the risk of viral cross-contamination or sperm damage by incorporating

cryoprotectants and antioxidants. Again, caution is needed for the routine use of
additives in sperm cryopreservation, which requires further investigation into the
outcome of pregnancy and the safety of offspring.
Cancer itself may impair semen parameters prior to the initiation of oncotherapy.
Many retrospective studies evaluating sperm samples obtained from the semen of
cancer patients who were cryopreserved before chemotherapy and those who under-
went semen analysis for infertility investigation found that men undergoing preche-
motherapy had lower sperm concentrations and reduced total motility when
compared to healthy controls with semen parameters above the World Health
Organization (WHO) 2010 reference limit. Reduced semen parameters were seen
irrespective of tumor type and were lowest in individuals with germ cell tumors [44].
The effect of malignancy on spermatogenesis may be due to several factors,
including disruption of the normal hypothalamic–pituitary–gonadal axis and injury
to the germinal epithelium from cytotoxic immune responses to cancer, fever, and
malnutrition [44].
Again, proper counseling is empirical, and assessment of health conditions
including erectile dysfunction, comorbidities such as diabetes, and neurological
conditions requiring long-term use of medications all play vital roles in successful
male fertility preservation.
While a comfortable environment for semen collection is desirable for young
men, teenagers, or men who are unable to ejaculate, other alternative options may
also be considered to obtain ejaculated sperm for cryopreservation.

16.9.1.1 Vibratory Stimulation and Electroejaculation

Penile vibratory stimulation induces ejaculation in males by increasing penile stim-
ulatory input and triggering the ejaculatory reflex among males who are unable to
provide semen through conventional masturbation in cases of neurologic injuries or
factors negatively impacting the ejaculatory reflex, including psychogenic anejacu-
lation [9]. Alternatively, electroejaculation may be offered for men and peri-­pubertal
males who are non-responsive to penile vibratory stimulation. The collection of
seminal emission following pelvic tissue stimulation, including the prostate and
seminal vesicles, with a transrectal probe may be performed under anesthesia.
Pseudoephedrine (alpha-agonists) may be used cautiously to restore antegrade
ejaculation in men suffering from retrograde ejaculation due to autonomic or pelvic
nerve injury or bladder neck injury.
For men who failed to respond to alpha-agonist therapy or whose use is contra-
indicated, the isolation of sperm for cryopreservation is done through the collection
and processing of the urine after ejaculation, following urinary alkalization with or
without the use of sperm wash media into the bladder just prior to ejaculation. For
cases of erectile dysfunction (ED), oral agents such as phosphodiesterase type 5
(PDE-5) inhibitors (sildenafil) may be used. The patient should be evaluated and
counseled on its contraindications, timing of administration, need for sexual stimu-
lation, and any other side effects prior to initiating any of these agents [9, 40].
260 N. Kazim

16.9.1.2 Surgical Aspiration and Extraction of Sperm

In cases of azoospermia, severe oligoasthenoteratospermia (OAT), or hypospermia,
TESA/PESA/testicular biopsy and microscopic testicular sperm extraction (micro-
TESE) may be considered. Although surgical aspiration may be done under local
anesthesia, most of these procedures are conducted in the operating room as an
outpatient day-case procedure and hence require scheduling.
Testicular tissue cryopreservation is the only method of fertility preservation for
prepubertal boys who are not yet producing sperm or for pubertal patients who can-
not or will not produce a semen sample. The procedure, done under GA, requires
the removal of testicular tissue by open biopsy of one testis, cutting the biopsied
testicular tissues into small pieces (1–25 mm3), and then freezing at a slow rate or
freezing the intact pieces of testicular tissue.
It is important that such procedures are done with ease of access to fertility
centers with a cryopreservation facility, whereby sperm found in testicular tissue
is processed and cryopreserved immediately after the procedure. Immature tes-
ticular tissue can be cryopreserved in case no mature sperm is recovered, as it may
be the only hope for future fatherhood. While testicular biopsy in young patients
is generally considered safe with no reported long-term impacts on testicular anat-
omy, growth, or hormonal function, it is still considered investigational by the
ASRM and must be performed in the setting of a clinical trial [9]. Autologous
testicular tissue transplantation of cryopreserved testicular cells or tissues may
not be appropriate for patients with blood-borne cancers or testicular cancers due
to the theoretical risk of reseeding tumors. Moreover, combining multiple tech-
niques, such as sperm extraction from the affected testis tissues immediately after
orchiectomy, may also be considered, referred to in the literature as “onco-TESE,”
as this may be the only potential source or instance for finding viable sperm for
cryopreservation.
No report for testicular tissue cryopreservation among pubertal or prepubertal
boys in the UAE is available. A patient as young as 15 years of age has undergone
oncofertility sperm cryopreservation as per Tawam Fertility Center sperm cryostor-
age records (internal, unpublished report).

16.10 UAE Fertility Preservation Legislations and Timeline

As per Federal Law No. (11) of 2008 [45] Concerning Licensing of Fertilization
Centres and based on the proposal of the Minister of Health, with the approval of the
Cabinet and the Federal National Council and the ratification of the Supreme
Council of the Federation, this law was applied to fertility centers operating in or
applying for a license to operate in the UAE.

–– The law advocated for the formation of the Fertilization Centres Oversight and
Control Committee under the Ministry of Health to include technical, Sharia
(Islamic law), and legal members (Article 3).
16 Fertility Preservation and Oncofertility in the UAE 261

–– Assisted reproductive techniques (ART) included intrauterine insemination

(IUI), in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI) of the
ovum, and subsequent embryo/gamete transfer (Article 8).
–– ART is provided for married couples only (Article 9).
–– It is prohibited to perform ART using donor embryos, donor eggs, or donor
sperm (Article 10).
–– Embryo freezing was not allowed with surplus fertilized ova that were left with-
out medical attention until they perished naturally. However, preserving unfertil-
ized ova (egg freezing) and sperm for future use was possible (Article 10).
–– Transportation of sperm, ovum, and embryos within the UAE was allowed; how-
ever, it was prohibited across borders (Article 18).
–– It is prohibited to establish or deal with embryo banks (Article 20).
–– The punishments and penalties stipulated under the law in cases of offenses or
regulation violations (Article 28–34).

Cabinet Decision No. (36) of 2009 came in soon after issuing the Implementing
Regulation of Federal Law No. (11) of 2008. Fertility centers that had frozen
embryos in their possession prior to the issuance of the law were allowed to dispose
of the stored embryos within 6 months from the date that the law was published
(Article 25). The consent for egg freezing required the signatures of both husband
and wife (Form 4), whereas the consent for sperm freezing could be given by the
male alone (married or unmarried) (Form 5).
On December 19, 2019, the late His Highness Sheikh Khalifa Bin Zayed Al
Nahyan, President of the United Arab Emirates at the time, announced the new IVF
law that came officially into effect on January 1, 2020, repealing the old IVF
law [46].
Freezing of human embryos by fertility centers is now permitted for a period of
5 years (extendable upon request). Prior to that, embryo freezing was done for med-
ical reasons after obtaining special approvals from the Ministry of Health on a case-­
by-­case basis.
Unmarried individuals are also allowed to freeze their eggs or sperm for a period
of 5 years, which is also extendable upon request. This allows options for fertility
preservation for individuals with medical or oncological conditions and treatments
affecting fertility. Sperm, egg, and embryo donation are still considered illegal.
Frozen samples of eggs, embryos, or sperm may be taken abroad if prepared in the
UAE or brought into the UAE if prepared abroad, of course, subject to compliance
with certain controls and procedures [46]. While Muslim couples must provide
proof of marriage before proceeding with IVF, non-Muslim unmarried couples can
now undergo IVF treatment after seeking permission from the health authority to
utilise IVF techniques under Article 8, of the new ruling published in the Official
Gazette. The unborn child’s rights are protected by requiring the parents to register
the baby under both their names. This change to UAE’s family laws is part of a
wider effort to update laws in line with the needs of all those living in the
country [47].
262 N. Kazim

While scientific research on gametes can be carried out for the purpose of
increasing knowledge or developing treatments for severe cases or diseases, repro-
ductive cloning, altering genetic traits for the purposes of changing the human
genetic structure, and commercial purposes are all prohibited.
Under the Daman-Thiqa plan, UAE nationals can receive total coverage for IVF,
embryo freezing, and oocyte freezing for medical indications or oncological diag-
nosis patients for up to 6 cycles of ovarian stimulation per year. ART funding is
provided to women between 18 and 47 years of age with cryostorage cost coverage
of their embryos or eggs for the duration of 5 years, with a yearly renewal of consent
to continue freezing. Cryostorage can extend beyond 5 years with the consent of
the MOH and the patient. It is worth noting that there is no age limit for sperm cryo-
preservation, nor is there a time limit for women to use their eggs or embryos at a
later stage in their lives [48].
Women undergoing chemotherapy or radiation treatments do not need to bear the
costs of fertility preservation. While this alleviates the psychological burden, it also
raises ethical concerns about the risks associated with early parenthood.
Thiqa coverage for assisted reproductive treatment for UAE nationals, including
fertility preservation, is available for oncology patients, which also includes women
with BRCA1 or BRCA2 genetic mutations and young women with borderline ovar-
ian tumors. Usually, only one cycle can be done on an emergency basis due to the
time constraint for cancer patients; however, exceptions are made for up to six
cycles of oocyte retrieval in a year in cases of borderline tumors, where more stimu-
lations can take place before definitive treatment. The cost of storage is covered for
5 years; beyond that, it is collected directly from patients [48].
The DOH Policy on THIQA Coverage for Assisted Reproductive Treatment and
Services requires gonadotropin injections to be administered by DOH-licensed
reproductive endocrinologists, IVF specialists, and consultants [48].
Tawam Fertility Center in Al Ain opened in 1990, thanks to the foresight of the
late Sheikh Zayed Bin Sultan Al Nahyan, and was quickly followed by Dubai
Gynaecology and Fertility Center (DGFC) in 1992, thanks to the generous support
of the late Sheikh Hamdan Bin Rashed Al Maktoum. Tawam Fertility Center cele-
brated the birth of the first child born following IVF in the UAE in 1991 [49], just a
decade after the announcement of the first IVF birth in the USA in 1981, and in the
same year of the introduction of pioneering techniques such as laser-assisted Zona
Pellucida drilling and the use of antagonists for preventing LH surge [50]. Assisted
reproductive technology (ART) procedures including intrauterine inseminations
(IUI), fresh IVF cycles using the agonist protocol with day 2–3 embryo transfers,
laparoscopic gamete and zygote intrafallopian transfer (GIFT), and ZIFT were
practiced commonly, with eventual sperm and embryo freezing using the older slow
freezing methods (internal email communication with DGFC). The first ICSI using
percutaneous epididymal sperm aspiration was done in August 1992 at the DGFC,
resulting in a live birth in May 1993 [51]. Egg and embryo vitrification (an efficient
newer technique known for higher pregnancy rates) were introduced by DGFC in
2007 and 2008, respectively (internal communication). The center announced the
birth of the first baby after injecting a vitrified-thawed egg with her husband’s fresh
sperm while using the fluorescence in situ hybridization (FISH) technique for
16 Fertility Preservation and Oncofertility in the UAE 263

Fig. 16.1 Fertility preservation legislations and timeline in UAE

gender selection in 2008 [52]. Most of the sperm surgical retrieval procedures and
andrology services, including testicular biopsies, were done earlier by gynecolo-
gists practicing reproductive endocrinology and infertility. While Tawam Fertility
Center made a niche for itself by being known as the biggest and longest-running
center offering oncofertility sperm cryopreservation, other surgical sperm retrieval
methods were also introduced in the UAE, including PESA by DGFC (1994) [51]
and the first microscopic testicular sperm extraction (microTESE) (2012) by a visit-
ing doctor at Fakih IVF clinic (internal communication). Over the years, numerous
advances have been made in the UAE, catching up with the worldwide pace of fer-
tility treatment protocols and expanding freezing technique services (Fig. 16.1,
Table 16.3). Around 25 centers now facilitate state-of-the-art fertility services,
including cryopreservation, four of which belong to their respective local govern-
ments (i.e., Corniche Fertility Center in Abu Dhabi and Tawam Fertility Center in
Al Ain, both under the SEHA umbrella, Dubai Gynecology and Fertility Center, and
Sharjah Fertility Center in University Hospital Sharjah). Private fertility clinics such
as Fakih IVF, Health Plus, ART Clinic, Bourn Hall Fertility Center, and Al Ain
Fertility Center provide services on a larger scale, with multiple branches across the
Emirates and some offering in-house genetic testing. Egg cryopreservation for
unmarried females is performed laparoscopically and transrectally in a few centers.
Recently, in Bourn Hall Mediclinic Al Ain, a 14-year-old girl with Hodgkin’s lym-
phoma underwent oocyte retrieval through a novel transabdominal route, resulting
in the freezing of 25 eggs, just 1.6 years after attaining her menarche [53]. She is
thought to be the UAE’s youngest female cryopreservation patient, expanding the
scope of oncofertility cryopreservation services to young adolescents.

16.11 Challenges and Opportunities

The quality of health services in the UAE is on par with international best practices
in the fertility market. Furthermore, the UAE has a strong health regulatory frame-
work that ensures top-notch quality health care with cutting-edge infrastructure run
264 N. Kazim

by both the public and private sectors and performing 15,000–16,000 cycles per
year, which is expected to increase further with population growth. Moreover, cur-
rent lenient visa rules position the UAE as a leading catalyst for medical tourism,
boosting the growth of IVF services [54]. The IVF law changes in recent years are
in line with the UAE’s National Agenda 2021 and the UAE Centennial 2071 project,
which aim to elevate the UAE’s position in the global community. It is worth high-
lighting that the UAE leadership’s continuous commitment to providing optimal
health and prenatal care to women in the country and prioritizing mother, child, and
youth strategies has all increased public confidence in the healthcare system.
Pregnancy rates in the UAE range from 50 to 80%, while the average success rate
in European countries, as per ESHRE, is less than 40%, with discrepancies possibly
attributed to the reporting methods of cycle outcome. Patients also come for gender
selection, as the UAE is one of the few countries where it is permitted. Owing to its
high success rates and the quality of treatment offered, the UAE is in the best posi-
tion to become a reliable hub for ART services, including fertility preservation, both
nationally and internationally.
Efforts to track IVF activity and its outcomes in the UAE have been seen since
the start of assisted conception treatment services, which initially were reported on
a voluntary basis. However, ART providers are now required on a mandated basis to
report ART outcomes, including JAWDA KPIs for ART and reporting of serious
untoward incidents associated with ART treatments, aiming at continued improve-
ment and evaluation of ART programs among service providers.
Also, public reporting through detailed analysis of data allows for transparency
and continued opportunities for evaluation of ART programs, aiding in the continu-
ous improvement of healthcare outcomes.
Since the US Congress passed the Fertility Clinic Success Rate and Certification
Act in 1992, clinics have been required to report IVF outcome data to the Centers
for Disease Control (CDC) to provide transparency and protect patients from false
claims of IVF success.
IVF success rates for all reputable clinics are now available on the web from both
the CDC and the Society for Assisted Reproductive Technology (SART), an affiliate
of the American Society for Reproductive Medicine. SART is a fantastic resource
for both patients and physicians, providing useful information such as detailed
guides to various ART protocols and procedures as well as success rates of indi-
vidual technologies at practices across the country. There is an urgent need for simi-
lar resources to be made available in Arabic.
There should also be a multidisciplinary approach for diagnosing and treating
neoplastic diseases involving oncologists, surgeons, reproductive endocrinologists,
gynecologists, urologists, mental health professionals, and genetic counselors.
The priority of the multi-specialty team is to address all possible available
resources and access to oncofertility preservation, including their risks and benefits,
prior to starting gonadotoxic treatment. It is important to effectively address
patients’ psychosocial distress and provide reproductive counseling at the time of
diagnosis or soon after the diagnostic therapeutic process.
16 Fertility Preservation and Oncofertility in the UAE 265

There is no standardized protocol to streamline oncofertility referrals or model

of care for preservation in the UAE. Referring to qualified reproductive specialists,
counseling, proper documentation in medical records with informed consent based
on what has been determined by legal regulations, and medical ethics provisions
wherever necessary have been suggested and considered worldwide (ESHRE FP
Guideline Development Group, 2020) [5]. There are no local or regional oncofertil-
ity organizations, leaving a niche in the global community of practice for oncofertil-
ity, although professionals may have individual membership in societies such as the
International Society for Fertility Preservation (ISFP) or the ARSM Fertility
Preservation Special Interest Group [55].

16.12 Summary

Before starting cancer therapy, patients and the parent(s) of children and adolescent
patients should be educated about the possibility of infertility resulting from cancer
therapy.
A multidisciplinary team of medical providers should discuss fertility preserva-
tion options and refer patients to appropriate reproductive specialists at the earliest
opportunity.
Male fertility preservation options include sperm cryopreservation, and female
fertility preservation options include egg and embryo freezing via assisted repro-
ductive technology. While ovarian tissue cryopreservation is no longer considered
experimental, there has been no report of cryopreservation using this method in the
UAE. Also in the UAE, any attempted in vitro gamete maturation from immature
sperm or eggs followed by cryopreservation has only been reported in the internal
communications of the embryology laboratories of some of the private clinics or
used as a marketing strategy on their websites, with no published data on its effi-
ciency or success. Other techniques, like ovarian suppression and ovarian transposi-
tion, are also used but not recommended as the sole option for fertility preservation.
Techniques for ovarian protection include oophoropexy, gonadotropin-releasing
hormone analogs, pelvic shielding, fractionated doses of chemotherapy, and
radiotherapy.
In the literature, several studies have shown a lower success rate of fertility pres-
ervation methods in women with advancing age due to a natural decline in ovarian
reserve, which may impact the chances of achieving a successful live birth.
Challenges in choosing fertility preservation options include lack of knowledge
both from the physician’s and the patient’s and family’s sides, ethical and UAE
fertility legislation considerations, time to treatment, and availability of financial
resources. To shorten the time frame for egg collection, ovarian stimulation proto-
cols such as random and luteal phase start have shown similar efficiency to the
conventional start of stimulation during the early follicular phase of the menstrual
cycle days 2–4, allowing for less delay in the cancer treatment plan. Routine use of
a GnRH agonist to protect gametes from the gonadotoxic effects of chemotherapy
is not only questionable but also should be considered carefully, as it may
266 N. Kazim

exacerbate OHSS in PCOS patients if ovarian stimulation is attempted within a

short time after downregulation. Also, it may negatively impact the outcome of
oncofertility preservation by further causing a poor response to ovarian stimulation
through the downregulation of the ovaries in patients with a low pre-existing ovar-
ian reserve. For the sake of collective, efficient, and organizational fertility preser-
vation, there needs to be a balanced tuning of the patient’s physical and mental
well-being, legal and moral considerations within the available resources, and
access to care in accordance with law provisions and the Code of Medical Ethics,
working together with multidisciplinary professionals participating in decision-
making. The mission of the FP network will extend to enhancing knowledge among
healthcare workers and the public on reproductive disorders induced by cancer
therapy and other medical treatments through national and international collabora-
tion among reproductive specialists, oncologists, and allied health workers, promot-
ing research and education, and keeping pace with the development of new
innovative strategies of fertility preservation customized to UAE demography and
legislation.

Conflict of Interest The author has no conflict of interest to declare.

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journals.humrep.a138393.
52. http://wam.ae/en/details/1395228472461.
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https://doi.org/10.1200/JGO.2015.000307.
270 N. Kazim

Dr. Nahla Kazim is one of the first UAE physicians to attain sub-
specialty degrees of Master’s (2001) and Doctorate (2010) in the
field of Reproductive and Developmental Sciences from the
University of Edinburgh, UK. She is a Consultant Reproductive
Medicine and Infertility at Bourn Hall Fertility Clinic, a Mediclinic
Middle East company, and is serving the role of Director of Fertility
Preservation in the Al Ain Branch. She has been appointed as an
Adjunct Assistant Professor in the Department of Obstetrics and
Gynecology, College of Medicine and Health Sciences, UAE
University (2023). Her past work achievements include serving as
a Scientific Director of Fakih IVF Fertility Center L.L.C., Al Ain,
2019–2022. She also worked as a Senior Specialist in Physician–
Assisted Conception-Infertility Services, Tawam Fertility Center,
Al Ain (2010–September 2019). Dr. Kazim was the Chief
Administrator, Tawam Fertility Center, 2018–2019. She worked as
a Specialist Obstetrics and Gynecology/Reproductive Health in
Mafraq Hospital, Abu Dhabi, UAE (2006–2010), and as a registrar
in Ob/Gyn, Mafraq Hospital, starting from 1999.
Dr. Kazim has been nominated and shortlisted for the presti-
gious Abu Dhabi Medical Distinction Award in the category of
medical volunteer twice, in 2012 and 2013. She received the Sheikh
Rashid Al Maktoum Award for Educational Excellence in 2002 and
2011. Her special interest is in implementing innovative technolo-
gies and procedures, including artificial intelligence and ovarian
PRP, into current clinical practice. She is the first in the UAE to
explore the uses of virtual and augmented reality (VR and AR)
technology in fertility treatment. She was the abstract reviewer for
the ASRM Scientific Congress 2018–2022 and the grant reviewer
for the ASRM Research Institute 2023. She is a member of the first
UAE National Anti-Doping Committee and a member of many
known professional societies, including the American Society of
Reproductive Medicine, the British Fertility Society, the European
Society for Human Reproduction and Embryology, the European
Fertility Society, the Society for Reproduction and Fertility, the
Society for Reproductive Endocrinology and Infertility, the
International Federation of Fertility Societies, and the ASRM
Special Interest Groups, including International Membership in
Fertility Preservation, Ovarian Insufficiency and Menopause,
Reproductive Immunology, and the Women’s Council.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
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The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
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statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Psycho-Oncology in the UAE
17
Melanie C. Schlatter

17.1 Introduction

The field of psycho-oncology originated in the 1970s in America, and it takes into
account specific dynamics of an individual undertaking cancer treatment—the psy-
chological impact of cancer on the individual, their family, caregivers, and medical
staff, as well as the impact of the individual (behaviors and psychosocial factors) on
cancer morbidity and mortality [1]. The field has gradually been embraced in other
countries with the development of centralized evidence-based cancer guidelines [2],
and proposals have been initiated in the United Arab Emirates (UAE) recently also
[3]. Guidelines advocate for a multidisciplinary team (MDT) approach in the man-
agement of cancer patients, inclusive of psychology and psychiatry [4, 5], so the
UAE has some unique advantages, given that it is recognized as having one of the
leading healthcare systems in the world [6].
Unfortunately, there is an increasing prevalence of cancer in the Middle East [7,
8] due to rapid population expansion [6], and although there have been continued
advancements in community screening initiatives, awareness campaigns, medical
and treatment protocols, and multidisciplinary frameworks to enhance quantity and
quality of life [3], it is estimated that, on average, anywhere between 10 and 30% of
patients diagnosed with cancer are also at risk of psychological distress (anxiety and
depression) and adjustment difficulties at some point during the illness trajectory [9,
10] and more so in inpatient settings [10, 11]. While some distress is to be expected
with such a life-changing event, if untreated or unrecognized, these diagnoses can
last months or years after diagnosis, even if the prognosis is favorable [12–14]. One
study reported the prevalence of depression to be as high as 58% in advanced cancer
cases [15]. Another study illustrated that the highest rates of depression were associ-
ated with testicular cancer, which actually has one of the best prognoses for cancer

M. C. Schlatter (*)
American Hospital Dubai, Dubai, United Arab Emirates
e-mail: mschlatter@ahdubai.com

© The Author(s) 2024 271

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_17
272 M. C. Schlatter

in general [16]. This indicates a need to be cautious when making assumptions

about how an individual might cope post-cancer diagnosis.

17.2 Psycho-Oncology Diagnoses and Risk Factors

Psychological diagnoses are often associated with specific individual characteristics

(e.g., age, gender, marital status), social and contextual factors (e.g., level of educa-
tion, income, and social support), premorbid psychological factors (e.g., personality
and prior coping behaviors), the response to illness (e.g., hopelessness, resilience),
the characteristics of cancer (e.g., type, stage, and grade), and the type of cancer
treatment [17] (Fig. 17.1). The risk factor most likely associated with the develop-
ment of mental health issues (anxiety, depression, and personality disorders) is
treatment involving all three protocols of chemotherapy, radiation, and surgery [16].
Although psychological distress has not been directly linked to an increased inci-
dence of cancer, it has been linked with higher rates of cancer-specific mortality [16]
and a greatly reduced quality of life overall [18]. Indeed, in other countries, the risk
of self-harm and suicide has been reported to be at its highest within 6-12 months of

Individual characteristics Psychological response to diagnosis

Age Psychological distress
Gender Coping behaviour
Ethnicity Hopelessness
Sexuality Denial
Disability Anger
Religion Fear
Biological factors (e.g. genetics) Grief
Co-morbid health conditions Resilience
Marital & cohabitation status Concern for others
Change in self image

Social & contextual factors Characteristics of cancer

Education level Diagnosis experience

Employment status & characteristics Depression & Symptoms
Household income & wealth Type of cancer
Family anxiety among Stage
Social support people with Grade
Stressful life events (e.g. bereavement) Prognosis & curability
Healthcare system
cancer Functional decline
Welfare system Recurrence

Prior psychological factors Cancer treatment

Pre-existing psychiatric disorder(s) Treatment modality & dose (e.g.
Previous suicidal behaviour radiotherapy, chemotherapy)
Personality (e.g. neuroticism) Side effects
Prior coping behaviour (e.g. adverse Long-term complications (e.g. infertility,
health behaviours) secondary cancers)
Setting (e.g. inpatient, outpatient)
Treatment burden & length
Cost of treatment
Response to treatment
Phase (e.g. acute, palliative)

Fig. 17.1 Factors that may contribute to depression and anxiety among people living with and
beyond cancer [17]. (Figure used with permission from Dr. Claire Niedzwiedz)
17 Psycho-Oncology in the UAE 273

a mental health diagnosis, which suggests that the initial months after a cancer diag-
nosis necessitate a critical time period for psychological intervention [12, 15, 19].

17.3 Interventions in Psycho-Oncology

Psychological interventions address several targets—physical, emotional, family,

and social problems; treatment optimization; improvement of health; and spiritual
aspects. Furthermore, the benefits of psychological intervention are numerous: a
reduction in disease progression, increased survival rates, enhanced health-related
quality of life (HRQoL), a sense of purpose and overall well-being, less hospitaliza-
tion, and lower medical costs [20–22].
Nonetheless, an issue commonly faced by patients around the world is the lack
of appropriate psycho-oncological support services available. Only 38% of patients
are thought to be aware of available help [23], and only 5–10% of patients seek
professional help voluntarily during these times [24, 25]. These statistics are likely
to be even lower in the UAE given various cultural dynamics, beliefs, and language
barriers, as well as the lack of specialized support programs and associated research
in this area. Indeed, pure medical management of both the condition and treatment-­
related side effects (the “medical model”) typically supersedes recognition and
treatment of psychiatric needs, even though the psychological ramifications remain
months or even years after an individual has completed treatment [16]. Physicians
typically cite a lack of time or knowledge when it comes to engaging with their
patients on nonmedical or sensitive issues, and nurses have traditionally taken on
the role of emotional caregivers on the ward; however, burnout and compassion
fatigue are common among all oncology practitioners [26–29]. Ironically, screening
questionnaires for psychological aspects of the cancer trajectory are easy to admin-
ister, short, and generally culturally acceptable, and some have been translated into
Arabic [30–32], the official language of the UAE. Unfortunately, the Emirates faces
a dearth of specialized psychology practitioners embedded directly within oncology
units who are trained to regularly administer these tools and report results back to
the team in an ethically appropriate and timely manner.

17.4 A Psycho-Oncologist’s Approach Toward Patient Care

A psycho-oncologist is a crucial member of the MDT who has the time to provide
supportive and educational psychological intervention right from the time of diag-
nosis and beyond. This may include preoperative and postoperative counseling,
learning how to cope with a new diagnosis, waiting for results, understanding mul-
tifactorial treatment/treatment side effects such as pain, nausea, and fatigue; changes
in relationships (personal, sexual, workplace), family dynamics, changes in body
image, loss (of autonomy, physical ability, perceived roles, income, friendships,
reproductive ability); fear of recurrence, uncertainty regarding genetic predisposi-
tion or risk; and lastly, the management of anxiety (including existential),
274 M. C. Schlatter

overwhelm, grief, depression, guilt, and anger. Regardless of the situation, the goal
is to compassionately weave in resilience, purpose, a sense of control, meaning, and
commitment to a new way of life through education, coping strategies, cognitive
techniques [33], supportive values, and compassion-based exercises [34] in either
individual or group settings, for both outpatients and inpatients. Liaison with oncol-
ogy-specific practitioners in the unit is also necessitated for more complex or deli-
cate cases, such as pregnancy-associated breast cancer, anxiety associated with
hereditary cancers, lack of treatment adherence, needle phobias, or individuals that
need psychiatric management, in which case involvement from gynecological,
genetic, nursing, and pharmacological counseling support and psychiatry is
important.
For more advanced cases of cancer, where the sanctity of life is often seen as
paramount for families due to cultural norms [35], psychological intervention and
support can address diminished quality of life as a result of recurrence and/or pro-
gression of disease, especially if death is imminent [36], but it is often preferred that
psychologists have additional training for end-of-life issues, especially if the patient
is a child. Collaboration with palliative services and the use of specific forms of
expertise and therapy are frequently required at these times to maintain pride, hope,
and continuity of self; reduce perceived burden; and enhance dignity so that indi-
viduals can believe, where possible, that their life has stood for something transcen-
dent of death [37] and that they will be able to face whatever they believe is next on
their journey. In some cases, though, families may be fearful of broaching informa-
tion about continued decline or metastatic spread to their loved ones, so these
nuances must be carefully navigated and sensitively addressed by all practitioners
involved. Ideally, information about support services and psychological support
should be accessible as soon as possible to patients, their families, and caregivers
throughout the cancer trajectory, including age-appropriate information for children.

17.5 Barriers in Psycho-Oncology in the UAE

Although the evidence thus far is strongly in favor of the provision of psychological
support for cancer patients, there are noted barriers to uptake, including older age,
less perceived need, a preference for self-reliance, negative beliefs about mental
illness and/or “labels,” and dissatisfaction from previous help-seeking or healthcare
interactions [38, 39]. Barriers may prevent individuals from expressing their true
difficulties and from getting their needs met [12], leading to more anxiety, depres-
sion, resentment, and a reduced quality of life [40], but research on unmet needs
does provide some insight into individuals’ experiences of the cancer process [41].
One recent study of attendees to a cancer survivorship clinic in Jordan showed that
late-stage diagnosis and quality of life score were significant predictors of need in
the physical, psychological, health system, information, and financial domains [42].
Some families decline psychological input because they may prefer either privacy,
to rely on their medical practitioner’s advice alone, to speak with their families,
elders, or selected others, or to seek guidance from pastoral or chaplaincy care
17 Psycho-Oncology in the UAE 275

instead [43]. Unfortunately, research on the needs of various religious groups, par-
ticularly Muslims (with Islam being the official and majority religion in the UAE),
is lacking [44, 45].

17.6 Conclusion

Although there is much evidence for the value of psychologists within oncology,
particularly with respect to improvements in HRQoL and reductions in psychologi-
cal and emotional burden for the patient and their loved ones, for many individuals
in the UAE, the diagnosis of cancer is still seen as a stigma or issue that must be
privately addressed with the immediate or most necessary members of the medical
team, family, or trusted others. Many others live alone in the region and are focused
on retaining their jobs, so trying to navigate the distressing new world of oncology,
even just from a financial perspective, is challenging, let alone from a psychological
perspective. The involvement of an individual whose role is to assess how an indi-
vidual is coping at the psychosocial level can thus be met with skepticism, quiet
intrigue, doubt, and confusion during a time when the urgency of the medical situa-
tion and treatment predominates. Given the lack of multidisciplinary teams inclu-
sive of both psychology and psychiatry in oncology, as well as the scarcity of time
to address psychological concerns by medical teams, it is imperative that the region
integrate more specialized psychologists directly into oncology units as part of stan-
dard care [46], where practitioners can easily identify those in need and adjust to the
flow of an individual’s treatment pathway and personal needs, as well as provide
relevant information back to the team as permissible and where warranted. The
psychologist’s role in recognizing one’s emotional needs and providing coping
strategies as a simple and natural sequel to addressing one’s physical or medical
needs must be supported by the primary practitioners in charge and, where possible,
normalized for patients. Those practitioners should also be very comfortable raising
the topic so that patients never feel they have been singled out because they are “not
coping.”
The UAE is also an ideal place to research and directly provide both structured
prehabilitation [47, 48] and survivorship programs to address and manage tradi-
tional predictors of poorer outcomes and longer-term impairments in physical, sex-
ual, psychological, cognitive, and social functioning [40]. Psychologists with
training in research and clinical methodology would be ideally suited to these pro-
grams, especially given advances in technology, which will be a viable source of
additional measurement and support in the future. It follows that, given the large
number of nationalities in the region, psychology practitioners also need to be sensi-
tive to the widely differing beliefs of individuals under treatment. They need to be
open to often strong opinions and perceptions around psychology, as well as the
importance of family and community contributions within decision-making strate-
gies throughout care, and they should appreciate the additional time it may take to
build a therapeutic relationship. New practitioners to the region cannot utilize a
“one-size-fits-all” approach, but they should strive to normalize the expected
276 M. C. Schlatter

psychological ramifications of a serious medical diagnosis and provide applicable

coping strategies. The integration and acceptance of psycho-oncology into standard
oncology care will symbolize a significant step toward comprehensive multidisci-
plinary support for patients in the UAE.

Conflict of Interest The author has no conflict of interest to declare.

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Dr. Melanie Schlatter (PhD) is a clinical health psychologist of

dual nationality (New Zealand and Swiss) who has lived in Dubai
since 2006. She presents a unique advantage to the field of oncol-
ogy, given her qualifications and research in psychoneuroimmunol-
ogy. After completing an honorary research fellowship, she became
the region’s first health psychologist, working for 13 years with Dr.
Houriya Kazim, the first Emirati female surgeon, while also con-
sulting as a community psychologist for the American Hospital
Dubai until she joined them full-time in oncology and psychiatry
in 2021.
Melanie is a board member and secretary of Brest Friends,
Dubai’s first breast cancer support group, and she helped to develop
Majlis Al Amal, the UAE’s first cancer drop-in center, both of
which are Dr. Kazim’s original concepts. Melanie has published in
the Annals of Behavioral Medicine, the Journal of Psycho-­
Oncology, Psychosomatic Medicine, the Journal of Vestibular
Research, Brain Behavior and Immunity, and the Middle East
Journal of Positive Psychology. Her most recent contribution was a
chapter on health psychology for a UAE university textbook. She
has also taught at universities in New Zealand and Dubai, and she is
a reviewer for two scientific journals.
17 Psycho-Oncology in the UAE 279

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Artificial Intelligence (AI) in Oncology
in the UAE 18
Khalid Shaikh and Sreelekshmi Bekal

18.1 Introduction

Ever since its inception decades ago, artificial intelligence (AI) has been a catch-
phrase for the sustainable future ahead. Like in every other sector, AI is believed to
be the potential panacea to radically alter the field of healthcare. Oncology and
related fields are examples of such focus areas where AI tools are now widely used.
It is critical to embrace this new wave of technological revolution in order to maxi-
mize potential and modify future strategies.
Cancer has a significant impact on health worldwide, leading to a high level of
sickness and death. While progress has been made in recent decades, there are still
challenges in providing individualized care. Artificial intelligence (AI) has emerged
as a technology that can enhance cancer care. Its applications in oncology range
from optimizing cancer research to improving clinical practices, such as predicting
patient outcomes and treatment responses, as well as gaining a better understanding
of tumor characteristics [1].
To better understand AI, it is important to grasp its history and key areas, which
will help us comprehend its current capabilities and future possibilities more effec-
tively. The concept of using computers to imitate intelligent behavior and critical
thinking was first proposed by Alan Turing in 1950. The term “artificial intelli-
gence” (AI) was coined by John McCarthy in 1956, defining it as the science and
engineering behind creating intelligent machines [2].
AI initially consisted of simple sets of rules (“if, then” statements) and has
evolved over time to include more complex algorithms that can perform tasks
resembling human brain functions [2, 3]. It relies on computers following algo-
rithms created by humans or learned through computer-based methods to support
decision-making or perform specific tasks [1]. Machine learning, a subfield of AI,

K. Shaikh (*) · S. Bekal

Prognica Labs, Dubai, United Arab Emirates
e-mail: khalid@prognica.com; sreelekshmi@prognica.com

© The Author(s) 2024 281

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_18
282 K. Shaikh and S. Bekal

enables computers to enhance their own performance by continuously incorporating

new data into existing iterative models. Deep learning, another subfield of machine
learning, utilizes mathematical algorithms implemented through multi-layered
computational units that resemble human cognition. This includes various types of
neural networks such as recurrent neural networks, convolutional neural networks,
and long-term short memory networks [1]. These two concepts, machine learning
and deep learning, are central to the AI revolution in managing cancer patients [2].
AI is a rapidly evolving model that encompasses various scientific disciplines,
including those focused on managing cancer patients. It can be defined as the capac-
ity of a machine to learn from representative models, recognize patterns and interac-
tions, and utilize this knowledge to enhance decision-making processes in a specific
field [2]. In the field of precision oncology, AI is transforming the current landscape
by integrating vast amounts of data from multi-omics analyses with advancements
in high-performance computing and innovative deep-learning techniques. Notably,
the scope of AI applications is expanding and now includes novel approaches for
cancer detection, screening, diagnosis, and classification. It also involves the char-
acterization of cancer genomics, analysis of the tumor microenvironment, evalua-
tion of biomarkers for prognostic and predictive purposes, as well as strategies for
follow-up care and drug discovery [2].

18.2 Global Cancer Statistics 2020

According to the data from GLOBOCAN 2020, there were 19.3 million new cancer
cases diagnosed in 2020, resulting in approximately 10.0 million deaths. Projections
from GLOBOCAN suggest that the number of cancer cases will rise to 28.4 million
by 2040. Globally, female breast cancer has become the most prevalent type of can-
cer, accounting for 11.7% of all cases, followed by lung cancer (11.4%), colorectal
cancer (10.0%), prostate cancer (7.3%), and stomach cancer (5.6%). In terms of
cancer-related deaths, lung cancer is the leading cause, causing 1.8 million deaths
(18%), followed by colorectal cancer (9.4%), liver cancer (8.3%), stomach cancer
(7.7%), and female breast cancer (6.9%). Among men, the most common cancer
types are lung, prostate, and colorectal cancer, while breast, colorectal, and lung
cancer are the most common among women. Overall, the top 10 cancers contribute
to more than 60% of cancer incidence and 70% of cancer-related mortality [4].
Based on the annual report of the United Arab Emirates (UAE) National Cancer
Registry in 2021, malignant neoplasm of colon was the leading cause of cancer-
related deaths, accounting for an estimated average of 11.49% of all cancer deaths
per year. Trachea, bronchus and lung cancer ranked second as the most common
cause of cancer death in both males and females, and breast cancer was the third
most common cause of cancer death for both sexes [5].
Emerging technologies have the potential to address the gaps in healthcare and
improve the continuum of care for cancer patients. Among these technologies, arti-
ficial intelligence (AI) has emerged as a transformative force. AI-guided clinical
care has the capacity to significantly reduce health disparities, especially in resource-­
limited settings. By incorporating AI technology into cancer care, we can enhance
18 Artificial Intelligence (AI) in Oncology in the UAE 283

the precision and efficiency of diagnosis, assist in clinical decision-making, and

ultimately achieve improved health outcomes [6].

18.3 Fundamentals of Artificial Intelligence

and Learning Algorithms

An AI system refers to a computer system capable of performing tasks that typically

require human intelligence. These systems utilize various learning methods, includ-
ing machine learning (ML) and deep learning (DL), to operate [7]. ML, which falls
under the umbrella of AI, involves algorithms that enable systems to learn automati-
cally. The ML process involves training and testing images, as depicted in Fig. 18.1,
allowing the system to enhance its learning experience without the need for com-
plex programming. These algorithms find extensive applications in fields such as
medical imaging, computer vision, biometric recognition, object detection, and
automation [7, 8]. Within ML, there are three key types: supervised learning, unsu-
pervised learning, and reinforcement learning [7, 8].
Deep learning (DL), a subset of machine learning (ML) and artificial intelligence
(AI), is recognized as a fundamental technology in the Fourth Industrial Revolution
(4IR) or Industry 4.0. With its ability to learn from data, DL has emerged as a
prominent field in computing and finds applications in diverse areas such as health-
care, visual recognition, text analytics, cyber security, and more. DL utilizes multi-
ple layers to abstract and represent data, enabling the construction of computational
models [9].

Training Image Training Learned

Image Features Process Model

Training
Labels Training Phase

Test Image Learned Output

Image Features Model Prediction

Testing Phase

Fig. 18.1 Steps of machine learning algorithm [7]

284 K. Shaikh and S. Bekal

W W

Input Values, x Ouput Values, y

Output Layer
Input Layer Hidden Layer

Fig. 18.2 Basic model of artificial neural network (ANN) [7]

DL was introduced by Hinton et al. and is built upon the concept of artificial
neural networks (ANNs) [9]. ANNs draw inspiration from the human brain’s neuro-
biology and its capacity to learn complex patterns through cascading, layered com-
binations of neurons that gradually extract more intricate features [10, 11]. Early
ANNs were designed by simulating human neurons in computers. A deep learning
algorithm is an extension of the ANN, consisting of an input layer, several hidden
layers, and an output layer (see Fig. 18.2). Each layer is connected through nodes,
with each hidden layer providing predictions based on the input received from the
previous layer. The primary distinction between ANNs and deep learning algo-
rithms lies in the number of hidden layers, with ANNs having a single hidden layer,
while deep learning algorithms have two or more hidden layers [7].

18.4 AI in Oncology and Related Fields

Similar to other areas of healthcare, AI is extensively employed in oncology to

interpret, analyze, and visualize complex medical data using diverse algorithms [7].
AI has demonstrated promise in enhancing cancer imaging diagnostics, evaluating
treatment responses, predicting clinical outcomes, optimizing research, enabling
personalized medicine, facilitating drug development, advancing translational
oncology, and supporting precision oncology. Unlike traditional healthcare tech-
nologies, AI technology collects and processes data before presenting it to end users
for informed decision-making. It leverages various machine learning and deep
learning algorithms that can analyze patterns in medical data and make autonomous
decisions [7].
In the field of cancer, diagnostics serve as a crucial starting point for designing
appropriate therapeutic approaches and clinical management, and the refinement of
diagnostics through AI represents a significant accomplishment. Furthermore, this
highlights the importance of future AI developments in unexplored yet critical areas
such as drug discovery, therapy administration, and follow-up strategies [2].
Breast cancer, lung cancer, and prostate cancer are the specific types of cancer
that currently benefit the most from AI-based devices in clinical practice. This pri-
marily stems from their higher incidence compared to other tumor types. However,
18 Artificial Intelligence (AI) in Oncology in the UAE 285

a b

Cancer radiology General cancers

Pathology Breast cancers
Radiation oncology Lung cancer
Gastroenterology Prostate cancer
Clinical oncology Colorectal cancer
Gynecology Brain tumour
Others

Fig. 18.3 Current status of artificial intelligence in oncology and related fields [2]

in the future, additional tumor types, including rare cancers that lack standardized
approaches, should also be considered. Since AI relies on large datasets of cases for
analysis, the improvement of treatment for rare neoplasms may be a later achieve-
ment [2]. The current status of artificial intelligence in oncology and related fields
is depicted in Fig. 18.3.
AI solutions have been created to address diverse challenges associated with
cancer. Various stakeholders, including medical institutions, hospital systems, and
technology companies, are actively developing AI tools with the goal of enhancing
clinical decision-making, expanding access to cancer care, and improving overall
efficiency in delivering safe and valuable oncology services. AI applications in the
field of oncology have exhibited precise technical performance in tasks such as
image analysis, predictive analytics, and the implementation of precision oncology
approaches [12].

18.4.1 Artificial Intelligence and Cancer Care in the UAE

The burden of cancer in the United Arab Emirates (UAE) is significant, ranking as
the second leading cause of non-communicable disease (NCD)-related mortality in
the country. The healthcare system in the UAE has experienced rapid growth and
286 K. Shaikh and S. Bekal

development, resulting in its ranking as the 27th worldwide by the World Health
Organization (WHO) [13–15].
The earliest published record of oncology care in the UAE dates back to 1981
when five cases of hepatocellular carcinoma were documented. The first major can-
cer care facility, Tawam Hospital, was established in Al-Ain, one of Abu Dhabi’s
main cities, in 1979. By 1983, Tawam Hospital had been designated as the UAE’s
cancer referral hospital. To improve accessibility, several general oncology care ser-
vices were introduced throughout the country, enabling cancer patients to receive
healthcare closer to their homes. Until 2007, the UAE government covered the
entire cost of oncology treatment for all UAE citizens and residents. Presently, the
government continues to bear the cost of cancer treatment for UAE citizens, while
non-citizens are covered by insurance plans. However, expatriates sometimes face
the challenge of having to return to their home countries for ongoing medical treat-
ment due to insurance plans with expiration dates. In response to this issue, the
prestigious Emirates Oncology Society (EOS) recently published a collaborative
document proposing alternative solutions to adjust cancer insurance packages
nationwide [13].
The leadership of the UAE has played a pioneering role in establishing robust
cancer screening programs. In 2009, an annual mammography screening program
was initiated, advising all UAE national women aged 40 and above to undergo
screening. Subsequently, in July 2010, a nationwide screening program for colorec-
tal cancer was launched, and by 2014, screening programs for breast, colorectal, and
cervical cancers were established. In 2017, following the release of lung cancer
data, a low-dose CT scan-based screening program for lung cancer was imple-
mented. Furthermore, several initiatives have been undertaken to raise awareness
and promote cancer screening, such as the annual “Pink Caravan” event, which
reaches over 45,000 women across the UAE, focusing on breast cancer awareness
and encouraging screening [13]. Alongside screening programs, the healthcare sec-
tor in the UAE leads the way in cancer prevention and diagnosis programs sup-
ported by extensive research efforts.
The UAE has been at the forefront among regional countries in embracing and
fostering cutting-edge technologies like artificial intelligence (AI) in cancer care.
Currently, multiple AI platforms are being utilized in the UAE, particularly for
assisting in cancer diagnosis through imaging, including breast and lung cancer
screening. Table 18.1 presents an overview of the current status of clinical and
research initiatives in the UAE [16].
Health-tech companies like Prognica Labs are dedicated to enhancing clinical
outcomes in the battle against breast cancer. They employ AI and deep learning to
analyze medical images and generate valuable information and data for cancer pre-
diction and diagnosis. Through meticulous research, they generate new knowledge
to drive effective innovation, education, and practice. In collaboration with top-tier
hospitals and universities in the region, they have launched a project called
“Retrospective analysis of breast cancer diagnosis among young and older women
in the UAE.” These retrospective studies will establish a benchmark to assess the
accuracy of diagnosis and ensure the provision of high-quality care.
18 Artificial Intelligence (AI) in Oncology in the UAE 287

Table 18.1 The current status of clinical and research initiatives in the UAE [16]
AI technology Facility Year Format Status
IBM™ Watson SEHA— 2016 Clinical decision in oncology Suspended
Oncology—Pilot Tawam
Hospital
AI enabled Digital International 2021 AI-enabled independent reader Active
mammography Radiology for breast cancer screening and
system, Lunit Centre— lung cancer screening
INSIGHT MMG Sharjah
Lung Cancer Commercial
screening—
Coreline—Medical
AI solutions
Prognica Labs Dubai 2021 Prognica Labs uses artificial Active
Commercial intelligence to detect masses in
mammography screenings
Mammography UAE 2021 First and only AI-enabled Active
Intelligent Commercial independent reader for breast
Assessment cancer screening to be
(Mia)™ commercially available in the
UAE
The GI Genius™ Sheikh 2021 Is the first-to-market, computer-­ Active
intelligent Shakhbout aided polyp detection system
endoscopy module Medical City powered by AI
Abu Dhabi
Khalifa University Research 2021 To identify cancer in tissue Active
researchers Abu Dhabi samples, which could speed up
diagnosis and improve outcomes
in patients with colorectal cancer
DoH—Abu Dhabi Research 2022 First Personalised Precision Active
Abu Dhabi Medicine for oncology in
collaboration with Mubadala
Health, Cleveland Clinic Abu
Dhabi, NYU Abu Dhabi,
Mohamed bin Zayed University
of Artificial Intelligence and G42
Healthcare
Mohamed bin Research 2022 AI tool to better diagnosis and Active
Zayed University Abu Dhabi treatment of pancreatic cancer
of Artificial
Intelligence team

The gastroenterology team at Sheikh Shakhbout Medical City (SSMC) in Abu

Dhabi has introduced an advanced AI system for gastrointestinal intestinal endos-
copy. This system significantly improves the detection of precancerous polyps in the
colon. While conventional medical examinations detect these growths in about
30–40% of individuals, AI technology increases the detection rate to approximately
50–55%, resulting in a substantial increase in the adenoma detection rate. This
benchmark is crucial as every 1% increase in the adenoma detection rate reduces the
risk of colon cancer by 3% and the risk of death from colon cancer by 5%. With a
288 K. Shaikh and S. Bekal

15% increase, there will be a 10% decrease in adenoma detection, leading to a 30%
decrease in the risk of colorectal cancer and a 50% decrease in the risk of death from
colon cancer [17].
A team of researchers from New York University (NYU) and NYU Abu Dhabi
has developed an innovative AI system capable of identifying breast cancer in ultra-
sound images. With “radiologist-level accuracy,” this system serves as a decision-­
support tool for clinicians [18].
In collaboration with Mubadala Health, Cleveland Clinic Abu Dhabi, NYU Abu
Dhabi, the Mohamed bin Zayed University of Artificial Intelligence, and G42
Healthcare, the Department of Health—Abu Dhabi (DoH) has launched the first
personalized precision medicine program for oncology in the region. Initially focus-
ing on breast cancer patients, this program aims to treat patients and reduce the risk
of disease recurrence [19].

18.4.2 Artificial Intelligence in Cancer-Related Image Analysis

Image analysis has emerged as a highly impactful application of AI, particularly

within the field of oncology, due to the abundance of digital imaging data in medi-
cine. The development of convolutional neural networks (CNNs) has revolutionized
image analysis by enabling pixel-level examination. CNNs have the advantage of
considering pixel orientation, allowing them to recognize lines, curves, and objects
within images. Recent studies have demonstrated that CNN-based models are on
par with humans in picture classification and object detection [11, 20, 21].
AI has the potential to enhance traditional medical imaging techniques such
as computed tomography (CT), magnetic resonance imaging (MRI), and X-rays
by offering computational capabilities that enable faster and more accurate
image processing at scale [7]. The benefits of AI in medical imaging include
higher automation, increased productivity, standardized processes, more accu-
rate diagnosis, computing quantitative data, and assistance for doctors. For
example, AI models developed by Google have achieved a 99% accuracy rate
in diagnosing breast cancer from medical images, surpassing the performance
of some doctors [7].
Computer-aided detection (CADe) and computer-aided diagnosis (CADx) sys-
tems are designed to assist doctors in interpreting medical images. Figure 18.4
depicts the general framework of CADe/CADx system. These interdisciplinary sys-
tems combine technologies such as AI and computer vision to extract essential
information from various imaging techniques like X-ray, MRI, and CT. CADe sys-
tems detect conspicuous structures, while CADx systems evaluate these structures.
Although CAD systems have been used in clinical environments for the past
50 years, they serve as supportive tools rather than providing a complete solution.
Ultimately, doctors are responsible for interpreting medical images. However, CAD
systems aim to detect early signs of abnormalities that may go unnoticed by doctors,
such as cancerous tumors or glaucoma [7, 22, 23].
18 Artificial Intelligence (AI) in Oncology in the UAE 289

Fig. 18.4 General

framework of CADe/ Input Medical Image
CADx system [7]

Preprocessing CADe

Segmentation

CAD / CADx
Feature Extraction

Classification

Decision Making

AI has found various applications in the field of medical imaging, encompassing

several areas [7]:

• Medical image analysis: AI technology has demonstrated superior capability in

identifying anomalies and diseases by analyzing medical images compared to
human doctors.
• Neurological condition diagnosis: AI can assist in diagnosing neurological dis-
eases such as amyotrophic lateral sclerosis (ALS), and it has shown potential in
predicting Alzheimer’s disease years before clinical manifestation.
• Detection of cardiovascular abnormalities: AI algorithms can assess a patient’s
heart structure and provide insights into their risk of cardiovascular disease or the
need for surgical intervention. Automated AI systems can analyze common med-
ical tests like chest X-rays, leading to faster identification of abnormalities and
reducing the likelihood of misdiagnosis.
• Cancer screening: Early detection of cancer significantly improves patient out-
comes. Recent advancements in AI, specifically utilizing convolutional neural
networks (CNNs), have shown remarkable success in accurately identifying vari-
ous types of cancer. These experiments highlight the potential of AI to reduce
detection times and enhance diagnostic rates.

18.4.2.1 Relevant Case Studies of AI in Cancer Imaging

AI is finding applications in oncologic radiographic imaging, specifically in the
areas of detection and diagnosis. AI-powered imaging algorithms are being
employed in clinical settings to detect and monitor potentially cancerous lesions
and provide guidance for patient management [24].
290 K. Shaikh and S. Bekal

Clinical Photographs
A pioneering study demonstrated the potential of deep learning (DL) in cancer
imaging by successfully identifying skin cancer based on skin photographs [11, 25].
The study trained a convolutional neural network (CNN) system on a dataset of
130,000 skin images, achieving higher sensitivity and specificity in classifying
malignant lesions compared to a panel of 21 board-certified dermatologists. This
breakthrough has led to practical applications in detecting skin pathology using
patient-generated imaging data [11, 26]. Another application of CNNs involves the
automatic detection of polyps during colonoscopy through digital photography. A
study showcased the ability of CNNs not only for image classification but also for
identifying regions of clinical significance. By training a CNN on colonoscopic
images from 1290 patients, researchers achieved a remarkable 94% sensitivity in
polyp detection [11, 27].

Radiographic Imaging
Given the remarkable success of AI techniques in computer vision, there is consid-
erable anticipation within the field of radiology, which deals with a multitude of
digitized images. The objectives of AI algorithms in this domain have encompassed
assisted diagnosis and outcome prediction [11].
AI algorithms have demonstrated effectiveness in streamlining cancer screening
and detection. A significant focus has been on automated lung nodule detection and
classification, which was the basis of the 2017 Kaggle Data Science Bowl, an inter-
national competition for machine learning scientists [11, 28]. Several CNN-based
models, arising from this competition and other research groups, have achieved
accuracy ranging from 80 to 95%, showcasing promise for lung cancer screening
[11, 29–34]. Additionally, CNNs have exhibited success in segmenting tumor vol-
umes, potentially influencing radiotherapy treatment planning [11, 35]. The
enhancement of breast cancer screening through AI has also been an active area of
investigation, including dedicated data science competitions [11, 36], leading to the
development of a CNN algorithm capable of detecting breast malignancy with a
sensitivity of 90% [11, 37, 38].
AI has shown promise in detecting radiographic anatomical features of malig-
nancies that surpass the reliability of human clinicians. For instance, diagnosing
extranodal extension (ENE) in head and neck cancer lymph nodes has historically
posed challenges, but a CNN-based model achieved an accuracy of over 85% in
identifying this feature on diagnostic contrast-enhanced CT scans [11, 39]. Since
identifying ENE is crucial for prognosis and management decisions in head and
neck cancer patients, this model holds potential as a clinical decision-making tool.
Expanding beyond anatomical characterization, AI has demonstrated promise in
the emerging field of radiogenomics, where radiographic image analysis is employed
to predict underlying genotypic traits. CNNs applied to brain MRIs of patients with
low-grade glioma have successfully predicted both IDH mutation and MGMT
methylation status with accuracy rates of 85–95% and 83%, respectively, using raw
imaging data alone [11, 40, 41].
18 Artificial Intelligence (AI) in Oncology in the UAE 291

DL also holds the potential in predicting treatment response based on imaging

findings. A recent CNN model achieved an 80% accuracy in predicting a complete
response to neoadjuvant chemoradiation [11, 42]. Furthermore, a radiomics signa-
ture utilizing extracted features from CT data and a machine learning algorithm was
able to predict underlying CD8 cell tumor infiltration and, notably, response to
immunotherapy across various advanced cancers [11, 43].

Digital Pathology
In the realm of digital pathology, the increasing digitization of histopathologic
tumor specimen slides provides a robust 2D image suitable for DL analysis. DL
CNN algorithms have proven to diagnose breast cancer metastasis in lymph nodes
with equivalent performance to a panel of pathologists and in a more time-efficient
manner [11, 44]. DL has also shown usefulness in the automated Gleason grading
of prostate adenocarcinoma hematoxylin and eosin-stained specimens, achieving a
75% agreement rate between the algorithm and pathologists [11, 45].
DL algorithms have advanced beyond automating pathologic diagnosis and have
been utilized to characterize the correlation between genotype and phenotype within
tumor specimens. By utilizing digitized tissue from lung cancer biopsies, a CNN
was trained to predict six different genetic mutations (STK11, EGFR, FAT1,
SETBP1, KRAS, and TP53), demonstrating that histopathologic architectural pat-
terns can provide insight into genotypic information [11, 46]. These methods have
the potential to assist pathologists in detecting cancer gene mutations and may offer
a more cost-effective alternative to direct mutational analysis. In the realm of endo-
scopic imaging, AI augmentation has consistently shown improved accuracy in
detecting esophageal cancer [24, 47].
AI-based models have become an integral part of breast imaging and are now
being used in clinical settings. Several breast imaging detection and diagnosis algo-
rithms have received approval from the U.S. Food and Drug Administration [24,
48]. A significant study published in The Lancet Digital Health directly compared
the performance of an AI system in breast cancer screening when operating inde-
pendently versus when assisting a human expert. Through evaluation using retro-
spectively collected mammographic images of 4463 screen-detected cancers and
100,055 confirmed normal studies, the study demonstrated the potential application
of AI through a decision-referral approach, hybrid triaging approach, and cancer
detection approach. Simulating the decision-referral approach revealed substantial
improvements in the sensitivity and specificity of individual radiologists compared
to the consensus conference when combining the strengths of radiologists and
AI. While the standalone use of the AI system on the external test dataset resulted
in a statistically significant reduction in radiologist sensitivity by 2.6% points and
specificity by 2.0% points, the same models could be employed in collaboration
with radiologists within the decision-referral mode. In fact, the AI system’s optimal
configuration within the decision-referral approach increased radiologist sensitivity
by 2.6% points and specificity by 1.0% point while automatically triaging 63.0% of
the studies [49] (Fig. 18.5).
292 K. Shaikh and S. Bekal

Fig. 18.5 Stages of breast

Image Acquisition
cancer detection and
diagnosis system [7]

Image Preprocessing

Image Segmentation

Feature Extraction

Classiffication

Normal Abnormal

A retrospective analysis carried out by academic hospitals in Korea showcased

the advantages of using AI for breast cancer detection through mammography
images. The study revealed that the AI system achieved a sensitivity of 88.8% when
operating independently, surpassing the sensitivity of radiologists at 75.3%.
However, when radiologists received assistance from AI, the accuracy improved by
9.5%, resulting in an overall accuracy of 84.8% [50]. Figure 18.6 illustrates a visual
depiction of an AI-powered diagnostic support software.
AI-based imaging models are being utilized for tumor characterization in medi-
cal practice. These models can perform tasks such as anatomic segmentation, which
involves identifying the boundaries of diseased tissue in relation to normal anatomy,
and tumor subtype classification, which uses various features like signal intensity,
texture, shape, and other descriptors to make accurate diagnoses. Anatomic segmen-
tation, whether in 2D or volumetric form, is employed in clinical settings for treat-
ment decisions like radiation planning. However, manual tumor segmentation is
subject to variability among observers. AI algorithms have the potential to over-
come such biases and improve segmentation accuracy [24, 51].
Radiomic analysis is another technique that involves automated extraction of
clinically relevant information from radiologic images. It enables the development
of radiomic biomarkers by correlating radiomic signatures with genetic, histologic,
and other data. This approach holds promise for providing additional insights into
tumor pathology and improving diagnosis without the need for invasive sampling,
giving rise to the concept of “virtual biopsy” [24, 52].
Moreover, imaging-based machine learning models can be used to predict future
outcomes for cancer patients, including locoregional recurrence, distant recurrence,
and mortality. For instance, emerging ML models based on imaging data have
18 Artificial Intelligence (AI) in Oncology in the UAE 293

Fig. 18.6 AI-based diagnostic support software. (Source: Adapted from Kim HE et al. [50])

shown predictive capabilities for pancreatic cancer outcomes, such as overall sur-
vival and disease-free survival. In the future, this information may guide personal-
ized care for cancer survivors, including surveillance and strategies to prevent
recurrence. Radiomic analysis and evolving imaging-based ML models also
294 K. Shaikh and S. Bekal

demonstrate potential in predicting tumor pathology and genomic alterations. This

can enable diagnosis and provide biomarker information without the need for inva-
sive sampling, leading to the concept of “virtual biopsy.” Notably, noninvasive
imaging-­based models are being developed for glioblastoma to predict genetic
alterations within tumors and influence clinical management [24, 53–55].
The rapid expansion of digital pathology has paved the way for numerous appli-
cations of AI in the analysis of pathologic images, offering benefits in diagnosis,
grading, and interpreting prognostic biomarkers. A significant focus has been on
automating time-consuming tasks, enabling pathologists to enhance their efficiency
and allocate more time to complex decision-making tasks associated with disease
presentation [24, 56].
Several noteworthy examples highlight the progress in this field. For instance, a
DL system has been developed to assess Gleason scores, outperforming general
pathologists by analyzing whole-slide images of radical prostatectomy specimens
[24, 57]. In addition, a convolutional neural network has been employed to auto-
mate the identification of tumor-infiltrating lymphocytes in tissue slide images from
The Cancer Genome Atlas. This feature serves as a prognostic indicator for patients
with various cancer subtypes [24, 58]. Furthermore, AI has demonstrated success in
the classification of dermoscopy images and the annotation of skin lesions, includ-
ing melanoma, achieving precision levels comparable to those of expert dermatolo-
gists [24, 59, 60].
These AI-based algorithms in oncologic imaging analysis are improving diag-
nostic accuracy and workflow efficiency, with ongoing efforts to translate them
from research to clinical practice. As these algorithms continue to advance, the
future holds great potential for further AI applications in oncologic imaging, offer-
ing opportunities for detection and management that were previously considered
unattainable [24].

18.4.3 AI Applications in Precision Oncology

and Cancer Genomics

Oncology heavily relies on evidence-based medicine scoring systems for various

aspects of cancer management, including risk assessment, diagnosis, prognostic
staging, treatment selection, and surveillance monitoring. Over time, these systems
have evolved from basic observations using light microscopy to incorporate
advanced techniques such as gene expression assays and next-generation sequenc-
ing of genomes, both somatic and germline. This evolution has led to an expanding
array of prognostic and predictive factors specific to each disease, as exemplified by
the growing prevalence of genomic-informed clinical models [24, 61–63].
Precision medicine, also known as personalized medicine, aims to provide tai-
lored therapies based on the unique characteristics of a patient or a specific
18 Artificial Intelligence (AI) in Oncology in the UAE 295

population group. These characteristics typically involve the patient’s genome, tran-
scriptome, and proteome and may include other factors like lifestyle, environment,
and socioeconomic status. Sequencing or analyzing the patient’s genome, transcrip-
tome, or proteome often plays a central role in this approach. In the context of preci-
sion medicine, a “digital twin” refers to a virtual replica of a real-world object. The
accuracy and level of detail in a digital twin depend on the precision, detail, and
currency of the information describing the object. In the context of precision medi-
cine, this concept can be applied to create a digital twin of an individual patient or a
specific population group [64, 65].
Artificial intelligence (AI) encompasses algorithms and computing frameworks
designed to perform tasks that typically require human intelligence, such as reason-
ing, decision-making, speech recognition, language understanding, and visual per-
ception [64, 66]. In simpler terms, AI can be described as software that attempts to
mimic human thought processes to accomplish tasks in a manner similar to human
experts in the respective field [64, 67]. In precision medicine, the ultimate goal of
AI is to identify patterns in data using models and algorithms, enabling predictions.
These predictions are initially performed and then refined through machine learning
using the software’s learning algorithms [64, 68].
The recent advancements in technology have led to the generation of vast amounts
of omics data, including genomic, transcriptomic, proteomic (phenotypic), and epig-
enomic data. This increase is attributed to next-generation sequencing (NGS) for
genomic and transcriptomic data and mass spectrometric analysis for proteomic data
[64, 66]. To advance precision oncology and provide accurate interpretations of an
individual’s cancer status, it is crucial for researchers and clinicians to utilize all
available information, allowing computational models to capture the complexity of
the biological system. AI, supported by high-performance computing and innovative
deep learning techniques, offers the only feasible approach to synthesize and under-
stand the magnitude and interdependencies present in multimodal data [24]. The
general application of artificial intelligence to genomics data is illustrated in Fig. 18.7.
Precision medicine holds the potential to revolutionize patient care and cancer
treatment by tailoring therapies to individual needs. Currently, a patient’s ethnicity
is often determined based on self-reporting or visual appearance, which may over-
look the patient’s actual genetic background. To achieve the highest level of accu-
racy in this regard, the creation of a “digital twin” of the patient becomes necessary.
Creating such a digital twin requires capturing and curating extensive data that
describes the patient’s lifestyle and biology. The management and effective utiliza-
tion of these large datasets to develop a digital twin for cancer control purposes
would be challenging without the assistance of AI. AI plays a vital role in process-
ing and analyzing this data, enabling timely and accurate generation of digital twins.
By leveraging AI, it becomes possible to monitor a patient’s response to a specific
treatment, track their recovery, and predict treatment outcomes. This capability
empowers healthcare professionals to fine-tune treatments based on the individual
296 K. Shaikh and S. Bekal

Cancer
Cancer Cancer Treatment
subtyping or
diagnosis prognosis monitoring
stratification

Genomics data

Data pre-processing
Neural network with learning algorithm

New data Feature selection

Model building

Prediction
Learning from data

Model evaluation

Fig. 18.7 General application of artificial intelligence to genomics data [64]

patient’s situation and needs [64]. Figure 18.8 illustrates the application of AI in
precision medicine.
The utilization of personalized genomic data obtained from the patient, analyzed
through AI, has the potential to enhance cancer screening and diagnosis, thereby
enabling the prevention of severe illnesses. Simultaneously, AI-driven analysis of
this data can facilitate the development of more precise and targeted treatments, as
well as enhance the monitoring of treatment outcomes. These advancements in pre-
cision oncology aim to improve patient care and align with the ultimate objective of
delivering better healthcare [64].
18 Artificial Intelligence (AI) in Oncology in the UAE 297

Fig. 18.8 The application

of AI to precision
medicine [64]

18.4.4 AI in Cancer Research and Clinical Outcomes

In conjunction with the increasing wealth of contemporary biomedical data, artifi-

cial intelligence (AI) and specifically deep learning (DL) have achieved notable
successes in cancer clinical research. AI-based methods are being increasingly
employed across various domains of cancer clinical research to enhance accuracy
and efficiency. These applications encompass the utilization of AI in cancer imaging
recognition, genomic analysis, mining medical records, drug discovery, and lever-
aging biomedical literature [69].
Within the field of clinical oncology, AI has been increasingly utilized to harness
the potential of electronic health records (EHRs). Particularly, AI-based natural lan-
guage processing techniques have shown promise in predicting the onset of diseases
within extensive healthcare systems. An exemplary instance involves a DL-based AI
algorithm developed by researchers at Mount Sinai, which accurately predicted the
development of diverse diseases, including prostate, rectal, and liver cancers, with
an overall accuracy of 93% [11, 70]. Acquiring clinical data poses challenges for
data science experts due to limited opportunities for clinical practice or the require-
ment of institutional approval. Additionally, the labor-intensive nature of manual
298 K. Shaikh and S. Bekal

data collection has hindered the incorporation of firsthand clinical data into models.
Leveraging Electronic Health Record (EHR) data has the potential to enhance the
outcomes of biomedical research, as these systems integrate various clinical narra-
tives, laboratory results, procedure and radiology reports, primary care notes, and
gastroenterology clinic notes [69].
Recent advancements have showcased several promising outcomes through the
application of AI in drug development, drug-target profiling, and drug repurposing
and repositioning [71]. In the realm of small-molecule drug design, AI can enhance
target specificity, selectivity, and account for pharmacodynamic, pharmacokinetic,
and toxicological effects. Various types of data have been utilized in AI-driven
cancer-­related drug discovery research. Traditional data types include drug chemi-
cal structures, physicochemical properties, and molecular targets [72]. Moreover,
RNA microarray, single nucleotide polymorphism (SNP) array, RNA sequencing
(RNA-Seq), reverse phase protein array, exome sequencing, and DNA methylation
status hold promise for identifying biomarkers and generating predictive models for
drug sensitivity [73]. Existing resources that facilitate cancer drug discovery include
DepMap, Genomics of Drug Sensitivity in Cancer (GDSC), canSAR, Open Targets,
TG-GATE, drugBank, and others. These databases and resources enable the corre-
lation of drug sensitivity and provide potential biomarkers for drug response [69].

18.4.4.1 AI in Cancer Clinical Research: Method and Application

The different subareas of cancer clinical research that have benefited from incorpo-
rating AI are given below.

Cancer Imaging Recognition

The advancement of computational capabilities and algorithms has facilitated the
successful application of artificial intelligence (AI) in radiology, aiding radiologists
in disease identification [74]. Prior to being inputted into the model, raw images
may undergo basic preprocessing to eliminate irrelevant image portions. This
involves extracting regions of interest (ROIs) by segmenting lesions within an
image, and then only the information within these ROIs is utilized for model predic-
tions. The annotation of regions can be performed by experts or assigned based on
diagnosis labels [74, 75]. However, in contrast to other typical medical image for-
mats, whole slide images (WSIs) are excessively large to be processed in their
entirety by DL models [76]. To address this limitation, WSIs are divided into numer-
ous small image patches, which are subsequently combined to generate predictions
at the patch level [77]. In some cases, a tumor probability heatmap can be utilized
to select geometrical and morphological features, serving as input to the model and
enabling the identification and characterization of disease patterns on digitized tis-
sue slides [78]. Traditional image recognition approaches employ manually
designed image features, including texture, shape, color, pixel density, and contrast/
brightness, to capture tumor or cell morphology [79]. However, these feature-based
algorithms possess certain limitations: (1) they rely on a separate feature extraction
step [80], and (2) these features may not consistently perform well under different
scanning conditions [81]. On the other hand, automatic feature extraction allows for
18 Artificial Intelligence (AI) in Oncology in the UAE 299

Fig. 18.9 Computational imaging recognition for cancer clinical research. (Source: Adapted from
Shao D et al. [69])

the direct use of raw images as input to the model (end-to-end), enabling simultane-
ous image classification [82]. The process of computational imaging recognition in
cancer clinical research is depicted in Fig. 18.9.

Genomic Analysis
In recent times, significant advancements have been made in applying artificial intelli-
gence (AI) to cancer research, particularly in utilizing various genomic data types as
input for models. Morais-Rodrigues et al. [83] developed a modified logistic regression
approach to analyze microarray gene expression data for breast cancer progression.
Similarly, Maros et al. [84] designed machine learning workflows to estimate class
probabilities for cancer diagnosis using DNA methylation microarray data. Another
noteworthy study by Albaradei et al. [85] introduced a deep learning-­based model that
differentiated pan-cancer metastasis status by integrating three heterogeneous data lay-
ers from TCGA: RNA-Seq, microRNA-Seq, and DNA methylation data. The model
employed a convolutional variational autoencoder for feature extraction and a deep
neural network for classification. The results demonstrated that the integration of mul-
tiple data types improved performance compared to using mRNA data alone.
Additionally, AI models have been employed in cancer-grade prediction.
Yamamoto et al. [86] trained a support vector machine (SVM) classifier using mor-
phometric classification of microenvironmental myoepithelial cells to quantitatively
diagnose breast tumors. The study involved the quantitative measurement of 11,661
nuclei across four histological types: normal cases, usual ductal hyperplasia, low-­
grade ductal carcinoma in situ (DCIS), and high-grade DCIS. The model achieved
an accuracy of 90.9% in classifying these histological types, with at least three
pathologists independently diagnosing and scoring all cases.
300 K. Shaikh and S. Bekal

Genomic data also enables the identification of disease-related biomarkers. For

example, Zeng et al. [87] utilized deep forests in combination with positive-­
unlabeled learning methods to predict potential disease-related circular RNAs (cir-
cRNAs). Furthermore, Radhakrishnan et al. [88] combined fluorescence imaging
and deep learning techniques to detect subtle changes in nuclear morphometrics at
the single-cell level. This approach opens new avenues for early disease diagnostics
and drug discovery.

Electronic Medical Record Mining

Certain AI-based models leverage integrated medical record data, which includes
genomic information, unstructured health records, and family history, to enhance
the accuracy of cancer prediction [69, 89]. For instance, when predicting the sur-
vival outcomes of lung cancer, a dataset incorporating observed cancer-related char-
acteristics of individuals is considered. These characteristics may include lung
cancer pathology images, age, gender, smoking status, and stage. Moreover, tumor
shape parameters such as area, perimeter, convex area, filled area, major axis length,
and minor axis length also contribute to the outcome [69, 75].
Natural language processing (NLP) systems play a significant role in captur-
ing relevant information for cancer research projects. As an example, a prepro-
cessor integrated with an existing NLP system, such as MedLEE, was developed
as part of an ongoing clinical research endeavor that focuses on assessing dis-
parities and risks associated with breast cancer development in minority women
[90]. NLP algorithms are utilized to identify primary and recurrent cancers by
extracting pertinent information from electronic pathology reports [91].
Additionally, NLP can enhance the identification of cancer testing within elec-
tronic medical records [92].

Drug Discovery
AI has emerged as a valuable asset in cancer drug research due to the availability of
extensive and refined public databases and resources. Choi et al. [69, 93] introduced
an innovative deep neural network model that enhances the prediction of drug resis-
tance and the identification of biomarkers associated with drug response. Huang
et al. [94] utilized gene expression profiles (RNA-seq or microarray) from individ-
ual patient tumors to predict the responses of 175 cancer patients to various standard-­
of-­
care chemotherapeutic drugs. Borisov et al. [95] predicted the clinical
effectiveness of anti-cancer drugs for individual patients by transferring features
obtained from expression-based data derived from cell lines. Another study by
Chang et al. [71] presented the Cancer Drug Response Profile Scan (CDRscan),
which predicts the responsiveness of anticancer drugs based on large-scale drug
screening assay data, encompassing genomic profiles of 787 human cancer cell
lines and structural profiles of 244 drugs. Moreover, the application of computa-
tional biology approaches to predict and interpret cancer drug response at the single-­
cell level has demonstrated significant value. Yanagisawa et al. [96] constructed a
convolutional neural network (CNN) model to forecast the efficacy of antitumor
drugs at the single-cell level.
18 Artificial Intelligence (AI) in Oncology in the UAE 301

Numerous computational tools have been proposed for cancer-related drug dis-
covery, employing various AI methodologies. Examples of these applications
include DeepChem [97], DeepTox [98], gene2drug [99], STITCH [100], AlphaFold
[101], and DeepNeuralNetQSAR [102]. For instance, the DeepTox algorithm
employs machine learning to predict the toxic effects of 12,000 environmental
chemicals and drugs in specifically designed assays [98]. AlphaFold utilizes deep
neural networks to predict the three-dimensional structure of drug target proteins
[101]. The development of these tools has contributed to the reduction in the cost of
drug discovery [69].

Biomedical Literature Utility

Over the past few decades, significant efforts by large consortiums have led to the
development of community-based knowledge bases in the field of cancer clinical
research, leveraging extensive collections of published literature. For instance, the
National Lung Screening Trial (NLST) [69, 102] serves as a comprehensive data-­
sharing platform that enables users to search, browse, download, and analyze
tumor regions of lung adenocarcinoma (ADC) patients. The National Cancer
Institute (NCI) Genomic Data Commons (GDC) [69, 103] acts as a unified knowl-
edge base that integrates genomic and clinical data from various research pro-
grams for the cancer research community. In a typical study, a deep convolutional
neural network (CNN) model is trained on the systematically studied tumor
regions of lung cancer patients from the NLST cohort, enabling automatic recog-
nition of tumor regions. The performance of the model developed from the NLST
cohort is then independently validated in the TCGA cohort for prognostic assess-
ment [69, 75].
The Sheikh Khalifa Bin Zayed Al Nahyan Institute for Personalized Cancer
Therapy (IPCT) at MD Anderson Cancer Center has developed a knowledge base
that provides valuable information on the functions of common genomic alterations
and their therapeutic implications, guiding personalized treatments in oncology [69,
104]. A precision oncology decision support (PODS) team comprising oncologists,
geneticists, molecular biologists, computational scientists, computer programmers,
and bioinformaticians manually reviews the literature for this knowledge base [69,
105]. Additionally, an integrated Precision Medicine Knowledgebase (PreMedKB)
has been established to seamlessly interpret the four essential components of preci-
sion medicine: diseases, genes, variants, and drugs [69, 106]. These knowledge
bases offer a wealth of information and serve as excellent resources and tools for the
research community.

18.4.5 AI and Translational Oncology

AI is gradually emerging in the field of translational oncology. In the past decade,

there has been a significant expansion of biological quantitative data, commonly
known as “-omic” data. Due to the inherent complexities and heterogeneity of this
data, deep learning (DL) has become an appealing approach for analysis. DL neural
302 K. Shaikh and S. Bekal

networks have been successfully applied to various tasks in translational oncology.

For instance, they have been used to predict protein structure [11, 107], classify
cells into specific mitotic stages [11, 108], and even forecast the future lineage of
progenitor cells based on microscopy images [11, 109].
DL has also found applications in drug development and repurposing, which
have garnered considerable interest. In one study, DL artificial neural networks
(ANNs) were trained on transcriptomic response signatures to drugs, achieving
high accuracy in predicting the likelihood of failure in clinical trials for over
200 example drugs [11, 110]. Another study utilized an ANN to predict the sen-
sitivity of cancer cells to therapeutics by combining genomic and chemical
properties [11, 111]. Convolutional neural networks (CNNs) have also been
employed to predict peptide-major histocompatibility complex binding [11,
112], a factor that holds potential implications for the development of oncologic
immunotherapy.
Overall, DL has shown promise in translational oncology, enabling valuable
insights and contributing to drug development, drug repurposing, and understand-
ing cellular processes in cancer research.

18.5 AI Challenges and Future Directions

In various domains of biomedicine, AI has demonstrated comparable performance

to that of human experts. However, despite the availability of certain AI solutions,
there are still numerous challenges that need to be addressed for AI to transition
from theoretical studies to real-world applications [69].
A significant challenge faced by AI, in general, is the need for large amounts of
data. In the context of cancer research, acquiring a sufficiently large and well-­
annotated dataset is an ongoing requirement for AI algorithms. While the inclusion
of images, genomic data, and clinical outcomes in certain open databases has greatly
advanced computational clinical research, there is still a need to obtain data of ade-
quate scale, quality, and diversity. For instance, patient histories documented in pre-
vious reports contain valuable information relevant to cancer risk and progression,
but gathering such data can be time-consuming. To address this challenge, data-­
sharing agreements play a crucial role. Sharing large datasets with the research
community can be facilitated through cloud computing and the continued develop-
ment of advanced predictive cancer models [69].
Furthermore, the effectiveness of an AI model heavily relies on the availability of
high-quality data. Despite the increasing volume and diversity of available data,
there is a lack of standardized methods to assess data quality [69].
Challenges in the deployment of AI include the following:
Proving Generalizability and Real-World Applications
Despite the rapid integration of AI into oncology research, there is still work to
be done in order to translate these studies into practical and clinically relevant appli-
cations. One major challenge involves the external validation and demonstration of
18 Artificial Intelligence (AI) in Oncology in the UAE 303

the generalizability of deep learning (DL) models. Due to the intricate nature of
neural networks and their extensive parameterization (often involving millions of
parameters), there is a considerable risk of developing overfitted models that lack
the ability to generalize across different populations. Moreover, the presence of
significant heterogeneity in medical data across various institutions necessitates the
need for multiple external validation sets to establish the performance of an AI
application [11, 113].
Data Access and Equity
As mentioned earlier, the problem of overfitting is exacerbated by limitations in data
access and quality. Deep learning (DL) neural networks, more than other machine
learning algorithms, require large volumes of data, which can be challenging in health-
care settings where diseases with lower prevalence are involved. Additionally, data is
often fragmented within individual institutions due to concerns regarding the transmis-
sion of protected patient health information. The lack of data-­sharing infrastructure,
along with heterogeneity and incompleteness in data collection, as well as competition
between institutions, contribute to this scarcity of data. However, efforts are being
made to address these challenges, with a growing focus on streamlined data capture
and the establishment of multi-institutional data-­sharing agreements. Guidelines pro-
moting the use of FAIR (findable, accessible, interoperable, and reusable) data have
been proposed, and there are now opportunities for research groups to publish their
data, which may encourage greater openness in data sharing [11, 114–120].
Interpretability and the Black Box Problem
One of the primary obstacles to the widespread adoption of AI in healthcare is
the issue of interpretability. Despite achieving impressive performance, AI models
often lack transparency. For example, a deep learning (DL) model might accurately
predict that a patient will develop pancreatic cancer based on their 2 years of past
data, but the precise reasoning behind this prediction remains unclear. This chal-
lenge is commonly referred to as the “black box” problem [11, 121]. In clinical
decision-making, understanding the rationale behind each decision has always been
crucial. Traditional machine learning (ML) algorithms like linear regression, while
limited in modeling complex relationships, offer interpretability. These algorithms
provide pre-defined features and corresponding feature weights that indicate their
impact. In contrast, DL models utilize unstructured input data, and the majority of
knowledge generation occurs within hidden layers, making it difficult to identify
which specific characteristics of the input data contribute to the outcome. This lack
of interpretability has significant implications for the acceptance of AI-based algo-
rithms in healthcare, both from the perspectives of practitioners and regulatory bod-
ies [11, 122–125].
Realizing the Potential of AI in Oncology: Overcoming Challenges and
Maximizing Benefits
The potential applications of AI in medicine and cancer research offer great
promise. However, to leverage these opportunities, it is necessary to make increased
investments and address several challenges [126]. The National Cancer Institute
(NCI) of the USA has put forward the following strategies to advance the field [126]:
304 K. Shaikh and S. Bekal

1. Establishing an AI cancer research community: Collaboration between the data

science, AI, and cancer research communities is crucial to harness the potential
of AI in cancer research. The NCI can facilitate this collaboration by providing
funding opportunities and data access, fostering connections between cancer
researchers and AI experts, and supporting the training and development of pro-
fessionals with expertise in AI, data science, and cancer. Workshops and initia-
tives are being organized, building upon the NCI’s collaboration with the
Department of Education, to encourage a community that pushes the boundaries
of computational practices in cancer research and develops new computational
technologies.
2. Bridging the gap between research and practice: Currently, the use of AI in cancer
research and care is in its early stages. Most research focuses on developing meth-
ods rather than implementing them in clinical practice. The NCI can lead the way
in integrating AI into cancer care by supporting research to identify effective path-
ways for clinical integration. This includes understanding uncertainty and validat-
ing AI approaches, educating medical professionals about the strengths and
limitations of AI technology, and conducting rigorous assessments of its benefits
in terms of clinical outcomes, patient experience, and cost-effectiveness.
3. Accessing high-quality cancer data: The scarcity of large, publicly available, and
well-annotated cancer datasets has been a significant barrier to AI research and
algorithm development. The absence of benchmarking datasets in cancer
research hampers reproducibility and validation. To drive AI innovation and
facilitate the training and validation of AI models, there is a need for support in
annotating, harmonizing, and sharing standardized cancer datasets. As data vol-
umes are expected to increase, it is critical to develop approaches that generate
and aggregate new research and clinical data coherently. The NCI aims to refine
its policies and practices to enhance and improve data sharing, making cancer
data broadly available for all types of research.

By implementing these strategies, the NCI seeks to overcome challenges and

promote the effective utilization of AI in oncology, ultimately leading to improved
cancer research, diagnosis, and treatment outcomes.

18.6 Conclusion

Despite the hurdles and growing concerns, it is a well-known truism that the inte-
gration of AI into the healthcare ecosystem allows for a multitude of benefits. With
its myriad of applications, AI is recasting the layout of oncology and the associated
sectors by maximizing its potential to facilitate efficient use of healthcare resources.
Integration of AI technology in cancer care could improve the accuracy and speed
of diagnosis, aid clinical decision-making, and lead to better health outcomes.
AI-guided clinical care has the potential to play an important role in reducing health
disparities, particularly in low-resource settings. The UAE healthcare system, with
its impressive trajectory, has the necessary infrastructure to develop and thrive in a
18 Artificial Intelligence (AI) in Oncology in the UAE 305

tech-enabled healthcare ecosystem. Given how rapidly the technology is evolving

and by recognizing the many potential applications in cancer science, AI will unde-
niably revolutionize oncology.

Conflict of Interest The authors have no conflict of interest to declare.

Disclosure QuillBot and ChatGPT are used to paraphrase selected segments.

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12 Sept.

Khalid Shaikh is the founder and CEO of Prognica Labs, a

healthcare technology company that specializes in developing
AI-powered solutions for breast cancer detection and treatment.
He is a serial entrepreneur, author, innovator, and business strate-
gist. He has received numerous awards for his innovations in
healthcare.
In addition to his professional commitments, he also gives back
to the aspiring entrepreneur community by serving as an advisor
and mentor. He has published and lectured extensively on health-
care performance improvement, digitalization, and innovation. He
is the author of the books artificial intelligence in breast cancer
early detection and diagnosis and several research articles pub-
lished in peer-reviewed journals.
18 Artificial Intelligence (AI) in Oncology in the UAE 311

Dr. Sreelekshmi Bekal is the medical director of Prognica labs

and has led the company to develop a breakthrough AI solution for
detecting early-stage breast cancer to make it more accurate,
affordable, and accessible. Dr. Sreelekshmi holds a BDS degree,
and she comes with over 8 years of experience in healthcare inno-
vation. She is an entrepreneur and wants to make cutting-­edge
medical care available to communities around the world, regardless
of their resources. She is very actively promoting and advocating
breast cancer awareness, screening, and research to help the com-
munity, society, and medical education.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
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adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
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statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Traditional, Complementary,
and Integrative Medicine and Cancer 19
Care in the UAE

Heidi Kussmann

19.1 Traditional, Complementary, and Integrative Medicine

and Conventional Cancer Care: Opportunities for Whole
Person Cancer Care

Patient use of both conventional and integrative oncology before, during, and after
conventional cancer care is increasing [1, 2]. Integrative oncology use can exist in
the United Arab Emirates (UAE) within a robust framework built on the foundations
of regulation, research, and collaboration. In other parts of the world, integrative
oncology is employed by patients who want to combine conventional treatment
with other therapies to decrease side effects and hopefully have a better treatment
outcome [3, 4]. Globally, cancer incidence affects low- and middle-income coun-
tries the most. The provision of evidence-based cancer screening, treatment, and
conventional care during survivorship and palliative stages of cancer is limited to
patients who have insurance or can afford it privately. In the scope of non-conven-
tional care, there is usually no insurance coverage, and patients must pay out of
pocket. In low- and middle-income countries, there is limited health literacy and
access to affordable oncology care, and patients are using culturally familiar medi-
cine that can be considered traditional, complementary, or integrative medicine [5].
The UAE has experienced definitive growth in the field of oncology and is a destina-
tion for top-tier oncology care. The next logical step is to incorporate integrative
oncology to combine the best of all care options for people with cancer. It is impor-
tant to define the fields of traditional, complementary, and integrative medicine and
naturopathic oncology in the context of this chapter.
Since 2002, the World Health Organization has adjusted its terminology to inte-
grative instead of alternative medicine to encourage the adoption of traditional,
complementary, and integrative medicines (TCIM) in health care systems around

H. Kussmann (*)
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates

© The Author(s) 2024 313

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_19
314 H. Kussmann

the world [5]. TCIM can be defined as the collaboration of qualified health profes-
sions within the subspecialty of oncology. Within the umbrella term of integrative
oncology, there exist over 40 professions specializing in supportive cancer care,
such as naturopathic doctors, doctors of acupuncture and traditional Chinese medi-
cine, homeopathic doctors, dieticians and nutritionists, anthroposophical medicine,
massage therapy, physical/movement therapy, yoga, meditation, psychology, and
pastoral care [6]. Each of these professions has strong competencies and supportive
care options for people with cancer. Each has research supporting use in cancer and
influencing overall survival, and each profession provides education for the public
and interested medical professionals via books, research, and accredited education
institutions.
There are many challenges to the inclusion of the integrative oncology profes-
sions in conventional cancer care [1, 6–19], for which an incomplete list of priorities
is summarized below [5, 6, 20]:

1. Develop a TCIM department within each of the UAE oncology hospitals to coor-
dinate and advance the collaboration and research needed between conventional
and integrative oncology professionals.
2. Establish professional and patient education about TCIM and establish guide-
lines for collaborative care.
3. Provide qualified integrative oncology professionals for both inpatient and out-
patient settings across the cancer continuum, from screening and early diagnosis
to survivorship and palliative care.
4. Contribute clinically relevant integrative oncology research findings to protocols
and guidelines for practice, in addition to the evidence in TCIM’s care of
treatment-­related side effects.
5. Address financial, perceptional, and cultural barriers for oncologists and patients
to access TCIM.
6. Set an example for the rest of the world on how to bring integrative medicine to
people with cancer that improves the patient experience, quality of life, efficacy,
outcomes, and overall survival.

19.2 Naturopathic Oncology Within TCIM

Due to the extensive information published about TCIM and the editorial limita-
tions of this chapter, this chapter will briefly review one of the qualified health care
professions in TCIM, that of naturopathic oncology, and the evidence supporting
some of the profession-based recommendations that can safely be used with con-
ventional oncology treatments. Naturopathic oncologists are licensed naturopathic
doctors (NDs) with additional oncology education and training who receive the
board-certified status of Fellow by the American Board of Naturopathic Oncology
(FABNO). To obtain a license, one must first attend a post-graduate degree-granting
program that is accredited by the Council of Naturopathic Medical Education
19 Traditional, Complementary, and Integrative Medicine and Cancer Care in the UAE 315

(www.cnme.org). The Council grants the naturopathic medicine doctorate degree to

schools that require in-person (not online), 4-year full-time programs and provide
standards-based education that combines natural healing systems (homeopathy,
Chinese medicine and acupuncture, nutrition, and botanical medicine) in addition to
the same curriculum as the medical training of medical schools. There are only
seven accredited schools in Canada and the USA that provide this extensive educa-
tion. After graduation, NDs must take the national exams, i.e., the Naturopathic
Physicians Licensing Examinations (NPLEX), in order to qualify for province- or
state-based licensing, which includes both written and oral examination processes.
Only after becoming licensed as an ND and further meeting the requirements for
specialization in oncology as set out by the American Board of Naturopathic
Oncology can an ND attempt the board certification examination. Renewal of the
FABNO board certification is required every 10 years from the original date of
certification.
The naturopathic oncology professional care guidelines [2] detail how naturo-
pathic oncology can work in the field of integrative oncology with patients and their
oncologists. It includes understanding the established standards and collaborating
with patients and oncology professionals to evaluate and prepare the patient for
treatment, to provide patients with information on what to avoid and what to use in
cancer treatment specific to the patient and his or her treatment details, as well as
helping with the side effects. A naturopathic oncology doctor would evaluate the
cancer treatment plan and the patient as a whole for deficiencies and use existing
research evidence to support the use of specific recommendations to maximize ther-
apeutic potential while reducing early and late side effect incidence and severity
[21, 22]. Naturopathic oncology also screens for and advises patients regarding
drug–nutrient and drug–herb interactions. This ensures, from the start of a cancer
diagnosis through treatment and beyond, that it provides optimal care individual-
ized to each patient according to their conventional oncology treatment touchpoints.
Most often, the collaboration starts between medical doctors and naturopathic doc-
tors at tumor board meetings prior to the initiation of therapy and ensures the best
integrative and conventional treatments are agreed upon and delivered as seamlessly
as possible.
In the context of integrative oncology, naturopathic oncology does more than
address concerns about the average quality of life and the common side effects [23]
of conventional cancer care through Natural Health Products (NHPs), diet and life-
style modifications [24, 25], homeopathy [9, 26–29], botanical medicine [30–33],
vitamin and nutrient therapy [34, 35], intravenous (IV) nutrient therapy, immune
supportive therapies [36], and other targeted treatments. It has been established for
years that these modalities work to address the most common detractors of quality
of life, such as fatigue [11], pain [37], nausea [38], weight loss or muscle loss [39],
sleep disturbances [40], and peripheral neuropathy [41–43].
Now that they have been defined, it makes logical sense to explore the evidence
supporting the use of naturopathic and integrative oncology from the start of diag-
nosis through survivorship and/or palliative care. The focus of this remaining
316 H. Kussmann

chapter is on the integration of naturopathic oncology throughout the listed conven-

tional treatments below:

1. Screening and diagnosis.

2. Radiation therapy [44–46].
3. Surgery [12, 47].
4. Cytotoxic chemotherapy [48, 49].
5. Targeted therapy [31, 50].
6. Immunotherapy [33, 51].

Disclaimer: The following are not complete or individualized recommendations

from naturopathic oncology. For details on doses and regimens, patients must con-
sult with a naturopathic oncologist, as there may be potential interactions and no
benefit. It is strongly advised that patients match their health history and cancer
treatment details with the correct timing of integrative treatment and that they obtain
risk and benefit information when adding TCIM therapy specific to their cancer
type, stage, and location. Assessment must include evaluation and NHP recommen-
dations made by a licensed professional (such as a naturopathic doctor) working in
either the broad field of integrative oncology or naturopathic oncology.

19.3 Radiation Therapy

This is intended to provide a foundation for combining the best of integrative oncol-
ogy and naturopathic oncology to work with radiation therapy. The need for guid-
ance is because, as in all aspects of cancer care, many radiation therapy patients are
including additional treatments, procedures, items, supplements, etc. without con-
sulting a naturopathic oncology professional and being fully informed of their risks
and benefits [52]. Herein lies a missed opportunity to develop integrative guidelines
for this area of treatment and to have qualified naturopathic oncology professionals
screen problematic or contraindicated items and advise on evidence-­based support-
ive care [53] before radiation-based scans and during radiation therapy.
Radiation has proven efficacious in the treatment of cancer, alongside surgery
and chemotherapy. Radiation induces changes in cancer tumor locations and sur-
rounding tissue that can be irreversible. The short-term (within 3 months) effects of
radiation therapy include the intended reduction or eradication of the tumor burden
on the patient and the adverse effect of inflammation of the nearby tissues and body
parts exposed to radiation. These usually subside a few weeks after the completion
of radiotherapy.
Prior to radiation treatment, the whole person and the systems-based assessment
outlined earlier for each patient include evaluating the following:

• Coping and mental health.

• Exercise or movement habits.
• Nutritional status and lifestyle factors (i.e., smoking).
19 Traditional, Complementary, and Integrative Medicine and Cancer Care in the UAE 317

• Biomarkers of inflammation and digestion.

• Digestive, microbiome, and elimination functions to reduce the incidence of
radiation resistance [54, 55].

There has been research into when and what to eat or take during radiation expo-
sure and treatment [45], but there is little evidence to support the use of radioprotec-
tants, and more robust research is needed to ensure the safety and efficacy of
everyone involved [56]. There are naturopathic oncology recommendations for
occupational exposure and imaging studies that differ from recommendations for a
daily radiation treatment schedule of 3–6 weeks duration, but the recommendations
for what to avoid remain the same for both scans and treatment. Naturopathic oncol-
ogy employs a protective protocol for imaging studies that use radiation to reduce
the oxidative stress on healthy cells [21, 22, 57–63]. Protection protocols are also
available during scans in general [64] and from various types of radiation-based
occupational exposure, with the exception of extremely low magnetic fields or elec-
trical shocks [65] that have no causal relationship to cancer development [58, 59,
62, 66–70]. Naturopathic oncology guidelines in preparation for scans and radiation
treatment include the following avoidances:

• Mistletoe homeopathic injections, metformin prescriptions, or berberine supple-

ments and IV vitamin C with PET imaging are not recommended, as they theo-
retically have the potential to interfere with contrast glucose distribution
and uptake.
• Multivitamins, iron, beta-carotene, methionine, cysteine, copper, CoQ10, and
topical use of mint and cinnamon all have the potential to increase the radia-
tion effect.
• Ozone therapy has the potential to increase the radiation effect.

The typical preparation protocol for imaging studies includes increasing

dietary intake of garlic, turmeric, green tea, pomegranate juice, cordyceps mush-
rooms, selenium from Brazil nuts, zinc from pumpkin seeds, shellfish, and
legumes. Following scans, one can supplement with concentrated turmeric, green
tea extract, cordyceps, selenium, and zinc, as well as sauna or exercise/sweating,
to aid in detoxification and cellular repair mechanisms. Most contrast media used
in imaging are metabolized by the liver and eliminated in urine, so hydration with
at least 2 L of clean water immediately after imaging is advised in addition to
the above.
Detailed radiation therapy protocols are provided for patients according to their
type of cancer, the treatment thus far, and their signs and symptoms. These individu-
alized assessment and treatment protocols are intended to reduce early and late
radiation adverse events like mucositis, dermatitis (resulting in desquamation,
wounds, non-healing ulcers, and radionecrosis), fatigue, neuropathies, weight loss,
and hematological suppression [11, 71–83]. These protocols can include, but are not
limited to, IV vitamin C, green tea, fish oils, zinc, vitamin D, astragalus, and probi-
otics [21, 22]. Details should be determined in collaboration with a qualified
318 H. Kussmann

naturopathic oncology doctor and the radiation oncologist. Not all effects are pre-
ventable or treatable with naturopathic or integrative oncology. It is important to
include wound care, oncology physical rehabilitation, surgical intervention, and
other similar resources as deemed important by the integrative oncology care team.
The support measures of hyperthermia and hyperbaric oxygen are two forms of
evidence-based, non-invasive, integrative oncology support and recovery options
for radiation therapy. Hyperthermia has been shown to have promising potential
when combined with radiation therapy [12, 44, 84–86]. If hyperthermia is not an
option but movement is possible, then patients can exercise for 10–15 minutes
before each radiation treatment to elevate their core body temperature, circulation,
and oxygen levels in the body and increase the radiation’s effects on tumor tissue
[87, 88]. Hyperbaric oxygen can also be employed to offset early- and late-onset
side effects. For example, it can support healing in oral microcirculation [89], in
cranial radiation to reduce hippocampal injury [90], in radiation cystitis [91], and in
some cancer types like glioblastoma [92]. Both hyperthermia and hyperbaric oxy-
gen have promise and potential in combination with IV vitamin C and radiation
treatment [93]. It is highly recommended that hyperthermia and hyperbaric oxygen
treatments be offered at the same location as the oncology treatment to facilitate
patient compliance and better outcomes.
Some people can experience late adverse effects from radiation after completion
that include the permanent reduction of supportive cells in tissue, free radical pro-
duction, DNA damage, tissue hypoxia, cell death, endothelial and vascular damage,
tissue dysfunction and damage, fibrosis, and reduced quality of life. These can show
up months or decades after radiation is completed. It is important to talk to patients
and identify if, after radiation completion, there are adverse late effects of radiation
and to always refer for appropriate management and corrective treatment.

19.4 Surgery

The majority of cancer surgery is resection-focused: the complete removal of the

tumor and any surrounding or affected lymph nodes, with as many clear tissue mar-
gins as possible. Biopsy and palliative surgery are also tools to help understand the
type and stage of cancer and to alleviate emergent issues (i.e., tumors obstructing
circulation or digestion). The effect of cancer surgery and the anesthetic agents used
in surgery can be compared to an endurance event for the body. The psychological
and physical stress from cancer surgery and anesthesia has both beneficial and
adverse effects on cancer growth. For patients, it is important to inhibit stress before
and after surgery and to target the biochemical mechanisms and signaling pathways
involved to inhibit an excessive stress response [94, 95]. The body produces an
optimal immune response in the first few days after surgery, yet within 2–3 weeks,
this becomes a suppressed immune response. This translates into post-surgery
trauma-induced growth factors and immune suppression-mediated tumor progres-
sion. This can predispose to T-cell impairment, cytokine reduction, and post-­
operative sepsis [96]. If this patient already has diabetes, the combined effects of
delays or complications in wound healing and immunosuppression must be
19 Traditional, Complementary, and Integrative Medicine and Cancer Care in the UAE 319

addressed for the best results. To support the immune system in all phases of cancer
treatment, and especially before surgery, this can be accomplished using any com-
bination of the following integrative therapies and options:

• Mindfulness techniques such as meditation, breathwork, and prayer.

• Music therapy, whether in the form of singing, listening, or playing a musical
instrument.
• Exercise, tai chi, yoga, and exercise if movement is possible.
• Anti-anxiolytic botanical medicine options such as l-Theanine, Passionflower
(Passiflora incarnata), Hops (Humulus lupulus), or Valerian root (Valeriana offi-
cinalis, Caprifoliaceae).
• Acupuncture.
• Art therapy.

In preparation for surgery, the patient would spend some time in the integrative
oncology department, and the involved professionals would assess and address the
areas of mental wellness, physical fitness, dietary intake, hydration, and digestion.
To accomplish changes or improvements before surgery depends on co-existing
health conditions, prior treatments, the tumor burden, and the time available before
surgery. For example, one patient can have anxiety, depression, hypertension, diabe-
tes, chronic liver disease, and cancer. Each condition needs monitoring and integra-
tive treatment to reach a better or more stable state before surgery to reduce immune
suppression and the incidence of wound healing challenges and complications
[97–99].
Strong evidence exists for the use of homeopathy, meditation, tai chi, yoga, and
music therapy to reduce stress before, in the acute recovery phase, and upon dis-
charge home to improve the outcome and reduce complications in healing [12, 47,
100–102]. Fasting mimicking diet (FMD), short-term fasting (STF), and intermit-
tent fasting (IF) in pre-habilitation/preparing for surgery and again in recovery from
surgery [103–105] have big benefits for patient recovery. The benefits are cumula-
tive when one combines exercise with intermittent fasting to maintain muscle mass
[97] before surgery and when cleared for physical activity afterwards. In addition to
specific diet and exercise recommendations, there are evidence-based options avail-
able such as oral nutrients [106–109], IV vitamin C [109–111], hyperthermia [112],
l-arginine [108], homeopathy [113], hyperbaric oxygen for wound healing [114,
115], acupuncture [7, 98], and botanical medicine [32, 116] to further support
recovery. Earlier conclusions about fish oils being a clotting risk have now been
refuted, and the current evidence supports the use of omega-3 fish oils without inter-
fering with blood clotting [117–119].
Both conventional and integrative cancer care providers, as in all cancer care,
must have a thorough understanding of what patients are doing and what they are
taking to achieve treatment goals. It is imperative that trustworthy, open communi-
cation about, screening for, and pausing the intake of all drugs, nutrients, and botan-
icals that are contraindicated for surgery be completed as part of the pre-operative
assessment. There is potential for botanical and nutrient interference with blood
clotting and anesthesia. Specific evidence-based examples of items to avoid in the
320 H. Kussmann

diet and supplement format before surgery include the following: ginkgo (Ginkgo
biloba), cayenne (Capsicum annuum), garlic (Allium sativum), ginger (Zingiber
officinalis), Dan Shen (Angelica sinensis), fenugreek (Trigonella foenum-graecum
L.), vitamin E as alpha-tocopherol, curcumin (Curcuma longa 90%), chondroitin,
and red clover (Trifolium pratense) [21, 22, 53].

19.5 Chemotherapy

Chemotherapy includes both targeted and cytotoxic therapies and now has the addi-
tional treatment combination of immunotherapies. In each, there exist integrative
oncology options for side effect management and augmentation of the therapeutic
effect in balance with patient quality of life goals. The most common side effects of
cytotoxic-type chemotherapy are listed below:

• Nervous system: neuropathy, tinnitus, vertigo, depression, anxiety.

• Digestive system: constipation, diarrhea, nausea, reflux, dysgeusia, hepatitis,
xerostomia, pancreatitis, anorexia/cachexia.
• Bone marrow: low numbers of red, white (including neutrophils), and plate-
let cells.
• Cardiac system: high or low blood pressure, fast or slow heart rate, heart mus-
cle damage.
• Reproductive system: effects of hormone blockade: impotence, low libido, early
or instant menopause, forgetfulness, hot flashes, and joint inflammation.
• Musculoskeletal system: joint pain and muscle aches; spasms, cramps, and pain;
reduced strength from muscle loss; cachexia-induced weight loss; loss of fitness.
• Other side effects include fatigue, scarring, insomnia, recurring or severe infec-
tions, hair loss, dry eyes, kidney inflammation, dyslipidemia, and an altered state.

Years of research on human safety and efficacy with specific oncology treat-
ments have been conducted in relation to the numerous IVs, oral nutritional supple-
ments, botanical medicine, or other natural health products (NHPs) consumed by
patients or prescribed by integrative oncology professionals. Some examples
include:

• The use of curcumin and nicotinamide reduces neuropathy [41, 42].

• Correcting liver damage from 5-FU with vitamin C [120].
• Vitamin B5 improves immunotherapy’s anti-cancer effects [121].
• Vitamin C induces positive effects with PARP inhibitors [122].

There is still widespread concern, as well as a perception bias or disregard for

this research and its value as an adjunct in cancer care. Understandably, the majority
of concerns revolve around cancer efficacy and patient safety. Considering recent
efforts to study cancer and NHPs in research, there is an appreciably larger body of
evidence delineating what works and what does not work. However, to address this
as competently as possible, it will always require more research. In the meantime,
19 Traditional, Complementary, and Integrative Medicine and Cancer Care in the UAE 321

where evidence does not yet exist, priority is given to supporting the patient’s con-
ventional care plan for the best possible outcome. It is a generally accepted practice
that when NHPs conflict with conventional oncology treatment, patients are strongly
advised to discontinue the item(s) after the conflicting treatment is completed.
To reassure colleagues, it is key that the TCIM professional doing the recom-
mending and prescribing have a thorough pharmacokinetic and pharmacodynamic
understanding of these items as well as be able to screen for interactions and contra-
indications to maintain safe prescribing. When a patient meets with a qualified pro-
fessional to discuss their IV, botanical and nutritional supplements, and other items
such as juices and protein powders purchased from the internet or on the recom-
mendation of a friend, patient satisfaction is met, harm is avoided, and there may
even be a cumulative benefit in improving quality of life and fighting cancer, which
is the highest priority goal during treatment. The summary is that the evidence sup-
ports dietary and botanical medicine supplements being generally recognized as
safe (GRAS) when the professional recommending them can evaluate the patient
properly and screen for contraindications. Individual patient pharmacodynamics
play a large role in drug interactions; there must be access to screening and items in
lab ordering to monitor hepatic and renal function when recommending items that
can pose a risk alongside chemotherapy treatments, just as when labs are done
before chemotherapy. Oncology is but one health care profession where there is
ongoing research and review, bringing new information, findings, and protocols for
patient care. Health care professionals can find specific items that are referenced in
all major peer-reviewed research publishing websites and applications to individu-
ally review in more detail as needed. This is a very time-consuming process and
should be part of the responsibility of the prescriber of the IV, dietary, and botanical
supplements to best serve the patient and the integrative oncology department.
Furthermore, it is recommended that, when recommending NHPs, objective data
points for the interactions be monitored.
The amount of research on lifestyle intervention, IV therapeutics, dietary, meta-
bolic, phytochemical, and botanical NHP use with cancer chemotherapies cannot be
individually reviewed in this work alone and requires ongoing updating as new
studies expand upon current knowledge. There is a lot of preclinical and empirical
evidence supporting the use of these strategies and options in cancer care in each of
the TCIM professions. For example, the use of fasting during chemotherapy has
evidence supporting it due to its synergy with cancer treatment. This is reflected
positively in the research on short-term fasting [104, 123, 124], fasting-mimicking
diets [24, 103, 105, 125–127], intermittent fasting [104, 128], and ketogenic diets
[129]. It is important to evaluate for GI, kidney, heart, and liver function; insulin
resistance; metabolic syndrome; or other co-morbidities, as well as to consider the
risk of disordered eating; the risk of developing cachexia; and cultural, seasonal,
and loco-regional influences on dietary patterns. Choosing and recommending the
correct dietary approach to complement conventional treatment needs time for
patient adaptation and implementation and does require the use of qualified nutri-
tional oncology professionals. Weight and muscle mass maintenance are linked to
longer overall survival, and the proper implementation of dietary plans and exercise
therapies can support these twin goals.
322 H. Kussmann

During the use of immunotherapies and targeted therapies in cancer, the role of
integrative oncology providers can continue with the use of synergists and efficacy
inducers. Evaluation of the microbiome is also important due to the proven fact that
an intact microbiome endures chemotherapy and provides for a better overall out-
come with immunotherapies.
As of this writing, the UAE has resources such as the Zayed Complex for Herbal
Research and Traditional Medicine through the Department of Health that provide
guidelines to consumers and are in ongoing development to remain current as a
resource for patients and professionals alike.
Table 19.1 provides a summary of commonly used TCIM NHPs with evidence
supporting chemotherapy, targeted therapies, and immune therapies. One statement
that is very commonly found in each study is the call for TCIM NHPs to be incor-
porated into clinical trials when clinical benefits are found.

Table 19.1 Summary of commonly used traditional, complementary, and integrative medicine
natural health products and lifestyle strategies employed with chemotherapy, immunotherapy, and
targeted therapies. Note that these should be screened for interaction with the specific chemother-
apy using an evidence-informed approach by a naturopathic doctor trained in drug-herb-nutrient
interactions
Study or supplement
name, reference Details/findings/recommendations
Meta-analysis,  • Among 19 trials including patients with cancer undergoing
supplement safety, chemotherapy, most (n = 18) of the DS studied (e.g., vitamins,
systematic review [130] botanicals, omega-3 fatty acids) were found to be safe
vitamins, botanical,
omega-3 fatty acids
Chemotherapy and  • Overall, treatment with curcumin in combination with
curcumin [131, 132] paclitaxel was superior to the paclitaxel-placebo combination
with respect to ORR and physical performance after 12 weeks of
treatment
 • Curcumin given intravenously caused no major safety issues
or reduction in quality of life, and it may be beneficial in reducing
fatigue
 • Advances in knowledge: This is the first clinical study to
explore the efficacy and safety of administering curcumin
intravenously in combination with chemotherapy in the treatment
of cancer patients
 • Curcumin exerted its anticancer effect by increasing reactive
oxygen species (ROS) production, which downregulated the DNA
repair protein RAD51, leading to upregulation of γH2AX
Curcumin [133] and  • Systematic review: curcumin increases the effectiveness of
radiotherapy and chemotherapy and radiotherapy, which results in improved patient
chemotherapy survival and increases the expression of anti-metastatic proteins
while reducing their side effects
Prostate Cancer  • The included trials involved 3418 prostate cancer patients—a
Progression and NHPs median of 64 men per trial—From 13 countries. Various trials
[134] evaluated the use of pomegranate seed, green tea, broccoli, and
turmeric; flaxseed, low-fat diet, lycopene, selenium, and
coenzyme Q10
 • All demonstrated beneficial effects
19 Traditional, Complementary, and Integrative Medicine and Cancer Care in the UAE 323

Table 19.1 (continued)

Study or supplement
name, reference Details/findings/recommendations
Vitamins B5 [121]  • In a small cohort of melanoma patients, the plasma levels of
Vitamin C [135–140] vitamin B5 positively correlated with responses to PD-1-targeted
D3 [141, 142] immunotherapy, favoring differentiation of CD8+ T cells into
IL-22 through fueling mitochondrial metabolism
 • High doses of vitamin C inhibit the growth of prostate, colon,
and pancreatic cancers, as well as mesothelioma cell lines
 • High-dose vitamin C improved fatigue and reduced nausea,
vomiting, and loss of appetite
 • It is generally regarded as safe, but blood vitamin D levels
should be monitored on a regular basis when taking it
 • Vitamin D has the potential to become a valid adjuvant in the
treatment of cancer
Fish oil/omega 3 fatty  • Preclinical evidence reveals that omega-3 PUFAs, and their
acids [143] or metabolites might modulate pivotal pathways underlying
polyunsaturated fatty complications secondary to cancer
acids (PUFAs)  • Anti-inflammatory and antinociceptive effects
 • Agonists of G protein-coupled receptors, namely, GPR40/
FFA1 and GPR120/FFA4
Gastrointestinal  • Of the agents studied for the prevention and treatment of
mucositis and probiotics gastrointestinal mucositis, the evidence continues to support the
[144, 145] use of probiotics containing lactobacillus spp. for the prevention
of chemoradiotherapy and radiotherapy-­induced diarrhea in
patients with pelvic malignancy and hyperbaric oxygen therapy to
treat radiation-induced proctitis
 • Twenty clinical trials published between 1988 and 2020 were
included in this review. Seventeen studies (85%) revealed
predominantly positive results when using probiotics to reduce
the incidence of treatment-related side effects in oncology
patients, while three studies (15%) reported no impact in their
findings
 • This study sheds some light on the significance of
chemotherapy and radiotherapy in altering the composition of the
gut microbiota, where probiotic strains may play an important
role in preventing or mitigating treatment-related side effects
Melatonin and NSCLC  • Enhance the overall survival rate in non-small-cell lung cancer
[146] patients (RR = 2.13; 95% CI, 1.41–3.24; P = 0.0004; I2 = 0%)
Melatonin and and various solid tumor patients (RR = 2.31; 95% CI, 1.78–2.99;
glioblastoma [147] P < 0.00001; I2 = 0%)
Melatonin and tumor  • Reduce the incidence of neurotoxicity (RR = 0.30, 95% CI,
effects [146] 0.19–0.45; P < 0.00001), thrombocytopenia (RR = 0.23; 95% CI,
0.16–0.33; P < 0.00001), and asthenia (RR = 0.43, 95% CI,
0.38–0.49; P < 0.00001) during chemotherapy
 • In a case report of a complete response in glioblastoma,
melatonin was combined with octreotide and retinoids, vitamin E,
and vitamin C
 • Melatonin improved the tumor remission rate and overall
survival rate while reducing the incidence of chemotherapy side
effects
(continued)
324 H. Kussmann

Table 19.1 (continued)

Study or supplement
name, reference Details/findings/recommendations
Quality of life and  • The mistletoe group showed a trend toward less neutropenia
mistletoe [148] (p = 0.178) and improved pain and appetite loss scores
(p < 0.0001 and p = 0.047, respectively), while having a positive,
but not significant, impact on other EORTC QLQ-C30 scores
 • Mistletoe extracts were safe in this clinical study
 • Neither did subcutaneous injections induce fever nor did they
influence the frequency of relapse and metastasis within 5 years.
This result suggests that mistletoe extracts had no adverse
interactions with the anticancer agents used in this study
 • Certain chemotherapy side effects were reduced in breast
cancer patients who received this complementary treatment
Flavonoids [149, 150]  • Silymarin, crocin, anthocyanidins, apigenin, quercetin,
luteolin, genistein, and resveratrol all have individual pathway
effects in modulating cancer growth
 • mTOR signaling showed the most targetable promise with
flavonoids in chemo-resistant breast cancer, and further clinical
trials are necessary to validate mTOR as a target
 • Apigenin, baicalein, curcumin, EGCG, genistein, luteolin,
oridonin, quercetin, and wogonin repress VegF, NF-kappa B
(NF-κB, a proinflammatory transcription factor) and inhibit
proinflammatory cytokines such as TNF-α and IL-6 in vitro
Exercise and breast,  • A circuit-based, interval-based aerobic and resistance exercise
prostate, or colorectal intervention improved patient-reported sleep quality in breast,
cancer survivors [151], prostate, and colorectal cancer survivors
and cardiotoxicity  • Additionally, this exercise-induced improvement in sleep
prevention [152], quality may result in reduced insulin resistance
muscle wasting  • Exercise is feasible with lung cancer and promotes quality of
prevention [39, 153] life and survival
Cancer-related pain [7]  • Adding non-pharmacological treatment such as acupuncture to
Climacteric symptoms conventional pain management is helpful in addressing a patient’s
[154] pain level
Fatigue [40] and  • Acupuncture has promising results in treating the severe side
acupuncture effects of hormone blockade in people with breast cancer
 • Functional assessment of cancer therapy-fatigue (FACT-F)
scores changed significantly with acupuncture
Functional food  • Cinnamaldehyde downregulates FAK signaling in
[155–157], diets [102, osteosarcoma
158] and metabolic  • Chlorella prevents bone marrow suppression from cisplatin
effects [159], and  • Beet and carrot juice in large amounts benefit when combined
immuno-­oncology [159, with chlorambucil in the treatment of chronic lymphocytic leukemia
160]  • This randomized trial showed improvement in the overall
functional life index and improvement in hemoglobin in patients
with stage 2 and stage 3 colon cancer treated with yoga,
naturopathy, and dietary interventions
 • It is possible to promote patients’ response rate to anti-PD-1
by manipulating the gut bacteria composition of non-responders,
thereby achieving long-term progression-­free survival
 • Protein arginine methyltransferases (PRMTs) have an effect in
combination with immune checkpoint inhibitors
 • Dietary fiber was associated with significantly improved
progression-free survival in 128 patients with melanoma receiving
anti-PD-1 immunotherapy
19 Traditional, Complementary, and Integrative Medicine and Cancer Care in the UAE 325

Table 19.1 (continued)

Study or supplement
name, reference Details/findings/recommendations
Astragalus [33, 161]  • Astragalus polysaccharide can promote the activities of
and curcumin macrophages, natural killer cells, dendritic cells, T lymphocytes,
B lymphocytes, and microglia and induce the expression of a
variety of cytokines and chemokines
 • Astragalus with curcumin reduced the expression of FGF2,
MMP2, VEGF, HGF, and TF in mouse models of human
hepatocellular carcinoma, giving potential for combination
therapy
Medicinal mushrooms  • Beneficial effects on quality of life and a reduction of the
Agaricus, Coriolus, and adverse effects of conventional treatment. Positive effects on
Ganoderma [36] antitumor activity and immune modulation were indicated; more
research is needed

19.6 Conclusion

In concluding this chapter, there are over 20 years of research and abundant support-
ing evidence presented for the use of traditional, complementary, and integrative
medicine professionals in the field of integrative oncology. Ongoing comparative
clinical effectiveness research and collaborative professional inclusion are needed
to further define benefits and validate effects within established oncology treat-
ments. Given the challenges and opportunities for the status of integrative oncology,
there is high potential for the UAE to become the world leader in providing integra-
tive oncology. This comes in the form of the development of collaborative research,
professional regulation, and the inclusion of safe, effective patient-centered care
unified with conventional cancer treatment.

Conflict of Interest The author has no conflict of interest to declare.

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Dr. Heidi Kussmann ND FABNO is a Canadian and American-

licensed naturopathic doctor (ND) and board certified in naturo-
pathic oncology (FABNO) since 2010, with recertification in 2020.
She completed her BSc in 1997 at the University of Victoria in
British Columbia, Canada, followed by the ND postgraduate
degree in 2002 from the Canadian College of Naturopathic
Medicine in Toronto, Ontario, Canada. She has been in practice for
over 20 years and has always worked in integrative cancer settings
with people in all stages of cancer. Dr. Kussmann recently com-
pleted the Harvard Medical School Global Scholars Clinical
Research Trials Certificate in March 2024. Professional member-
ships include:

• Massachusetts Society of Naturopathic Doctors,

Massacheussetts, USA
• Vermont Association of Naturopathic Physicians,
Vermont, USA
• The Association of Clinical Research Professionals,
Alexandria, Virginia
• European Society of Medical Oncology, Lugano, Switzerland
• Society of Clinical Research Associates, Chalfont, Pennsylvania
• Society for the Immunotherapy of cancer, Milwaukee, Wisconsin
• Metabolic Terrain Institute of Health, Tucson, Arizona
• Oncology Association of Naturopathic Physicians,
Juneau, Alaska
• European Society of Integrative Medicine, Berlin, Germany
• Society for Integrative Oncology, Pepper Pike, Ohio
• Emirates Oncology Society, Dubai, UAE
• Canadian Association for Naturopathic Doctors,
Toronto, Ontario, Canada
19 Traditional, Complementary, and Integrative Medicine and Cancer Care in the UAE 335

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Radiation Oncology in the UAE
20
Ibrahim H. Abu-Gheida, Rana Irfan Mahmood, Fady Geara,
and Falah Al Khatib

20.1 Introduction

20.1.1 What Is Radiation Oncology

Radiation oncology is a medical specialty that combines the fields of biology, phys-
ics, and medicine to utilize the use of ionizing radiation to treat malignancies,
benign tumors, and sometimes functional diseases refractory to conventional
treatment(s) [1]. Ionizing radiation can be delivered in the form of high-dose X-rays,
photons, neutrons, protons, electrons, and heavy ion particles, such as in carbon
therapy [2]. While radiation is delivered most commonly as external beam radiation,
sealed radiation sources placed in close proximity to the target are also often used,
and this technique is called Brachytherapy [2].

I. H. Abu-Gheida (*)
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Burjeel Medical City, Abu Dhabi, United Arab Emirates
R. I. Mahmood
Mediclinic City Hospital, Dubai, United Arab Emirates
F. Geara
Cleveland Clinic, Abu Dhabi, United Arab Emirates
e-mail: gearaF@clevelandclinicabudhabi.ae
F. A. Khatib
Emirates Oncology Society, Emirates Medical Association, Abu Dhabi, United Arab Emirates
Al Zahra Hospital, Dubai, United Arab Emirates
e-mail: fak@eim.ae

© The Author(s) 2024 337

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_20
338 I. H. Abu-Gheida et al.

20.1.2 Origin of Radiation

While people think that the field of radiation therapy is new, its origin actually
dates back more than 130 years, when Wilhelm Conrad Rontgen described X-rays
as being used to treat cancer in 1896. Natural radioactivity was discovered by
Antoine Henri Becquerel in 1896. Pierre and Marie Curie utilized this concept to
treat a pharyngeal carcinoma in 1904 by placing a radioactive substance in close
proximity to and into the tumors [3]. The concept of fractionated radiotherapy was
established by Regaud and Ferroux in the 1920s, and since then, the radiotherapy
field has been in a constant state of progress and development [4]. The goal of
modern radiotherapy is to deliver the highest dose required for tumor eradication
while exposing normal tissues to the least amount of radiation. The major progress
happened with the introduction of the CT scan and the ability to plan and deliver
3D-based treatment. Subsequently, further progress was made in beam calculation
and delivery with the introduction of intensity-modulated radiotherapy (IMRT),
volumetric modulated arc therapy (VMAT), image-guided radiotherapy (IGRT),
stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT), and more
recently, stereotactic ablative body radiation (SABR) due to its ablative character-
istics [3, 5]. With an improved understanding of radiation biology and the effec-
tiveness of heavy particles, protons and carbon ions were introduced with
advancements in treatment modalities such as intensity-modulated proton therapy
(IMPT) [6]. Our ability to plan and deliver radiotherapy with high precision and
accuracy continues to improve due to enhanced data processing, the use of robot-
ics, and artificial intelligence.

20.1.3 How Often Is It Used?

Approximately 48–62% of all cancer patients will benefit from radiation ther-
apy [7, 8]. However, at least one in four people needing radiotherapy does not
receive it [9]. Radiotherapy remains a mainstay in the treatment of cancer. A
comparison of the contributions toward cure by the major cancer treatment
modalities shows that of those cured, 49% are cured by surgery, 40% by radio-
therapy, and 11% by chemotherapy [10]. Radiotherapy can be utilized in the
primary setting for definitive treatment, such as prostate cancer, or in combina-
tion with other local therapies, such as surgeries. It can also be used to palliate
symptoms in advanced cancer cases where the cancer has spread to other organs,
causing symptoms such as pain [11]. More importantly, with the advancement
in systemic therapy and the introduction of targeted and immune therapies, can-
cer is becoming more of a chronic disease, so the likelihood of needing radiation
therapy throughout the disease process is increasing. Moreover, with the
improvement of radiation treatment planning, patient positioning, and treatment
delivery, the radiotherapy dose is being delivered at the target with more sparing
of the surrounding normal structures; therefore, the utilization of re-irradiation
is also increasing [12].
20 Radiation Oncology in the UAE 339

20.2 The Radiation Oncology Team

A radiation oncology department is composed of multiple different individuals with

separate and direct roles and responsibilities working together in harmony to pro-
vide this highly complex service, which includes:

1. A radiation oncologist is a certified physician who is responsible for assessing

each case, providing consultation for patients, and overseeing the radiotherapy
plan and treatment delivery.
2. Radiation oncology medical physicists usually hold a graduate degree in medical
physics along with certification and clinical experience. They are responsible for
commissioning and acceptance testing of the radiotherapy machines. They work
along with radiation oncologists, dosimetrists, and therapists to design and
ensure adequate delivery of treatment plans, as well as carry out all the quality
assurance measurements needed for plans and machines.
3. Radiation therapy technologists (RTTs) are highly qualified and trained techni-
cians who are responsible for ensuring proper patient identification and operat-
ing the machines to provide patients with their treatment [13].
4. Radiation therapy machine engineers are usually biomedical engineers with spe-
cialized training in radiotherapy machine installation and maintenance.
5. Radiation oncology nurses have special experience in oncology nursing and
understand the workflow and process of radiation. They also assist in procedures
such as brachytherapy, IV insertion for simulations, and patient monitoring.

20.3 Equipment Suppliers and Support

Within the United Arab Emirates (UAE), rather than purchasing from the primary
source, end users (hospitals and facilities) purchase required radiotherapy machines
and equipment through third parties. There are several companies based in the UAE
that facilitate it. These companies are well equipped and staffed to facilitate and
ease the logistics of acquiring and maintaining an adequate supply of all radiother-
apy-related equipment and upgrades. For example, companies like Emitac Solutions,
Atlas Medical, Al Zahrawi Group, Al Naghi Group, and several others are known to
represent major radiotherapy-­related companies and equipment suppliers in the
UAE, along with all accessories associated with setting up the department, such as
quality assurance equipment and patient positioning devices, etc.
Having third-party companies’ mediation has both pros and cons. An advantage
would be that end-users do not need to contact many different primary providers, as
there are many additional equipment and accessories that might be needed but are
not provided by the main primary source. This way, the third party helps facilitate
the end-user’s requests and ensure delivery, customs clearance, and all other steps
taken to ensure delivery in a timely fashion. On the other hand, this might hinder
and delay direct communications that end users sometimes need to have with their
primary source.
340 I. H. Abu-Gheida et al.

20.4 Rules and Regulations

Setting up any department of radiation oncology in the UAE undergoes vigorous

evaluation and inspection led by the Federal Authority of Nuclear Regulation
(FANR), the Department of Health for Abu Dhabi, the Dubai Health Authority in
Dubai, and the Ministry of Health and Prevention for the Northern Emirates. This
includes reviewing all the engineering and shielding preparations, manpower
preparations, applied protocols and guidelines for clinical practice, and peer
review. No department can import machines and begin operations until all neces-
sary clearances have been obtained. Furthermore, inspecting those facilities that
operate is also something done in order to ensure patient and public safety are
met. Prior to going live, the authorities require a second independent audit of the
departments to ensure the safety of the department and neighboring departments
or spaces in the facility. Any potential unsafe practice or condition shall be high-
lighted and adjusted before any facility can start accepting patients for treatment.
All department members must have basic training in radiation safety, and their
credentials must be reviewed and approved by the governing entity before they
can work in this field. Furthermore, TLDs sensitive to photons and neutrons must
be worn by the entire department, and the readings must be sent on a regular
basis to the authorities.

20.5 Radiotherapy Population in the UAE

According to the UAE Federal Competitiveness and Statistics Center, the popula-
tion of the UAE has seen a steady increase since 1971 up until 2020 [14]. That
increase in population is related to massive growth and economic stability, along
with the opportunity provided. This is reflected in the Ministry of Health and
Prevention (MOHAP) cancer registry data, with the latest published records from
2019 indicating a steady increase in cancer incidence [15]. Breast cancer remains
the most commonly diagnosed cancer in the UAE, and it is also the most common
cancer site treated in radiotherapy departments across the UAE [15].
The rising population of the UAE demands an increase in the number of radio-
therapy machines to continue to provide optimal use. ESTRO-QUARTS guidelines
suggest, on average, one linear accelerator per 80,000–250,000 people in high-­
resource countries [16]. The European Coordination Committee of the Radiological
Electromedical and Health Care IT Industry (COCIR) endorsed this recommenda-
tion of 7 machines per million population [17]. A recently proposed national cancer
control plan for the UAE aims to not only focus on cancer screening and prevention
but also improve equitable access to high-quality treatment [18]. In 2017, the UAE
reported 4299 new cases of cancer, which is expected to rise each year [19]. Given
that radiotherapy is expected to be required in 60% of these new cases, 2500 new
patients are expected to seek this treatment each year. The real workload is likely to
20 Radiation Oncology in the UAE 341

be higher due to the increasing use of re-irradiation. The IAEA recommends one
LINAC for 200 patients per year [20], and this workload will necessitate 15
LINACS, not including specialized equipment such as the Cyberknife or Gamma
knife. While this calculation is based on registry data from 2017, with a 10% annual
increase expected, a total of 25 LINACS would be required to meet the demands by
2025. Reassuringly, Table 20.1 shows that 20 LINACS are either in operation or are
being planned from 2023 onwards.

Table 20.1 Overview of operational departments as of October 2022

Operational
(as of
Emirate/ October
city Hospital Machine 1 Machine 2 Machine 3 Brachy 2022)
Abu-­ Tawam Clinac Clinac Tomotherapy Yes Yes
Dhabi/ Hospital
Al Ain
Abu Gulf Trilogy True Beam NA Yes Yes
Dhabi/ International
Al Bahia Cancer
Center
Abu Burjeel Versa HD Versa HD NA TBA Yes
Dhabi/ Medical
MBZ City
city
Abu Mediclinic True Beam NA NA NA Yes
Dhabi Airport
City Road
Dubai American Trilogy NA NA Yes Yes
Hospital
Dubai
Mediclinic True Beam NA NA Yes Yes
City hospital
Advanced Versa HD NA NA NA Yes
Care
Oncology
Center
Saudi Versa HD NA NA NA Yes
German
Hospital
NeuroSpinal CyberKnife Tomortherapy NA NA Yes
Hospital
Ras Al Sheikh Versa HD Clinac ViewRay NA Yes
Khaimah Khalifah MR Linac
Specialty
hospital
Varian/Elekta/Accuray/Others
342 I. H. Abu-Gheida et al.

20.6 Departments of Radiation Oncology in the UAE

Radiation oncology practices have been available since 1979, when Tawam Hospital
in Al-Ain became operational. This department has been up and running until our
day today, and Tawam is considered to be the largest comprehensive cancer hospital
in the UAE. There has been a significant increase in the development and invest-
ment in radiotherapy in the UAE since the foundation of oncology practice until
now, with an exponential increase in the number of radiotherapy departments open-
ing within the past 2 years. Mafraq Hospital in Abu Dhabi, founded in 1983, was the
only department that ended its services in 2007, while another facility was estab-
lished in the same Emirate. Currently, there are at least 10 centers providing radia-
tion therapy services in the UAE: 4 in Abu Dhabi and Al Ain, 5 in Dubai, and 1 in
Ras Al-Khaimah. These centers are currently operating 7 linear accelerators
(LINACs), 1 tomotherapy unit, and 2 brachytherapy units in the Abu Dhabi/Al Ain
region; 2 linear accelerators and 1 ViewRay MR Linac are in Ras Al-Khaimah;
while in Dubai, there are currently 4 linear accelerators, 1 tomotherapy machine, 1
cyberknife machine, and 2 brachytherapy units in use (Fig. 20.1 summarizes the
timetable of different radiotherapy departments in the UAE). Most LINACS in the
UAE are of recent generation and of new status, with Elekta Versa HD™ and
Varian—TrueBeam® being the most widely used in the UAE. Complex intensity-­
modulated radiation therapy (IMRT), RAPID-ARC, and volumetric modulated arc
therapy (VMAT) accompanied by advanced image guidance radiation (IGRT) are
used in all of those sites. Cyberknife radiosurgery has been introduced for the first
time by a Neuro Spinal Hospital in Dubai. Novalis’ full system with BrainLab and
Elements software, which is a tool for the delivery of precision radiotherapy and
stereotactic radiosurgery (SRS), has been introduced for the first time in the UAE by
Burjeel Medical City. Finally, in Ras Al-Khaimah, an MRI-guided radiation therapy

The radiotherapy providing facilities that are currently operational in the UAE
0.28m 4.1m 8.2 m* 8.6 m* 9.5 m* 12.4m

2007 – Present
Mafraq’s
radiotherapy
department was
closed with the
opening of GICC

1971---1979 1981 1983 1985 2002 2005 2007 2010 2011 2013 2014 2015 2016 2017 2019 2020 2021 2022 2023-----2040

1979 – Present 1983 – 2007 2007 – Present 2011 – Present 2015 – Present 2016 – Present 2019 – Present 2021 – Present 2022 – Present 2023 – Onwards
Opening of first Opening of Mafraq Opening of Gulf American Hospital Opening of Opening of Advanced Care Burjeel Medical - Saudi German - Cleveland Clinic
radiation center in Hospital Radiation International Dubai Sheikh Khalifa Mediclinic City Oncology Center City Abu Dhabi Hospital Dubai Abu Dhabi
the UAE (Tawam Facilities in Abu Dhabi Cancer Center Specialty Hospital Hospital Dubai - Neurospinal - Shaikh Shakbout
Hospital-Al-Ain) (GICC) in Abu Radiation in Ras Radiation in Hospital Medical City in
Dhabi Al Khaimah Dubai Dubai collaboration
- Mediclinic with Mayo Clinic
Airport Road - Merdiff Hospital
– Abu Dhabi - Rashed Hospital
- Gulf International
Cancer Center 2

Radiotherapy
Providing UAE Facility
Population Establishment Termination
Facilities

*Source: Federal Competitiveness and Statistics Centre

Fig. 20.1 A sketch of the timetable of different radiation departments in the UAE to date
20 Radiation Oncology in the UAE 343

cancer treatment system that combines magnetic resonance imaging with adaptive
radiotherapy has been established (Table 20.1).
Finally, as mentioned earlier, there are a number of relatively high-capacity
departments that are soon to become operational in Abu Dhabi, as well as expansion
into the upper and northern emirates by the Gulf International Cancer Center.
Furthermore, the introduction of new treatment modalities such as Gamma Knife
and Particle therapy has been announced as part of future expansion plans in at least
two centers.

20.7 Education and Training

Currently, there is no formal or accredited radiation oncology training in the

UAE. All practicing radiation oncologists have obtained training and certification
from abroad and, thereafter, obtained their license to practice in the UAE. Whether
it is through Abu Dhabi’s Department of Health, Dubai Health Authority, or the
Ministry of Health and Prevention, all physicians’ documentation gets thorough
verification and assessment before a license is granted. Practicing radiation oncolo-
gists in the UAE come from different backgrounds of training. Some went through
pure radiotherapy training, while others underwent clinical oncology training,
which includes both medical and radiation oncology. According to their current
active medical licenses in the UAE, the latter group is permitted to practice either
medical oncology or radiation oncology, or both, in the UAE.
Specialized training for radiation oncology medical physicists and radiation ther-
apists (RTTs) is currently not available in the UAE. Most of the currently licensed
individuals have obtained their training certification abroad. The UAE licensing
health authorities have a rigorous process for verifying degrees and training.

20.8 Professional Societies for Radiation Oncology

in the UAE

Currently, there is no official radiation oncology society in the UAE. Most of the
radiation oncologists are part of or members of oncology societies, with the largest
being the Emirates oncology society, under the umbrella of the Emirates Medical
Association. There is currently an ongoing attempt through the MOHAP cancer
control group to help establish a UAE-level radiotherapy collaborative group.

20.9 Research in Radiation Oncology

Research is an area of active development in the UAE health care sector and in
radiation oncology within the UAE. There are several research-active radiation
oncologists practicing in the UAE who participate in the ongoing projects locally
and internationally. Some centers are accredited as part of international research
344 I. H. Abu-Gheida et al.

collaborative groups. For example, the Cleveland Clinic Abu Dhabi is a National
Research Group (NRG) site. Burjeel Medical City is involved in several ongoing
research projects as a Novalis center. To our knowledge, Burjeel Medical City
Radiotherapy has a prospective cancer registry for which at least one abstract has
been submitted and a full paper is pending.

20.10 Conclusion

In conclusion, the future of radiation oncology in the UAE is promising. The UAE’s
diverse population and nationalities provide a very unique and comprehensive
patient population and cohort for research. There seems to be a trend toward an
oversupply of radiotherapy machines in the UAE. However, with future plans for
increased medical tourism and international patients visiting the UAE for treatment,
this option is becoming more viable. Creating collaborative radiotherapy groups
across the UAE would be another significant and beneficial step forward for society
and patient care. It is important to share experience and knowledge through an open
and supportive collaborative network, especially in the era of radiotherapy sub-­
specialization and site-specific expertise. Furthermore, establishing a unified
research governance for radiotherapy centers will allow for the enrollment of more
patients in future clinical studies. Creating an accredited training program for medi-
cal physicists, dosimetrists, and radiation therapists, which is critical to maintaining
a sufficient supply of those difficult to recruit, highly specialized, and qualified
individuals. Finally, having more novel approaches and utilizing major develop-
ments in artificial intelligence and machine learning could help reduce physician
time while standardizing and improving the quality of treatment delivery.

Acknowledgments We would like to thank Ms. Faryal Iqbal from Burjeel Medical City for her
assistance with Fig. 20.1 as well as our industrial partners for data verification.

Conflict of Interest The authors have no conflict of interest to declare.

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346 I. H. Abu-Gheida et al.

Dr. Ibrahim H. Abu-Gheida is the Clinical Director of the

department of radiation oncology at Burjeel Medical City. He also
serves as a regional Radiological Society of North America
(RSNA) committee representative for the Middle East and Africa.
Dr. Abu-Gheida completed his undergraduate training, where he
earned a Bachelor of Science with honors degree from the American
University of Beirut. Following this, Dr. Abu-Gheida completed his
Medical School training at the American University of Beirut
Medical Center. He continued and joined the Department of
Internal Medicine at the American University of Beirut. Then he
did his training in the Department of Radiation Oncology at the
American University of Beirut Medical Center, where he also
served as the chief resident. During his training, Dr. Abu-Gheida
completed a Harvard-affiliated NIH-funded research program as
well. After his residency, Dr. Ibrahim went to the Cleveland Clinic
in Ohio, where he was appointed as an Advanced Clinical Radiation
Oncology Fellow. Dr. Abu-Gheida went and joined the University
of Texas MD Anderson Cancer Center, where he sub-specialized in
treating breast, gastrointestinal, and genitourinary cancers. Dr. Abu
Gheida played an instrumental role in establishing and heading the
radiation oncology facility and department at Burjeel Medical City.
He has chaired and co-chaired multiple international oncology con-
ferences. Dr. Ibrahim has more than 40 peer-reviewed papers in
prestigious medical journals, including the American Society of
Radiation Oncology official journal - the International Journal of
Radiation Oncology Biology and Physics, Nature, the Journal of
Clinical Oncology, and several others. He is also the primary author
and editor of several book chapters published in prestigious books.

Dr. Rana Mahmood completed specialist clinical oncology

training in the UK and has been a consultant for the last 16 years.
He had several managerial roles and, most recently, was clinical
director for cancer services across East Suffolk and North Essex
(ESNEFT NHS Trust). He is a passionate teacher and is currently
an associate professor at the MBR University of Medicine and
Health Sciences in Dubai. Dr. Mahmood has a special interest in
advanced image-guided radiotherapy (IM-IGRT), stereotactic
radiotherapy (SABR), and image-adapted high-­dose-­rate brachy-
therapy (HDR). He set up an interstitial brachytherapy practice in
King Faisal Specialist Hospital, Riyadh, and later at Colchester
Hospital, university NHS trust, to benefit a wide population in
Essex and Suffolk. He is the first to introduce and the only practi-
tioner to provide gynecological interstitial brachytherapy in the
UAE. He has also set up the only service in the UAE to provide
prostate HDR brachytherapy and a trans-perineal spacer device. He
has been the principal investigator for several landmark radiother-
apy trials, including STAMPEDE, RADICALS, CHHiP, PACE,
RAIDER, and EMBRACE, and he has extensively published
his work.
20 Radiation Oncology in the UAE 347

Dr. Fady Geara is a professor and chairman of the department of

radiation oncology at the oncology Institute of the Cleveland Clinic
Abu Dhabi. He graduated in medicine from the University of Paris
and completed his training in radiation oncology both in France
and at the University of Texas MD Anderson Cancer Center in
Houston, Texas.
He started his professional career at MD Anderson, where he
led innovative research in radiation biology and was a major con-
tributor to the development of clinical radiation oncology programs
in head and neck and thoracic radiation oncology. He later moved
to the American University of Beirut, where he built a modern,
state-of-the-art radiation oncology program. He has recently joined
the Cleveland Clinic Abu Dhabi to develop the radiation oncology
program at the new oncology institute.
Dr. Geara is a diplomate of the American Board of Radiology in
radiation oncology, and a holder of a Ph.D. degree in radiation biol-
ogy. He is a well-known authority in clinical radiation oncology
and program development. He is also a prolific writer, with over
126 peer-reviewed articles published, and a committed teacher,
with more than 200 teaching lectures given in many countries on
current radiation and general oncology topics.

Dr. Falah Al Khatib graduated from the faculty of medicine

at Ain Shamis University in 1969. He completed his training and
residency in general and thoracic surgery in Iraq from 1970 to
1975. Later, he changed his specialty to radiotherapy, took DMRT
in 1980, and obtained fellowship FFRRCSI in 1984.
He worked as a consultant and chief of radiotherapy at Tawam
Hospital between 1986 and 2007 and was involved in the manage-
ment of more than 12,000 patients.
Dr. Falah helped establish Tawam as the main cancer center in
the UAE and in the region, and he started a hospital-based tumor
registry in 1986, which later became the foundation for the UAE
cancer registry in 1998. During his time at Tawam, he created many
multidisciplinary clinics for different cancers, like breast, gyneco-
logical, H + N, and thyroid. He has been a member of many
national, regional, and international committees and a member of
the UAE National Cancer Committee. He has been very active in
the public education and cancer awareness programs in the UAE
via TV, radio, newspaper articles, interviews, and conferences.
From August 2007 to August 2014, Dr. Falah worked as a con-
sultant clinical oncologist at the Gulf International Cancer Center
(GICC) in Abu Dhabi, which is the first private oncology facility in
the UAE and the region. This center provides radiotherapy and
medical oncology as an outpatient facility and has the first PET/CT
scan in the region.
From January 2011 to 31/12/2021, he has worked as a consul-
tant clinical oncologist (radiation oncology and medical oncology)
at the Mediclinic City Hospital, Dubai, UAE, first as a part-time
and since January 2016 as a full-time consultant.
From February 2022, he is working as part-time consultant
clinical oncologist at the Advanced Care Oncology Center and at
Al Zahra Hospital, Dubai.
348 I. H. Abu-Gheida et al.

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Surgical Oncology in the UAE
21
Faek R. El Jamali, Chafik Sidani, and Stephen R. Grobmyer

21.1 Overview of Cancer Care in the UAE

The healthcare sector in the United Arab Emirates (UAE) has seen a tremendous
evolution over the past two decades, commensurate with the overall rapid ascent of
the economic standard of the country as a whole. From the first and only hospital
that opened in the city of Al Ain in 1960, the country has rapidly moved to its cur-
rent state of over 150 hospitals and over 150 primary healthcare centers in the short
span of 40 years. At least 30 of these centers are tertiary care centers. This rapid
evolution in the health sector has been coupled with a dramatic improvement in
healthcare outcomes [1, 2].
In parallel with the overall evolution of the healthcare sector in the country, can-
cer care has similarly gradually evolved over time. Cancer care was provided in
individual medical centres based on the interests and expertise of the local medical
team. As the individual medical centers evolved, so did the oncology practice within
each, and this in turn followed the worldwide evolution of cancer care toward a
centralized multidisciplinary approach with the emergence of at least four compre-
hensive cancer centers in the UAE in 2022.
The private sector in both Dubai and Abu Dhabi plays an important role in the
delivery of healthcare services. In the remaining five Emirates, the Ministry of
Health is both the regulator and the main provider of most healthcare services.
Nonetheless, when it comes to cancer care, it appears that the activity is concen-
trated in specialized centers.
In the UAE, in 2021, the number of deaths from cancer totaled 975 (506 in males
and 469 in females) and accounted for 8.2% of all deaths, regardless of nationality,

F. R. El Jamali (*) · C. Sidani · S. R. Grobmyer

Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
e-mail: eljamaf@clevelandclinicabudhabi.ae; SidaniS@clevelandclinicabudhabi.ae;
GrobmyS@clevelandclinicabudhabi.ae

© The Author(s) 2024 349

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_21
350 F. R. El Jamali et al.

type of cancer or gender. Colon (11.49%), trachea, bronchus, and lung (9.85%), and
breast (9.64%) cancers cause most cancer deaths [UAE - National Cancer
Registry] [3].
In the Emirate of Abu Dhabi, cancer caused 15.2% of all deaths in the Emirate in
2017. Breast (11.5%), bronchus and lung (8.7%), and colon (8.5%) cancers cause
the most cancer deaths [4]. In 2017, cancer-related clinical activity occurred most
frequently at the nationally designated cancer center Tawam Hospital (36.8% of the
total volume of cancer care), followed by Sheikh Khalifa Medical City (SKMC) at
24.8%, Cleveland Clinic Abu Dhabi at 10.9%, Mafraq Hospital at 10.5%, and NMC
Specialty Hospital at 4.8% [4]. These numbers have drastically changed over the
last few years with the establishment of Sheikh Shakhbout Medical City (as the
fusion between SKMC and Mafraq) and the significant growth of cancer services at
the Cleveland Clinic Abu Dhabi and other private hospital systems like VPS
Healthcare/Burjeel Medical City.
Assuming cancer surgery is generally considered major surgery, and looking at
all the major surgery procedures that were carried out in 2020 in the Emirate of
Dubai, we note that there were 71,339 major procedures done [5]. Of these, 44,990
major procedures (63%) were done in the private sector, highlighting the impor-
tance of the private sector in the overall delivery of healthcare in that Emirate. One
major source of concern is the number of major oncology procedures performed as
emergencies. Out of 462 oncology-Diagnosis Related Group (DRG) related cases,
252 were done as an emergency. This can be multifactorial, but it indicates a delayed
presentation with advanced disease or disease complications. In the Emirate of
Dubai, there were close to 100,000 outpatient visits that were cancer-related in 2020
among 11,525 patients.
Interestingly, there were 135 international patients who received oncology treat-
ment in the emirate of Dubai in the year 2020, representing 41% of all international
medical tourism cases for that year {DHA}. 58 such patients came from the UK, 31
from Germany, and 19 from the USA. Only five international patients underwent
surgery in Dubai in 2020. On the other hand, the WHO and other sources estimate
that the UAE government spent almost a quarter of its total healthcare expenditure
in 2010 to send its citizens abroad for medical care [6]. Looking at the DHA data for
health expenditure abroad for the emirate of Dubai, 326 patients traveled abroad for
medical care with an average cost of 620,000 AED per patient, of which 70% were
direct medical expenditures. The United Kingdom was the most popular destination
for international medical care, followed by Germany and the United States [5]. This
represents a 28% drop from the prior year, which may be related to the global lock-
down related to the COVID-19 pandemic or the population’s increased confidence
in the UAE healthcare sector.

21.2 The Evolution of Surgical Oncology as a Specialty

General surgical oncology has seen a tremendous evolution in the last two decades
into a distinct surgical specialty with multidisciplinary care at its core. Training is
primarily focused on GI, endocrine, soft tissue, and breast oncology. This evolution
21 Surgical Oncology in the UAE 351

Table 21.1 Significant dates 1975 James Ewing society renamed Society of
in the evolution of surgical Surgical Oncology
oncology in the United States 1983 First surgical oncology fellowship training
and the United Arab Emirates program approved
2003 First breast oncology fellowship program
approved
2011 American Board of Surgery approves surgical
oncology subspecialty certification
2021 Arab Board of Surgery approves surgical
oncology subspecialty certification

has been spearheaded internationally by many bodies, including surgical societies

and regulatory boards. Many of these societies have had a profound impact on shap-
ing surgical oncology into the distinct specialty it is today, but perhaps none more
than the Society of Surgical Oncology (SSO) in the United States of America due to
the prominent position American medicine holds on the world stage.
The Society of Surgical Oncology was established in the USA in 1975 as an
evolution of the James Ewing Society, which was made up of alumni who had
trained at the Memorial Sloan-Kettering Cancer Center and gathered in New York
for both scientific and social purposes [7]. Early surgical oncologists placed great
emphasis on the total care of the patient. They often oversee not only the surgical
aspect of the treatment but also pathology, radiation therapy, and chemotherapy.
With time and as each of these specialties evolved into a separate discipline, the role
of the surgical oncologist transitioned into focusing on providing surgical care for
the cancer patient within this multidisciplinary team.
The impact of the Society of Surgical Oncology on the definition of the spe-
cialty was tremendous. The society sets the training curriculum as well as the
formal minimum requirements for training. Surgical oncology training guide-
lines were formalized in 1978, and criteria for approving surgical oncology train-
ing programs were defined and utilized until 2014, when the Accreditation
Council for Graduate Medical Education (ACGME) took over the process of
reviewing the programs [8].
This focus on surgical oncology as a specialty has allowed the value that a well-­
trained surgical oncologist can bring to cancer care to become quite tangible and has
served as the basis for the growth and expansion of surgical oncology training pro-
grams, as well as increased recognition of the specialty worldwide. Surgical oncolo-
gists bring with them advanced surgical training, having worked with some of the
world’s foremost experts in cancer surgery at high-volume centers. They also bring
with them the multidisciplinary approach that is at the heart of cancer care in this
day and age (Table 21.1).

21.3 Current Status of Surgical Oncology in the UAE

It is a challenging task to try and accurately assess the current status of surgical
oncology in the UAE due to the lack of objective data on current surgical oncology
practices and outcomes. There are at least four fellowship-trained general surgical
352 F. R. El Jamali et al.

oncologists who completed training in the USA, including Faek Jamali, who com-
pleted training at the University of Pittsburgh; Yasir Akmal at City of Hope National
Medical Center; Stephen Grobmyer at Memorial Sloan Kettering Cancer Center;
and Sadir Al Rawi at Rosewell Park Cancer Center. This is a reflection of the fact
that the United States only graduates 39 fellows in surgical oncology per year, com-
pared to close to 1500 general surgery graduates per year. This is coupled with the
fact that, worldwide, surgical oncology continues to lag behind in terms of becom-
ing a well-­recognized and defined specialty. Using Europe as an example, 67% of
European countries still do not recognize surgical oncology as a separate discipline
[9]. As a result, oncologic surgery has largely been confined to the domain of gen-
eral surgeons in the UAE. There are also physicians who have completed subspe-
cialty training in surgical oncology, such as Dr. Waleed Hassan (urologic oncology
at Memorial Sloan Kettering Cancer Center (MSKCC)), Stephanie Ricci in GYN
oncology at Johns Hopkins, Dr. Muhieddine Seoud at Kansas University Medical
Center, and Dr. Usman Ahmed in thoracic surgical oncology at MSKCC, to
name a few.
John Birkmeyer has focused attention on the benefits of specialization in opti-
mizing outcomes in complex cancer surgery [10]. In his seminal paper, he high-
lighted the clear association between low hospital volume and high operative
mortality for major cancer operations, especially esophagectomy and pancreatec-
tomy. These findings have been further corroborated in a number of additional stud-
ies and expanded to include rectal, gastric, hepatobiliary, and many other cancer
sites. However, volume is not the only driver of improved outcomes. As demon-
strated by Bilimoria et al., the outcomes of cancer surgery are improved across a
large number of procedures when performed by a trained subspecialist as compared
to surgeons with no specialized training [11], highlighting the value of additional
focused training in cancer surgery.
Using rectal cancer as a reference model, it has been amply demonstrated
that specialization improves the outcome of rectal cancer surgery. The treat-
ment of rectal cancer has been challenging due to its complexity at multiple
levels. The anatomical location of the rectum in the deep pelvis, the risk of
injury to nearby organs, the complexities related to re-establishing continuity
after proctectomy, and the prevention of leaks are formidable technical chal-
lenges, to name a few. This complexity is further compounded when we add
ever-growing options for neoadjuvant treatment, including TNT, organ preser-
vation, and early rectal cancer management. This complexity has resulted in
important variations in the outcomes of rectal cancer surgery among hospitals
and surgeons in Europe. Statistically significant differences in R0 resection
rates, postoperative morbidity and mortality rates, and long-term oncologic and
functional outcomes are noted as a result of the subspecialization [12–14].
Most notable, the operating surgeon was noted to be an independent risk factor
in rectal cancer outcomes [15].
Clearly, then, surgical oncology in the UAE is facing challenges. The major
challenge relates to the lack of specialization, with most of the cancer surgery
being in the domain of the general surgeon. This is compounded by the overall
21 Surgical Oncology in the UAE 353

low volume of cases since the population in the UAE is relatively young and
cancer incidence rates are generally low in this subgroup. Additional challenges
include a lack of awareness, resulting in failure to follow common cancer screen-
ing recommendations [16]. Furthermore, healthcare in the UAE is decentralized,
with no clear mechanisms of referral and no regionalization of cases into specific
centers based on expertise and/or outcomes. Finally, there are significant varia-
tions in care across the cancer centers, with a lack of well-defined quality control
mechanisms.

21.4 Future Prospects of Surgical Oncology in the UAE

Despite all the above challenges, the future of healthcare in general and surgical
oncology in the UAE is bright. The UAE government’s policies have led to an era
of stability and prosperity, even when the whole world is suffering from multiple
crises. This has led to the Emirates becoming a highly attractive place to work. In
addition, the UAE leadership has highlighted healthcare as one of the top areas of
investment and growth and has brought the top 2 US health systems (Mayo Clinic
and Cleveland Clinic) to the UAE. This has led to a parallel rise in healthcare invest-
ment in the private sector. Furthermore, over the last few years, the UAE has seen
an influx of highly trained, specialized physicians, including fellowship-trained sur-
gical oncologists.
There are currently five comprehensive cancer centers that are in operation in the
UAE (Table 21.2). These are defined as centers that offer hematology and oncology,
dedicated surgical oncology, expert pathology, radiation oncology, nuclear medi-
cine, and oncology patient support services [17]. Additionally, there is at least one
more state-of-the-art cancer center that is currently under active construction or
development at Sheikh Shakhbout Medical City in partnership with the Mayo Clinic.
Given the challenges associated with the training and recruitment of surgical
oncologists in the Arab world, the Arab Board of Surgery has approved in 2021 the
standards and curriculum for the establishment of fellowship training programs in
surgical oncology across the Arab world. The standards and criteria are parallel to
those that are set forth by the Society of Surgical Oncology and are stringent in set-
ting the requirements needed to approve a fellowship program and a designated
center as a training center. Nonetheless, this move by the Arab Board will lead to the
establishment of several surgical oncology fellowship programs across the Arab
world, leading to an improved workforce that is locally trained and groomed and an
increased awareness of the specialty and the importance and value of specialists
rendering complex cancer care. Anyone interested in obtaining further information
may contact the Arab Board of Surgical Oncology representative in the UAE, Dr.
Faek Jamali (first author), or consult the Arab Board website at www.arab-­board.org.
Surgical oncology could benefit from the recognition of surgical oncologists as
members of the Emirates Oncology Society, similar to the American Society of
Clinical Oncology, which welcomes surgeons into membership. In fact, the recently
appointed director of the National Cancer Institute in the USA was a former
354 F. R. El Jamali et al.

Table 21.2 Currently established comprehensive cancer centers in the United Arab Emirates
International Services not
Hospital Location Established accreditation Unique services offered
Tawam Al Ain 1979 JCI accredited Brachytherapy Hepatobiliary
Hospital breast cancer Pediatric surgery
unit oncology Bone marrow
Palliative care transplantation
Genetic
counselling
American Dubai 2010 JCI clinical care Acute Genetic
Hospital certification in hematology and counselling
Dubai 2017 bone marrow
National transplantation
accreditation Pediatric
program for oncology
breast centers Palliative care
(NAPBC) in
2015
Mediclinic Dubai 2016 JCI accredited Brachytherapy Genetic
City breast cancer Palliative care counselling
Hospital unit Pediatric Acute
Dubai oncology hematology and
bone marrow
transplantation
Burjeel Abu 2020 European Adult and Genetic
Medical Dhabi Society of pediatric bone counselling
City Medical marrow
Oncology transplantation
(ESMO) Acute
designated hematology
center of Palliative care
oncology and Cancer research
palliative care unit
Cleveland Abu 2022 Membership Gynecologic Pediatrics
Clinic Abu Dhabi NSABP, NRG, oncology
Dhabi JCI accreditation Urologic
oncology
Advanced
reconstructive
services
Adaptive
radiotherapy
General surgical
oncology
Breast oncology
HIPEC program
Robotic surgery
Genetic
counseling:
Solid organ
transplant
IRB and clinical
trials program
Tumor registry
21 Surgical Oncology in the UAE 355

president of ASCO. Alternatively, the formation of an Emirati Society of Surgical

Oncology or Gulf Region Society of Surgical Oncology could help advance the
field in the region and increase recognition of the value of surgical oncologists in
cancer care.
Further, the establishment of national quality metrics for the surgical care of
patients could also help further the role of surgical oncologists in the care of patients
in the UAE. Finally, efforts to establish surgical oncology fellowships within the
UAE would help to ensure a future pipeline of caregivers to meet the popula-
tion’s needs.
With healthcare at the center of the future vision of the country, the UAE is
poised to become a destination for health tourism, catering to the requirements of
nearly a billion people in the Middle East and North Africa (MENA) region. Surgical
oncology stands to play an important role in this vision, and the authors hope to see
the establishment of the Emirati Society of Surgical Oncology, which will act as a
source of collaboration and leadership in steering the future of surgical oncology.

21.5 Conclusion

The healthcare sector in the UAE has seen a tremendous evolution over the past two
decades, commensurate with the overall rapid ascent of the economic standard of
the country as a whole.
In parallel, the practice of surgical oncology in the UAE is rapidly evolving from
the domain of the general surgeon to the realm of specialized cancer centers that
provide the highest level of multidisciplinary, state-of-the-art cancer care. This has
been the result of the establishment of several state-of-the-art cancer centers across
the country as well as the recruitment of high-quality professionals in all fields
related to oncology.
With healthcare at the center of the future vision of the country, the UAE is
poised to become a destination for health tourism, catering to the requirements of
nearly a billion people in the MENA region.

Conflict of Interest The authors have no conflict of interest to declare.

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9. Tyler D. 2022 SSO presidential address: what is a surgical oncologist ? Evolution of surgi-
cal oncology and the society of surgical oncology in an era of hyperspecialization. Ann Surg
Oncol. 2022;29:4005–13. https://doi.org/10.1245/s10434-­022-­11770-­3.
10. Birkmeyer JD, et al. Hospital volume and surgical mortality in the United States.
NEJM. 2002;346:1128–37.
11. Bilimoria KY, et al. Effect of surgeon training, specialization and experience on outcomes for
cancer surgery: a systemic review of the literature. Ann Surg Oncol. 2009;16:1799–808.
12. McArdle C, Hole D. Impact of variability among surgeons on postoperative morbidity and
mortality and ultimate survival. Br Med J. 1991;302(6791):1501–5.
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1999;230(3):404.
14. Dorrance HR, Docherty GM, O’Dwyer PJ. Effect of surgeon specialty interest on
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2000;43(4):492–8.
15. Renzulli P, Laffer UT. Learning curve: the surgeon as a prognostic factor in colorectal cancer
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16. Al Mansouri A, et al. Colorectal screening in ambulatory healthcare service clinics in Abu
Dhabi, United Arab Emirates in 2015-2016. BMC Cancer. 2021;21(1):897.
17. Al Shamsi H. The state of cancer care in The United Arab Emirates in 2022. Clin Pract.
2022;12(6):955–85. https://doi.org/10.3390/clinpract12060101.

Dr. Faek R. El Jamali is Consultant Surgical Oncologist and

colorectal surgeon at the Cleveland Clinic Abu Dhabi (CCAD). Dr.
El Jamali completed training in general surgery at the University of
Connecticut and an SSO-approved surgical oncology fellowship at
the University of Pittsburgh, leading to American Board certifica-
tion. He also completed a fellowship in advanced minimally inva-
sive colorectal surgery at IRCAD/EITS in Strasbourg, France. Dr.
EL Jamali joined the American University of Beirut Medical Center
in 2002, where he practiced until August 2020, progressing to the
rank of tenured Professor of Surgery and Vice Chair for Clinical
Affairs before relocating to the UAE to join SSMC as a senior con-
sultant and chief of the division of colorectal surgery at Sheikh
Shakhbout Medical City in partnership with Mayo Clinic. Dr.
Jamali has joined the ranks of the faculty at CCAD in 2023. His
practice focuses on surgical oncology, the management of perito-
neal surface malignancies, and minimally invasive/robotic colorec-
tal surgery.
21 Surgical Oncology in the UAE 357

Dr. Chafik Sidani is the section head of colon and rectal surgery
at Cleveland Clinic Abu Dhabi (CCAD). He is a clinical assistant
professor at the Cleveland Clinic Lerner College of Medicine. He
established the colorectal surgery Enhanced Recovery After
Surgery (ERAS) program at CCAD. He is an active member of the
American Society of Colon and Rectal Surgeons and has authored
numerous publications and book chapters. Dr. Sidani completed
medical school at the American University of Beirut (AUB). He
then completed a 2-year postdoctoral research fellowship in gas-
trointestinal physiology at Yale University. He completed his train-
ing in general surgery at Yale New Haven Hospital and Georgetown
University Hospital in Washington, DC, USA. Subsequently, he
completed a Colon and Rectal Surgery Fellowship at the University
of Minnesota in Minneapolis, Minnesota, USA. He then served as
Chief of Colon and Rectal Surgery at the Virginia Hospital Center,
Arlington, VA, USA, prior to moving with his wife and three chil-
dren to Abu Dhabi to join Cleveland Clinic Abu Dhabi.
Dr. Stephen R. Grobmyer completed his fellowship in surgical
oncology at Memorial Sloan Kettering Cancer Center. He was previ-
ously the Section Head of Surgical Oncology and Director of the
Breast Center at the Cleveland Clinic in Cleveland, Ohio. He was and
is currently Professor of Surgery, at the Lerner College of Medicine
at Case Western Reserve University. In Ohio, he held the Lula Zapis
Endowed Chair in Breast Cancer Research. He currently serves as
Oncology Institute Chair at the Cleveland Clinic Abu Dhabi in the
United Arab Emirates. In 2018, Dr. Grobmyer was elected to the
American Surgical Association. He is a member of ASCO, and in
2011, he was selected for participation in the ACSO leadership devel-
opment program. He currently serves on the editorial board of the
Annals of Surgical Oncology, Surgery, the European Journal of
Surgical Oncology, Gland Surgery, and the Annals of Breast Surgery.
He has published over 200 peer-reviewed manuscripts and 25 book
chapters (h-index = 53). He has edited a book on cancer nanotechnol-
ogy. His research programs focused on breast cancer prevention and
treatment have been funded by over $16 million in extramural fund-
ing. His research has been featured in The New York Times, National
Public Radio, NBC Nightly News, and Vogue Magazine.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
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Commons license, unless indicated otherwise in a credit line to the material. If material is not
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statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Palliative Care in the UAE
22
Neil A. Nijhawan and Humaid O. Al-Shamsi

22.1 Introduction to Palliative Care

Palliative care (PC) refers to comprehensive and proactive care provided to people
across all age groups who experience significant suffering related to severe illness,
particularly those in the final stages of life. Its primary objective is to enhance the
well-being of patients, their families, and their caregivers. Figure 22.1 presents the
fundamental principles and goals of PC, as outlined on the World Health
Organization’s (WHO) website [1] (Fig. 22.1).
PC is a relatively new medical specialty, having only achieved specialty status in
the United Kingdom (UK) in 1987 and the United States (USA) in 2006 [2], though
the roots of what we now recognise as the modern palliative care movement can be
traced back to post-World War 2 (WW2) Britain, when Dr. Cicely Saunders

N. A. Nijhawan (*)
Consultant in Palliative Medicine, Burjeel Medical City, Abu Dhabi, United Arab Emirates
Khalifa University College of Medicine and Health Sciences,
Abu Dhabi, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
H. O. Al-Shamsi
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 359

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_22
360 N. A. Nijhawan and H. O. Al-Shamsi

. Includes, prevention, early identification, comprehensive assessment, and management of

physical issues, including pain and other distressing symptoms, psychological distress,
spiritual distress, and social needs. Whenever possible, these interventions must be evidence-
based.
. Provides support to help patients live as fully as possible until death by facilitating effective
communication and helping them and their families determine goals of care.
. Is applicable throughout the course of an illness, according to the patient’s needs.
. Is provided in conjunction with disease modifying-therapies whenever needed.
. May positively influence the course of the illness.
. Intends neither to hasten nor postpone death, affirms life, and recognizes dying as a natural
process.
. Provides support to the family and the caregivers during the patient’s illness and in their own
bereavement.
. Is delivered while recognizing and respecting the cultural values and beliefs of the patient and
the family.
. Is applicable throughout all health care settings (place of residence and institutions) andat all
levels (primary to tertiary).
. Can be provided by professionals with basic palliative care training.
. Requires specialist palliative care with a multiprofessional team for referral of complex cases.

Fig. 22.1 Principles and aims of palliative care [1]

Active Minimal No
Diagnosis disease disease disease
directed Death
directed directed
treatment treatment treatment
Bereavement
Screening

Palliative Care
EOLC
Curative Care

Course of illness

Fig. 22.2 The continuum of palliative and end-of-life care [3]

established the first hospice (St. Christopher’s Hospice) in Southeast London in

1967. After visiting St. Christopher’s Hospice in 1973, Dr. Balfour Mount helped to
create a PC ward at the Royal Victoria Hospital in Montreal, Canada, and is credited
with coining the term “palliative care.”
Palliative care (PC) is fundamentally a collaborative approach to providing the
kind of care one would desire when facing a serious, life-threatening illness, whether
it is for oneself or a loved one. PC focuses on addressing the individual’s needs, not
solely the diagnosis, and it extends across the entire care journey, starting from the
moment of diagnosis through the stage when death is approaching and even into the
post-bereavement period (Fig. 22.2) [3]. In the past, PC has primarily been associated
22 Palliative Care in the UAE 361

with the care provided to adult patients in advanced stages of cancer. This narrow
focus has led to the misconception that PC is exclusively connected to end-­of-­life
care. Indeed, a growing body of evidence supports the earlier integration of PC with
disease-directed treatments for both non-malignant diseases [4] and cancer [5].
Jennifer Temel’s ground-breaking research conducted in 2010 [5] showcased the
positive impact of early PC intervention for individuals diagnosed with metastatic
non-small cell lung cancer. The study revealed notable benefits, including signifi-
cant improvements in quality of life and mood reported by patients. Interestingly,
despite the fact that the group receiving earlier palliative care had less aggressive
end-of-life treatments, their median survival time was longer compared to the con-
trol group: 11.6 months versus 8.9 months (P = 0.02).
The transformation of PC from a philosophy focused solely on end-of-life care
to a comprehensive discipline that encompasses the well-being of patients and their
families throughout the entire course of illness is clearly evident. This shift is evi-
dent in the recent broadening of the concept of supportive care, especially within the
field of oncology [6].
The significance of implementing PC in the context of non-malignant illnesses
with limited life expectancy cannot be emphasized enough. Given the global rise in
aging populations and the corresponding rise in individuals with multiple chronic
conditions, the demand for palliative care will inevitably grow [7]. This includes the
United Arab Emirates (UAE) as well.

22.2 Palliative Care Provision in the UAE

PC is a relatively recent addition to the medical landscape in the UAE, as depicted in

Fig. 22.3. The first PC service in the public health sector was established in 2007 at
Tawam Hospital in Al Ain, Abu Dhabi. Initially operating as a consult service along-
side their oncology department, it has since evolved into a distinct division within the
oncology department. Currently, it offers outpatient clinics, inpatient consultation
services, dedicated inpatient beds, and a PC nurse outreach service. Notably, the
Tawam PC team remains the only palliative care service within the public health sec-
tor. In contrast, the private healthcare sector has witnessed an increase in PC services
since 2015. The American Hospital in Dubai, for instance, provides outpatient clin-
ics, inpatient consultation services, and inpatient PC beds, with the majority of their
referrals being patients diagnosed with cancer, similar to Tawam.
In September 2019, Mediclinic City Hospital in Dubai introduced its PC service,
which presently offers outpatient clinics, inpatient reviews, and a consultation

Fig. 22.3 The UAE palliative care landscape timeline

362 N. A. Nijhawan and H. O. Al-Shamsi

service. A similar consult service was initiated at Parkview Hospital, a sister facility,
in 2020. The most recent expansion in the PC service landscape occurred in March
2020 with the launch of the palliative and supportive care service at Burjeel Medical
City (BMC) in Abu Dhabi. Similar to Tawam Hospital, BMC offers a comprehen-
sive PC service, including integrated outpatient clinics with pain medicine and
physical medicine and rehabilitation clinics, an inpatient consultation service, dedi-
cated palliative care inpatient beds, and a PC nurse outreach service. Additionally,
within the Burjeel healthcare ecosystem, there is a homecare service available,
enabling the PC team to provide support for patients in need of palliative and end-­
of-­life care within the comfort of their homes.

22.3 Factors Influencing Palliative Care Provision in the UAE

22.3.1 Philosophical Culture Clash

Cultural attitudes play a significant role in the realm of palliative care (PC), particu-
larly when it comes to addressing cultural variations in end-of-life care. Western
medicine emphasizes the autonomy of the individual patient, whereas Middle
Eastern cultures place greater importance on the extended family as the primary
social institution and decision-maker. Middle Eastern patients often rely heavily on
the support of others during times of crisis or illness, as opposed to relying solely on
personal coping mechanisms, which is more aligned with Western ideals of indi-
vidual autonomy and maintaining personal independence. In the UAE, the avail-
ability of this extended family support network is not always guaranteed, especially
for many expatriate workers.
In the Middle East, Islam is not merely a religious choice but rather a compre-
hensive way of life that encompasses specific beliefs shaping perspectives on health
and illness. Common themes include the beliefs that [8]:

• The destiny of each individual is determined when their soul is brought into
existence. While fate is predetermined, one cannot be aware of their own destiny,
thus it is advisable to seek God’s favor through obedience.
• Illness is perceived as a divine punishment bestowed by God.
• Every aspect of existence is aligned with God’s grand design.

These convictions are manifested in an almost fatalistic acceptance of death and

illness. However, this perspective is balanced by the belief within Islam that it is a
duty to preserve life until God determines its end. This duality creates a common
scenario for healthcare providers, where a patient with an advanced progressive ill-
ness is rapidly deteriorating with a bleak prognosis, yet the family often insists on
exhausting all available options. Discussions regarding maintaining the patient’s
quality of life by avoiding medically futile interventions are often met with resis-
tance and negativity. The perception is that doctors are abandoning hope, whereas
in reality, only God knows the true extent of the prognosis. It is firmly believed that
hope must never diminish, as relinquishing hope would mean forfeiting God’s
22 Palliative Care in the UAE 363

assistance. Even if hope appears futile according to Western medical standards, it is

believed that hope aids patients in coping with their illness. Consequently, openly
discussing the removal of hope from the patient is deemed both tactless and unpar-
donable [9]. These underlying beliefs typically give rise to contrasting viewpoints
among doctors regarding the importance of being transparent and truthful with
patients about their illness. Additionally, these beliefs contribute to the elevated
expectations held by the general population regarding the effectiveness of medical
treatments. It is worth noting that hope is not a fixed concept, as there is evidence
suggesting that patients’ hopes evolve over time [10]. There is ample evidence to
support the fact that patients worldwide frequently choose to wait until their family
members have left the room before requesting the doctor to be candid with them and
validate their suspicions regarding their illness [11, 12].
The challenge at hand is how to balance the physician’s requirement for com-
plete disclosure regarding a patient’s condition with the family’s desire to protect
their loved one and maintain hope. The solution lies in effective communication.
While it is crucial to have open and honest discussions with both the patient and
their family, it is also important to recognize that not all patients wish to receive all
the intricate details of their condition. In primary care consultations, it is common
to begin by inquiring about the patient’s preferred level of information. This helps
determine whether they prefer to have all the specifics or if they are content with
knowing just enough. It is beneficial to engage in this conversation in the presence
of family members, reassuring them that there are no hidden motives behind the
consultation and that it will be conducted according to the patient’s or family’s pref-
erences and at their desired pace.

22.3.2 Palliative Care Education in the UAE

Regardless of the location, nearly all publications addressing the obstacles to pallia-
tive care provision emphasize the attitudes of healthcare providers. The stigma sur-
rounding palliative care teams is pervasive worldwide, including in the UAE, where
there remains a prevailing belief that palliative care solely revolves around pain
management and end-of-life care [13].
The majority of the existing literature concerning the attitudes of healthcare
workers towards palliative care predominantly concentrates on physicians. However,
it is the nursing staff who frequently shoulder the responsibility of engaging in chal-
lenging conversations with patients and their families [14]. A significant portion of
nurses in the UAE are expatriates from India and the Philippines. Many of these
nurses are relatively inexperienced, with less than 5 years of clinical experience
since completing their qualifications. Despite their limited experience, they fre-
quently find themselves in the challenging position of caring for terminally ill
patients and having to navigate emotionally difficult conversations with family
members.
Offering specialized training to our nursing colleagues in the UAE presents a
challenge. Although there are nursing education practitioner positions available,
there is a scarcity of individuals with sufficient palliative care training and
364 N. A. Nijhawan and H. O. Al-Shamsi

experience. In various other regions, nurses with specialized training in palliative

care, adept at comprehensive patient assessment and managing physical and psy-
chological symptoms, are integral members of interdisciplinary palliative care
teams. These roles, known as clinical nurse specialists (CNS), have been established
since the 1990s in the UK and the USA, and their positive impact on patients and
families is well-documented. These benefits include enhanced symptom control,
psychological support, and increased advocacy for patients and their families [15].
The shortage of doctors with sufficient palliative care training was one of the pri-
mary factors that prompted the creation of the clinical nurse specialist (CNS) role.
Consequently, two parallel efforts were undertaken: (1) training a group of pallia-
tive care CNS professionals and (2) establishing clinical governance structures to
support this clinical role. These initiatives resulted in the rapid growth of the CNS
role, both in hospitals and community settings worldwide.
However, there are several obstacles hindering the development of this role in
the UAE:

• There is a global scarcity of clinical nurse specialists in palliative care [16].

• The hierarchical structure in healthcare within the UAE remains predominantly
traditional and physician-centered, where doctors make decisions and nurses fol-
low their orders.
• In the Emirati society, similar to many Middle Eastern cultures, the guidance of
the most senior physician is highly respected and followed. Consequently, it may
be culturally challenging to accept clinical advice from a nurse, as the nursing
profession is traditionally considered subordinate to physicians.
• The migration pattern of nurses in the UAE generally follows a familiar pattern.
Inexperienced nurses often come to the UAE for a temporary period of 2–3 years
before moving on to countries like the US, Canada, or the UK. Additionally, the
continuous influx of nurses from Southeast Asia further diminishes the motiva-
tion to provide specialized training for these nurses.

22.3.3 Palliative Care and Opioid Medications

It is understandable that there is a common misconception that PC primarily focuses

on pain management, considering that pain is the most prevalent symptom among
patients receiving such care. Ensuring proper pain management at the end of life is
both the patient’s right and the responsibility of healthcare providers. The World
Health Organization has a clear stance on this matter: patients have the right to
receive appropriate treatment and effective control of their pain, following well-­
defined guidelines and recommendations [17]. Through our observations, we have
learned that unmanaged pain significantly impacts every aspect of an individual’s
life. Conversely, when pain is adequately controlled, it results in enhanced well-­
being and improved quality of life for patients and their families. Despite the exis-
tence of effective pain relief options, the issue of inadequate cancer pain management
persists. According to the World Health Organization (WHO), approximately five
22 Palliative Care in the UAE 365

billion people reside in countries with limited or no access to pain medications.

Among them, an estimated 5.5 million terminally ill cancer patients [18] face ineq-
uitable access to medicines, resulting in approximately 80% of them experiencing
moderate to severe pain.
In PC, our primary emphasis is on prioritizing pain relief, as this brings about a
notable enhancement in the quality of life. By addressing pain, we can improve
comfort, foster a better sense of well-being, and promote improved sleep for
patients. This, in turn, creates a conducive environment for patients to openly dis-
cuss their hopes, fears, and aspirations. While we employ a wide range of interven-
tions, such as non-pharmacological methods and radiation therapy for specific
cancers, opioids play a crucial role in managing moderate to severe pain.
Non-specialists often struggle with effectively managing severe pain, which is
most commonly experienced by individuals diagnosed with cancer. The WHO
guidelines for cancer pain in adults [19] recommend the three-step analgesic ladder
(Fig. 22.4), although there is no pharmacological need for Step 2, and compared to
weak Step 2 opioids, the benefit from low dose morphine (20–30 mg/24-h PO) is
greater and more rapid [20]. Step 2 is necessary due to the challenging and, at times,
impossible accessibility of potent (Step 3) opioids in numerous countries. This is
despite the fact that morphine, which is relatively inexpensive, is the most readily
accessible and extensively studied opioid analgesic.
Based on the Atlas of Palliative Care in the Eastern Mediterranean region, the
UAE’s median consumption of opioids (excluding methadone) stands at 3.03%,
slightly lower than the regional median of 3.27% [21]. Based on data from the
International Narcotic Control Board (INCB), opioid consumption in the UAE is
lower than anticipated. The defined daily dose for statistical purposes (SDDD) per
million inhabitants per day is 162, which falls under the category of inadequate
usage, as values below 200 are considered inadequate and values below 100 are
considered very inadequate [22].
Two recurring topics found in all publications discussing palliative care provi-
sion in the UAE are (1) the prevalent belief that using potent opioids will inevitably
result in addiction and (2) challenges related to limited access and prescription
restrictions for strong opioids and other frequently used medications.

Fig. 22.4 The World Health Organization three-step analgesic ladder [23]
366 N. A. Nijhawan and H. O. Al-Shamsi

Patients diagnosed with cancer frequently experience intense pain that may
require the use of opioids for effective management. However, this situation can
become more complicated when physicians feel uneasy about utilizing strong opi-
oids, particularly for severe and complex pain. The apprehension regarding poten-
tial opioid abuse or misuse by the patient can actually hinder the successful
management of pain.
In reality, the UAE does have access to all the necessary medications for pallia-
tive care as recommended by the International Association of Hospice and Palliative
Care (IAHPC)—as shown in Table 22.1 [24]. Although methadone is typically asso-
ciated with the treatment of opioid misuse, the 5 mg tablets of methadone are acces-
sible for utilization in palliative care settings. Moreover, hydromorphone is now
accessible in various forms, including immediate and sustained-release oral prepa-
rations, as well as an injectable form.

Table 22.1 The IAHPC list of essential medications for palliative care [24]
UAE
Medication Formulation Indication availability
Amitriptyline 50 mg tablets Depression Yes
Neuropathic pain
Bisacodyl 10 mg tablets Constipation Yes
10 mg rectal suppositories Yes
Carbamazepine 100–200 mg tablets Neuropathic pain Yes
Citalopram 10–20 mg tablets Depression Yes
Codeine 30 mg tablets Pain: mild to Yes
moderate
Diarrhoea
Dexamethasone 0.5–4 mg tablets Anorexia Yes
4 mg/mL injection Nausea and vomiting
Neuropathic pain
Diazepam 2.5–10 mg tablets Anxiety Yes
5 mg/mL injection Muscle relaxant Yes
10 mg rectal suppository Yes
Diclofenac 25–50 mg tablets Inflammatory pain Yes
50–75 mg/3 mL injection
Diphenhydramine 25 mg tablets Antihistamine
50 mg/mL injection Motion sickness
Fentanyl transdermal 12.5–100 μg/h Pain: moderate to Yes
patch severe
Gabapentin 300–400 mg tablets Neuropathic pain Yes
Haloperidol 0.5–5 mg tablets Delirium Yes
0.5–5 mg/mL injection Nausea and vomiting
Terminal restlessness
Hyoscine butylbromide 10 mg tablets Visceral pain Yes
10 mg/mL injection Nausea and vomiting
Terminal respiratory
congestion
Ibuprofen 200–400 mg tablets Inflammatory pain Yes
Levomepromazine 5–50 mg tablets Delirium Yes
25 mg/mL injection Terminal restlessness Yes
22 Palliative Care in the UAE 367

Table 22.1 (continued)

UAE
Medication Formulation Indication availability
Loperamide 2 mg tablets Diarrhoea Yes
Lorazepam 0.5–2 mg tablets Anxiety Yes
2–4 mg/mL injection Yes
Megestrol acetate 160 mg tablets Anorexia Yes
40 mg/mL solution Yes
Methadone 5 mg tablets Pain: moderate to Yes
severe
Neuropathic pain
Metoclopramide 10 mg tablets Nausea and vomiting Yes
5 mg/mL injection
Midazolam 1–5 mg/mL injection Anxiety Yes
Terminal restlessness
Fleet® mineral oil enema Yes
Mirtazapine 15–30 mg tablets Depression Yes
Anorexia
Morphine Immediate release Pain: moderate to Yes
10–60 mg tablets severe Yes
Immediate release Dyspnoea Yes
10 mg/5 mL solution Yes
Immediate release 10 mg/ Yes
mL injection
Sustained release 10 mg
tablets
Sustained release 30 mg
tablets
Octreotide 100micrograms/mL Diarrhoea Yes
injection Vomiting
Oral rehydration salts Diarrhoea Yes
Oxycodone 5 mg tablets Pain: moderate to Yes
severe
Paracetamol 100–500 mg tablets Pain: mild to Yes
500 mg rectal moderate
suppositories
Prednisolone 5 mg tablets Anorexia Yes
(dexamethasone alt)
Senna 8.6 mg tablets Constipation Yes
Tramadol 50 mg immediate release Pain: mild to Yes
tablets/capsules moderate
50 mg/mL injection
Trazodone 25–75 mg tablets Insomnia Yes
Zolpidem 5–10 mg tablets Insomnia Yes

The introduction of the Unified Electronic Platform [25] (Openjet) in 2019 has
simplified the process of monitoring and tracking the prescription and distribution
of controlled and narcotic medications, including opioids. This national online pre-
scribing platform requires the use of the patient’s national identity card (Emirates
ID) with a specialized card reader. This development has enhanced safety for
368 N. A. Nijhawan and H. O. Al-Shamsi

prescribers and decreased the potential for opioid medication misuse. Furthermore,
the platform reduces inefficiencies associated with paper prescriptions and ensures
accurate monitoring of prescription and medication distribution.
The primary concern lies in the restrictive regulations surrounding the prescrip-
tion of controlled medications. Specifically:

• Only consultant physicians are authorized to provide a 30-day supply of con-

trolled medications, while other physicians are limited to prescribing between
7- and 14-day supplies.
• Current regulations prohibit the prescription of injectable forms of controlled
substances, including opioids and other centrally acting medications, for
non-­hospitalized patients. This poses a challenge to providing end-of-life
care at home for patients who prefer this option, as we are unable to initiate
intravenous or subcutaneous infusions of commonly used palliative care
medications.

While progress has been made in the UAE to enhance access to frequently used
palliative care (PC) medications, there is still a significant amount of work remain-
ing. This includes the crucial step of mandating the inclusion of all commonly used
PC medications and their various formulations in the national formulary.

22.3.4 Palliative Care Multidisciplinary Team Approach

Due to its comprehensive approach, PC considers all aspects of a patient’s well-­

being, encompassing physical, psychological, emotional, sociocultural, and spiri-
tual needs. Therefore, a PC assessment typically covers these various domains. To
ensure comprehensive care, most palliative care teams strive to be multi-­disciplinary
in their composition, consisting of professionals such as nurses, doctors, social
workers, psychologists, chaplains, physiotherapists, occupational therapists, and
complementary therapists. As previously mentioned, the availability of PC-trained
nurses and doctors in the UAE has been addressed. While social worker and psy-
chologist roles do exist in the UAE healthcare system, many may not have received
specific training in PC.
When patients are faced with a recent diagnosis of a life-limiting illness or are
nearing the end of their lives, we acknowledge that addressing their spiritual well-­
being is just as significant as addressing their clinical concerns. Spiritual health
plays a vital role in overall human well-being as it enables individuals to navigate
personal existential challenges in different aspects of life, including stressful cir-
cumstances, illness, or the presence of death [26]. Attending to the spiritual care
needs of patients and their families is essential for enhancing their overall quality of
life. While not all patients may adhere to a specific religious affiliation, many grap-
ple with existential questions related to life, illness, and finding meaning in suffer-
ing. While palliative care nurses and doctors are typically trained to assess patients’
spiritual needs, they cannot replace the role of a chaplain. It is widely acknowledged
that patients often require someone who can listen to their concerns, fears, and
22 Palliative Care in the UAE 369

regrets without judgment [27]. Chaplains recognize the significance of providing a

non-judgmental presence that does not necessarily offer advice or solutions but
rather creates a space where all emotions and challenges can be acknowledged.
They are trained to extend their support to everyone, irrespective of their religious
or spiritual beliefs, and their unique perspective adds depth to the medical team by
emphasizing the importance of finding meaning in both life and death. Currently,
the role of a hospital chaplain is not established in the UAE, although patients are
free to practice their chosen faith. However, considering the UAE’s population,
which primarily consists of expatriates from diverse backgrounds, it becomes cru-
cial to provide culturally appropriate care, especially for patients nearing the end
of life.
The role of physiotherapists and occupational therapists within a palliative care
(PC) team is of utmost importance. Physiotherapists primarily focus on maximizing
movement and comfort, while occupational therapists prioritize optimizing func-
tional abilities. These therapists work collaboratively to help patients engage in
daily life activities to the best of their abilities despite limitations or restrictions
caused by the progression of their illness. When patients experience sudden limita-
tions in their functional abilities due to illness, it becomes crucial to facilitate a shift
in their mindset as part of the rehabilitation process. Therapists initiate the process
by conducting assessments with the patient and their family, attentively listening to
the patient’s narrative, observing their capabilities, and discussing their physical,
social, emotional, and spiritual needs. Based on these evaluations, goals are estab-
lished that align with the patient’s desires to continue specific activities and achieve
personal milestones. These goals may involve tasks like self-care during showering,
getting in and out of bed independently, spending quality time with loved ones, or
completing a particular activity. As a result, patients can re-prioritize their daily
activities, conserving energy for the activities that hold the most significance to
them. This process is dynamic and not fixed, with goals regularly reassessed and
adjusted to accommodate the evolving nature of disease progression and the
patient’s physical capabilities [28].

22.3.5 Advanced Care Planning (ACP)

Advance care planning (ACP) involves the crucial task of making significant deci-
sions regarding the care an individual wishes to receive if they become incapable of
expressing their preferences. Although some patients may believe they are too
young or in good health to consider creating an advanced care plan, it holds particu-
lar importance for those with progressive, life-limiting illnesses. As part of pallia-
tive care, we frequently assist patients in this process. ACP entails both legal and
personal decision-making to develop a comprehensive plan that can be shared with
key individuals, outlining the individual’s desires and preferences as they near the
end of life. It serves as a means to ensure that the patient’s wishes are respected and
upheld when they are unable to communicate their choices.
In various regions around the world, the process of advance care planning (ACP)
encompasses several considerations, such as an advanced directive and discussions
370 N. A. Nijhawan and H. O. Al-Shamsi

related to cardiopulmonary resuscitation (CPR), preferred place of care (PPC), and

preferred place of death (PPD). An advanced directive is a written document that
outlines an individual’s healthcare preferences to be followed if they are unable to
make decisions or express their wishes. Typically, it focuses on situations where the
person is terminally ill and specifies which medical treatments they do or do not
want healthcare providers to pursue in the absence of their informed consent. For
instance, it may indicate preferences regarding the use of ventilators or the insertion
of feeding tubes. Additionally, the advanced directive can address any religious or
spiritual preferences that the individual wishes to be observed.
While advanced directives do not hold formal or legal recognition within the
UAE, it is customary for the medical team to engage in discussions with the patient’s
relatives regarding the patient’s preferences. Within the prevailing cultural attitude
toward serious illness in the UAE, the belief is that everything is ultimately in the
hands of God. Therefore, there is a perception that attempting to predict, prognosti-
cate, or plan for the future is unnecessary since whatever unfolds will be in accor-
dance with God’s will. Consequently, the predominant approach is to continue with
all available medical treatments, even those that may be considered medically futile
or inappropriate. Unfortunately, when healthcare workers are compelled to prolong
a patient’s suffering and death by pursuing futile curative treatments, they may
experience moral distress. This occurs when there is a conflict between their profes-
sional obligations and the knowledge that the interventions being employed are
unlikely to yield any meaningful benefit [29].

22.3.6 Allow Natural Death

Cardiopulmonary resuscitation (CPR) is a medical intervention that involves inva-

sive measures, and its original purpose was not to be administered to patients who
are in the process of dying from an irreversible condition [30]. Decisions regarding
do not attempt cardio-pulmonary resuscitation (DNACPR) serve as a means of com-
munication, indicating when CPR should not be performed on patients either due to
their personal wishes or because it is unlikely to succeed. DNACPR decisions play
a crucial role in safeguarding patients from potential harm, although they have
acquired practical, legal, and emotional implications that extend beyond their origi-
nal purpose. Doctors often hesitate to initiate discussions about DNACPR due to
concerns of causing distress to patients and their families, as well as fears of poten-
tial complaints or legal action.
Since August 2016, the implementation of UAE Federal Law No. 4 on Medical
Liability has brought about various revisions to the previous Medical Liability law.
One significant change is the acceptance of natural death as a permissible outcome
for patients diagnosed with terminal illnesses [31]. Under this new law, healthcare
professionals are now authorized to withhold cardiopulmonary resuscitation (CPR)
from terminally ill or dying patients with incurable illnesses, allowing natural death
to occur. However, certain conditions must be met in order to proceed with this
approach:
22 Palliative Care in the UAE 371

• The patient experiences an irreversible medical condition.

• All available treatment options have been attempted.
• The treatment has been established as ineffective for the specific medical
condition.
• The attending doctor recommends against administering CPR to the patient.
• A minimum of three consulting doctors concur that it is in the patient’s best
interests to allow natural death and withhold CPR (in this situation, the patient’s
consent, guardian’s consent, or custodian’s consent is not necessary).

Nevertheless, if a patient explicitly requests CPR, it cannot be denied even if

healthcare providers deem it medically futile. Unfortunately, there are no available
national-level statistics that illustrate the frequency of implementing the “allow
natural death” policy or how often terminally ill patients request full CPR.
Even if a patient and their family agree that allowing natural death aligns with
their preferences and desires, significant challenges persist regarding the preferred
location for receiving care and passing away. Although official statistics on the
place of death are unavailable, it is probable that most patients receive end-of-life
care in hospitals. Even patients who express a desire for home-based end-of-life
care are unlikely to have their preference fulfilled due to the absence of established
community palliative care teams or community-based palliative care units (hos-
pices) within the UAE currently.

22.3.7 Financial Cost of Palliative Care

Whether healthcare services are provided through the government health system or
the private sector, the payment for such services is typically facilitated either within
a health insurance framework or by patients covering the costs themselves. In the
UAE, each emirate has its own regulations regarding medical insurance, with Abu
Dhabi and Dubai requiring employers to provide mandatory medical coverage for
employees and their dependents. The existing reimbursement system adds complex-
ity to the ability to deliver palliative care (PC) services to patients. Similar to other
non-procedural healthcare interventions, PC consultations, including advanced care
planning, often face underappreciation, with insufficient value placed on these com-
passionate, communication-centered procedures [33]. The potential complications
can have equally harmful and potentially irreversible effects. Historically, medical
insurance providers did not include coverage for palliative care services under their
policies. However, this has undergone a transformation with the introduction of
specific diagnosis-related group (DRG) codes for palliative care, encompassing
both inpatient and outpatient consultations.
The financial benefits of PC have been well-established. Patients who receive PC
services, in comparison to those receiving standard care, generally experience a
decrease in hospitalizations, shorter hospital stays, fewer admissions to intensive
care units, and fewer visits to the emergency department. Notably, PC has been
associated with cost savings of US$ 4251 per hospital stay for cancer patients and
US$ 2105 per hospital stay for patients with non-cancer illnesses [32].
372 N. A. Nijhawan and H. O. Al-Shamsi

22.4 Conclusion

Palliative care services in the UAE are continuously developing. As the global pop-
ulation ages and the incidence of cancer and other life-limiting illnesses rises, the
demand for comprehensive palliative care will also increase. However, addressing
this need in the UAE goes beyond solely recruiting more nurses and doctors, as
there is a worldwide shortage of palliative care-trained healthcare professionals.
Enhancing palliative care in the UAE will require a multifaceted approach beyond
increasing staffing numbers. Our recommendations for improving palliative care in
the UAE were highlighted in a previous publication [33], and they have since been
refined and diagrammatically represented [34] (Fig. 22.5).

Fig. 22.5 Recommendations for palliative care in the UAE

Conflict of Interest The authors have no conflict of interest to declare.

22 Palliative Care in the UAE 373

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Dr. Neil A. Nijhawan is a UK-trained consultant in Palliative

Medicine at Burjeel Medical City. After medical school at Kings
College London, he pursued speciality training in Palliative
Medicine in London, with rotations in acute general hospitals,
domiciliary visits, community hospices, and tertiary oncology cen-
tres. Prior to completing his palliative medicine training, Neil
returned to his childhood home, Trinidad in the West Indies, to help
set up and commission the new Caura Hospital Palliative Care Unit,
where he was the Medical Director. This unit was opened in 2014
and provides a comprehensive palliative care service, including a
12-bed inpatient unit, weekly outpatient clinics, and a palliative
care consult service at the local university hospital. After complet-
ing his specialty training, Neil worked as a consultant in palliative
medicine at the Imperial College Healthcare NHS Trust in London,
where he was the clinical lead for palliative medicine. His clinical
area of interest is symptom control (including pain, nausea, breath-
lessness, and fatigue) and assistance with complex treatment deci-
sion-making at the end of life, and he is often called on to provide
an independent second opinion. He is active in palliative care edu-
cation and palliative care advocacy and is currently the UAE repre-
sentative to the WHO Eastern Mediterranean Region Palliative
Care Expert Network. Neil holds adjunct faculty positions with
both Khalifa University and Gulf Medical University where he is
Clinical Associate Professor in Hospice& Palliative Medicine.

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer of

Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
22 Palliative Care in the UAE 375

Chairman of the Oncology and Hematology Fellowship Training

Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty fel-
lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fel-
lowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new dis-
tinct subgroup of CRC, NON V600 BRAF-mutated CRC. In 2022,
he published the first book about cancer research in the UAE and
also the first book about cancer in the Arab world, both of which
were launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to docu-
ment the cancer care in the UAE with many topics addressed for the
first time, e.g., neuroendocrine tumors in the UAE. He is passionate
about advancing cancer care in the UAE and the GCC and has made
significant contributions to cancer awareness and early detection
for the public using social media platforms. He is considered as the
most followed oncologist in the world with over 300,000 subscrib-
ers across his social media platforms (Instagram, Twitter, LinkedIn,
and TikTok). In 2022, he was awarded the prestigious Feigenbaum
Leadership Excellence Award from Sheikh Hamdan Smart
University for his exceptional leadership and research and the
Sharjah Award for Volunteering. He was also named the Researcher
of the Year in the UAE in 2020 and 2021 by the Emirates Oncology
Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
of research training for medical trainees to enhance their clinical
and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.
376 N. A. Nijhawan and H. O. Al-Shamsi

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Nuclear Medicine in the UAE
23
Abdulrahim Al Suhaili

23.1 Introduction

On December 2, 1971, the newly formed nation’s medical services were truly
deplorable. Still, leaders with vision understood that and put in place a system to
improve healthcare both horizontally to cover the whole country and vertically by
creating high-standard medical facilities. As a result, high-medical facilities such as
Mafraq, Tawam, and Al Jazeera in Abu Dhabi; Al Baraha, Al Maktoum, Rashid
Hospital, and Latifa Hospital in Dubai; Kuwait Hospital; and Al Qassimi hospitals
in Sharjah provide healthcare services in all cities and rural areas.
Nuclear medicine services were added as a new service in Abu Dhabi at Mafraq
Hospital in 1979, followed by Tawam Hospital in 1982. Dubai Hospital started in
1983, to the author’s knowledge.
All radiopharmaceuticals were imported on a weekly basis; therefore, positron
emission tomography (PET) was not available until the first cyclotron was built in
Abu Dhabi by the Gulf International Cancer Centre (GICC) in 2009, and then the
first PET scan was done. Al Mulla Group established the second cyclotron in Al
Nahda, followed by the first PET study in Dubai at an American hospital in 2010.
Nowadays, nuclear medicine services for diagnosis and therapy are available in
many emirates, whether owned by the government or the private sector.
Radionuclide therapy started in Mafraq and Tawam for high-dose treatment, par-
ticularly for hyperthyroidism, thyroid cancer, and neuroblastoma cases. It was a
long journey from the early 80s until today, when we have more sophisticated thera-
pies at our fingertips.

A. Al Suhaili (*)
Department of Nuclear Medicine, Burjeel Medical City, Abu Dhabi, United Arab Emirates
e-mail: abdulrahim.suhaili@burjeelmedicalcity.com

© The Author(s) 2024 377

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_23
378 A. Al Suhaili

The strategic collaboration between universities and hospitals in the United Arab
Emirates (UAE) was blooming.

23.1.1 What Is Nuclear Medicine?

The best description of what nuclear medicine is “the medical specialty that is dif-
ferent than radiology, immunology, cell biology, and physiology, but has a little bit
of all of them in one specialty.”
There is no single definition for this specialty since it started to be available after
the Second World War in 1945. However, the path to using radioactivity in medicine
began after Henri Becquerel’s discovery of radioactivity in 1897 and Roentgen’s
discovery of X-rays a year earlier. All attempts by doctors to treat failed due to a
lack of understanding of cell biology and molecular behavior [1, 2].
Although radiation exposure can cause cancer, it can also cure it. Oncology was
the driving force behind nuclear medicine’s development and innovation, and as
oncology progressed deeper into the cellular and genetic levels, nuclear medicine
followed the same path faster to create molecular imaging and theranostic. In recent
years, hybrid systems have solved anatomic issues by having radiology merge with
nuclear imaging to create SPECT-CT, PET-CT, and then SPECT-MRI and PET-­
MRI. Nuclear medicine is used in oncology for early detection, establishing diagno-
sis, and determining the staging of cancers. It is also used for determining the early
response to therapy.

23.2 Nuclear Medicine Services in the UAE

The nuclear medicine services in the UAE are divided into three categories:

–– Gamma ray detection, and imaging using gamma camera and SPECT
detectors
–– Positron emission and dual photon detection tomography (PET and
PET-CT)
–– Radionuclides therapy, by using alpha and beta particles to induce regional ion-
ization, which causes cell destruction (theranostic) [3].

23.2.1 Gamma-Ray Imaging

Single photon emission computerized tomography (SPECT), and then in the

twenty-­first century, SPECT merged with CT to create SPECT-CT. It is used in
80% of the procedures performed in nuclear medicine (see scope of services)
attached.
23 Nuclear Medicine in the UAE 379

Technetium-99m, iodine-131, 123, Ga-67, Tl-201, and In-111 were in use until
today. They were used for imaging and functional studies.
Examples:

• Radioiodine is taken up by the thyroid gland for manufacturing tri-iodo-­

thyronine (T3), or tetra-iodo-thyronine (T4), or thyroxine. The speed and amount
of uptake can determine the status of thyroid function (normal, hyperthyroidism,
or hypothyroidism). The time of radioiodine residency in the thyroid can deter-
mine the status of function, like cold, neutral, or hot nodules. Iodine-131 can be
used for therapy, which will be discussed later.
• Gallium-67 was first discovered as a bone agent, but it was found to be accumu-
lated in cancer and inflammatory cells and has since been used in oncology for
the localization and spread of cancers. It was used to detect occult cancer and
pyrexia of unknown origin (PUO) before the PET era.
• Thallium-201 chloride is used for myocardial imaging to detect ischemia
and infarction, but it was also found to be helpful in differentiating between
recurrence and fibrosis in treated masses. It plays an important role in
brain tumors.
• Indium-111 chloride is used in neuroendocrine tumors (NEN and NET) and is
labeled as somatostatin receptor agent like octreotide. It was the main imaging
modality in neuroblastoma, paraganglioma, medullary thyroid cancer, and GI-­
NEN. It also opened the door to using it to treat these patients by replacing
indium-111 with iodine-131. It is still being used successfully in children with
neuroblastoma.

23.2.2 What Are Radiopharmaceuticals?

Pharmaceuticals are chemical compounds that have certain physiological character-

istics and can be easily directed to certain targets or images. When a radionuclide is
labeled, it will transport it to the same target organ, hence the term “radiopharma-
ceutical compound”.
If the radioactive compound emits gamma rays, then it can be seen by the gamma
camera until it reaches the target organ, which allows us to see the uptake percent-
age, distribution, and viability, for example, of prostate cancer [4].
Prostrate-specific membrane antigen, known as PSMA, is a protein that is found
mainly in prostate cancer cells, and when labeled with a gamma or PET compound
and then injected into patients with elevated PSA, it will accumulate in these tissues,
whether it is a primary disease, a recurrence, or elsewhere, such as metastatic dis-
ease. The isotope is the radionuclide, PSMA is the pharmaceutical, and the com-
pound is called radioactive-PSMA. If labeled with a PET tracer like fluorine-18 to
form 18F-PSMA or gallium-68 to form 68GA-PSMA.
380 A. Al Suhaili

If the scan shows spread or recurrence and the main treatment for prostate cancer
has failed, the fluorine or gallium can be replaced by a beta or alpha emitter like
lutetium-177 (beta), actinium-225 or astatine-211 (alpha) for treatment.
Gamma camera imaging is used in detecting skeletal metastasis and localization
of the sentinel lymph node (SLN) in most cancers prior to surgery, which revolu-
tionized surgical management and minimized morbidity.
In renal cancer, a gamma camera is used to assess the remaining function of the
other kidney prior to nephrectomy or to predict pulmonary function prior to lung
resection.

23.2.3 Positron Emission Tomography (PET) in Oncology

The electron (e-) is a negatively charged particle found in all atoms’ orbits on earth.
It is the source for X-ray imaging. But in nuclear medicine, the source of radiation
comes from the nucleus of the atom. As a result, it earned the name “nuclear
medicine.”
But there is another type of electron that lives for a very short period before being
annihilated (disappearing) completely. The matter mass is converted to energy,
which is used in PET. The electron here does not have a negative charge (negatron-),
but a positive charge, and is hence called a “positive electron” (positron+), which
can be detected by positron emission tomography (PET) scanners.
PET tracers are designed to target certain organs through the metabolic
route. Because of their high demands, cancer cells are always hungry for
glucose. If a molecule of glucose is labeled as a PET tracer, it will be con-
sumed by cancer cells at a higher rate than normal tissue. And by modifying
the glucose molecule by taking one oxygen atom, it will end up with deoxy-
glucose (DG). When we label it fluorine-­1 8 (a positron emitter), a new com-
pound will be formed called 18F-fluorodeoxyglucose ( 18F-FDG). Cancer cells
cannot recognize the difference between glucose and deoxyglucose and con-
sume FDG. Once it enters the cancer cells, it will not be able to leave like
ordinary glucose and remain there, allowing us to obtain images after the
uptake period (about 1 h).
Fluorine-18 can be labeled with other compounds to increase the specificity
of 18F-PSMA uptake; however, since fluorine-18 has a 110-min half-life, the
production centers (cyclotron) should be located within 2 h from the imaging
facility.
The UAE has cyclotrons in a few places in the country (Table 23.1).
All the cyclotrons in the UAE produce mainly 18F-fluorine, and there is a need for
a bigger cyclotron that can produce other PET tracers and iodine-123, which is very
much needed for imaging the thyroid and other organs using SPECT/CT.
PET imaging can use another source, such as gallium-68, which is produced by
a generator that can be milked daily and makes 68Ga available every day within the
department, avoiding the logistical problems associated with cyclotrons.
23 Nuclear Medicine in the UAE 381

Table 23.1 Functioning S. No Location

cyclotrons’ availability 1 Gulf International Cancer Center (GICC) is
in the UAE located in Al Bahia, near Abu Dhabi
2 Monrol cyclotron, located in Al Nahda, Dubai
3 Tawam Mubadala Cyclotron in Al Ain, which
was later owned by the Cleveland Clinic

A new field of imaging was opened several years ago by using an alternative to
18
F and cyclotron called “fibroblast activation protein,” FAP inhibitors are overex-
pressed in cancer-associated fibroblasts of several tumor entities. FAPI can be
detected in various malignant neoplasms and is associated with tumor cell migra-
tion, invasion, and angiogenesis.
By targeting FAP, the 68gallium-labeled FAP-inhibitor (68GA-FAPI) is developed
and used in imaging tumor stroma. 68Ga-FAPI uptake is more specific than 18F-FDG
uptake, since the latter has a higher false positive rate than 68GA-FAPI, such as in
cases of inflammatory disease, physiologic G.I. uptake, and infected tissue. 18F-­
FDG has less uptake in certain cancers like well-differentiated hepatocellular carci-
noma (HCC), renal cell carcinoma, gastric, and signet ring cell carcinoma, resulting
in a high false-negative rate. 68Ga-FAPI is favorable for diagnosing G.I. cancers.
68
Ga-FAPI uptake was found to be very high, SUV max > 12 in sarcoma, esopha-
geal, breast, cholangiocarcinoma, and lung cancers [5].
68
Ga-FAPI uptake with SUV max < 6 was observed in pheochromocytomas, dif-
ferentiated renal cells, thyroid, adenoid, cystic, and gastric cancers. The average
SUV max of hepatocellular, colorectal, head and neck, ovarian, pancreatic, and
prostate cancer was intermediate.
Because the 68Ga-FAPI races contain the universal DOTA tracer, the chelator
also adds theranostic approach after labeling the ligand with beta emitter, opening
up another avenue for a more specific approach to cancer diagnosis and ther-
apy [6, 7].

23.2.4 Theranostic

Because of the creators of newly used therapeutic tracers, nuclear medicine is mov-
ing more towards therapy than diagnostics.
The benefits of radiotracer therapy include the ability to focus on the most active
part of the cancer while sparing neighboring organs from unnecessary irradiation.
The radionuclides used in therapy are either elements, molecules, or compounds.
The most classical element is radioactive iodine-131. In 1939, it was the first to
be used in thyroid disease to image the thyroid gland, and it was later used to treat
hyperthyroidism. After World War II, it became widely available and was also used
to treat thyroid cancer.
Most well-differentiated thyroid cancers can be diagnosed, staged, and treated
with radioiodine.
382 A. Al Suhaili

Thyroid surgery is the first line of treatment. Nuclear medicine is used to evalu-
ate the outcome of surgery using postoperative radioiodine imaging. Therefore, it is
important to keep the patient away from iodine-rich medications like thyroxine,
iodine-based antiseptics, and contrast media used with CT imaging. These can
cause delays in management. The American Thyroid Association (ATA) put out
guidelines on how to manage thyroid cancer, which are the best guidelines
worldwide.
Very rarely, thyroid cancer cells become resistant to the trapping of iodine (radio-
iodine refractory cancer cells), which is usually associated with a loss of thyroid
differentiation features. Such changes correlate with mitogen-activated protein
kinase (MAPK), which is found to be higher in tumors with BRAF (B-Raf proto-­
oncogene) mutations. A tyrosine kinase inhibitor (TKI) was found to be helpful in
improving thyroid uptake and therapy.
A patient with high thyroglobulin (TG) and a negative radioiodine whole-body
scan can have a positive scan with 18FDG PET. Because these cancers are rare, a
PET scan can only be performed after a negative iodine scan. This was given the
name “TENIS syndromes” (TG Elevated Negative Iodine Scan). Treatment of these
types of cancers with radioiodine is still possible using very high doses of
150–300 mCi, with a good response judged by a continuous fall in TG [9].

23.2.4.1 Trance Arterial Radio Embolization (TARE)

Many cancers were previously treated with interventional procedures, such as
embolization of feeding vessels, intra-tumoral chemotherapy, and electromechani-
cal ablation. An alternative approach to covert inoperable hepatic cell carcinoma
(HCC) was used with good success and involves the injection of microparticles that
are loaded with beta emitters such as yttrium-90 (90Y), aiming to:

1. Convert inoperable liver cancer to an operable disease

2. Increase survival in patients with primary or metastatic liver disease, primarily
from GI cancers

This type of treatment needs a good setup and the selection of the proper candi-
dates. It should consist of an oncologist, G.I. surgeon, interventional radiologist,
and nuclear medicine physician. The nuclear medicine team should also have a
qualified medical physicist, a hot lab, and imaging technology.
TARE is expanding to other cancers but still needs more studies, guidelines,
endorsement by regulatory bodies, and insurance reimbursement.

23.3 Equipment and Manpower Availability in the UAE

23.3.1 Equipment Availability in the UAE

Gamma cameras (Table 23.2) and PET scanners (Table 23.3) are available in a few
places in the UAE.
23 Nuclear Medicine in the UAE 383

Table 23.2 Availability of Emirate Facility name

gamma cameras in the UAE Abu Dhabi Cleveland Clinic Abu Dhabi
Mediclinic
Burjeel Medical City (BMC)
Sheikh Shakhboot Medical City
(SSMC)
Sheikh Khalifa Medical Centre
(SKMC)
Al Ain Tawam Hospital
Dubai Dubai Hospital
American Hospital Dubai
Mediclinic City Hospital
Clemenceau Medical Center
Hospital
Saudi German Hospital
Sharjah NMC Royal Hospital
Fujairah Fujairah Hospital
Ras Al Khaimah Sheikh Khalifa Specialist Hospital

Table 23.3 Availability of Emirate Facility name

PET scanners in the UAE Abu Dhabi Burjeel Medical City (BMC)
Gulf International Cancer Centre
(GICC) in Al-Bahia
Al Ain Cleveland Clinic Abu Dhabi
(CCAD) (There will be more in the
future)
Dubai American Hospital Dubai
Mediclinic City Hospital
Advanced Care Oncology Centre
(ACOC)
Clemenceau Medical Center
Hospital
Ras Al Khaimah Sheikh Khalifa Specialist Hospital

23.3.2 Manpower

Manpower consists of:

23.3.2.1 Nuclear Medicine Physicians

Approximately, the total number of nuclear medicine physicians is around 27 which
are currently working in the UAE (Table 23.4).

23.3.2.2 Technical Staff

There is a standard formula that states that the technical staff for each piece of
equipment should be at least 1.5 times the number of pieces of equipment plus at
384 A. Al Suhaili

Table 23.4 An estimation of nuclear medicine physicians currently working in the UAE
Total no. of nuclear medicine physicians Emirates
11 Abu Dhabi and Al Ain
10 Dubai
2 Sharjah
2 Ras Al Khaimah
2 Fujairah

least one medical physicist for each center. The number of technical staff is not
fixed, and there is a shortage everywhere.

23.3.2.3 Nursing Staff in Nuclear Medicine

Nurses’ availability in each center depends on whether there are outpatient services
or admissions for radionuclide therapy. The anticipated number is around 25 nurses.
PET-CT is used mainly for oncology patients for:

• Initial diagnosis, staging, and restaging

• Assessment of response to treatment
• Early detection of a recurrence or metastasis
• Aiding in radiotherapy planning and dosimetry
• Selecting the site of biopsy or finding an occult primary

PET-CT is extremely useful in both pediatric and adult cancers. It changed the
way Hodgkin’s and non-Hodgkin’s lymphomas were managed. It is the main eco-
nomic player in cancer management by minimizing the use of expensive chemo-
therapy when the PET-CT scan does not show a good response.

23.4 Scope of Service

Nuclear medicine facilities should be able to offer the following services (to UAE
and international patients) a variety of nuclear and molecular scans, and radionu-
clide therapy.

23.4.1 SPECT-CT Studies

• Endocrines: Thyroid scan, parathyroid scan, radioiodine whole-body scan for

thyroid cancer, neuroendocrine tumors imaging, and adrenal gland scintigraphy.
• Gastrointestinal: Esophageal reflux, transit time, and gastric emptying scintig-
raphy; Meckel’s diverticulum scintigraphy; salivary gland scintigraphy; gastro-
intestinal tract (GIT) bleeding with red blood cell labeling scintigraphy;
hepatobiliary study (HIDA); liver scintigraphy; and Barret’s esophagus scan.
23 Nuclear Medicine in the UAE 385

• Cardiovascular System: Myocardial perfusion study (rest and stress), heart

ejection fraction with gated studies for left ventricle function, and myocardial
viability study.
• Urogenital System: Dynamic renal study, diethylenetriamine pentaacetate
(DTPA), mercaptoacetyltriglycine (MAG3), ethylene cysteine (EC) with diuret-
ics, static renal study (DMSA), cysto-scintigraphy for direct and indirect vesico-
ureteral reflux (VUR), varicocele study, testicular perfusion scintigraphy,
assessment of renal function for donors, and assessment of transplant perfusion,
function, rejection, and leak.
• Musculoskeletal Studies: Bone scintigraphy (3 phase, 2 phase, and whole-body
bone scan), joint scintigraphy, Charcot foot scintigraphy, stress fracture, bone
mineral densitometry (BMD), body composition study, Fracture Risk Assessment
Tool (FRAX), and trabecular bone score (TBS).
• Inflammation/Infection: Gallium 67 scintigraphy, white blood cell (WBC)
leuko-scan, thallium scintigraphy, and pyrexia of unknown origin (PUO).
• Miscellaneous Studies
–– Dacryo-scintigraphy (for lachrymal duct)
–– Lung ventilation and perfusion studies, V/Q ratio, and pulmonary hypertension
–– Lympho-scintigraphy (for upper and lower limbs)
–– Sentinel lymph node scintigraphy
–– Brain scintigraphy (for epilepsy, parkinsonism, dementia, and brain death).

23.4.2 PET-CT Studies

• Oncology: Useful in the staging and restaging of solid organ malignancies and
to search for the unknown primary, response to treatment, and detection of early
recurrence.
• 18F-FDG whole body/regional PET-CT, 18F-NaF PET-CT bone scan, 18F-choline,
gallium 68Ga-PSMA and DOTA.
• Non-oncology: Useful in pyrexia of unknown origin (PUO), epilepsy, dementia,
myocardial viability, cardiac sarcoidosis, inflammatory pathologies like sarcoid-
osis, prosthesis related infections, osteomyelitis, etc.

The average minimum staffing plan for any nuclear medicine department to
establish, according to the author’s knowledge, is shown in Table 23.5, and
Table 23.6 lists the additional equipment needed to establish a nuclear medicine
department.
386 A. Al Suhaili

Table 23.5 Minimal staffing plan for a nuclear medicine department to initiate
Staff type Total number Staff breakdown
Physician 3 Consultant (1)
Specialist (1)
General physician/resident (1)
Medical physicist 1 Consultant physicist (1)
Nurses 3 Nuclear medicine experienced nurses (3)
Clinical Support Staff 5 Senior nuclear medicine technologist (3)
Nuclear medicine technologist (2)
Administrative Staff 3 Coordinator, receptionist/insurance (3)

Table 23.6 List of the S. No Equipment

additional equipment needed 1 Dual energy X-ray absorptiometer (for bone
to establish a nuclear mineral density)
medicine department
2 Technigas—lung ventilation delivery system
3 Radiation (area monitoring system)
4 Dose calibrator
5 Contamination monitor
6 Personal dosimeter
7 Fume hood
8 Processing and reviewing station
9 Archiving computer system
10 Glucose monitoring machine
11 Crash trolley
12 Treadmill and cardiac stress facility
13 Defibrillator, cardiac monitors, oximeters
14 Infusions pumps

23.5 Future Outlook

The future of nuclear medicine is moving towards the molecular level and targeting
genes. The standard approach to prostate cancer is surgical, medical, and radio-
therapy, depending on the protocol used. Radionuclide therapy with prostate-­
specific membrane antigen (PSMA) was used when other treatments failed, but the
new approach is to start with beta- or alpha-labeled PSMA before surgery, and the
results are encouraging.
In breast cancer, an intratumoral single dose of astatine-211 as gold nanoparti-
cles can suppress the growth of tumor tissue strongly without radiation exposure to
other organs. Other attempts are still going on, like labeling raloxifene or herceptin
with radionuclides for therapy. HER-2 imaging with 64Cu-DOTA-transluzumab
can pick up a very early and small metastasis and subsequently be dealt with very
early [10, 11].
The new LU-177 LUTATERA is more effective in treating neuroblastoma than
I-131 mIBG [8].
Radionuclides targeted gene therapy as the ultimate direction for the treatment of
many cancers and achieving a complete cure.
23 Nuclear Medicine in the UAE 387

TARE is expanding for many single or multiple metastases in the liver that origi-
nated from intestinal cancers.

23.6 Conclusion

It has been a great achievement in a relatively short period of time since the begin-
ning of nuclear medicine in the UAE by a few pioneers. Now that we have proudly
achieved the current level in this promising field, we hope to advance in this direc-
tion, as we have in many other fields.
Forty-three years was a hard and difficult but enjoyable mission, particularly
when you see patients coming from many neighboring countries for treatment in
the UAE.
The ultimate goal is to conduct original research and create a scientific base to
make new discoveries that we can share with the rest of the world on a recipro-
cal basis.

Acknowledgement I would like to thank Dr. Anshu Misra for her support in writing the chapter.

Conflict of Interest The author has no conflict of interest to declare.

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388 A. Al Suhaili

Dr. Abdulrahim Al Suhaili graduated from Ain-Shams Medical

School with honors in Egypt. He was SHO at the Institute of
Radiology and Nuclear Medicine in Baghdad, Iraq, and then
Registrar at the same place. He got a scholarship to Johns Hopkins
University (Nuclear Cardiology and Oncology), USA, in 1976. He
was a specialist at the Ibn Al-Nafis Cardiovascular Hospital in
Baghdad, Iraq. He did his postgraduate from Royal Postgraduate
Medical School, University of London, MSc. 1983. Dr. Abdulrahim
worked in the nuclear medicine department of Hammersmith
Hospital in London, UK, from 1982 to 1984. He worked at Mubarak
Al Kabeer Hospital and Amiri Hospital (1984–1987), Kuwait. He
was Head of Nuclear Medicine at Tawam Hospital from 1987 to
2004 in Abu Dhabi, UAE. He also worked as an Associate Professor
at the UAE University, Al Ain, UAE (1990–2007). He was an
Associate Clinical Professor at Dubai Medical School (2004–2019).
He was head of nuclear medicine and densitometry at Dubai
Hospital from 2004 to 2014. He was the first to start BMD in the
UAE in 1995 and the first to teach bone densitometry in the
UAE. Dr. Abdulrahim was the founding member of the Pan Arab
Osteoporosis Society in 1998 and the Emirates Osteoporosis
Society. He was the president of the Pan Arab Osteoporosis Society
from 2005 to 2008 and is also the current president of the Emirates
Osteoporosis Society. His research, along with that of his col-
leagues, on osteoporosis among women in the UAE was awarded
the Sh. Hamdan Medical Awards in 2006.
Dr. Abdulrahim Ibrahim Al Suhaili has become the Director of
Nuclear Medicine and Bone Densitometry in Burjeel Medical City,
UAE. He has published 51 articles in US, UK, EU, and UAE jour-
nals. He wrote chapters in two books on nuclear medicine. He is a
member of the editorial boards of many journals in nuclear medi-
cine and densitometry.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Pediatric Cancer in the UAE
24
Zainul Aaabideen Kanakande Kandy, Ammar Morad,
and Eman Taryam Alshamsi

24.1 Introduction

Globally, progress in the field of pediatric oncology is one of the biggest success
stories in the oncology field in the last few decades. The 5-year survival rate for
most pediatric cancers is now 80–90% (1–3); however, there are very few pub-
lications from the United Arab Emirates (UAE) on the survival rate of childhood
cancers in the UAE (4–6). The UAE has made remarkable progress in the field
of pediatric oncology in the last few decades. The UAE as a country has highly
advanced infrastructure and provides a safe environment and very comfortable
facilities for both residents and visitors. These attract many visitors to come to
the UAE for the holiday and for healthcare. It is the vision of the government to
promote medical tourism, and it has tremendous potential to explore and

Z. A. Kanakande Kandy (*)

Department of Pediatric Oncology Hematology and BMT, Burjeel Medical City, Abu Dhabi,
United Arab Emirates
e-mail: zainul.aabideen@burjeelmedicalcity.com
A. Morad
Mediclinic City Hospital, Dubai, United Arab Emirates
e-mail: ammar.morad@mediclinic.ae
E. Taryam Alshamsi
Hematology and Oncology Division, Pediatric Department,
Al Jalila Children’s Specialty Hospital, Dubai, United Arab Emirates

© The Author(s) 2024 389

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_24
390 Z. A. Kanakande Kandy et al.

establish. Therefore, it is important to reflect on and analyze the past and current
challenges and use this insight to plan for the future. The most important
domains in pediatric oncology care, as in any other medical field, are service,
research, and education, and we need all-round development in all these
domains, which will make pediatric oncology in the UAE among the best in
the world.

24.2 History of the UAE’s Pediatric Oncology Services

Cancer care services for children were initially developed in the public sector but
are now available in both the public and private sectors (4, 7, 8). Tawam Hospital,
the first hospital in the UAE, was opened by the UAE government in September
1979 in Al Ain, Abu Dhabi, to deliver care to children with cancer (4, 7, 8). Dubai
Hospital was established in 1983 in Dubai and also provides pediatric oncology
services. The Dubai pediatric hempathology oncology unit moved to Al Jalila
Children’s specialty hospital in April 2023. It is under the government of Dubai.
Sheikh Khalifa Medical City (SKMC) in Abu Dhabi was the second government
hospital in Abu Dhabi to also deliver pediatric cancer care, and it was opened
in 2005.
In the private sector, hospitals that provide pediatric cancer care in the UAE
include Burjeel Medical City, Abu Dhabi; Royal NMC, Abu Dhabi; American
Hospital; and Mediclinic City, Dubai (Tables 24.1 and 24.2).
The first dedicated cancer hospital in the UAE is the Gulf International Cancer
Centre (GICC), which was opened in 2007 (7). This hospital, however, does not
offer pediatric oncology services.

Table 24.1 Names of a few Hospital City

hospitals providing pediatric Public
oncology in the UAE
Tawam Hospital Al Ain
Sheikha Khalifa Medial City (SKMC) Abu
Dhabi
Al Jalila Children’s Hospital Dubai
Private
Burjeel Medical City Abu
Dhabi
NMC Hospital Abu Dhabi Abu
Dhabi
American Hospital Dubai
Mediclinic City Hospital Dubai
Clemenceau Medical Center (CMC) Dubai
Hospital
NMC Hospital Sharjah Sharjah
24 Pediatric Cancer in the UAE 391

Table 24.2 Incidence of pediatric cancer in the UAE as per National Cancer Registry (NCR) (9)
2014 2015 2017 2019 2021
New pediatric 154 165 146 125 154
cancer case age
group of
0–14 years
Male/female 55.2% / 44.8% 57% / 43% 55% / 45% 53.6% / 46.4% 55% / 45%
0–4-year age 77 (50.0%) 75 (45.5%) 62 (42.5%) 63 (50.4%) 72 (46.8%)
group
5–9-year age group 41 (26.6%) 48 (29.1%) 50 (34.2%) 24 (19.2%) 39 (25.3%)
10–14-year age 36 (23.4%) 42 (25.5%) 34 (23.3%) 38 (30.4%) 43 (27.9%)
group
Leukemia 67 (43.5%) 68 (41.2%) 61 (41.8%) 44 (35.2%) 66 (42.9%)
Brain and CNS 22 (14.3%) 21 (12.7%) 7 (4.8%) 14 (11.2%) 23 (14.9%)
Connective and 4 (2.6%) 4 (2.4%) – 9 (7.2%) –
soft tissue
Non-Hodgkin 11 (7.1%) 15 (9.1%) 10 (6.8%) 9 (7.2%) 13 (8.4%)
lymphoma
Hodgkin’s 11 (7.1%) 10 (6.1%) – – –
lymphoma
Bone and articular 5 (3.2%) 3 (1.8%) – 7 (5.6%) 7 (4.5%)
cartilage
Kidney & Renal 6 (3.9%) 10 (6.1%) 11(7.5%) – –
pelvis
Liver and 4 (2.6%) 5 (3.0%) 8 (5.5%) – –
intrahepatic bile
ducts
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2014–2021

24.3 Radiation Oncology Service for Children in the UAE

The first radiation oncology program was started at Tawam Hospital, followed by
GICC (7). The first radiation oncology service in the Northern Emirates was started
at Sheikh Khalifa Speciality Hospital in Ras Al Khaimah in 2015. The first radiation
oncology service in the private sector was started at an American hospital in Dubai.
Currently, there are many private hospitals in the UAE that provide radiation ser-
vices, including Burjeel Medical City (7).

24.4 Pediatric Hematopoietic Stem Cell

Transplantation (HSCT)

Stem cell transplantation (SCT) is one of the more advanced treatments. It is curative
and lifesaving for many pediatric conditions, including childhood cancer. This ser-
vice was not available in the UAE until March 2022. This was one of the main rea-
sons for children going abroad. The first allogenic bone marrow transplant (BMT)
was successfully done in the UAE in March 2022 at Burjeel Medical City, Abu Dhabi
(10). In August 2022, the first BMT in a child with Acute Lymphoblastic Leukemia
392 Z. A. Kanakande Kandy et al.

(ALL) was successfully completed. The first BMT for Acute Myeloid Leukemia
(AML) was done in January 2023. The first haploidentical BMT was done in the
UAE in January 2023 (unpublished data on file).
A total of 164 pediatric patients underwent HSCT outside the UAE between
2016 and 2018 (11) including children residing in the UAE. An estimated 200
patients, including non-citizens, need HSCT annually in the UAE. Currently,
CAR-T cell therapy and gene therapy are not offered in the UAE.
It is a need of the hour to develop a center of excellence for stem cell transplanta-
tion in children, which has previously been a major reason to travel abroad.

24.5 Long-Term Fertility Issue and Sperm Banking

As the outcome for children with cancer improves, the number of adults who are
childhood cancer survivors is also increasing. Infertility is one of the long-term side
effects of many cancer drugs and radiation treatments. Fertility preservation is
becoming increasingly important for these younger patients. This service is avail-
able in the UAE; however, lack of awareness about this program is the main obsta-
cle. In addition to this, insurance coverage for this service is also an issue, especially
for expatriates.

24.6 Funding for the Pediatric Cancer Care in the UAE

Cancer care in the UAE is expensive, but it is funded by the government for UAE
nationals. But for expatriates, it is covered by insurance. There are many expatriates’
children, especially in the Northern Emirates, without insurance or whose insurance
is inadequate to cover the expense. They do get free treatment through the mandate
program available at Tawam Hospital. In effect, all resident children with cancer,
irrespective of their nationalities and insurance coverage, get most of the cancer
treatment available in the UAE. In addition to this, there are many charities, such as
the Red Crescent Society, Sharjah TV, the Child Fund under the umbrella of the Al
Jalila Foundation, Rahma, and Friends of Cancer Patients (FOCP), that support chil-
dren with cancer financially. Recently, BMT services were established in the
UAE. Since it is a new service in this country, many insurance companies have not
yet recognized it and are not covering the expenses.

24.7 Availability of Cancer Medicines and Investigation

Facilities for Treating Children with Cancer in the UAE

Most of the cancer drugs used for treating children with cancer as per the interna-
tionally recognized protocols, including the latest Food and Drug Administration
(FDA)-approved medications, are available in the UAE. But they are expensive.
However, a few medications in syrup form are still unavailable in the UAE.
24 Pediatric Cancer in the UAE 393

24.8 Pathology, Molecular Cytogenetics, and MRD (Minimal

Residual Disease) Testing in the UAE

Laboratories in the UAE are accredited by the College of American Pathologists

(CAP), which standardizes pathology reporting. However, cytogenetic and molecu-
lar diagnostic testing for soft tissue sarcoma, Wilms tumors, and brain tumors is not
easily available in the UAE. These tests are sent abroad to centers in the USA,
Europe, Canada, and India, resulting in significant delays in diagnosis and the start
of treatment in many cases. Minimal residual disease (MRD) is another important
test for leukemia management. Recently, it was established in the UAE in two hos-
pitals. There is a need for such facilities to be well established in the UAE, which
will provide the UAE with all of the services required to provide treatment at an
international level.

24.9 Medical and Nursing Team in Pediatric Oncology

in the UAE

Consultant pediatric oncologists, junior doctors, pediatric oncology nurses, nurse

coordinators, and pediatric oncology advanced nurse practitioners are important
human resources in pediatric cancer care.
Delivery of pediatric oncology services in the UAE is led by consultants. Most
of the consultants in the UAE were trained either in the USA, Canada, or the UK.
There are an estimated 16 pediatric oncologists in the UAE. All the hospitals that
deliver pediatric oncology services have pediatric surgical departments. Pediatric
surgeons perform most of the pediatric oncology surgeries. There is no dedicated
pediatric radiation oncologist in the UAE.

24.10 Pediatric Oncology Nursing

The pediatric oncology nurse shortage is a challenge in the UAE. Most oncology
nurses in the UAE are from India, the Philippines, Jordan, and Lebanon. There are
very few pediatric oncology nurses who are UAE nationals.
Furthermore, the role of a pediatric oncology advanced nurse practitioner is not
very well established in the UAE. Pediatric oncology advanced nurse practitioners
provide a significant contribution in western countries like the UK and the USA.
Developing an advanced nurse practitioner role in oncology nursing in the UAE
will foster and improve nursing care for cancer patients and their families.
Communication between the nurse and parents is very important in pediatric oncol-
ogy practice. Therefore, foreign nurses should be encouraged to learn the local
Arabic language as a priority.
There are no structured training programs for pediatric oncology nursing in the
UAE. As it is mandatory to have attendance at the continuing medical education
(CME) for license renewal, pediatric oncology nurses attend the conference with
394 Z. A. Kanakande Kandy et al.

CME hours. Having a pediatric oncology nursing track in the pediatric oncology
annual conference for continuing their education and improving evidence-based
nursing practice will help advance their skills.

24.11 Protocol-Based Cancer Treatment in the UAE

Most of the international pediatric cancer centers that treat children with cancer are
based on evidence-based protocols. This is one of the main reasons for the improved
outcome of pediatric cancer treatment globally (1, 3, 12). These are the Children’s
Oncology Group (COG), the UKCCLG, the BFM Protocol, etc. (3, 12, 13). Although
the UAE does not have national protocols and guidelines, all pediatric oncology
centers in the UAE follow either one of the above-mentioned protocols.

24.12 Pediatric Oncology Research in the UAE

The foundation of research in the medical field is accurate knowledge of the epide-
miology of diseases. Unfortunately, there is a real paucity of epidemiologic data on
pediatric cancers in the UAE (6, 12, 14). After an extensive literature search, the
number of publications in PubMed related to pediatric oncology in the UAE is sur-
prisingly low. So far, we could find only 27 publications in the last 50 years (4–8,
11, 14–35). At present, there is no recent publication related to outcomes in children
with cancer treated in the UAE except for three published before 2003 (4, 5, 8).
Internationally, pediatric cancer outcomes have improved as a result of the use of
uniform guidelines and the very effective enrolment of patients in prospective mul-
ticentric clinical trials conducted by professional organizations such as COG and
UKCCLG (12, 13). However, the UAE lacks a national pediatric oncology
research group.
There are no organized clinical trials related to pediatric oncology in the UAE,
and there is a lack of good prospectively published studies on the epidemiology,
biology, or outcome of childhood cancers in the UAE.

24.12.1 Cancer Registry

Since 2014, data on the incidence of pediatric cancer in the UAE has been made
available through the National Cancer Registry (NCR).

24.13 The Pediatric Oncology Education in the UAE

There is no formal postgraduate program in pediatric hemo-oncology in the

UAE. UAE nationals who want to further pursue pediatric oncology after medical
graduation go abroad for specialization.
24 Pediatric Cancer in the UAE 395

24.13.1 Pediatric Oncology Continuing Medical Education (CME)

in the UAE

Continuous medical education of primary care practitioners and pediatricians in the

early diagnosis and prompt referral of childhood cancers is a very important step to
improving the outcome of pediatric cancer care.
In the last 5 years, there has been an annual Emirates Pediatric Hematology and
Oncology conference in the UAE, which has played a big role in the continuous
medical education of practicing pediatricians in the UAE by improving their knowl-
edge in pediatric oncology to diagnose cancers in children early. The first Emirates
Pediatric Bone Marrow Transplantation Congress was held in the UAE in 2022.
Both conferences were attended by renowned international and national speakers.

24.14 Emirates Pediatric Hematology and Oncology Society

Organizations like the Emirates Pediatric Hematology and Oncology Society do not
exist as they do among adult oncologists like the Emirates Oncology Society (EOS)
and Emirates Hematology Society (EHS). It is the official organization representing
adult oncology healthcare providers in the UAE under the Emirates Medical
Association’s (EMA) umbrella. We recommend establishing such an organization
to represent pediatric oncologists in the UAE.

24.15 Support Program for Families with Children

on Cancer Treatment

In many countries, there are many support groups to help families with children
diagnosed with cancer. In addition to financial support, they have a big role in pro-
viding psychological support to the parents during their most difficult time. In the
UAE, there are many organizations like the Red Crescent Society, Rahma, and
Friends of Cancer Patients (FOCP) that provide lots of support, including financial
support, for such families. Many hospitals in the UAE do activities on International
Cancer Day in February and Childhood Cancer Awareness Month in September to
motivate children with cancer and their families and to raise awareness regarding
childhood cancer.

24.16 Medical Tourism for Pediatric Cancer Care: Bringing

Revenue to the UAE Rather Than Spending Huge Sums
Abroad for Cancer Treatment of Children

The UAE is a popular holiday destination for people all around the world.
Considering the infrastructure and very comforting facilities, the UAE can become
a very popular destination for healthcare services.
396 Z. A. Kanakande Kandy et al.

The UAE, as a nation, has a lot of potential to become a hub for medical tourism.
Many factors distinguish it from other countries, including its geographical loca-
tion, the availability of healthcare expertise with US and UK training and experi-
ence in the UAE, and the recent establishment of many world-class hospitals,
including a pediatric BMT facility and the availability of cancer medicine in
the UAE.
But there are many obstacles, including the high price of the cancer treatment
and the trust of international patients in the existing healthcare system in the UAE.
On the contrary, the UAE spent vast sums of money outside the UAE for cancer
treatment and bone marrow transplantation for children seeking treatment elsewhere.
The USA, the Federal Republic of Germany, the Republic of Singapore, the
Republic of Korea (South Korea), the Kingdom of Thailand, and the UK are the
most chosen destinations for healthcare tourism for UAE nationals.
There are several sponsoring agencies in the UAE that cater to pediatric cancer
care abroad, including all the health authorities (Department of Health, Dubai
Health Authority, and Ministry of Health and Prevention), Presidential Affairs
offices, the armed forces, police, and charity organizations. The lack of treatment
options in the UAE is one of the criteria for sending patients abroad. However,
despite the availability of pediatric cancer treatments and a recently opened BMT
facility in the UAE, many patients go abroad for the treatment.

24.17 Recommendations for the Progress of Pediatric

Oncology Services in the UAE

Cancer Registry: Optimal utilization of the existing national cancer registry through
optimal reporting and use of the data for analysis for proper understanding of the
current incidence, outcome, and challenges for further development.
Encourage Research Publications: Peer-reviewed journals should be encouraged
for all pediatric oncologists. They should be given appropriate support and recogni-
tion for their commitment to publishing evidence.
Establish Services: There are services that need to be established as a priority to
deliver pediatric oncology services locally at an international standard.
It is a need of the hour to develop a center of excellence for stem cell transplanta-
tion in children, which has previously been a major reason to travel abroad.
National Multidisciplinary Tumor (MDT) Board: There is a need for a national
MDT board to discuss difficult cases to improve patient care.
Invest in nurse training: Regular nurse training and CME in pediatric oncology
will educate and empower the nursing workforce in pediatric oncology.
We recommend that oncology nurses in the UAE receive incentives for their
dedication and commitment with a periodic hike in their salary.
Medical Tourism: Reduce residents’ going abroad for pediatric oncology treat-
ments and bone marrow transplants that are already available in the UAE by improv-
ing their trust in the healthcare system. Promote medical tourism, which attracts
more visitors to the UAE for medical treatment.
24 Pediatric Cancer in the UAE 397

We recommend that treatment abroad be limited to complex pediatric cancer

cases. Promoting public trust in cancer care within the UAE is an important aspect
that needs special attention.

24.18 Conclusion

The pediatric oncology services have developed significantly in the UAE since the
country was formed. All the children who reside in the country are entitled to get
treatment, irrespective of their nationalities and insurance coverage. However, there
are areas that need close attention and improvement as a priority.

Conflicts of Interest The authors have no conflict of interest to declare.

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24 Pediatric Cancer in the UAE 399

Dr. Zainul Aaabideen Kanakande Kandy is highly skilled and

experienced in paediatric haematology, oncology, and bone mar-
row transplants. He received his degree in medicine at Calicut
University in Kerala, India; subsequently, he took his post-graduate
degree in paediatrics from the University of Mumbai .
In 2001, Dr. Zainul moved to the United Kingdom, where he
specialized and undertook further training and experience in paedi-
atric haematology, paediatric oncology, and paediatric bone mar-
row transplantation in various hospitals in the UK.
Royal Marsden Hospital, London, IK
University College Hospitals of London UCLH London
Imperial College London, UK
Manchester Children Hospital, Manchester, UK
Alder Hey Children Hospital, Liverpool, UK
Great North Children Hospital, Newcastle, UK
Dr. Zainul gained his master’s degree in paediatric oncology at
Birmingham University as well as a certificate in medical education
at Manchester University. Subsequently, he completed his
International Fellowship in paediatric bone marrow transplantation
at Great North Children’s Hospital in Newcastle.
He worked previously as a consultant pediatric at the University
Hospital of Coventry, Warwickshare, and Royal Oldham Hospital
before moving to the UAE.
In the UAE, he had worked at the Department of pediatric
hematology and oncology at Tawam Hospital as a consultant, Al
Ain, before joining at Burjeel Medical City as head of pediatric
hematology, oncology, and BMT.
Aside from his commitment to further advance his experience
and knowledge in the fields of paediatrics, paediatric haematology,
oncology, and bone marrow transplantation in the United Kingdom,
he also published articles and actively supported the community by
sharing his knowledge and participating in international confer-
ences across countries.

Dr. Ammar Morad completed his training in pediatric hematol-

ogy and oncology at Texas Children’s Hospital and subsequently
practiced as an assistant professor. He has practiced in the USA for
the past 35 years, and his most recent position was at Cincinnati
Children’s Hospital, ranked among the top three pediatric cancer
centers in the USA.
He has published extensively in world-renowned journals and
taught several generations of future pediatric oncologists. His pas-
sion for teaching earned him the title of most outstanding faculty
member in the pediatric department at Texas Tech University.
400 Z. A. Kanakande et al.

During his tenure, he created and directed the pediatric cancer

centre at the Women’s and Children’s Hospital in Louisiana, where
he achieved a 90% cure rate for the 150 cases he has managed
according to the latest treatment protocols.
Dr. Morad brings with him a wealth of experience in all aspects
of pediatric blood conditions and childhood cancers, backed by
access to and collaboration with premier paediatric cancer centers
to provide unrivalled, personalized care in Dubai and the UAE.

Dr. Eman Taryam Alshamsi is currently serving as a consultant

pediatric hematologist and oncologist at Al Jalila Children’s
Hospital. She graduated in 2002 from the faculty of medicine and
health sciences at the United Arab Emirates University. Following
graduation, she trained and practiced at Tawam Hospital UAE in
2005 and as staff from January 2017 until June 2021, when she
joined Al Qassimi Women and Children Hospital AQWCH as a
consultant in hematology oncology and head of department until
July 2023. She acquired the Arab Board diploma of medical spe-
cialization in pediatrics and RCPCH. She has been trained and
obtained a diploma in clinical research affiliated with Vienna
School of Clinical Research.
Later on, she completed a clinical fellowship program in pedi-
atric hematology oncology and bone marrow transplant at Sickkids
Hospital in Toronto, Canada, which included full training in pedi-
atric clinical hematology oncology /bone marrow transplant and
thrombosis for 3 years and 6 months as a hemostasis fellow. She
has also attended an administrative fellowship program in MD –
Anderson, Texas, USA.
Dr. Al Shamsi has been part of several on-going collaborative
research projects at Tawam and AQWCH hospitals, MBRU,
UAEU, and Zayed University with PubMed publications. Author
and reviewer for bleeding disorder and pediatric cancer chapters.
She hosted the SIOP Asia conference in Abu Dhabi in April
2019. Dr. Al Shamsi is involved in many national and international
committees and activities, including the Scientific Sub-Committee
of the International Medical Awards 2023-2024 (Sheikh Hamdan
Bin Rashid Al Maktoum Award for medical science), the
Transfusion Committee in AQWCH/AQH, the NIHS pediatric
hematology oncology accreditation (Head of the Sub-committee),
national bone marrow transplants, national cancer screening and
prevention, SIOP, and the Women Leader in pediatric oncology
SIOP (WLPO). Patient support activity and awareness with CCI
and Friends of cancer patients (FOCP) UAE.
24 Pediatric Cancer in the UAE 401

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Geriatric Oncology in the UAE
25
Hassan Shahryar Sheikh and Kiran Munawar

25.1 Introduction

The United Arab Emirates (UAE) is situated in the southeast of the Arabian
Peninsula, bordering Oman and Saudi Arabia, and is a member of the Gulf
Cooperation Council (GCC) of Arab countries. It has an estimated population of
about 9,282,410 in 2020 [1–3]. The World Bank classifies it as a high-income
country [4].
In 2017, the age group >60 years does not represent a large share of the popula-
tion, and the demographics of the UAE are fast changing [5, 6]. Life expectancy at
birth in the UAE continues to improve slowly, and the most recent estimates for
2020 are 78 and 81.4 years for males and females, respectively [7]. The projection
is that the younger workforce will work their way up the population pyramid.
Furthermore, the recent incentives from the government to attract and retain highly
skilled expatriate workers and foreign investors with long-term residency and retire-
ment options may increase the number of expatriates living past their retirement age
in the UAE. As a result, the geriatric population in the UAE is likely to surge in the
next 20–40 years. The World Health Organization (WHO) estimated that countries
like the UAE should anticipate a fivefold or greater increase in the proportion of
their geriatric population from 2000 to 2050 [8].

H. S. Sheikh (*)
Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
Khalifa University, Abu Dhabi, United Arab Emirates
e-mail: hssheikh@ssmc.ae
K. Munawar
St Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
e-mail: kiran.munawar@nhs.net

© The Author(s) 2024 403

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_25
404 H. S. Sheikh and K. Munawar

25.1.1 Definition of the Older Individuals

Ageing is commonly measured by chronological age, and, as a convention, a person

aged 65 or more is often referred to as “older individual” [9]. The elderly are divided
into three groups by the American National Institute for Ageing: young adults
(65–74 years old); older adults (75–84 years old); and the oldest adults (over
85 years old) [10]. As per the National Policy on Senior Emiratis, individuals who
are 60 years of age or older are considered seniors [11].
The current retirement age for most employees is 60 years. Therefore, the defini-
tion of “elderly” in the UAE is here considered to be above the age of 60 years.

25.2 Cancer Incidence in the Elderly (Age ≥60 years)

in the UAE

According to the 2021 Annual Report of the UAE National Cancer Registry, a total
of 5830 new malignant cases were reported in the country. 25.6% of these cases
occurred among Emirati nationals. Females made up 55.1% of these cases, regard-
less of origin.
When stratified by age groups, 29.18% of all cancer cases occurred in the age
≥60 years, irrespective of gender and origin. As a result, nearly one-third of all
cancer cases in the UAE occurred among the elderly. The data indicate the highest
incidence of malignant cases in the age groups 40–44 years (12.6%), 50–54 years
(11.2%), 45–49 years (11.1%), and 50–59 years (10.8%) 35–39 years (10.3%) as
shown in Fig. 25.1(a) [6].
According to gender in the total population, among females, 23% of all new
malignant cases were diagnosed in the age range ≥60 years, and among males,
36.2% or one third of all new malignant cases occurred in the age range ≥60 years,
as shown in Fig. 25.1(b, c) [6].
People over the age of 60 accounted for 40.4% of new malignant cases among
Emirati nationals, compared to 25.1% among non-citizens. The data indicate that
the highest incidence of malignant cases in Emirati citizens was observed in the age
group 55–59 years (9.6%), as shown in Fig. 25.1(d). Among the Emirati male citi-
zens, almost half (50.5%) of all the new malignant cases were diagnosed in people
aged ≥60 years, compared to one-third (33.1%) in the Emirati female citizens. The
data show that the highest frequency of cancer was observed among Emirati females
in the age group of 40–44 years (11.4%), and among Emirati males in the age group
of 70–74 years (10.7%), followed by a second highest frequency in the age group of
60–64 years (10.3%) (Fig. 25.1(e, f), Table 25.1) [6].
The most commonly diagnosed cancers in the UAE population also vary consid-
erably by age group, with particular differences in the cancer types diagnosed in
adults’ aged ≥60 years compared to the younger population. The breast, colorectal,
prostate, and lung were the most frequent solid malignant tumors, respectively,
25 Geriatric Oncology in the UAE 405

a All gender d Emirati

800 160
700 140
600 120
500 100
400 80
300 60
200 40
100 20
0 0
0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+
b females e Emirati females
500 100
450 90
400 80
350 70
300 60
250 50
200 40
150 30
100 20
50 10
0 0
0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+
c males f Emirati males
350 70
300 60
250 50
200 40
150 30
100 20
50 10
0 0
0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

0-4

5-9

10-14

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84
15-19

85+
Fig. 25.1 Annual Report of the UAE—National Cancer Registry—2021. Statistics and Research
Center, Ministry of Health and Prevention. Adapted from the Cancer Incidence in United Arab
Emirates [6]. Age group distribution of malignant cases in UAE among all gender (a), females (b),
males (c), Emirati (d), Emirati females (e), and Emirati males (f)

among all populations aged ≥60 years. In the Emirati citizens, the most frequent
malignant tumors were breast, colorectal, prostate, lung, and uterus, respectively, in
the age ≥60 years. Further specifics of the data by gender, age, and nationality are
limited and not available for further analysis. The incidence of cancer burden is
expected to rise significantly by 2040 (Table 25.2) [6, 12, 13].
Similar to the cancer incidence, the mortality rate from cancer also increases
with age (Fig. 25.2) [2]. According to the Department of Health (DOH) report on
Abu Dhabi health statistics 2017, the death rate per 1000 increases significantly
starting at around age ≥60 years [2, p. 21].
These statistics clearly demonstrate that older patients with cancer in the UAE
constitute a sizable and significant population. Among Emirati citizens, individuals
aged ≥60 years carry a high burden of cancer.
Cancer incidence rates in neighbouring GCC countries follow a similar trend of
increasing cancer incidence with age, with the age group ≥60 years representing the
population with the highest cancer burden (Fig. 25.3) [14].
Table 25.1 Distribution of primary sites (malignant cases) by age group, among all, in 2021, in the UAE
406

Primary site ICD-10 (0–9) (10–19) (20–29) (30–39) (40–49) (50–59) (60–69) (70–79) (80+)
C00–C14 Lip, oral cavity & pharynx 0 1 3 24 42 43 28 7 6
C15 Esophagus 0 0 2 4 7 4 1 6 3
C16 Stomach 0 0 5 15 29 25 33 24 3
C17 Small intestine 0 0 3 4 6 6 4 2 1
C18–C21 Colorectal 1 2 10 69 107 129 112 77 25
C22 Liver and intrahepatic bile ducts 0 0 3 10 8 33 23 31 6
C23, C24 Gallbladder, other and unspecified 0 0 0 4 9 8 14 7 4
part of biliary tract
C25 Pancreas 0 0 1 11 15 32 29 14 8
C26 Other and ill-defined digestive organs 0 0 0 0 4 1 1 1 1
C30, C31 Nasal cavity, middle ear, accessory 0 0 0 1 3 5 3 0 0
sinuses
C32 Larynx 0 0 0 0 5 10 7 7 0
C34 Bronchus and lung 0 0 4 16 32 62 47 50 20
C37 Thymus 0 0 0 5 4 1 0 0 0
C38 Heart, mediastinum, and pleura 0 0 2 2 1 0 0 1 0
C40–C41 Bone and articular cartilage 1 11 1 6 7 4 2 1 1
C43 Skin melanoma 0 0 6 13 12 15 3 2 0
C44 Skin (Carcinoma) 0 1 7 44 70 77 39 24 11
C45 Mesothelioma 0 0 1 0 2 1 1 1 0
C46 Kaposi sarcoma 0 0 0 1 1 0 1 0 0
C48 Retroperitoneum and peritoneum 2 1 0 2 5 3 2 2 1
C49 Connective and soft tissue 2 7 1 12 10 8 4 2 1
C50 Breast 0 0 13 223 407 275 149 55 17
C51 Vulva 0 0 0 1 1 0 0 0 1
C52 Vagina 0 0 1 0 0 0 2 0 0
C53 Cervix uteri 0 0 5 38 45 34 14 4 1
H. S. Sheikh and K. Munawar
C54–C55 Uterus 0 0 2 21 37 42 46 24 1
C56 Ovary 0 1 4 19 27 33 12 9 3
C57 Other and unspecified female genital 0 1 0 0 0 3 2 0 0
organs
C58 Placenta 0 0 2 0 1 1 0 0 0
C61 Prostate 0 0 0 1 9 56 107 60 18
C62 Testis 2 1 17 30 9 1 0 0 0
C64–C65 Kidney & renal pelvis 10 0 3 19 43 32 27 12 5
C66, C68 Ureter and other urinary organs 0 0 1 0 0 2 1 0 1
C67 Urinary bladder 0 0 1 4 16 24 37 26 18
25 Geriatric Oncology in the UAE

C69 Eye 1 0 0 1 3 0 0 0 0
C70–C72 Brain & CNS 13 12 9 30 25 29 21 8 2
C73 Thyroid 2 16 69 206 169 94 27 8 4
C74–C75 Other endocrine glands 2 0 3 4 1 1 0 0 0
C76–C80 Unknown or unspecified sites 6 2 1 5 8 13 11 8 7
C81 Hodgkin’s lymphoma 2 16 29 21 14 3 2 3 1
C82–C85, C96 Non-Hodgkin lymphoma 7 8 19 35 41 52 32 24 10
C88, C90 Multiple myeloma 0 0 2 3 20 22 27 10 5
C91–C95 Leukemia 59 15 23 56 64 36 28 19 4
Other hematopoietic malignancies 0 0 0 3 11 10 6 2 4
Other malignancy 1 0 0 0 1 0 0 0 0
Grand total 111 95 253 963 1331 1230 905 531 193
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease Registry—UAE National Cancer Registry Report, 2021
407
Table 25.2 Distribution of primary sites (malignant cases) by age group, among Emirati, in 2021, in the UAE
408

Primary site ICD-10 (0–9) (10–19) (20–29) (30–39) (40–49) (50–59) (60–69) (70–79) (80+)
C00–C14 Lip, oral cavity & pharynx 0 0 0 5 5 7 5 4 4
C15 Esophagus 0 0 0 1 1 1 0 3 3
C16 Stomach 0 0 2 3 4 4 9 6 2
C17 Small intestine 0 0 1 0 1 1 1 2 0
C18–C21 Colorectal 1 1 2 17 13 39 37 33 17
C22 Liver and intrahepatic bile ducts 0 0 0 1 1 3 4 17 4
C23, C24 Gallbladder, other and unspecified part 0 0 0 0 0 3 3 5 1
of biliary tract
C25 Pancreas 0 0 0 1 7 10 4 7 2
C26 Other and ill-defined digestive organs 0 0 0 0 1 0 0 1 0
C30, C31 Nasal cavity, middle ear, accessory 0 0 0 0 0 1 0 0 0
sinuses
C32 Larynx 0 0 0 0 2 3 4 3 0
C34 Bronchus and lung 0 0 1 1 7 11 15 14 11
C37 Thymus 0 0 0 1 2 0 0 0 0
C40–C41 Bone and articular cartilage 0 6 1 0 2 1 0 1 1
C43 Skin melanoma 0 0 0 2 1 0 0 0 0
C44 Skin (Carcinoma) 0 0 2 3 3 3 3 4 6
C45 Mesothelioma 0 0 0 0 0 1 0 0 0
C46 Kaposi sarcoma 0 0 0 1 0 0 0 0 0
C48 Retroperitoneum and peritoneum 1 1 0 0 1 1 1 1 0
C49 Connective and soft tissue 1 5 0 2 3 2 2 1 1
C50 Breast 0 0 3 35 55 60 38 22 5
C51 Vulva 0 0 0 0 1 0 0 0 0
C52 Vagina 0 0 0 0 0 0 1 0 0

(continued)
H. S. Sheikh and K. Munawar
C53 Cervix uteri 0 0 2 0 9 7 3 1 1
C54–C55 Uterus 0 0 0 5 12 12 18 12 1
C56 Ovary 0 1 0 3 4 9 1 3 2
C57 Other and unspecified female genital organs 0 0 0 0 0 1 0 0 0
C61 Prostate 0 0 0 0 0 11 30 21 9
C62 Testis 1 1 3 9 0 1 0 0 0
C64–C65 Kidney & renal pelvis 1 0 1 5 11 5 10 7 2
C66, C68 Ureter and other urinary organs 0 0 0 0 0 1 0 0 1
C67 Urinary bladder 0 0 0 0 4 6 14 14 11
C69 Eye 0 0 0 0 1 0 0 0 0
25 Geriatric Oncology in the UAE

C70–C72 Brain & CNS 7 8 2 6 3 6 7 4 1

C73 Thyroid 1 10 37 49 50 29 9 4 4
C74–C75 Other endocrine glands 2 0 0 0 0 0 0 0 0
C76–C80 Unknown or unspecified sites 4 1 1 1 2 2 4 3 5
C81 Hodgkin’s lymphoma 0 9 12 1 5 1 2 1 1
C82–C85, C96 Non-Hodgkin lymphoma 0 4 7 11 8 14 12 14 7
C88, C90 Multiple myeloma 0 0 0 1 1 9 5 4 2
C91–C95 Leukemia 16 9 6 4 13 9 4 9 2
Other hematopoietic malignancies 0 0 0 0 1 1 3 1 2
Other malignancy 1 0 0 0 0 0 0 0 0
Grand total 36 56 83 168 234 275 249 222 108
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease Registry—UAE National Cancer Registry Report, 2021
409
410 H. S. Sheikh and K. Munawar

Fig. 25.2 Cancer death cases by age group. Source: Abu Dhabi Health Statistics 2017 [2]

Fig. 25.3 Age-specific incidence rates of all cancers in females (a) and males (b) in the Gulf
Cooperation Council. Source: Incidence of cancer in Gulf Cooperation Council countries,
1998–2001 [14]
25 Geriatric Oncology in the UAE 411

Fig. 25.3 (continued)

25.3 Geriatric Oncology

Geriatrics is a discipline of medicine that deals with the healthcare of older indi-
viduals, and geriatric oncology is a sub-discipline of geriatrics that recognizes the
uniqueness of older individuals with cancer that requires specialized care and treat-
ment. Cancer is a complex disease that requires a multidisciplinary approach, and
special aspects need to be emphasized for the older individuals [15, 16]. The pres-
ence of competing comorbidities makes this age group complex. Studies show that
only 8% of older patients with cancer have no comorbidities, while up to 55% have
three or more co-morbidities. Finding the right balance between overtreatment and
undertreatment is challenging yet critical in the clinical decision-making process for
older patients with cancer. It is an area of ongoing research to ascertain the priority
of care among competing cancers and comorbidities in an older patient with cancer
[17, 18].
The field of geriatric oncology has now fully come of age since its beginnings in
the 1980s, when American Society of Clinical Oncology (ASCO) President Dr.
Kennedy recognized the study of ageing and cancer as a distinct area of interest and
unmet need. Since then, it has seen major advancements and recognition as a sub-
specialty within oncology by several organizations and major cooperative groups.
In order to promote awareness, ASCO organized a clinical practice forum in 2000,
a symposium during its annual meeting in 2002, and published a document titled
“Cancer Care in the Older Patient” as part of their Curriculum Series [15, 16].
Similarly, the International Society of Geriatric Oncology, headquartered in
412 H. S. Sheikh and K. Munawar

Switzerland, established various task forces to assess current literature and provide
treatment recommendations. In the United States, the National Comprehensive
Cancer Network issued practice guidelines for older adult oncology, while the
Geriatric Oncology Consortium was founded to initiate clinical trials and raise
awareness about challenges faced by elderly patients. The Journal of Clinical
Oncology (JCO) released a dedicated series on Geriatric Oncology (GO) in 2007
and subsequently in 2014. These publications aimed to showcase the advancements
made by researchers in this field, provide updated evidence-based treatment recom-
mendations for older cancer patients to clinical oncologists, and identify areas of
limited knowledge to inspire future research endeavours. Despite being a very fer-
tile area of research and practice, the field of GO is not without its own unique chal-
lenges. These challenges can be broadly classified into three categories: (1)
establishing a GO clinical service; (2) educating and training personnel; and (3)
conducting research in GO. These challenges are being met to varying degrees,
depending on the resources of individual countries and organizations. To fulfil this
resource disparity from a global oncology perspective, several GO initiatives have
been taken across the globe that are revolutionizing the way older adults with cancer
are treated [19]. Major oncology organizations have now integrated geriatric oncol-
ogy (GO) into their global oncology curriculum and have issued guidelines on
enhancing clinical practice, training, and research in this field. Notably, the Food
and Drug Administration (FDA) is spearheading a global regulatory initiative aimed
at expanding the body of evidence for older adults with cancer [19].

25.3.1 Geriatric Oncology in the UAE

A quick look at the global landscape in geriatric oncology will reveal that cancer
centers around the world with a dedicated GO service or program are mostly located
in high-income countries (HICs), where older adults represent a large share of their
populations. GO, like other specialities, is highly resource-dependent, and the pres-
ence of skilled personnel and multidisciplinary teams is one of the key resources
required to establish a GO program. Unfortunately, skilled personnel and multidis-
ciplinary teams in GO are globally lacking. Therefore, it comes as no surprise that
currently no formal GO programs or clinical services exist in the UAE, and provi-
sions for elder care in the UAE remain very limited [5]. There are limited options
when it comes to home care programs, typically provided by hospitals or private
service providers. In the United Arab Emirates (UAE), for example, there were only
21 licensed geriatricians available in 2020 [5, p. 5], and it is unclear whether they
are involved in the treatment of cancer patients. Additionally, there are few health-
care providers with specialized training in this area, and there is a notable absence
of local research on ageing and eldercare. Furthermore, there is a scarcity of pub-
lished studies addressing geriatric oncology issues, and medical students and post-­
graduate trainees lack a formal educational curriculum on geriatric oncology.
25 Geriatric Oncology in the UAE 413

At present, there are only two residential nursing care facilities available for the
elderly in the entire country [5]. These facilities are typically considered as a last
resort, as specific eligibility criteria must be met by senior citizens seeking care. A
recent survey conducted among 2735 UAE residents examined the attitudes of the
population towards older individuals, their knowledge and perceptions of elder care,
as well as the experiences, expectations, and preferences of Emiratis regarding older
age. The findings revealed that the current care system for the elderly in the UAE is
not well-developed. Information regarding elder care was severely limited, and
respondents were unaware of the emerging challenges associated with the care of
older individuals [5].
Moreover, apart from the lack of physical infrastructure, there are also notable
changes in social dynamics, particularly the decline of the extended family model
and the growing trend towards smaller nuclear families. These transformations will
also affect elderly care since the majority of older individuals currently receive care
at home from their families or with the assistance of domestic helpers. It is worth
noting that UAE nationals have insufficient awareness about the country’s increas-
ingly ageing population. Younger individuals are also unaware of the consequences
of ageing, while senior Emiratis lack adequate knowledge about maintaining healthy
lifestyles, engaging in active pursuits, and understanding the demand for care and
support required by the elderly [5].
In the coming years, the demand for elder care is anticipated to increase due to
various factors, including shifting demographics within the country, changes in dis-
ease patterns and dependency rates, evolving expectations of older individuals, and
the changing structure of families. The resources available, at present, are not suf-
ficient to cater to the greater number of older people with cancer that will exist in
the future. As a result, it is incumbent on private and public stakeholders in the
UAE’s healthcare sector to investigate and plan for the development of a sustainable
and effective elderly care system capable of meeting the demands of complex medi-
cal care such as cancer treatment in the near future.

25.4 Future Directions

Many efforts are underway to advance the care of older individuals with cancer
globally. In 2018, an international multidisciplinary working group at the
International Society of Geriatric Oncology (SIOG) proposed a comprehensive
framework for the global advancement of care for older adults with cancer world-
wide [20]. This broad expert consensus, known as the Top Priorities Initiative,
addressed four priority domains: education, clinical practice, research, and strength-
ening collaborations and partnerships.
These 12 priorities, listed in Table 25.3, can serve as the framework for setting
up a robust and comprehensive geriatric oncology clinical service and infrastruc-
ture, along with the skilled personnel, in the UAE.
414 H. S. Sheikh and K. Munawar

Table 25.3 The 12 priorities of the Top Priorities Initiative, proposed by the International Society
of Geriatric Oncology (SIOG) in 2018
Education
Priority 1 Integrate geriatric oncology into training programs for health-care professionals
Priority 2 Provide educational material and activities on geriatric oncology for health-care
professionals
Priority 3 Educate the general public about the relevance of providing age-appropriate care
for older adults with cancer
Clinical practice
Priority 4 Implementing models to provide optimal care for older adults with cancer
Priority 5 Develop guidelines for the optimal treatment of older adults with cancer
Priority 6 Establish centers of excellence for delivering clinical care, doing clinical and
translational research, and providing educational opportunities
Research
Priority 7 Improve the relevance of clinical trials to older adults with cancer
Priority 8 Evaluate the benefits of allocated treatments and co-management in improving
treatment outcomes for older adults with cancer
Priority 9 Use personalized medicine technologies to improve cancer understanding and
management for older adults
Collaborations and partnerships
Priority 10 Strengthen links between SIOG and the geriatric oncology workforce,
international specialized agencies, global and regional professional organizations,
policy makers, and patient advocacy groups
Priority 11 Promote the inclusion of specific provisions for delivering evidence-based care for
older adults in national cancer control plans
Priority 12 Create global funding mechanisms for professional development and promote
research on the interface of cancer and ageing
Source: Priorities for the global advancement of care for older adults with cancer: an update of the
International Society of Geriatric Oncology Priorities Initiative [20]

25.5 Conclusion

In conclusion, while the proportion of the older population with cancer in the UAE
is modest compared to the younger population, the demographics and social dynam-
ics of the population are fast changing. Cancer remains a significant cause of mor-
bidity and mortality and affects the older population disproportionately. The
incidence of cancer is high in older individuals, and they carry a large burden of
cancer in the UAE. It is expected that the proportion of older individuals will rise
significantly in the near future. As a result, the demand for ageing care for cancer
patients is expected to skyrocket in the coming years. Due to a lack of ageing care
resources, the country currently lacks formal geriatric oncology clinical services.
Education, training, and research in the field of geriatric oncology are also lacking.
To provide optimal care to cancer patients over the age of 65, comprehensive plan-
ning and resource allocation to establish centers of excellence, training programs,
research, and aged care facilities, international collaborations, and partnerships in
geriatric oncology are urgently required.

Conflict of Interest The authors have no conflict of interest to declare.

25 Geriatric Oncology in the UAE 415

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Dr. Hassan Shahryar Sheikh is a consultant medical oncologist

and hematologist at Sheikh Shakbout Medical City in Abu Dhabi,
UAE, and an adjunct associate professor of medicine at Khalifa
University. He is a Diplomate of the American Board of Internal
Medicine, Geriatrics, Medical Oncology, and Hematology. He
graduated from Aga Khan University Medical College in Pakistan
and completed residency and fellowship trainings in internal medi-
cine, medical oncology, and hematology at Penn State University
Milton S. Hershey Medical Center, Hershey, USA. He also took
fellowship training in geriatrics and ageing at the University of
Rochester, New York, USA. He served as an Assistant Professor of
Medicine at Penn State University for a few years prior to returning
to Pakistan, where he served as the Head of Medical Oncology at
the Shaukat Khanum Memorial Cancer Hospital in Lahore,
Pakistan. Dr. Shahryar is well published in peer-­reviewed interna-
tional journals and is a speaker at many national and regional can-
cer conferences.

Dr. Kiran Munawar is a Clinical Fellow in Solid tumour

Oncology at St Bartholomew’s Hospital, Barts Health NHS Trust,
London, UK. She received her medical degree from Allama Iqbal
Medical College, University of Health Sciences, Lahore, Pakistan.
After working as a Medical Officer in Medical Oncology at Shaukat
Khanum Memorial Cancer Hospital and Research Centre, Pakistan,
she joined Addenbrookes Hospital, Cambridge University Hospitals
NHS Foundation Trust, Cambridge, UK, as a Clinical Fellow in
Oncology. She aims to pursue clinical work and research in
­oncology, with an emphasis on melanoma and cutaneous oncology.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
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Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Breast Cancer in the UAE
26
Aydah Al-Awadhi , Faryal Iqbal , Hampig R. Kourie,
and Humaid O. Al-Shamsi

26.1 Introduction

Breast cancer (BC) emerged as the most prevalent cancer globally in 2020, with
approximately 2.26 million new BC cases and nearly 685,000 BC-related fatalities
reported worldwide during that year [1]. Regarding cancer-related mortality, BC is
ranked fifth overall and first among women [1]. Based on the UAE National Cancer
Registry 2021 report [2], breast cancer claimed approximately 9.64% of annual
cancer-related deaths. Throughout the year, the UAE National Cancer Registry

A. Al-Awadhi
Tawam Hospital, Al Ain, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
e-mail: ayawadhi@seha.ae
F. Iqbal
Burjeel Medical City, Abu Dhabi, United Arab Emirates
e-mail: faryal.iqbal@burjeelmedicalcity.com
H. R. Kourie
Hematology-Oncology Department, Faculty of Medicine, Saint Joseph University,
Beirut, Lebanon
e-mail: hampig.kourie@usj.edu.lb
H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 417

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_26
418 A. Al-Awadhi et al.

recorded a total of 1139 breast cancer cases among the country’s population, which
constituted 20.3% of all reported malignant cases in 2021.
Based on 2020 data from the World Health Organization (WHO), breast cancer
stands as the predominant form of cancer in the UAE, representing an incidence rate
of 21.4% (1054 cases). It also holds the unfortunate distinction of being the primary
cause of cancer-related deaths in the region [1]. The majority of diagnosed cases are
individuals below the age of 50 [3]. The situation represents a significant public
health concern in the UAE.
In this chapter, we will examine published articles and research findings from the
United Arab Emirates (UAE) to gain a deeper understanding of the characteristics
and outcomes associated with breast cancer. Additionally, we will supplement this
knowledge with our own experiences in managing breast cancer at renowned cancer
facilities. We believe that individuals interested in the status of breast cancer in the
UAE will find this review to be thorough and inclusive. Furthermore, we will high-
light existing gaps and areas for improvement, emphasizing the importance of
resource allocation and future clinical and research endeavors.

26.2 Epidemiology of Breast Cancer in the UAE

According to the latest information available from the UAE National Cancer Registry
in 2021, there were 1139 new instances of breast cancer. Out of these cases, 1128
were reported among women, while the remaining eleven were identified in men.
These figures account for approximately 20.2% of all cancer cases reported during
the same year. The crude incidence rate was calculated at 40.1 per 100,000 for female
population, while the age-standardized incidence rate (ASR) was determined to be
52 per 100,000 for female population based on 2021 data. Notably, breast cancer
ranked as the most prevalent malignancy among women, comprising 36.9% of all
female cancer cases [2]. In 2021, breast cancer ranked third among cancer-related
fatalities, accounting for an approximate average of 9.64% of annual cancer deaths
[2]. The incidence of male breast cancer is approximately 1%, similar to rates
observed in the United States (US) and the United Kingdom (UK). In comparison,
the prevalence of male breast cancer in central Africa is reported to be as high as 6%
of all breast cancer cases [4, 5].
Historical data on breast cancer in the UAE were limited prior to 2011, when the
UAE National Cancer Registry was initially established. Hence, we sought previ-
ously unreported historical data from prominent oncology facilities and clinics
across the country, spanning various time periods prior to 2011. The aggregate data
from reports from the UAE National Cancer Registry that have been published, as
well as unpublished sources from clinics during the previous 40 years, are summa-
rized in Fig. 26.1.
26 Breast Cancer in the UAE 419

Fig. 26.1 Registered breast cancer cases in the UAE over the past four decades. Source: NCR,
National Cancer Registry; UAE, United Arab Emirates

Previous reports have indicated that the average age in Arab nations, as a
whole, tends to be around 10 years lower compared to Western nations [6]. The
potential causes of this phenomenon include genetic and environmental factors,
a relatively younger population in comparison to Western countries, and cultural
influences leading to reduced rates of breast cancer screening among elderly
Arab women [7].
Based on reports, the typical age of breast cancer diagnosis in the UAE falls
within the range of 48–49 years old [3, 8, 9]. In 2021, the majority of breast can-
cer cases were observed among patients below the age of 60, as depicted in
Fig. 26.2a. More specifically, for UAE nationals, individuals aged 50–59 (60 out
of 218 cases, accounting for 27.5%) and, for non-UAE citizens, those aged 40–49
(352 out of 921 cases, making up 38.2%) represented the highest proportions [2].
Based on 2021 data, the average age of the population in the UAE is reported to
be 32.8 years [10]. The age-specific incidence rates rise steadily from age 25 in
females. After age 74, age-specific breast cancer incidence decreases drastically
as depicted in Fig. 26.2b [2].
420 A. Al-Awadhi et al.

Fig. 26.2 (a) Age group distribution of female breast cancer cases in the UAE in 2021. (b) Age-­
specific incidence rate (ASIR) for female breast cancer cases in the UAE in 2021. Source: Ministry
of Health and Prevention, Statistics and Research Center, National Disease Registry—UAE
National Cancer Registry Report, 2021

26.3 Clinicopathological Features of Breast Cancer

In general, breast cancer in the Arab population exhibits distinct clinicopathological

features when compared to the Western world. These include an earlier age of onset,
a higher tumor grade, an increased prevalence of HER2 amplification, and a lower
occurrence of the luminal subtype [11]. Regrettably, there is a scarcity of available
data regarding the clinicopathological characteristics of breast cancer in the
UAE. However, a research study carried out by the University of Sharjah examined
94 breast cancer patients from the Northern Emirates of the United Arab Emirates.
The findings revealed that the majority of patients (78 out of 94, or 83%) exhibited
invasive ductal carcinoma and tested positive for hormone receptors. Additionally,
26 Breast Cancer in the UAE 421

it was observed that women under the age of 40 were more likely than older women
to exhibit HER2 overexpression, as determined by immunohistochemistry (IHC) or
fluorescence in situ hybridization (FISH), with a statistically significant correlation
(p = 0.007) [3].
In a separate study involving a group of 78 Arab patients, including 25% from
the United Arab Emirates, the median age at diagnosis was reported as 52.3 years,
ranging from 37 to 82 years, with 38.5% of individuals being 50 years old. Among
this cohort, 82.1% had invasive ductal carcinoma, 19.2% exhibited HER2 overex-
pression, and 26.9% had triple-negative breast cancer. Notably, at the time of diag-
nosis, 46.2% of cases were identified as stage IV disease [12].
A different study provided insights into the clinicopathological attributes of 130
breast cancer patients with BRCA1/2 mutations. The average age of these patients
was 42.9 years, and approximately 50.7% of them had a positive family history of
breast cancer. The majority of patients (66.2%) exhibited stage I/II disease, with
invasive ductal carcinoma being the prevalent subtype (81.5%). Additionally, 45.3%
of patients had hormone receptor-positive breast cancer [13].
Although comprehensive stage data are unavailable in the UAE Cancer Registry,
there is evidence indicating a decline in the incidence of stage IV breast cancer
cases compared to other stages. Notably, the proportion of localized disease has
shown an increase from 10% in 2011 to 25% in 2017 [2]. This could potentially be
attributed to heightened societal awareness regarding the significance of early detec-
tion, consequently prompting an increase in breast cancer screening practices.
Conversely, a qualitative study carried out in the UAE focused on 19 breast can-
cer survivors ranging in age from 35 to 70 years old. These individuals had exhib-
ited delayed medical attention-seeking and diagnosis after experiencing symptoms.
The study identified that the primary reasons for such delays were spousal abandon-
ment and the fear of facing social stigmatization [14]. Culture exerts a substantial
influence on the decisions made by women in UAE society. The limited understand-
ing of breast cancer signs and symptoms, as well as the absence of regular screen-
ing, significantly affects how symptoms are assessed and subsequent choices
regarding follow-up diagnostic procedures. Consequently, this can lead to the pre-
sentation of advanced-stage disease and a delay in receiving timely treatment [14].
A separate study conducted at Tawam Hospital, a prominent cancer center in the
UAE, focused on male breast cancer. The study spanned from 2000 to 2020 and
revealed that male breast cancer accounted for 0.75% (28 out of 3733 cases) of all
breast cancer cases. The median age at diagnosis was 51, and the majority of patients
(26 out of 28) were diagnosed at an early stage, with only 2 cases identified as stage
IV disease. Among the male breast cancer patients, 21 out of 28 were diagnosed
with hormonal receptor (HR)-positive, or HER-2-negative disease [15].

26.3.1 Somatic and Germline Mutations

There is a scarcity of comprehensive data regarding somatic and germline mutations

in breast cancer, specifically within the UAE and other Gulf Cooperation Council
422 A. Al-Awadhi et al.

(GCC) nations. However, based on available information, it seems that BRCA1/2

mutations do not play a prominent role in hereditary breast cancer in GCC coun-
tries. Currently, there is a lack of available data on the involvement of hereditary
genetic mutations in breast cancer, specifically within the UAE [16]. Another study
examined the prevalence of germline BRCA mutations in the UAE BC population
and found a positive incidence of 130/309 (11.9%). Pathogenic and potentially
pathogenic mutations were detected in 34.6% of patients. BRCA2 was the most
prevalent gene discovered [13]. During the period between 2015 and 2017, a
research study was conducted in the UAE involving 276 individuals diagnosed with
hereditary cancer syndromes, with a majority of patients having breast cancer. The
majority of participants were from the Middle East and Asia-Pacific regions. Out of
the 276 patients, 24 individuals (8.7%) were found to have a pathogenic mutation in
either the BRCA1 gene (13 cases), the BRCA2 gene (eight cases), or c.1100delC in
the CHEK2 gene (three cases). Additionally, 30 patients (10.8%) had a variant of
unknown significance (VUS) detected in one of the three genes [17].
The Arab genome project, initiated by Saudi Arabia and continued by Qatar,
Kuwait, and the United Arab Emirates, aims to facilitate the identification of novel
breast cancer biomarkers. These biomarkers have the potential to enhance the prog-
nosis and enable targeted therapies for the disease. To improve the treatment and
genetic counseling for Arab patients with breast cancer-associated genetic muta-
tions, it is crucial to conduct comprehensive and well-controlled genetic epidemio-
logical studies. These studies will provide accurate estimates of the frequency of
genetic variants, including BRCA1/2 and non-BRCA1/2 mutations, among breast
cancer patients in the Gulf States.
The National Arab Genome Project in the UAE aims to address this gap in
knowledge by leveraging Next-Generation Sequencing (NGS) technology. This
project aims to create a comprehensive catalog of mutations that are unique to the
Arab population in the UAE. By collecting and analyzing this data, it seeks to
enhance our understanding of the Arab genome. The primary objective is to com-
pare the Arab genome with other ethnic groups’ genomes, highlighting both simi-
larities and differences. Such comparisons may provide insights into the genetic
predisposition to breast cancer within the UAE population [18].
Conversely, there is a lack of available data concerning somatic genetic muta-
tions specific to breast cancer in Arab women.
The only study to date addressing this is a cross-sectional analysis of Arab
breast cancer patients who were diagnosed at a single facility between 2000 and
2018 and underwent Ampliseq 46-Gene or 50-Gene next-generation sequencing.
It included 78 Arab women, and the somatic mutation rates were discovered by
next-generation sequencing to be: NPM1, 2.5%; MPL, 1.3%; JAK2, 2.5%; KIT,
7.7%; KRAS, 3.8%; and NRAS, 3.8%. TP53, 23.1%; ATM, 2.6%; IDH1, 2.6%;
IDH2, 3.8%; PTEN, 7.7%; PIK3CA, 15.4%; and APC, 7.7%. This study implies
potential differences from estimates for the Western population. These findings
demand more extensive epidemiology research that takes into account the chang-
ing significance that these variants play in prognostication and individualized
treatment [12].
26 Breast Cancer in the UAE 423

26.4 Breast Cancer Screening Knowledge and Practice

The UAE’s “National Guidelines for Breast Cancer Screening and Diagnosis” by
the Ministry of Health and Prevention, 2022, advises beginning mammography at
age 40 and continuing every 2 years.
Based on a cross-sectional survey conducted on 492 females in the UAE,
aged 25 to 45, the level of awareness among respondents regarding basic breast
cancer information, including risk factors, warning signs and symptoms, and
screening practices, was lower than expected. The study attributed these find-
ings to the inadequate involvement of physicians and health authorities in rais-
ing awareness. It recommended addressing this issue by implementing
awareness campaigns to bridge knowledge gaps and actively engaging medical
professionals in educating both patients and the general public [19]. Additional
studies examining awareness of breast cancer and breast self-examination
(BSE) have indicated that knowledge regarding risk factors, warning signs and
symptoms, and the practice of BSE is relatively limited among individuals in
the UAE [20].
Although women expressed a desire for increased year-round breast cancer
awareness initiatives and improved screening accessibility, they generally conveyed
positive attitudes towards breast cancer screening [21]. Therefore, it remains evi-
dent that there is a need to enhance women’s awareness of breast cancer in the UAE,
with the aim of promoting breast cancer screening. There is a necessity to improve
the national screening program by enhancing accessibility and optimizing resource
allocation to ensure its effectiveness and focus [22].
In general, there has been a rise in collaborative endeavors by the government,
private sectors, nonprofit organizations, charities, and individuals to elevate aware-
ness about breast cancer. These efforts have been particularly prominent during the
month of October, recognized globally as Breast Cancer Awareness Month. Some
examples of the effort to promote early detection and screening include the aware-
ness campaign “Pink Caravan,” organized walks for fundraising and awareness, free
screenings, breast health checkups, etc.

26.5 Treatment Modalities

26.5.1 Surgery

Overall, in the UAE, there are a good number of well-trained breast surgeons, some
of whom have been dedicated to oncoplastic training.
In the UAE, there is a rapid expansion of oncoplastic and reconstructive breast
surgery, despite the limited availability of published techniques and outcomes. Over
the past decade, oncoplastic lumpectomy procedures have become the established
standard of care as needed. Initially, level I procedures primarily involved the
removal of less than 20% of breast volume, allowing for glandular displacement to
repair the defect. With time, level 2 treatments became more prevalent, permitting
424 A. Al-Awadhi et al.

the resection of up to 50% of breast volume through operations such as mammo-

plasty reduction. These advancements have led to a reduction in positive margin
rates and an increase in breast conservation rates. In collaboration with the American
Society of Breast Surgeons, the UAE has hosted annual oncoplastic workshops with
practical training over the past 5 years. In 2021, the UAE adopted the use of mag-
netic seed localization technology, a groundbreaking wire-free approach that assists
radiologists and surgeons in locating breast abnormalities for tissue excision, to the
author’s knowledge.
However, based on our observations, we have noticed that total mastectomies,
and at times even double mastectomies, are still being performed more frequently
than necessary. This trend is more evident among general surgeons who lack spe-
cialized oncology training or experience, and particularly when these procedures
are carried out against the recommendations of multidisciplinary teams (MDT). To
address this issue, potential solutions include education and training initiatives,
streamlining reimbursement processes, and implementing mandatory MDT consul-
tations prior to surgical interventions.
In the past, women who anticipated postoperative radiation treatment before
2009 did not undergo immediate reconstruction following mastectomy. The primary
approach for delayed reconstruction during that period was the transverse rectus
abdominis myocutaneous (TRAM) flap. However, after 2009, instant two-stage
breast reconstruction involving an expander-implant technique became available for
women scheduled to receive postoperative radiation, to the author’s knowledge. As
the expansion of tissue expanders caused discomfort for irradiated women, this pro-
cedure was swiftly replaced by rapid direct-to-implant reconstruction performed in
a single step. The introduction of synthetic or biological advancements in surgical
meshes facilitated the shift from two-stage to one-stage reconstruction. Previously,
subpectoral implant placement was the standard, but there has been an increasing
preference for pre-­pectoral insertion. These advancements in breast surgery have
significantly reduced the need for delayed reconstruction using autologous flaps.
Nonetheless, certain patients may still require delayed reconstruction, and special-
ized clinics in the UAE are proficient in performing autologous flaps, such as the
deep inferior epigastric perforator (DIEP) flap.

26.5.2 Radiotherapy

Radiotherapy plays a crucial role in the comprehensive management of breast can-

cer, whether it is administered in the early-stage setting after breast-conserving sur-
gery, for postmastectomy radiotherapy (PMRT), or in metastatic scenarios. In the
UAE, radiation oncologists are frequently involved in the initial treatment planning
for breast cancer patients, often as part of a multidisciplinary team (MDT). However,
there are instances in certain locations where their consultation occurs later in the
treatment process [23]. Numerous radiation facilities have been established through-
out the United Arab Emirates, with additional centers announced for the future.
These facilities offer advanced and state-of-the-art care for various types of cancer,
including breast cancer [22].
26 Breast Cancer in the UAE 425

Radiotherapy in the United Arab Emirates has experienced substantial advance-

ments over the last two decades, leading to improved treatment delivery and a
reduction in both early and potential long-term side effects. Notably, the current
recognized standard of care involves the utilization of 3D-conformal computed
tomography-based radiation planning and dosage computation, replacing the tradi-
tional 2D X-ray film approach. Forward planning, field-in-field intensity modulated
radiation (IMRT), image-guided radiotherapy (IGRT), and volumetric arc radio-
therapy (VMAT) are now commonly employed in radiotherapy centers throughout
the country. Additionally, sophisticated systems for patient mobility and tracking,
such as deep inspiration breath hold (DIBH) and active breath control (ABC) treat-
ment, have proven effective in significantly reducing radiation exposure to the heart,
coronary veins, and lungs [24]. This is crucial due to the relatively young age of the
breast cancer population in the UAE and the high prevalence of comorbid condi-
tions like diabetes and cardiovascular disease.
The COVID-19 epidemic has hastened the adoption of mild hypofractionated
therapy for early-stage breast cancer after breast-conserving surgery [25, 26], as a
result of recent technological advancements and level-I evidence data.
Conversely, there is limited utilization of extreme hypofractionated treatment,
partial breast radiation, and intraoperative radiotherapy. This may be attributed
to patient demographic characteristics and the stage of cancer at the time of
diagnosis.
In the context of PMRT, the most frequent fractionation employed in the UAE
remains the conventional 5–6 weeks of 2 Gy per fraction; mild hypofractionation is
rarely used despite the outcomes of the Chinese hypofractionation trial [27], but
concerns surrounding the lymphedema rate have recently been addressed [27].
In metastatic BC, radiation is mostly administered for symptom treatment in a
palliative context. Recent years have seen the availability and standardization of
stereotactic ablative body radiation (SABR), particularly for individuals with oligo-
metastatic illness [28]. Stereotactic radiosurgery or stereotactic radiation is fre-
quently administered for brain metastases and is preferred, if possible, prior to
whole-brain radiotherapy or hippocampal-sparing whole-brain radiotherapy, if
required.

26.5.3 Palliative and Supportive Care

Palliative care, which prioritizes the needs of the patient rather than the specific
diagnosis, varies in its level of input and involvement depending on the stage of
breast cancer. In the UAE, multidisciplinary treatment teams (MDTs) often recom-
mend and consider palliative mastectomy and radiation for the management of fun-
gating chest wall cancers [29]. The recently published guidelines for palliative care
by the Department of Breast Medical Oncology at the MD Anderson Cancer Center
were developed to specifically address various symptoms, aiming to support oncol-
ogists in delivering more customized treatment options [30]. Special attention is
given to addressing the management of various symptoms, including pain, breath-
lessness, fatigue, distress, anxiety, exercise, nutrition, and advance care planning.
426 A. Al-Awadhi et al.

These recommendations recognize the global shortage of palliative care profession-

als, which is further confirmed by our experience in the UAE. When the initial
evaluation highlighting the urgent requirement for palliative care in the UAE was
published in 2018, only two hospitals (Tawam Hospital in Abu Dhabi and The
American Hospital in Dubai) offered palliative care services [31]. Presently, Burjeel
Medical City in Abu Dhabi, Mediclinic City Hospital in Dubai, and soon the
Cleveland Clinic Abu Dhabi will also offer palliative care services, either in an
inpatient or clinic setting. As these relatively recent additions to the healthcare
workforce develop closer collaborations with their oncology counterparts, the early
integration of palliative care becomes more feasible. This integration holds the
potential to enhance outcomes and improve the quality of life for breast cancer
patients and their families. Additionally, regulatory authorities are actively address-
ing obstacles to ensure the availability of opioid analgesics, thus promoting better
pain management in palliative care settings.

26.5.4 Survivorship Programs

The only study conducted on breast cancer survival in the UAE involved a retro-
spective analysis of 988 patients from a single institution, with a follow-up period
of 35 months. The study projected 2-year and 5-year survival rates of 97% and 89%,
respectively, which were similar to those observed in Western countries like
Australia (89.5%) and Canada (88.2%) during the same timeframe [14, 32]. The
5-year survival rate in the UAE is notably impressive when compared to other coun-
tries in the same region, such as Qatar (71.95%) and Kuwait (75.2%) [32].
The care provided to cancer survivors is a crucial but often overlooked com-
ponent of cancer treatment. It addresses both short-term and long-term complica-
tions of treatment, the risk of cancer recurrence, the potential for developing
second primary malignancies, adherence to prescribed adjuvant hormonal thera-
pies, and recommended lifestyle adjustments such as weight management, physi-
cal activity, and exercise [33]. Breast cancer survivorship services and established
programs are still in their early stages of development in the UAE, highlighting
a significant gap in meeting the needs of survivors. Furthermore, existing pro-
grams should share their experiences and challenges to contribute to the develop-
ment of best practices in this field.

26.5.5 Social Support Programs

Support groups for cancer patients and their families play a vital role in helping
individuals cope with their condition. These groups offer valuable resources such as
knowledge, comfort, coping strategies, anxiety reduction, and a platform for shar-
ing similar experiences and receiving emotional support. In the UAE, there are sev-
eral breast cancer support groups available, including The Cancer Patient Care
Society—Rahma, Friends of Cancer, Breast Friends, Moazzara—Emirates
26 Breast Cancer in the UAE 427

Association for Cancer Support, The Cancer Majlis, Bosom Buddies, and Pure
Heart 4 Cancer. Some of these organizations also provide financial assistance for
cancer treatment. Additionally, there has been a significant increase in the utiliza-
tion of social media platforms and WhatsApp support groups, facilitating virtual
connections between patients and healthcare providers. The primary challenge lies
in the lack of coordination among different support groups, but we believe that col-
laboration will greatly enhance the impact and effectiveness of these supportive
initiatives.

26.5.6 Accreditation of Oncology Centers

The accreditation of oncology practices involves an impartial assessment conducted

by external peers to evaluate and enhance the quality of treatment. It serves as a
means to promote practice improvement, advance research, teaching, and clinical
practice, and establish criteria for the development of services. Moreover, accredita-
tion increases public confidence in the organization. Burjeel Medical City in Abu
Dhabi is the first facility in the UAE to receive approval from the European Society
of Medical Oncology as an integrated oncology and palliative care center, a distinc-
tion it has held since 2021. Additionally, Tawam Hospital has been accredited as a
breast center by the Joint Commission International since 2017, followed by Al
Zahra Hospital in 2020 and Mediclinic City Hospitals in 2022.

26.5.7 Use of Predictive and Prognostic Genomic Score Testing

The Amsterdam 70-gene profile (MammaPrint) and the Oncotype DX 21-gene (more
prevalent in the UAE) recurrence scores are essential in generating a predictive and/
or prognostic signature for some cases to decide the benefit of adjuvant chemother-
apy in BC [34, 35]. In a particular study, the Oncotype DX recurrence score assess-
ment had a clear impact on the recommendations for adjuvant treatment [36]. Few
insurance companies cover the cost of some of these tests; otherwise, the Emirates
Oncology Society urged regulators that these tests be covered in the appropriate clin-
ical environment, given their high price. Recommendations are based on additional
clinicopathologic criteria and recurrence estimating techniques (e.g., www.breastre-
currenceestimator.onc.jhmi.edu) when recurrence score testing is not possible.

26.5.8 Cost and Monetary Burden of Cancer Treatments

There is limited available data regarding the cost of breast cancer anticancer therapy
in the UAE. The only existing report evaluated the top 20 cancer medications uti-
lized in Abu Dhabi in 2011, which revealed that breast cancer accounted for a sig-
nificant portion of drug expenditures (8 out of the top 20). The introduction of newer
drugs and innovative therapies is expected to contribute to increased expenses for
428 A. Al-Awadhi et al.

cancer treatment in the United States. To mitigate some of the rising costs, there is
a need for greater utilization of biosimilars. While there has been partial adoption of
our recommendation to incorporate biosimilars in the formularies of cancer centers
in the UAE, further improvements are necessary [37].

26.6 Breast Cancer Research in the UAE

We systematically conducted an extensive literature search to identify articles

related to breast cancer in the UAE. On August 8, 2021, we performed a PubMed
search using specific terms such as “breast” AND “Cancer* OR oncology* OR
malignant* OR tumor OR tumour” AND “emirates OR UAE.” This search yielded
a total of 203 journal articles authored by individuals from the UAE, with the earli-
est publication dating back to 2001. The majority of studies fell into the categories
of fundamental science or translational research (45.8%) or observational studies
(26.1%). Non-data-driven publications, such as reviews, consensus statements, and
editorials, accounted for 40 articles (19%). Interestingly, we found only six clinical
studies (as shown in Fig. 26.3). It is worth noting that out of the 163 publications
with data-driven content, only 62 (38%) were conducted within the UAE. The
remaining research was carried out abroad, with many authors having affiliations
both in the UAE and international institutions, indicating a significant level of inter-
national collaboration [38]. Over time, there has been an overall increase in breast
cancer research output, despite the persistence of significant gaps in evidence. The
growth of academic institutions and research programs dedicated to molecular and
cellular research has contributed to the expansion of fundamental and translational
research in the UAE. Observational studies have primarily focused on screening and
fundamental epidemiological aspects. Moving forward, it is crucial to prioritize the
expansion of national registries and the longitudinal collection of clinically relevant
factors. These efforts can provide valuable insights into the clinical and molecular
profiles of breast cancer in the country, as well as inform survival measures that can
impact management decisions. It is worth noting that there is a noticeable lack of
therapeutic clinical studies, which is a shared concern in the broader region.

Fig. 26.3 Breast cancer

journal publications from
the UAE (2001–2021) by
study type
26 Breast Cancer in the UAE 429

Previous efforts to initiate large-scale randomized studies have been limited, pri-
marily due to challenges in recruiting participants. This highlights the importance of
increasing public and healthcare provider awareness regarding the significance of
clinical trials in facilitating access to innovative cancer therapies.
As the regulatory and resource infrastructures in the country are well-developed
and capable of meeting international standards and requirements, there are several
ongoing initiatives to form partnerships with sponsors of clinical trials. These
endeavors aim to facilitate the implementation of interventional studies within the
country.

26.7 Hereditary Predisposition of Breast Cancer in the UAE

Based on the existing statistics, consanguinity may be associated with a decreased

occurrence of breast cancer [39–41]. In Arab women, the occurrence of parental
consanguinity may contribute to a lower incidence of breast cancer. This could be
attributed to a reduced gene conflict resulting from a higher prevalence of first
cousin marriages, particularly those involving the father’s brother’s son. Additionally,
the protective effect of homozygosity for an unknown gene or genes related to
breast cancer may further contribute to this phenomenon [39]. In a study conducted
among the population of the United Arab Emirates, which compared cases of breast
cancer to a control group, it was found that parental consanguinity was associated
with a decreased risk of breast cancer in younger women below the age of 50 [41].
In a separate study conducted in the UAE, computer simulations were employed to
investigate the impact of mating patterns on the carrier rate of BRCA1/2 mutations
over 40 generations. The findings indicated that in a predominantly consanguineous
population, the carrier rate of BRCA1/2 mutations decreased at an average rate of
0.022% per 25 years. This decrease occurred six times faster compared to a non-­
consanguineous population [42].

26.8 Conclusion

Breast cancer (BC) is highly prevalent in the UAE and ranks among the leading
causes of cancer-related mortality, posing significant challenges to the healthcare
system. The increasing incidence of breast cancer diagnoses can be attributed to
both population growth and improved data collection through registries and screen-
ing programs. Notably, breast cancer cases in the UAE are commonly observed in
individuals in their 40s, which aligns with the relatively young population of the
country compared to other developed regions like the United States and the European
Union. However, there is a scarcity of studies examining the clinical and genetic
risk factors specific to the UAE population, warranting further research in this area.
Despite positive attitudes among women, breast cancer screening and general
awareness remain insufficient, highlighting the need for increased efforts to improve
education and screening programs. The UAE offers management options for breast
430 A. Al-Awadhi et al.

cancer, including palliative care and survivorship initiatives, which are similar to
those available in Western nations. However, there is a noticeable lack of therapeu-
tic clinical trials, although progress is being made in the academic and regulatory
sectors to address this gap.

Conflict of Interest The authors have no conflict of interest to declare.

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432 A. Al-Awadhi et al.

Dr. Aydah Al-Awadhi is a consultant medical oncologist who

graduated from medical school at the United Arab Emirates
University in 2012, then completed her internal medicine resi-
dency in the United States and completed her medical oncology
and hematology fellowship at the University of Texas, MD
Anderson Cancer Center, in 2019. She is American Board Certified
in Internal Medicine, Hematology, and Medical Oncology. She
was awarded the Emirates Oncology Society (EOS) Member of
the Year award for 2021 and the Emirates Oncology Society
Women in Oncology of the Year award. She is also currently the
scientific chairperson of the Emirates Oncology Society and the
chair of the breast cancer working group. Dr. Al-Awadhi has pub-
lished many articles and book chapters on breast cancer and oncol-
ogy, with main expertise in breast cancer and sarcoma.
In 2022, he was awarded the prestigious Feigenbaum
Leadership Excellence Awards from Sheikh Hamdan Smart
University for his exceptional leadership and research, as well as
the Sharjah Award for Volunteering. He was also named the
Researcher of the Year in the UAE in 2020 and 2021 by the
Emirates Oncology Society.
Ms. Faryal Iqbal is the research associate at Burjeel Medical
City, Abu Dhabi, United Arab Emirates. She completed her
undergraduate studies in molecular biology and biotechnology.
Following that, she received a postgraduate qualification in
molecular genetics. She co-edited “Cancer in the Arab World,”
the first extensive book covering cancer care across all Arab coun-
tries. The book succeeded significantly, with over 450,000 down-
loads within just two years. She has several peer-reviewed papers
under her name. In September 2023, Ms. Iqbal received the “EOS
Research Award” from the prestigious Emirates Oncology Society
for her research efforts. Moreover, she assists in different aspects
of clinical trial implementation at a research site. Her research
interests and publications encompass oncology, hematology, and
genetics.

Dr. Hampig Raphael Kourie is an assistant professor in

Hematology-oncology department, Faculty of Medicine, Saint
Joseph University, Beirut, Lebanon.
Hampig Raphael Kourie gained his medical doctor degree
from the Faculty of Medicine of Saint Joseph University in Beirut
Lebanon in 2010. He started his fellowship in Hôtel-Dieu de
France, Saint Joseph University hospital in Beirut, Lebanon and he
continued his medical oncology fellowship in Jules Bordet
Institute in Brussels, Belgium from 2014 to 2016. Since September
2016, he worked in the digestive oncology department in Hôpital
Européen Georges Pompidou (HEGP) in Paris as a researcher in
the Association des Gastro-entérologues Oncologues en France
(AGEO). He is also certified from Paris Diderot and Paris
Descartes universities in hereditary cancers and digestive oncol-
ogy. He gained his PhD in genetics from Saint Joseph University
of Beirut in 2023 and his MEMS from ESA business school in
26 Breast Cancer in the UAE 433

2023. He is practicing as hematologist-oncologist in Hôtel Dieu

de France, Hôpital Saint Joseph des Soeurs de la Croix and
Bellevue Medical Center.
He is actually an ESMO Faculty in the colorectal cancer
group. He founded and directed the Middle East Biomarkers
course and the Middle East and North Africa GI Oncology
Summit. He has more than 200 peer-reviewed articles, mainly
in immunotherapy, oncogenomics and digestive oncology fields.
Prof. Humaid Obaid Al-Shamsi is the Chief Executive
Officer of Burjeel Cancer Institute in Abu Dhabi, UAE,
President of the Emirates Oncology Society, Lead of the Gulf
Cancer Society, Full Professor of Oncology at the Ras Al
Khaimah Medical and Health Sciences University, Ras Al
Khaimah, UAE, and an Adjunct Professor of Oncology at the
College of Medicine, University of Sharjah. He is the first
Emirati to be promoted as a professor in oncology in the
UAE. He is also the Chairman for Colorectal Cancer in the
MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member
of Lung Cancer Policy Network in the MENA region that aims
to advance lung cancer research and screening globally. He is
the Chairman of the Oncology and Hematology Fellowship
Training Program for the National Institute for Health
Specialties in the United Arab Emirates. He is the only member
in GCC in the WIN Consortium which is comprised of organi-
zations representing all stakeholders in personalized cancer
medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow)
in 2024. He is the only physician in the UAE with a subspe-
cialty fellowship certification and training in gastrointestinal
oncology and the first Emirati to train and complete a clinical
post-doctoral fellowship in palliative care. He was an assistant
professor at the University of Texas MD Anderson Cancer
Center between 2014 and 2017. He has published more than
140 peer-reviewed articles in JAMA Oncology, Lancet
Oncology, The Oncologist, BMC Cancer, and many others. His
area of expertise includes precision oncology and cancer care in
the UAE. In 2016, he published with his group from MD
Anderson the JCO paper describing a new distinct subgroup of
CRC, NON V600 BRAF-mutated CRC. In 2022, he published
the first book about cancer research in the UAE and also the first
book about cancer in the Arab world, both of which were
launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months
of publication and is the ultimate source of cancer data in the
Arab region. He also published the first comprehensive book
about cancer care in the UAE which is the first book in UAE
history to document the cancer care in the UAE with many top-
ics addressed for the first time, e.g., neuroendocrine tumors in
the UAE. He is passionate about advancing cancer care in the
434 A. Al-Awadhi et al.

UAE and the GCC and has made significant contributions to

cancer awareness and early detection for the public using social
media platforms. He is considered as the most followed oncolo-
gist in the world with over 300,000 subscribers across his social
media platforms (Instagram, Twitter, LinkedIn, and TikTok). In
2022, he was awarded the prestigious Feigenbaum Leadership
Excellence Award from Sheikh Hamdan Smart University for
his exceptional leadership and research and the Sharjah Award
for Volunteering. He was also named the Researcher of the Year
in the UAE in 2020 and 2021 by the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan,
Vice President of the United Arab Emirates, awarded him the
first place in UAE Nafis program for outstanding leadership in
private sector across all business and medical disciplines. Beside
his clinical and administrative duties, he is engaged in educa-
tion and various levels of research training for medical trainees
to enhance their clinical and research skills. His mission is to
advance cancer care in the UAE and the MENA region and
make cancer care accessible to everyone in need around
the globe.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Colorectal Cancer in the UAE
27
Humaid O. Al-Shamsi , Faryal Iqbal , Hampig R. Kourie,
Adhari Al Zaabi , Amin M. Abyad,
and Nadia Abdelwahed

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca
F. Iqbal
Burjeel Medical City, Abu Dhabi, United Arab Emirates
e-mail: faryal.iqbal@burjeelmedicalcity.com
H. R. Kourie
Hematology-Oncology Department, Faculty of Medicine, Saint Joseph University,
Beirut, Lebanon
e-mail: hampig.kourie@usj.edu.lb
A. A. Zaabi
College of Medicine and health Sciences, Al Seeb, Oman
e-mail: adhari@squ.edu.om
A. M. Abyad · N. Abdelwahed
Burjeel Medical City, Abu Dhabi, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
e-mail: nadia.abdelwahed@burjeelmedicalcity.com

© The Author(s) 2024 435

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_27
436 H. O. Al-Shamsi et al.

27.1 Introduction

Colorectal cancer (CRC) is currently the third leading cause of cancer-related death
worldwide and the fourth most commonly diagnosed cancer, according to
GLOBOCAN 2018 data. The incidence of CRC is steadily increasing, particularly
in developing countries. This form of cancer, also known as colorectal adenocarci-
noma, typically originates from the glandular epithelial cells in the large intestine.
Cancers emerge as a result of a series of genetic or epigenetic mutations that give
them a selective advantage [1, 2]. The hyper-proliferative cells that have an abnor-
mal replication and survival boost induce benign adenomas that may evolve into
carcinomas and metastasize over the years [1, 3].
Researchers and physicians should empower themselves with a robust under-
standing of CRC development patterns, genetic and environmental risk factors, and,
lastly, the molecular transformation of CRC in such a way that leads to the preven-
tion and treatment of this deadly neoplasm [1].

27.2 Epidemiology of Colorectal Cancer (CRC) in the UAE

27.2.1 Overall Cancer Incidence Rate in the UAE

In 2021, the UAE National Cancer Registry (UAE-NCR) recorded a total of 5830
newly diagnosed cancer cases, both malignant and in situ, affecting individuals of
both genders across the UAE population. Of these, malignant cases comprised the
majority with 5612 instances (96%), while in situ cases accounted for 218 instances
(4%). The data revealed a higher incidence among females [3210 (55.1%)] com-
pared to males [2620 (44.9%)], across all nationalities. Among the total cancer
cases, UAE citizens accounted for 1493 (25.6%), while non-UAE citizens repre-
sented 4337 (74.3%). The overall crude incidence rate of cancer in 2021 cancer data
was 60.5/100,000 for both genders [4].

27.2.2 Incidence of CRC in the UAE

In 2021, CRC was the third most commonly diagnosed malignancy among the UAE
population for both genders, accounting for 532 out of 5612 anger cases. Non-UAE
citizens in the UAE population represented a higher proportion of these cases, with
372 diagnoses (71.1%), while UAE citizens accounted for 160 cases (30.5%). CRC
affected males more significantly, constituting 12.5% of male cancer cases com-
pared to 7% of female cancer cases [4]. Figure 27.1 shows a clear predominance of
colorectal cancer in males.
The data from UAE-NCR indicate a steady increase in the incidence of colorec-
tal cancer over the last decade, with the number of cases rising from 377 in 2013
[females: 160; males: 217] to 532 cases in 2021 [females: 213; males: 319]
(Fig. 27.2; Table 27.1) [4]. There are many factors to consider while contemplating
this data, such as the exponential growth of the UAE population, the improved
 27 Colorectal Cancer in the UAE 437

600
No. of colorectal cancer cases in the UAE

500

213
400

148 166 157

156
300 160 141

200
319
256 232 242 256 256
100 217

0
2013 2014 2015 2016 2017 2019 2021
Years

Male Female

Fig. 27.1 Distribution of colorectal cancer cases by gender, 2013–2021. Source: Ministry of
Health and Prevention, Statistics and Research Center, National Disease Registry—UAE National
Cancer Registry Report, 2013–2021

600
532
550
No. of colorectal cancer cases in the

500
450 422 413
404 398
400 377 373
UAE

350
300
250
200
150
2013 2014 2015 2016 2017 2019 2021
Years

Fig. 27.2 Number of colorectal cancer cases in the UAE. Source: Ministry of Health and
Prevention, Statistics and Research Center, National Disease Registry—UAE National Cancer
Registry Report, 2013–2021

documentation system through UAE-NCR, and the improvement in population-

wide screening and awareness initiatives across the country [5].
Currently, the UAE hosts approximately 200 nationalities who work and reside
within the country. The largest non-UAE community hails from India, followed by
Pakistan, Bangladesh, other Asian countries, Europe, and Africa [6]. This diversity
is reflected in the recent CRC statistics, which show a higher incidence of CRC
cases among non-UAE nationals compared to UAE nationals (Fig. 27.3) [4].
 438 H. O. Al-Shamsi et al.

Table 27.1 Colorectal cancer demographics among the UAE population, 2013–2021
UAE Total malignant CRC cancer Crude rate CRC
population (in cases (in cases (in Percentage cancer cases per
Year millions) numbers) numbers) (%) 100,000
2013 8.66 3574 377 10.55 –
2014 8.79 3610 404 11.19 4.45
2015 8.93 3744 373 9.96 4.1
2016 9.12 3982 398 9.99 –
2017 9.3 4123 422 10.24 4.5
2019 9.5 4381 413 9.43 –
2021 – 5612 532 9.47 5.7
Source: UAE population: https://fcsc.gov.ae/en-us/Pages/Statistics/Statistics-by-Subject.
aspx#/%3Fsubject=Demography%20and%20Social&folder=Demography%20and%20Social/
Population/Population
Ministry of Health and Prevention, Statistics and Research Center, National Disease Registry—
UAE National Cancer Registry Report. 2013–2021

400 372
No. of colorectal cancer cases in the UAE

350
305
294 284
300 282 279
256
250

200
160
150 125 117 129
117
95 104
100

50

0
2013 2014 2015 2016 2017 2019 2021

Years

UAE Non-UAE

Fig. 27.3 Number of colorectal cancer cases among the UAE population by nationality,
2013–2021. Source: Ministry of Health and Prevention, Statistics and Research Center, National
Disease Registry—UAE National Cancer Registry Report, 2013–2021

27.2.2.1 CRC Cases by Age

The age-standardized incidence rate (ASR) of CRC in the UAE in 2021 was
13/100,000 for males and 12.8/100,000 for females, and the crude incidence rate
was 7.6/100,000 for females and 4.9/100,000 for males [4]. Figure 27.4 (a) repre-
sents the age group distribution of CRC cases in the UAE, while (b) shows the age-­
specific incidence rate for CRC cases in the UAE in 2021 [4].
27 Colorectal Cancer in the UAE 439

Fig. 27.4 (a) Age group distribution of colorectal cancer cases in the UAE in 2021. (b) Age-­
specific incidence rate (ASIR) for colorectal cancer cases in the UAE in 2021. Source: Ministry of
Health and Prevention, Statistics and Research Center, National Disease Registry—UAE National
Cancer Registry Report, 2021

27.2.3 Reported Stages of CRC Cases in the UAE

The development of colorectal cancer (CRC) typically begins with the noncan-
cerous growth of mucosal epithelial cells, forming structures known as polyps.
These polyps can grow very slowly over a period of 10–20 years before poten-
tially becoming malignant [1, 7]. The most common type of polyp is an ade-
noma, which originates from glandular cells that produce mucus to line the large
intestine. While the risk of cancer increases with the growth of these polyps,
approximately 10% of adenomas will progress to invasive cancer. Polyps that
become invasive are referred to as “adenocarcinomas,” which account for 96%
of all CRCs [1, 8].
Colorectal cancer arises from the wall of the colon or rectum and has the poten-
tial to invade lymphatic vessels or blood vessels, leading to metastasis to distant
organs through nearby lymph nodes or the bloodstream. The staging of CRC is
440 H. O. Al-Shamsi et al.

450
No. of colorectal cancer cases in the UAE

400
350
131 173
115
300
250
106 74 80
200 79

150 48
125 115
100 120
91
50
59 72 50
29
0
2012 2015 2016 2017

Years
Localized Regional
Distant Metastasis / Systemic Disease UnstagedUnknown, or Unspecified

Fig. 27.5 Distribution of colorectal cancer cases by SEER stages in the UAE across the years.
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2012–2017

determined by the extent of the invasion, which is crucial for diagnosis. Polyps that
have not invaded the wall of the colon or rectum are classified as in situ cancers and
are thus not reported as CRCs. Cancers that have penetrated the walls but have not
spread beyond them are considered local cancers. In regional cancers, the surround-
ing lymph nodes or tissues are invaded. Distant cancers have metastasized via the
blood stream to distant organs with capillary beds, such as the liver or the lung [1].
The distribution of CRC cases among the UAE population according to the
Surveillance, Epidemiology, and End Results (SEER) stage over the years is illus-
trated in Fig. 27.5 [4].

27.2.4 Mortality Rates of CRC in the UAE

According to the UAE-NCR latest report, malignant neoplasm of the colon was the
most lethal cancer, accounting for 11.49% of all cancer deaths, while malignant neo-
plasm of the rectum ranked the tenth, with 1.33% of cancer deaths [4]. The distribution
of mortality from colorectal cancer over the previous years is detailed in Table 27.2.

27.2.5 Trends in the Incidence and Mortality of CRC in the UAE

The trend of CRC incidence and mortality due to malignant neoplasm of the colon
and rectum for the years 2017, 2019, and 2021 through UAE-NCR was analyzed
(Fig. 27.6) [4]. The chart shows a decrease in both CRC mortality and incidence
27 Colorectal Cancer in the UAE 441

Table 27.2 Distribution of malignant colorectal cancer mortality cases in the UAE
Year Underlying cause of death Percentage (%)
2014 Malignant neoplasm of colorectal 8.8
2015 Malignant neoplasm of colorectal 10.6
2017 Malignant neoplasm of colon 10.3
Malignant neoplasm of rectum 1.7
2019 Malignant neoplasm of colon 8.9
Malignant neoplasm of rectum 1.1
2021 Malignant neoplasm of colon 11.49
Malignant neoplasm of rectum 1.33
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2014–2021

1.33

2021 11.49

9.47
Years

1.1

2019 8.9

9.4

1.7

2017 10.3

10.24

0 5 10 15

CRC incidence & mortality cases in percentage (%)

Mortality due to malignant neoplasm of rectum

Mortality due to malignant neoplasm of colon

Incidence

Fig. 27.6 The trend of incidence and mortality cases of CRC in 2017, 2019, and 2021. Source:
Ministry of Health and Prevention, Statistics and Research Center, National Disease Registry—
UAE National Cancer Registry Report, 2017, 2019, and 2021
442 H. O. Al-Shamsi et al.

among the UAE population. Although the drop is considered insignificant, it shows
the country’s considerable efforts for optimized screening and awareness in the
UAE in order to bring the numbers down.

27.3 Early-Onset Colorectal Cancer in the UAE

Colorectal cancer that is diagnosed before the screening age, which is less than
50 years, is characterized as “Early Onset Colorectal Cancer” (EOCRC). According
to the American Cancer Society (ACS), the adult onset of CRC incidence (>50 years)
has decreased by 2% per year. Meanwhile, an increase in EOCRC cases of 2% per
year has been observed [9, 10]. The predominance of young people at diagnosis,
younger than the western population, was observed among all CRC reports across
the Arab region. Around 17–38% of CRC patients were younger than 40 years old
when diagnosed [10–12].
To date, there is an incomplete understanding of why there has been such an
increase in the incidence rate of EOCRC. A crucial challenge in determining the
components influencing the rise in the incidence rate of EOCRC is whether EOCRC
and LOCRC are equivalent diseases or if there are any distinct underlying biological
trails that interact with various risk factors for EOCRC. EOCRC was strongly
believed to be closely associated with hereditary familial syndromes or genetic fac-
tors. Astonishingly, new evidence contradicts this belief. The discovery of genetic
group assessment in a young CRC patient cohort revealed that germline genetic
mutations were carried by only one in five of these patients, with approximately
25% having first-degree relatives with CRC. The bulk of the remaining patients are
sporadic [10, 13, 14].

27.4 Risk Factors for CRC Development in the UAE

The development of CRC is influenced by both non-modifiable and modifiable risk

factors. Non-modifiable factors include personal medical history (such as sex, age,
race, history of adenomatous polyps, and inflammatory bowel disease) and family
history, which individuals cannot control. On the other hand, modifiable factors are
associated with individual habits and lifestyles. By changing these modifiable fac-
tors, individuals can reduce their risk of developing CRC [15].
There are several theories regarding the development of colorectal cancer and its
association with red meat. One theory suggests that gut microbiomes might play a
role in this relationship, impacting the connection between CRC and diet and influ-
encing how red meat affects the progression of CRC [16, 17]. A study found that the
disability-adjusted life years (DALYs) per 100,000 and age-standardized mortality
27 Colorectal Cancer in the UAE 443

rates (ASMRs) associated with diets high in red meat, low in calcium, milk, fiber,
and whole grains were higher in men from Palestine, the United Arab Emirates,
Jordan, Lebanon, Turkey, and Bahrain compared to the other countries. Similarly,
for women, the DALYs per 100,000 and ASMRs related to such diets and their
impact on the CRC were higher in Palestine, the United Arab Emirates, Jordan,
Lebanon, Qatar, Libya, Afghanistan, Turkey, and Bahrain compared to the other
countries [18].
Environmental factors and dietary habits in this region might also increase the
risk of CRC. A meta-analysis identified smoking as a significant risk factor for CRC
in the Eastern Mediterranean Region (EMRO) region [19, 20].
A large retrospective analysis revealed that a history of Helicobacter pylori infec-
tion was modestly but statistically significantly associated with an increased risk of
CRC, including fatal cases [21].
The increasing incidence of colorectal cancer, particularly among younger age
groups, is largely due to dietary and lifestyle changes. These changes include the
adoption of a Westernized diet, higher consumption of animal-source foods, excess
body weight, sedentary lifestyles, increased alcohol consumption, smoking, and
increased intake of red and processed meats. These shifts are linked to the ongoing
socioeconomic development in several Middle Eastern countries [22, 23].
Understanding these risk factors can help in developing comprehensive public
health strategies and personalized interventions to reduce CRC incidence in
the UAE.

27.5 Screening for CRC in the UAE

Screening is widely recognized as the most effective measure to reduce cancer inci-
dence and mortality rates [24]. The development of CRC can be prevented by
detecting and removing precancerous lesions through regular screening [25]. The
UAE governmental healthcare system has announced the revised recommendations
for performing early screening for CRC in the UAE. The UAE national cancer reg-
istry in 2021 has observed the most common CRC cases in males and the third
among females [4]. MOHAP has released colorectal cancer screening guidelines in
2023, and they apply to all healthcare providers (facilities and professionals) in the
United Arab Emirates providing CRC screening services, including mobile units.
Screening tests for individuals at average risk of colorectal cancer, as specified in
Fig. 27.7, are colonoscopy, every 10 years or fecal immunochemical test (FIT),
every year. The eligible population must be offered colonoscopy screening as per
Fig. 27.7; in case of refusal, the patient should be offered a FIT. Detailed guidelines
are given in Appendix O: The National Guideline for Colorectal Cancer Screening
and Diagnosis in this book [26].
444 H. O. Al-Shamsi et al.

Fig. 27.7 Colorectal cancer screening and diagnosis pathway [26]. *Physician consultation: New
patient or existing patient identified during visit for other purpose. μUrgent referral to oncology
center within 2 weeks. $Consider age, comorbidity, family history accuracy, and completeness of
examination high-risk adenoma C^. #Stop surveillance if there is a further negative result (no ade-
noma). ^All histopathologically diagnosed cancers should be treated as per colon cancer guide-
lines. Source: The national guideline for colorectal cancer screening and diagnosis–2023–Ministry
of Health and Prevention, UAE
27 Colorectal Cancer in the UAE 445

27.6 Conclusion

One of the most common malignancies among Arabs is colorectal cancer (CRC),
whose annual incidence rate is sharply rising. Hence, the UAE is also bearing a
greater burden from the CRC. The updated guidelines for doing early CRC screen-
ing in the United Arab Emirates have been released by the Ministry of Health and
Prevention, UAE, in 2023. The UAE should undertake CRC prevention programs,
and all infrastructure and resources should be directed toward offering complete
cancer care at every stage of the illness. To alleviate the burden of CRC in the
nation, research on the cost-effectiveness of high-risk populations or nationwide
screening alternatives must be conducted in the UAE.

Conflict of Interest The authors have no conflict of interest to declare.

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Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow)
in 2024. He is the only physician in the UAE with a subspecialty
27 Colorectal Cancer in the UAE 447

fellowship certification and training in gastrointestinal oncology and

the first Emirati to train and complete a clinical post-doctoral fellow-
ship in palliative care. He was an assistant professor at the University
of Texas MD Anderson Cancer Center between 2014 and 2017. He
has published more than 140 peer-reviewed articles in JAMA
Oncology, Lancet Oncology, The Oncologist, BMC Cancer, and
many others. His area of expertise includes precision oncology and
cancer care in the UAE. In 2016, he published with his group from
MD Anderson the JCO paper describing a new distinct subgroup of
CRC, NON V600 BRAF-mutated CRC. In 2022, he published the
first book about cancer research in the UAE and also the first book
about cancer in the Arab world, both of which were launched at
Dubai Expo 2020. Cancer in the Arab World has been downloaded
more than 450,000 times in its first 18 months of publication and is
the ultimate source of cancer data in the Arab region. He also pub-
lished the first comprehensive book about cancer care in the UAE
which is the first book in UAE history to document the cancer care in
the UAE with many topics addressed for the first time, e.g., neuroen-
docrine tumors in the UAE. He is passionate about advancing cancer
care in the UAE and the GCC and has made significant contributions
to cancer awareness and early detection for the public using social
media platforms. He is considered as the most followed oncologist in
the world with over 300,000 subscribers across his social media plat-
forms (Instagram, Twitter, LinkedIn, and TikTok). In 2022, he was
awarded the prestigious Feigenbaum Leadership Excellence Award
from Sheikh Hamdan Smart University for his exceptional leadership
and research and the Sharjah Award for Volunteering. He was also
named the Researcher of the Year in the UAE in 2020 and 2021 by
the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
of research training for medical trainees to enhance their clinical
and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Ms. Faryal Iqbal is the research associate at Burjeel Medical

City, Abu Dhabi, United Arab Emirates. She completed her under-
graduate studies in molecular biology and biotechnology.
Following that, she received a postgraduate qualification in molec-
ular genetics. She co-edited “Cancer in the Arab World,” the first
extensive book covering cancer care across all Arab countries. The
book succeeded significantly, with over 450,000 downloads within
just two years. She has several peer-reviewed papers under her
name. In September 2023, Ms. Iqbal received the “EOS Research
Award” from the prestigious Emirates Oncology Society for her
research efforts. Moreover, she assists in different aspects of clini-
cal trial implementation at a research site. Her research interests
and publications encompass oncology, hematology, and genetics.
448 H. O. Al-Shamsi et al.

Dr. Hampig R. Kourie gained his medical doctor degree from

the Faculty of Medicine of Saint Joseph University in Beirut
Lebanon in 2010. He started his fellowship in Hôtel-Dieu de
France, Saint Joseph University hospital in Beirut, Lebanon,
and he continued his medical oncology fellowship in Jules
Bordet Institute in Brussels, Belgium from 2014 to 2016. Since
September 2016, he worked in the digestive oncology depart-
ment in Hôpital Européen Georges Pompidou (HEGP) in Paris
as a researcher in the Association des Gastro-entérologues
Oncologues en France (AGEO). He is also certified from Paris
Diderot and Paris Descartes universities in hereditary cancers
and digestive oncology. He gained his PhD in genetics from
Saint Joseph University of Beirut in 2023 and his MEMS from
ESA business school in 2023. He is practicing as hematologist-
oncologist in Hôtel Dieu de France, Hôpital Saint Joseph des
Soeurs de la Croix and Bellevue Medical Center.
He is actually an ESMO Faculty in the colorectal cancer
group. He founded and directed the Middle East Biomarkers
course and the Middle East and North Africa GI Oncology
Summit. He has more than 200 peer-reviewed articles, mainly
in immunotherapy, oncogenomics, and digestive oncol-
ogy fields.
Dr. Adhari Al Zaabi is an MD-PhD and Assistant Professor at
Sultan Qaboos University’s College of Medicine and Health
Sciences. She earned her PhD in cancer prevention from
Brigham Young University, USA, and was awarded a presti-
gious Fellowship in Molecular and Behavioral Cancer
Prevention by the National Cancer Institute in USA, 2018.
Her expertise lies in the early detection and prevention of
colorectal cancer, particularly early-onset colorectal cancer, and
the application of artificial intelligence in healthcare. Adhari has
secured numerous research grants, including two consecutive
awards from His Majesty’s Fund for projects focused on cancer
registry automation using machine learning and analyzing the
need for a national colorectal cancer screening program.
Recently, she received the Women in Artificial Intelligence
Award in Dubai in 2023 and was the first Arab woman to win
the International Brain Research Award from France in 2020. In
2021, she earned the Best Poster Award at the prestigious
European Society of Medical Oncology conference in
Singapore, 2022. Adhari has contributed several chapters to
books in areas such as colorectal cancer and artificial intelli-
gence in health.
27 Colorectal Cancer in the UAE 449

Dr. Amin M. Abyad earned his medical degree, Bachelor in

Medicine and Surgery (MBChB), from Beirut Arab University.
After completing his internship, he joined the Internal Medicine
Residency at Makassed Hospital in Beirut, Lebanon, which is
affiliated with the American University of Beirut Medical
Center (AUBMC). Dr. Amin was appointed as Chief Resident
of Internal Medicine (2017–2018). Then Dr. Amin started his
fellowship in hematology and medical oncology at Makassed
Hospital, where he received intensive training in hematology
and medical oncology. Dr. Amin joined Burjeel Medical City in
July 2021. Dr. Amin is highly interested in malignant hematol-
ogy and solid malignancies. He has been highly involved in
clinical research, being involved in multiple research projects
and publishing in multiple peer-reviewed journals. Dr. Abyad
believes in patient-centered care, trying to enhance patient out-
comes through the application of the latest evidence-based prac-
tice and personalized medicine.
Dr. Nadia Abdelwahed with a solid foundation of medical
studies, specialized in the branch of medical oncology and
added valuable practical experience in the administration of
oncology intervention and therapy by addressing cases from all
stages and conditions of the disease. Her specialty practice
began in 2015 and continued for 3 years, making her an expert
in the diagnosis and screening of all cancer types, especially
breast cancer, and an expert in cancer treatment methods, quali-
fying her through the School of Medicine residency program.
During this period, she addressed both the inpatient and outpa-
tient categories of patients. After this academic training and
practical performance, Dr. Nadia secured a placement as a med-
ical oncologist (specialist) in a leading university oncology hos-
pital in Damascus, Syria. After completing her tenure of office
there, she joined another multispecialty center as a medical
oncologist from 2018 until 2021. Alongside her postgraduate
studies and practical training, Dr. Nadia conducted her indepen-
dent research studies leading to the master’s degree (Neoadjuvant
Capecitabine in Rectal Cancer) Research in 2018. In 2017, she
passed the European Society of Medical Oncology (ESMO)
exam and was certified for a period of 5 years. In 2021, she also
excelled at the Immune Oncology Course at Harvard Medical
School in the United States, earning a Certificate of
Achievement. She is also a recipient of the FRON Prize (Forum
of Research in Oncology) for her research work on “Impact of
HER-2 Ratio on Efficacy of Trastuzumab in Early Breast
Cancer” in 2017. In 2021, Dr. Nadia relocated to the UAE and
qualified for the HAAD Licensing Exam as a Specialist in
Medical Oncology; soon after, she joined VPS Healthcare at the
Burjeel Cancer Institute of the Burjeel Medical City.
450 H. O. Al-Shamsi et al.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
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adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
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Gastric Cancer in the UAE
28
Nadia Abdelwahed, Salem Al Asousi, Faryal Iqbal ,
Amin M. Abyad, Neil A. Nijhawan, Hampig R. Kourie,
Ibrahim H. Abu-Gheida, Basil Ammori,
and Humaid O. Al-Shamsi

N. Abdelwahed · A. M. Abyad · I. H. Abu-Gheida

Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Burjeel Medical City, Abu Dhabi, United Arab Emirates
S. Al Asousi
Al Sabah Hospital, Kuwait City, Kuwait
F. Iqbal · N. A. Nijhawan · B. Ammori
Burjeel Medical City, Abu Dhabi, United Arab Emirates
e-mail: faryal.iqbal@burjeelmedicalcity.com; neil.nijhawan@burjeelmedicalcity.com;
basil.ammori@burjeel.com
H. R. Kourie
Hematology-Oncology Department, Faculty of Medicine,
Saint Joseph University, Beirut, Lebanon
e-mail: hampig.kourie@usj.edu.lb
H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi, United Arab
Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 451

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_28
452 N. Abdelwahed et al.

28.1 Introduction

Gastric cancer remains a major health problem, as it is one of the most aggressive
cancer types with high death rates globally [1]. Although its incidence rate has
decreased over time in the United States and Western Europe, gastric cancer is still
the fifth most common and the third leading cause of cancer death worldwide. This
is largely due to the later presentation with a diagnosis of locally unresectable or
metastatic gastric cancer, which generally carries a poor prognosis [2]. The inci-
dence rate of gastric cancer varies widely between countries, and its 5-year survival
rate varies extensively in Japan, where it reaches 90% vs. only 30% in Europe [3].
This different rate is mostly due to the early routine screening methods with endo-
scopic evaluation in Japan [4]. Gastric cancer, in its early stages, is located mostly
in the antrum of the stomach, with a rate of 57.5% and a lesser curvature at 37.8%
[5]. Multiple factors can trigger gastric cancer when combined, like genetic disor-
ders (which make up only 3–5% of the cases), such as hereditary diffuse gastric
cancer from mutations in the tumor suppressor gene CDH1, Lynch syndrome, and
other genetic defects [6].
Other risk factors related to gastric cancer include an unhealthy lifestyle,
including smoking, with a relative risk rate of 1.62 in males, making it one of
the most risky factors [7], alcohol abuse, although four prospective large cohort
trials provided little support for the association between alcohol intake and
gastric cancer [8], processed food, and high salt diets, which cause damage to
the gastric mucosa and trigger the carcinogenic pathway of cancer [9]. Obesity
with a body mass index (BMI) of more than 30 increases the risk of gastric
cancer by 1.5-fold [10]. Infection with Helicobacter pylori is reported to be the
strongest risk factor correlated with gastric cancer, which occurs in 3% of
H. pylori-infected patients [11]. Gastric cancer is adenocarcinoma in 95% of
cases, arising from epithelial cells, and is subdivided, according to Lauren’s
classification, into the intestinal well-differentiated type, which is mostly spo-
radic and linked to environmental risk factors, and the diffuse undifferentiated
type, which frequently presents metastatic disease and has a poor prognosis
[12]. In the Arab World and reviewing the Globocan 2020 database, reviews
show that the incidence of gastric cancer is low in this region, and most of the
cases are diagnosed at advanced stages, making the 5-year survival rates low
when compared to European countries. The figures seem similar: 21.1% in
Oman compared to 30% in Europe. Oman had the highest incidence, with a rate
of 8.0 per 100,000, while Saudi Arabia and the United Arab Emirates (UAE)
had rates of 2.7 and 4.4 per 100,000, respectively [13]. Some retrospective
studies for Saudi Arabia in 2017 showed that the mean age was 50 years and
the male-to-female ratio was 2.3:1, with most of the tumors located in the body
of the stomach [14]. A cohort study of gastric cancer from Gulf Council
28 Gastric Cancer in the UAE 453

countries showed that the cancer was located anatomically in 53% of the stom-
ach antrum, with histologic features classified as intestinal type in 61.50% of
patients and signet ring morphology in 30.20% of patients. This was the first
study to look at the HER-2 status in relation to gastric cancer in Gulf Cooperation
Council (GCC) countries; the findings revealed HER-2 gene amplification in
20% of GCC gastric patients [14].
In this article, we aim to highlight the updated data on gastric cancer in the
UAE and to review and try to understand the risk factors, clinical features, and
histologic characteristics of gastric cancer in the UAE. This can help determine
if preventive steps can aid in the workup and treatment of such an aggressive
disease.

28.2 Epidemiology of Gastric Cancer

28.2.1 Overall Cancer Incidence in the UAE

In 2021, the UAE—National Cancer Registry (NCR) recorded 5830 newly diag-
nosed cancer cases (both malignant and in situ). Newly diagnosed malignant
cases totaled 5612 (96%), and 218 (4%) were in situ cases. Taking all cancer
types together, the female gender was diagnosed with cancer more than the male
gender; cancer was diagnosed in 3210 (55.1%) females versus 2620 (44.9%)
males [15]. Among Emiratis, 1431 cancer cases in 2021 were newly diagnosed as
new malignant cases, versus only 62 (4.2%) in situ cases. Cancer case incidents
involving non-Emiratis were higher and counted at 4337, with a total of 4181
(96.4%) malignant cases and 156 (3.6%) in situ cases [15].

28.2.2 Gastric Cancer Incidence

Gastric cancer is not among the ten most common cancer types in the UAE. It had
a low incidence from 2013 to 2021, with 134 cases out of 5612 (2.38%) newly diag-
nosed in 2021 (Table 28.1). Among the population in the UAE, individuals who
were not UAE citizens represented a larger proportion of gastric cancer cases, total-
ing 104 cases (77.6%). In contrast, a smaller number of cases, specifically 30
(22.3%), were reported among UAE citizens. These proportions are depicted in
Fig. 28.1. Gastric cancer affects men more than women, accounting for 70.8% of
cases versus 29% of women. Figure 28.2 shows a clear predominance of gastric
cancer in males. The crude incidence rate of gastric cancer per 100,000 people is
generally stable and low, from 1.1 in 2014 to 1.4 in 2021 for both genders [15]
(Table 28.1).
 454

Table 28.1 Stomach cancer demographics among the UAE population during 2013–2021
Crude incidence rate of
UAE population Total malignant cases Stomach cancer cases stomach cancer cases per
Year (in millions) (in numbers) (in numbers) Percentage (%) 100,000 population
2013 8.66 3574 105 2.94 –
2014 8.79 3610 101 2.79 1.1
2015 8.93 3744 108 2.88 1.2
2016 9.12 3982 111 2.78 –
2017 9.3 4123 95 2.30 1.0
2019 9.5 4381 89 2.03 –
2021 – 5612 134 2.38 1.4
Source: UAE population: https://fcsc.gov.ae/en-­us/Pages/Statistics/Statistics-­by-­Subject.aspx#/%3Fsubject=Demography%20and%20
Social&folder=Demography%20and%20Social/Population/Population
Ministry of Health and Prevention, Statistics and Research Center, National Disease Registry—UAE National Cancer Registry Report, 2013–2021
N. Abdelwahed et al.
 28 Gastric Cancer in the UAE 455

120
104
No. of stomach cancer cases in the UAE

100

77 78
80 74
67 68
60
60

37
40 34
28 30 29 30
27

20

0
2013 2014 2015 2016 2017 2019 2021

Years
UAE Non-UAE

Fig. 28.1 The number of stomach cancer cases (malignant) among the UAE population according
to nationality, 2013–2021. Source: Ministry of Health and Prevention, Statistics and Research
Center, National Disease Registry—UAE National Cancer Registry Report, 2013–2021

160
No. of stomach cancer cases in the UAE

140

120
39
100
32 33 40
80 47 36 24

60
95
40 75
73 71
59 65
54
20

0
2013 2014 2015 2016 2017 2019 2021
Years

Male Female

Fig. 28.2 Distribution of stomach cancer cases (malignant) according to gender, 2013–2021.
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2013–2021
 456 N. Abdelwahed et al.

28.3 Chronicled Data of Gastric Cancer in the UAE,

2013–2021

28.3.1 Incidence

This chapter summarizes the overall data obtained from UAE-NCR reports. The data
show steady stability in the occurrence of gastric cancer over the last decade, with 105
cases in 2013 [females: 32; males: 73] to 134 cases in 2021 [females: 39; males: 95]
[15] (Fig. 28.3, Table 28.1). There are many factors to consider while preparing this
observatory data: the documentation system through UAE-NCR is becoming more
evolved, and the screening programs and the awareness campaign are becoming more
popular and advanced [16]. This could be attributed to the UAE’s rapid population
growth, particularly among young people, with over 200 nationalities settled and
working in the UAE. The largest population residing in the UAE is from India,
Pakistan, Bangladesh, other Asian nations, Europe, and Africa, respectively [17].
Figure 28.4 shows the distribution of stomach cancer cases by the Surveillance,
Epidemiology, and End Results (SEER) stages in the UAE across the years.

28.3.2 Mortality

Malignant neoplasm of the stomach is the fifth most common cause of cancer death
in both sexes in the UAE, with an estimated average of 4.3% of cancer deaths occur-
ring during the year 2021 [15]. The distribution of mortality cases due to malignant
neoplasm of the stomach over the previous years is shown in Table 28.2.

150

140 134
No. of stomach cancer cases in the UAE

130

120
111
108
110 105
101
100 95
89
90

80

70

60

50
2013 2014 2015 2016 2017 2019 2021
Years

Fig. 28.3 Number of stomach cancer cases (malignant) in the UAE across the years
2013–2021. Source: Ministry of Health and Prevention, Statistics and Research Center, National
Disease Registry—UAE National Cancer Registry Report, 2013–2021
28 Gastric Cancer in the UAE 457

120
No. of stomach cancer cases in the UAE

100
36
45 40
80
53
60 26
32
35
40
27 16
21
20 17 14
22
12 15 12
0
2012 2015 2016 2017

Years
Localized Regional
Distant Metastasis / Systemic Disease Unstaged, Unknown, or Unspecified

Fig. 28.4 Distribution of stomach cancer cases by SEER stages in the UAE across the years.
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2012–2017

Table 28.2 Distribution of malignant neoplasm of stomach mortality cases in the UAE
Year Percentage (%)
2014 5.4
2015 5.1
2017 5.2
2019 4.7
2021 4.3
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2014–2021

28.4 Risk Factors for Gastric Cancer in the UAE

Helicobacter pylori (H. pylori) is a gram-negative bacteria that affects the stomach,
causing chronic inflammation in the gastric mucosa and is the leading cause of
stomach cancer [18].
It’s the cause of noncardiac gastric cancer in 90%, as this infection stimulates the
pathway of dysplasia going through atrophic gastritis and intestinal metaplasia [19].
The prevalence of H. pylori in the UAE has been investigated in a prospective
study of healthy people living in the UAE of different nationalities with no symp-
toms who were found to have these bacteria through stool testing. Infection was
found in 41% of the study sample, with more females infected than males, and the
458 N. Abdelwahed et al.

median age was in their 30 s [20]. Another major challenge is adhering to follow-up
after H. pylori eradication. To provide an illustration, more than two-thirds (71%) of
patients infected with H. pylori at a tertiary care center in the UAE failed to attend
their scheduled follow-up appointments [21].
Smoking is considered one of the riskiest environmental factors causing cancer
in the stomach [22]. The risk increases with duration, reaching 33% when smoking
for 40 years [23]. In a cross-sectional study, smoking affects 24.3% of males in the
UAE population, mostly Arab residents, and 0.8% of females. Cigarettes have the
highest prevalence, at 77.4%. An alarming survey found that Midwakh smoking
affects young UAE nationals, with 16% still smoking in the UAE, despite the fact
that the prevalence is lower than that in other Arab countries [24].
Metabolic disorders are accused of being risk factors for cancer of the stomach;
a cohort study revealed a higher incidence of gastric cancer in the metabolically
abnormal obese population. Obesity is associated with a higher prevalence of
H. pylori infection, according to multiple studies. Other explanations of obesity’s
correlation to gastric cancer can be related to gastroesophageal reflux and insulin
resistance [25]. Obesity affects non-UAE citizens far more than Emiratis, according
to the UAE national diabetes and lifestyle style [26].
A systematic review published in 2015 showed a significant relationship between
gastric cancer and a high-salt diet, with a higher risk of injury of 12% for each 5 g/
day [27].
A meta-analysis of multiple cohort studies published in 1987–2016 found that
high-dose alcohol intake has a higher risk of incidence of gastric cancer, with a 7%
increase for each 10 g/day [28].
The national rehabilitation center in the UAE studied alcohol and multiple sub-
stance misuse in adults aged 13–18 between 2013 and 2015. Results showed an
increase in alcohol intake [29].

28.5 Screening

Screening for gastric cancer in healthy populations is still under investigation. It is

preferred for high-risk areas, as in Japan and Korea, but still, there is no unified modal-
ity and guidelines regarding when to start and how to screen [30, 31]. In Japan, screen-
ing is advised for people aged 50 and above using endoscopy as a modality every
2–3 years or barium imaging annually [32]. Interscreen gaps are still under evaluation
in randomized trials. A Korean cohort study found that screening at 2–3-year intervals
reduced the risk of advanced care and, as a result, mortality [33].
Prevention of H. pylori infection by routine tests and treatment for this infection
in the asymptomatic population has been applied in multiple regions and has shown
a decrease in the incidence rate of gastric cancer, especially in first-degree relatives
of patients diagnosed with gastric cancer [34, 35].
28 Gastric Cancer in the UAE 459

28.6 Clinicopathological Features of Gastric Cancer

in the UAE

A single cross-sectional study involving 96 patients from the GCC, with 26% of
them being Emiratis, was the only research that examined the clinicopathological
characteristics of gastric cancer in the UAE. This study specifically investigated the
anatomical location, histology, and stages of the disease. No other studies have been
conducted on this topic in the UAE.
In this particular study, the authors identified 96 patients who were diagnosed
with gastric adenocarcinoma, confirmed through histological examination. These
patients originated from various countries, including Saudi Arabia (41.6%), the
United Arab Emirates (27%), Qatar (14.6%), Kuwait (9.5%), Oman (4.2%), and
Bahrain (3.1%). The initial symptoms reported by the patients were epigastric pain
in 52% of cases, dyspepsia in 67.7%, weight loss in 72.9%, and melena (blood in
the stool) in 7.3%. The median time from the onset of symptoms to diagnosis was
9.3 months, ranging from 2 to 18 months. The median age of diagnosis was
54.5 years, with 40 patients (42%) being under the age of 50. The male-to-female
ratio was 1.7, with 61% of the patients being male and 39% female. In 90% of cases,
the diagnosis was made before the patients visited MD Anderson, while in 10.4% of
cases, the diagnosis was made in the United States. At the time of diagnosis, 76% of
cases were already characterized as metastatic. Histological analysis revealed that
the intestinal type of gastric cancer was predominant in 61% of cases, while 30%
exhibited “signet cell” histology, and 9% had an indeterminate type. Notably, among
the patients under the age of 50, the signet ring type was the most common, account-
ing for 71.4% of cases (30 out of 40). Among the tested samples, 6 out of 28 (20.1%)
showed HER-2 amplification.
This study provided the initial report on the clinicopathological characteristics of
gastric cancer (GC) in patients from the GCC. Prior to this study, previous reports
had separately assessed GC patients in each individual GCC country [36–38].
During a span of 34 years, from 1981 to 2015, our retrospective study examined 96
patients originating from GCC countries who received treatment for gastric carci-
noma at the MD Anderson Cancer Center. The majority of these patients came from
Saudi Arabia, the UAE, and Qatar. It is noteworthy that 57% of the patients (55
individuals) underwent treatment before the year 2000, which can be attributed to
the limited availability of well-established cancer centers in the GCC region during
that time.
The average age of the group of patients from the GCC in this study was
54.5 years, ranging from 20 to 80 years. Notably, 40 patients (42%) were younger
than 50 years old. This stands in contrast to the average age of males and females in
the United States, which was 67.4 years according to the SEER data spanning from
1973 to 2014 [39]. The difference in age between this cohort and the population in
460 N. Abdelwahed et al.

the United States is 12.9 years, with the GCC patients being notably younger. This
finding aligns with data observed in other Arab countries. For instance, a study con-
ducted in Tunisia analyzed 860 cases of gastric cancer, revealing an average age of
59 years and 27% of the cases being younger than 50 years old [40]. The sex distri-
bution in this study exhibited a ratio of 1.7, indicating a higher prevalence among
males. This observation is consistent with a previous study conducted in Oman,
which also reported a comparable sex ratio of 1.7 [37] and was lower than the
reported study from the Kingdom of Saudi Arabia (KSA) with a male to female
ratio of 2.3 [38].
Lauren’s classification, developed in 1965, is widely recognized as the primary
classification system for gastric carcinoma. This classification categorizes gastric
carcinoma into two main types: intestinal and diffuse. These types possess distinct
characteristics, including differences in morphology, genetics, clinical presenta-
tion, progression patterns, and epidemiology [41]. Within our group of patients, the
histology classification revealed that the intestinal type of gastric carcinoma was
the most prevalent, accounting for 61.5% of cases. Additionally, 30.2% of cases
exhibited a “signet cell” histology, while 8.3% fell under the category of indeter-
minate GC type. These findings differ from a study conducted in KSA, where
91.5% of gastric carcinoma cases were identified as intestinal type [38]. It is note-
worthy that among younger patients, there was a remarkable prevalence of the
signet ring type, accounting for 71.4% (30 out of the 40 cases) in individuals below
the age of 50. This observation aligns with previous studies indicating that the dif-
fuse type, characterized by signet ring cells, tends to be more prevalent in younger
populations. Moreover, this subtype is associated with a poorer prognosis and the
highest recurrence frequency (63%) among the four molecular subtypes of gastric
carcinoma [42].
Limited information is available regarding the prevalence of HER2 in gastric
cancer patients from GCC countries. The only existing study on HER2, as men-
tioned earlier, was conducted in the KSA and involved only nine patients, all of
whom tested negative for HER2 amplification. In our cohort, a total of 28 patients
were tested, and 6 of them (20.1%) exhibited HER2 amplification. This represents
the first report of the HER2 amplification rate in GCC patients, which aligns with
the reported incidence of HER2 amplification in advanced gastric cancer. It has
been observed that between 7% and 38% of gastroesophageal adenocarcinomas
display amplification and/or overexpression of HER2. Notably, the frequency of
overexpression tends to be slightly higher in cancers of the esophagogastric junction
(EGJ) compared to those in the stomach (32% versus 21%, respectively).
Furthermore, overexpression in the stomach varies based on histological type, with
intestinal-type cancers exhibiting a higher prevalence (ranging from 3 to 23%) com-
pared to diffuse-type gastric cancers (ranging from 0 to 6%). Additionally, the
degree of differentiation also influences HER2 overexpression, with well and mod-
erately differentiated cancers displaying higher rates compared to poorly differenti-
ated ones [43].
28 Gastric Cancer in the UAE 461

The distribution of gastric cancer (GC) across anatomical locations in our study
was as follows: 51 cases (53%) in the antrum, 24 cases (25%) in the body, 9 cases
(10%) in the fundus, and 12 cases (12%) in the cardia [14].

28.7 Treatment Modalities for Gastric Cancer in the UAE

Molecular testing is a critical step in the management of almost all cancers, particu-
larly advanced gastric cancer. HER2 testing is widely available in the UAE for
advanced gastric cancer. On the other hand, MSI testing, PDL-1 (CPS combined
positive score), tumor mutational burden (TMB), neurotrophic tyrosine receptor
kinase (NTRK), and next-generation sequencing (NGS) availability vary according
to hospital and insurance coverage; many patients in our experience may not have
access to these tests due to these limitations.

28.8 Multidisciplinary Team (MDT)

An integrated multidisciplinary approach has become the standard of practice for

managing cancer patients at major governmental and private healthcare centers in
the UAE [44]. Weekly MDT tumor board meetings take place at major healthcare
institutions with the active participation of consultants from various disciplines,
including gastroenterology, radiology, nuclear medicine physicians, pathology, gas-
trointestinal surgeons, medical and radiation oncologists, as well as palliative care
physicians. MDT is encouraged by almost all cancer specialists in cancer care in the
UAE, but some patients with a gastric cancer diagnosis are treated without MDT
input at smaller hospitals and clinics.

28.9 Centralization of Cancer Services

There is no doubt that the centralization of cancer care to create high-volume hos-
pitals, particularly for less common cancers requiring high-risk surgery, such as
gastric cancer, can be associated with reduced postoperative mortality and improved
overall outcomes [45]. In the Netherlands, as an example, the implementation of
centralized gastric cancer surgery in 2012 was associated with significant changes
in outcomes, including reductions in cardiac morbidity and 30- and 90-day postop-
erative mortality and improvements in lymph node retrieval and 2-year overall sur-
vival [46]. Furthermore, the centralization of gastric cancer treatment in the
Netherlands resulted in the successful introduction of laparoscopic surgery at high-­
volume centers (6 vs. 40%, p < 0.01), which was associated with a significant reduc-
tion in hospital stays [47]. In the UAE, the Emirates Oncology Society established
an Oncology Task Force in 2019 and recommended the establishment of tertiary
cancer centers for better healthcare delivery and improved outcomes [48].
462 N. Abdelwahed et al.

28.10 Neoadjuvant Chemotherapy (NAC)

Although either perioperative or adjuvant chemotherapy improves the survival of

patients with non-early operable gastric cancer (stage 1B or higher) [49], neoadju-
vant chemotherapy (NAC) followed by D2 gastrectomy has become the more
widely practiced standard of care in patients with atypical glandular cells (AGC),
including in the UAE. UAE oncologists widely use the FLOT protocol for periop-
erative chemotherapy for eligible patients [50].

28.11 Surgery

Function-preserving limited gastric resections for EGC, with its low rate of regional
lymph node metastases, are increasingly being applied and could include endo-
scopic, laparoscopic, or combined endoscopy-laparoscopy approaches that offer
excellent survival and improved quality of life [51]. In patients with resectable,
nonmetastatic AGC, gastrectomy with D2 lymphadenectomy—which involves
retrieval of perigastric lymph node stations and those along the branches of the
celiac axis—is the standard of care [52]. While D2 gastrectomy is conventionally
and more commonly performed by open laparotomy, selected high-volume centers
globally adopt minimally invasive approaches (laparoscopic, laparoscopic-assisted,
or robotic-assisted). A meta-analysis of eight randomized controlled trials and 22
high-quality non-randomized comparative studies of laparoscopic versus open dis-
tal gastrectomy performed by experienced surgeons at high-volume centers for
AGC that included 16,029 patients showed benefits in terms of reduction in opera-
tive blood loss, serious complications, and hospital stay [53]. The 5-year overall
survival of the laparoscopic approach to D2 distal gastrectomy was comparable to
that of open surgery, as shown in the multicenter randomized CLASS 0–1 Chinese
trial (n = 1056 patients). In the Middle East and the UAE, the minimally invasive
approach to D2 gastrectomy for AGC is not widely adopted, yet it is recommended,
and the authors advocate for it in keeping with the best surgical practices. The
author reported a comparative case-matched controlled study of laparoscopic versus
open D2 gastrectomy for AGC where patients were matched for age and extent of
resection (total vs. subtotal gastrectomy) and demonstrated significant reductions in
intraoperative blood loss and hospital stay (median, 3.0 vs. 7.5 days, p < 0.001)
while maintaining comparable early oncologic outcomes (median lymph node
retrieved, 40.5 vs. 31.5, p = 0.181; R0 resection rates 100% vs. 89%, p = 0.486) [54].

28.12 Radiation Therapy

As in most of the world, the practice of involving radiation therapy in the treatment
of gastric tumors varies across institutions in the UAE and is case-specific. As all
cases are typically discussed on tumor boards, the role of the radiation oncologist is
definitely vital. For patients presenting with metastatic disease, palliative
28 Gastric Cancer in the UAE 463

radiotherapy is usually offered to patients with controlled symptoms. While for non-
metastatic diseases, surgery remains the best curative approach. However, for
patients with unresectable disease, radiotherapy (with or without chemotherapy)
may be used to provide local control benefits [55]. Patients who present with
respectable disease require a thorough discussion of their pathological findings
(whether these patients received neoadjuvant systemic therapy or not) to determine
the indication or not for adjuvant radiation therapy. While surgery is crucial in the
treatment of gastric cancer, surgical expertise and the extent of lymph node dissec-
tion vary across institutions within the UAE. This reflects on the indications for
adjuvant radiation, especially if patients haven’t received adequate D2 dissection.
For patients who undergo upfront surgery without preoperative treatment, the role
of adjuvant radiation is based on pathology findings and extends surgical node dis-
section. Adjuvant fluoropyrimidine-based concurrent chemoradiotherapy is recom-
mended for patients with more than pT1 any N+ disease, unless primary D2
dissection is made with an R0 resection. Almost all radiotherapy centers within the
UAE are equipped with state-of-the-art, advanced machines and have good exper-
tise in treating that cancer. Moreover, most, if not all, departments do have advanced
image guidance and gating tools, which allow treatment delivery in the most accu-
rate way possible using 3-D conformal radiation or intensity-modulated radiother-
apy (IMRT). More recently, with the shift towards neoadjuvant systemic therapy in
patients presenting with locally advanced resectable gastric tumors and especially
after the results of the CRITICS trial [56], the utilization of radiation in the adjuvant
setting for patients who received neoadjuvant systemic therapy has gone down.
However, for patients with high-risk features such as R1 resection, which cannot be
re-resected, current practice guidelines, including the National Comprehensive
Cancer Network (NCCN) guidelines, which are mostly followed across the UAE,
still recommend adjuvant fluoropyrimidine-based concurrent chemoradiotherapy
[57]. Finally, the utilization of neoadjuvant radiation therapy for gastric cancer is
still not fully endorsed in the UAE, most likely because current guidelines do not
state it and the role of this approach is still being evaluated [58].
Therefore, there remains a great deal of controversy in the radiation practice for
gastric cancer within the UAE as well as in the rest of the world. Multidisciplinary
approaches and case-by-case individualized treatment are key. While surgical
expertise for treating gastric cancer varies, this remains the key point in reflecting
on the outcome of this patient population in the nation. However, having advanced
technologies and good radiotherapy expertise in almost all centers in the UAE
makes enrolling patients in ongoing international trials addressing the role of neo-
adjuvant radiation in gastric cancer quite appealing.

28.13 Systemic Therapy

Anticancer therapies are widely available in the UAE, including chemotherapy, tar-
geted therapies, and immunotherapies. FOLFOX/CAPOX/FOLFIRI are the most
widely used chemotherapy combinations for advanced gastric cancer. The addition
464 N. Abdelwahed et al.

of anti-HER2 or immunotherapy is also utilized in keeping with the NCCN guide-

lines. Ramucirumab and paclitaxel are commonly used as second-line therapies in
patients with metastatic disease.

28.14 Palliative Care

Most patients with gastric cancer have advanced-stage disease at the point of diag-
nosis, resulting in a significant symptom burden that adversely affects their quality
of life. The early integration of palliative care into the care of patients with cancer
is now accepted as standard of care since the landmark Temel trial of 2010 [59],
which demonstrated that in patients with advanced non-small-cell lung cancer, early
palliative care involvement resulted in not only improved quality of life but also
longer survival as compared to patients who received standard care. Gastric cancer
is particularly morbid, with poor food tolerance (including early satiety), nausea
and/or vomiting, abdominal pain and bloating, bleeding, fatigue, and a low mood
commonly reported [60].
Improved interdisciplinary symptom control may increase the chances of a
patient’s functional status being good enough to tolerate systemic anticancer ther-
apy. As the condition progresses, or in cases of advanced gastric cancer, malignant
gastric outlet obstruction (GOO) can dominate. Whether treated via an endoscopic
or surgical approach, the aim of GOO treatment is to reduce nausea and vomiting
and enable the patient to tolerate oral intake. If it is not possible to restore physio-
logical gastrointestinal tract integrity by surgically bypassing the obstruction, a
combination of a gastrostomy tube (to vent the stomach) and a separate distal jeju-
nostomy tube (for enteral nutrition) may be utilized. As patients survive longer with
advanced gastric cancer, these palliative approaches are likely to be utilized more
commonly.
While we are fortunate within the UAE to have access to both the full comple-
ment of modern medical equipment and essential palliative care medications [61],
access to palliative care teams remains limited to a few specialist hospitals in the
major conurbations of Dubai and Abu Dhabi [62]. Early palliative and supportive
care input for patients with gastric cancer may help patients deal with the physical
and psychological morbidity of gastric cancer.

28.15 Conclusion

Gastric cancer has a lower incidence rate in the UAE when compared to global
rates, but it is the fifth leading cause of cancer-related death. This process helps us
understand cancer behavior in the stomach and the mechanisms triggering it.
Infectious control of H. pylori bacteria by screening healthy asymptomatic popula-
tions, launching screening programs for highly at-risk populations, and launching
awareness campaigns to encourage balanced diets and healthy lifestyle rules could
prevent and decrease the mortality rate of gastric cancer.
28 Gastric Cancer in the UAE 465

Conflict of Interest The authors have no conflict of interest to declare.

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Dr. Nadia Abdelwahed With a solid foundation of medical stud-

ies, Dr. Nadia Abdelwahed specialized in the branch of medical
oncology and added valuable practical experience in the adminis-
tration of oncology intervention and therapy by addressing cases
from all stages and conditions of the disease. Her specialty practice
began in 2015 and continued for 3 years, making her an expert in
the diagnosis and screening of all cancer types, especially breast
cancer, and an expert in cancer treatment methods, qualifying her
through the school of medicine residency program. During this
period, she addressed both the inpatient and outpatient categories
of patients. After this academic training and practical performance,
Dr. Nadia secured a placement as a medical oncologist (specialist)
in a leading university oncology hospital in Damascus, Syria. After
completing her tenure of office there, she joined another multispe-
cialty center as a medical oncologist from 2018 until 2021.
468 N. Abdelwahed et al.

Alongside her postgraduate studies and practical training, Dr.

Nadia conducted her independent research studies leading to the
master’s degree (Neoadjuvant Capecitabine in Rectal Cancer)
Research in 2018. In 2017, she passed the European Society of
Medical Oncology (ESMO) exam and was certified for a period of
5 years. In 2021, she also excelled at the Immune Oncology Course
at Harvard Medical School in the United States, earning a
Certificate of Achievement. She is also a recipient of the FRON
Prize (Forum of Research in Oncology) for her research work on
“Impact of HER-2 Ratio on Efficacy of Trastuzumab in Early
Breast Cancer” in 2017. In 2021, Dr. Nadia relocated to the UAE
and qualified for the HAAD Licensing Exam as a Specialist in
Medical Oncology; soon after, she joined VPS Healthcare at the
Burjeel Cancer Institute of the Burjeel Medical City.

Dr. Salem Al-Asousi is a graduate of the Royal College of

Surgeons in Ireland. He trained in internal medicine at the
University of British Columbia in Vancouver, Canada. He has been
practicing since 2012 in both internal medicine and gastroenterol-
ogy in both government and private hospitals in Kuwait. Salem's
main interest is advanced gastrointestinal therapies and the effect
of weight reduction/management on overall health.

Ms. Faryal Iqbal is the research associate at Burjeel Medical

City, Abu Dhabi, United Arab Emirates. She completed her under-
graduate studies in molecular ­ biology and biotechnology.
Following that, she received a postgraduate qualification in molec-
ular genetics. She co-edited “Cancer in the Arab World,” the first
extensive book covering cancer care across all Arab countries. The
book succeeded significantly, with over 450,000 downloads
within just two years. She has several peer-­reviewed papers under
her name. In September 2023, Ms. Iqbal received the “EOS
Research Award” from the prestigious Emirates Oncology Society
for her research efforts. Moreover, she assists in different aspects
of clinical trial implementation at a research site. Her research
interests and publications encompass oncology, hematology, and
genetics.
28 Gastric Cancer in the UAE 469

Dr. Amin M. Abyad earned his medical degree, Bachelor in

Medicine and Surgery (MBChB), from Beirut Arab University.
After completing his internship, he joined the Internal Medicine
Residency at Makassed Hospital in Beirut, Lebanon, which is affil-
iated with the American University of Beirut Medical Center
(AUBMC). Dr. Amin was appointed as Chief Resident of Internal
Medicine (2017–2018). Then Dr. Amin started his fellowship in
hematology and medical oncology at Makassed Hospital, where he
received intensive training in hematology and medical oncology.
Dr. Amin joined Burjeel Medical City in July 2021. Dr. Amin is
highly interested in malignant hematology and solid malignancies.
He has been highly involved in clinical research, being involved in
multiple research projects and publishing in multiple peer-reviewed
journals.
Dr. Abyad believes in patient-centered care, trying to enhance
patient outcomes through the application of the latest evidence-
based practice and personalized medicine.

Dr. Neil A. Nijhawan is a UK-trained consultant in Palliative

Medicine at Burjeel Medical City. After medical school at Kings
College London, he pursued specialty training in Palliative
Medicine in London, with rotations in acute general hospitals,
domiciliary visits, community hospices, and tertiary oncology cen-
ters. Prior to completing his palliative medicine training, Neil
returned to his childhood home, Trinidad in the West Indies, to help
set up and commission the new Caura Hospital Palliative Care
Unit, where he was the Medical Director. This unit was opened in
2014 and provides a comprehensive palliative care service, includ-
ing a 12-bed inpatient unit, weekly outpatient clinics, and a pallia-
tive care consult service at the local university hospital. After
completing his specialty training, Neil worked as a consultant in
palliative medicine at the Imperial College Healthcare NHS Trust
in London, where he was the clinical lead for palliative medicine.
His clinical area of interest is symptom control (including pain,
nausea, breathlessness, and fatigue) and assistance with complex
treatment decision-making at the end of life, and he is often called
on to provide an independent second opinion. He is active in pallia-
tive care education and palliative care advocacy and is currently the
UAE representative to the WHO Eastern Mediterranean Region
Palliative Care Expert Network. Neil holds adjunct faculty posi-
tions with both Khalifa University and Gulf Medical University
where he is Clinical Associate Professor in Hospice & Palliative
Medicine.
470 N. Abdelwahed et al.

Dr. Hampig R. Kourie gained his medical doctor degree from

the Faculty of Medicine of Saint Joseph University in Beirut
Lebanon in 2010. He started his fellowship in Hôtel-Dieu de
France, Saint Joseph University hospital in Beirut, Lebanon and
he continued his medical oncology fellowship in Jules Bordet
Institute in Brussels, Belgium from 2014 to 2016. Since September
2016, he worked in the digestive oncology department in Hôpital
Européen Georges Pompidou (HEGP) in Paris as a researcher in
the Association des Gastro-entérologues Oncologues en France
(AGEO). He is also certified from Paris Diderot and Paris
Descartes universities in hereditary cancers and digestive oncol-
ogy. He gained his PhD in genetics from Saint Joseph University
of Beirut in 2023 and his MEMS from ESA business school in
2023. He is practicing as hematologist-oncologist in Hôtel Dieu de
France, Hôpital Saint Joseph des Soeurs de la Croix and Bellevue
Medical Center.
He is actually an ESMO Faculty in the colorectal cancer group.
He founded and directed the Middle East Biomarkers course and
the Middle East and North Africa GI Oncology Summit. He has
more than 200 peer-reviewed articles, mainly in immunotherapy,
oncogenomics and digestive oncology fields.

Dr. Ibrahim H. Abu-Gheida is the Clinical Director of the

department of radiation oncology at Burjeel Medical City. He also
serves as a regional Radiological Society of North America
(RSNA) committee representative for the Middle East and Africa.
Dr. Abu-Gheida completed his undergraduate training, where he
earned a Bachelor of Science with honors degree from the
American University of Beirut. Following this, Dr. Abu-Gheida
completed his Medical School training at the American University
of Beirut Medical Center. He continued and joined the Department
of Internal Medicine at the American University of Beirut. Then
he did his training in the Department of Radiation Oncology at the
American University of Beirut Medical Center, where he also
served as the chief resident. During his training, Dr. Abu-­Gheida
completed a Harvard-affiliated NIH-funded research program as
well. After his residency, Dr. Ibrahim went to the Cleveland Clinic
in Ohio, where he was appointed as an Advanced Clinical
Radiation Oncology Fellow. Dr. Abu-Gheida went and joined the
University of Texas MD Anderson Cancer Center, where he sub-
specialized in treating breast, gastrointestinal, and genitourinary
cancers. Dr. Abu Gheida played an instrumental role in establish-
ing and heading the radiation oncology facility and department at
Burjeel Medical City. He has chaired and c­o-­chaired multiple
international oncology conferences. Dr. Ibrahim has more than 40
peer-reviewed papers in prestigious medical journals, including
the American Society of Radiation Oncology official journal - the
International Journal of Radiation Oncology Biology and Physics,
Nature, the Journal of Clinical Oncology, and several others. He is
also the primary author and editor of several book chapters pub-
lished in prestigious books.
28 Gastric Cancer in the UAE 471

Prof. Basil Ammori graduated from Baghdad University medi-

cal school in 1986, completed his surgical training in the UK, and
obtained the CCST in 2000, and was granted a Hunterian
Professorship by the Royal College of Surgeons of England in
2000. Appointed a consultant surgeon, he led the laparoscopic bar-
iatric and HPB (hepato-pancreato-biliary) surgery service in
Manchester between 2002 and 2017 and was the first to introduce
laparoscopic Whipple’s procedure in the U.K. He was appointed
as an Honorary Professor at the University of Manchester in 2011
and later joined King Hussein Cancer Center, Amman, Jordan, as
a full member in November 2017 as a Laparoscopic Gastrointestinal
Oncology Surgeon before moving to Burjeel Hospital, Abu Dhabi,
in January 2020. He sat on the editorial boards of a number of
medical journals and has over 240 peer-reviewed publications and
book chapters.

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow)
in 2024. He is the only physician in the UAE with a subspecialty
fellowship certification and training in gastrointestinal oncology
and the first Emirati to train and complete a clinical post-doctoral
fellowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new
distinct subgroup of CRC, NON V600 BRAF-mutated CRC. In
2022, he published the first book about cancer research in the UAE
and also the first book about cancer in the Arab world, both of
which were launched at Dubai Expo 2020. Cancer in the Arab
World has been downloaded more than 450,000 times in its first 18
months of publication and is the ultimate source of cancer data in
the Arab region. He also published the first comprehensive book
472 N. Abdelwahed et al.

about cancer care in the UAE which is the first book in UAE his-
tory to document the cancer care in the UAE with many topics
addressed for the first time, e.g., neuroendocrine tumors in the
UAE. He is passionate about advancing cancer care in the UAE
and the GCC and has made significant contributions to cancer
awareness and early detection for the public using social media
platforms. He is considered as the most followed oncologist in the
world with over 300,000 subscribers across his social media plat-
forms (Instagram, Twitter, LinkedIn, and TikTok). In 2022, he was
awarded the prestigious Feigenbaum Leadership Excellence
Award from Sheikh Hamdan Smart University for his exceptional
leadership and research and the Sharjah Award for Volunteering.
He was also named the Researcher of the Year in the UAE in 2020
and 2021 by the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various lev-
els of research training for medical trainees to enhance their clini-
cal and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

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Pancreatic Cancer in the UAE
29
Humaid O. Al-Shamsi , Faryal Iqbal , Neil A. Nijhawan,
Hampig R. Kourie, Nadia Abdelwahed,
Ibrahim H. Abu-Gheida, and Basil Ammori

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi, United Arab
Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca
F. Iqbal · N. A. Nijhawan · B. Ammori
Burjeel Medical City, Abu Dhabi, United Arab Emirates
e-mail: faryal.iqbal@burjeelmedicalcity.com; neil.nijhawan@burjeelmedicalcity.com;
basil.ammori@burjeel.com
H. R. Kourie
Hematology-Oncology Department, Faculty of Medicine, Saint Joseph University,
Beirut, Lebanon
e-mail: hampig.kourie@usj.edu.lb
N. Abdelwahed · I. H. Abu-Gheida
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Burjeel Medical City, Abu Dhabi, United Arab Emirates
e-mail: nadia.abdelwahed@burjeelmedicalcity.com

© The Author(s) 2024 473

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_29
474 H. O. Al-Shamsi et al.

29.1 Introduction

Pancreatic cancer originates in the pancreas, with pancreatic adenocarcinoma being the
prevalent form. Less common are pancreatic neuroendocrine tumors (NETs). Pancreatic
adenocarcinoma arises from the unchecked growth of exocrine cells within the pan-
creas, whereas endocrine cells, constituting a smaller portion, produce hormones such
as insulin and glucagon, pivotal in regulating blood sugar levels. Pancreatic neuroendo-
crine tumors, on the other hand, originate from the endocrine cells [1]. A critical aspect
influencing the classification of pancreatic neoplasms is the degree of cellular differen-
tiation they exhibit. Most pancreatic epithelial neoplasms mirror, to some extent, the
normal epithelial cell types found in the pancreas, namely ductal, acinar, and endocrine
cells. Over 90% of pancreatic neoplasms demonstrate ductal differentiation, encom-
passing the prevalent infiltrating ductal adenocarcinoma, along with various cystic and
intraductal neoplasms. A smaller subset of pancreatic neoplasms, referred to as ‘non-
ductal,’ encompasses endocrine and acinar neoplasms, as well as those with mixed or
unclear differentiation patterns. Examples include pancreatic endocrine neoplasms,
acinar cell carcinoma, pancreatoblastoma, and solid-pseudopapillary neoplasm [2].
Exocrine elements account for more than 95% of pancreatic malignant neo-
plasms. The endocrine pancreas gives rise to neoplasms (i.e., pancreatic neuroendo-
crine [islet cell] tumors), which account for less than 5% of pancreatic neoplasms
[3]. Neuroendocrine pancreatic cancer will be discussed in the “Neuroendocrine
tumors in the UAE” chapter.
The incidence of pancreatic cancer in the United Arab Emirates (UAE) is similar
to that in the US [4]. The pancreatic cancer incidence is relatively low in the
UAE. While data on the stage of diagnosis of pancreatic cancer within the UAE are
still unpublished, extrapolation from international studies indicates that only 15–20%
of those patients are diagnosed at an early stage where the tumor is considered “resect-
able”. Unfortunately, most pancreatic cancer cases are diagnosed at a later stage,
when surgery is not a suitable option or the cancer has spread elsewhere (Stage IV).
Pancreatic adenocarcinoma, increasingly prevalent and anticipated to rank as the
second most fatal cancer in certain regions, typically manifests at an advanced
stage. This advanced presentation significantly contributes to dismal five-year sur-
vival rates, ranging from 2% to 9%. Consequently, it stands at the bottom of the list
among all cancer types in terms of patient prognostic outcomes [5]. This type of
cancer can occur at any age. However, the peak incidence is between 60 and 80 years
of age. At the beginning of pancreatic cancer onset, the symptoms are quite nonspe-
cific and progressively worsen over time, including weight loss, fatigue, nausea,
malaise, and midepigastric pain that usually radiates to the back [6].
Jaundice is an indication of tumors in the head of the pancreas caused by the
constriction of the common bile duct and can be the presenting symptom of these
tumors. A tumor may invade the duodenum or stomach, leading to gastric outlet
obstruction. Pancreatic cancer is usually diagnosed based on clinical symptoms. As
a result, diagnosis is commonly delayed until there is little prospect of a cure.
However, if the tumor is detected in those who are predisposed to pancreatic cancer
or have a family history of the specified disease, an earlier detection may be con-
ceivable. Approximately 90% of all pancreatic cancer cases are sporadic, with the
remaining 10% having a hereditary pattern [6].
29 Pancreatic Cancer in the UAE 475

This chapter will focus on the clinical presentation, diagnostic evaluation, and
staging workup for pancreatic cancer, in addition to pathology, adjuvant and neoad-
juvant therapy, surgical management, radiotherapy, and palliative treatment.

29.2 Epidemiology of Pancreatic Cancer

29.2.1 The Global Burden of Pancreatic Cancer

The number of pancreatic cancer-related deaths (466,000) is approximately similar

to the number of reported cases, i.e., 496,000, because of its dismal prognosis. It is
the seventh-leading cause of cancer deaths in both sexes, with 4.7%. The occurrence
and mortality rates are approximately three to four times greater in countries with
high Human Development Index (HDI) scores compared to those with low to
medium scores, with slightly higher rates observed in men than in women. The
highest incidence and mortality rates are observed in Europe, North America, and
Australia/New Zealand, with only slight variations in their severity attributed to the
bleak prognosis associated with the disease [7, 8]. As of now, the risk factors for
pancreatic cancer are not fully comprehended. However, there is evidence indicat-
ing that smoking, diabetes, obesity, and certain dietary habits such as high intake of
red and processed meats, along with excessive alcohol consumption, are all likely
linked to an elevated risk of developing the disease [7, 9].

29.2.2 Data Sources

This is the first systematic effort to comprehensively unify the pancreatic cancer inci-
dence reports over the last decade in the UAE. The code “C25–Pancreas” in the tenth
revision of the International Classification of Diseases (ICD-10) was identified as pan-
creatic cancer. We retrieved the open access data from the Ministry of Health and
Prevention’s (MOHAP) National Cancer Registry (NCR) for the UAE across the
years (2013–2017, 2019, and 2021) that included data on all cancers, including pan-
creatic cancer, along with gender- and nationality-wise distribution in the country [10].

29.2.3 The UAE Burden of Pancreatic Cancer

During the year 2021, the UAE-NCR recorded 110 pancreatic cancer cases out of a
total of 5612 cancer cases, representing 1.96% of all malignant cases in 2021. Non-­
UAE citizens accounted for a higher proportion of pancreatic cancers in the UAE
than UAE citizens, accounting for 79 (71.8%), whereas UAE citizens represented a
lower proportion of cases, accounting for 31 (28.1%) (Fig. 29.1). Males were
affected by pancreatic cancer at a higher rate (69 [62.7%]) than females (41 [37.2%])
(Fig. 29.2) [11]. Figure 29.3 summarizes data on pancreatic cancer occurrences in
the UAE from published UAE-NCR reports over the last decade [10].
 476 H. O. Al-Shamsi et al.

90
79
No. of pancreatic cancer cases in the UAE

80

70

60
51 49
50 45
41
40 34 34
31
30 24
22
19
20 16 14
11
10

0
2013 2014 2015 2016 2017 2019 2021

Years
UAE Non-UAE

Fig. 29.1 The number of pancreatic cancer cases (malignant) among the UAE population accord-
ing to nationality, 2013–2021. Source: Ministry of Health and Prevention, Statistics and Research
Center, National Disease Registry—UAE National Cancer Registry Report, 2013–2021

120
No. of pancreatic cancer cases in the UAE

100
41
80

60 27 26
20
17
40 16 22
69

20 42 44 43
34 38
31

0
2013 2014 2015 2016 2017 2019 2021
Years

Male Female

Fig. 29.2 Distribution of pancreatic cancer cases (malignant) according to gender, 2013–2021.
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2013–2021
 29 Pancreatic Cancer in the UAE 477

120
110
110
No. of pancreatic cancer cases in the UAE

100

90

80 71 69
70 62
60 53 55
50
50

40

30

20

10
2013 2014 2015 2016 2017 2019 2021
Years

Fig. 29.3 Number of pancreatic cancer (malignant) occurrences in the UAE across the years
2013–2021 Source: Ministry of Health and Prevention, Statistics and Research Center, National
Disease Registry—UAE National Cancer Registry Report, 2013–2021

29.3 Surgery for Pancreatic Cancer in the UAE

Presentation with locoregionally advanced and inoperable (30–35%) or metastatic

disease (50–55%) remains the most commonly encountered scenario in patients
with pancreatic ductal adenocarcinoma, for whom there is no role for palliative
resection [12]. However, approximately 15–20% of patients presenting with locore-
gional disease can be offered surgical resection, which is the only potentially cura-
tive treatment, though the majority of these will later relapse [12].

29.3.1 Determining Disease Resectability

A triple-phase (arterial, delayed arterial, and venous) helical computed tomography

(CT) of the chest, abdomen, and pelvis with thin slices (the pancreas protocol) is the
most commonly applied imaging modality to assess the locoregional disease status
and excludes overt metastases in patients with suspected pancreatic ducal adenocar-
cinoma (PDAC), and for the avoidance of confusion, it is performed before any
endoscopic diagnostic or interventional procedures. Magnetic resonance imaging
(MRI) with magnetic resonance cholangiopancreatography (MRCP) is an equiva-
lent alternative. Positron emission tomography (PET)-CT is employed selectively in
patients with suspected metastases on helical CT or MRI [12]. All the above modali-
ties are available in the UAE, yet their exact utilization in this setting is not stan-
dardized, and variation occurs between physicians and hospitals.
478 H. O. Al-Shamsi et al.

While preoperative histological diagnosis is not required and is not always pos-
sible in patients with PDAC, the increasing use of neoadjuvant chemotherapy
(NAC) with or without radiotherapy protocols in patients with borderline resectable
(BR) or resectable disease in the UAE generally requires a prior tissue diagnosis.
This is often obtained with an endoscopic ultrasound (EUS)-guided fine needle
aspiration biopsy (FNAB), a service that is by and large led by dedicated interven-
tional gastroenterologists. Obtaining a biopsy prior to beginning any cancer treat-
ment in general is widely practiced in order to avoid any medicolegal
consequences.
The disease can be considered resectable if the patient’s Eastern Cooperative
Oncology Group (ECOG) performance status is <3 in the absence of overt metasta-
ses and when the major vascular structures, including the superior mesenteric vein
(SMV), portal vein (PV), superior mesenteric artery (SMA), celiac axis, and hepatic
artery, are clear of the tumor [13]. In this setting, while upfront surgery is the stan-
dard of care, the concept of NAC is being tested in clinical trials [14]. On the other
hand, neoadjuvant regimens have become the standard of care in patients with
BR-PDAC, followed by reevaluation of resectability [14]. There is heterogeneity in
the definition of BR-PDAC, as quoted in the National Comprehensive Cancer
Network 2021 anatomical criteria [15]. Biological factors suggestive of BR-PDAC
were defined at the 20th consensus meeting of the International Association of
Pancreatology (IAP) in Sendai, Japan, in 2017, as a tumor potentially resectable
anatomically with clinical findings suspicious of, but not proven, distant metastasis,
including serum carbohydrate antigen 19-9 (CA19-9) level >500 units/mL or
regional lymph node metastasis diagnosed by biopsy or PET-CT [13]. Anatomical
features that define unresectable disease include distant metastases, ≥180° SMA
encasement, PDAC of the head/uncinate process with celiac artery abutment, infe-
rior vena cava (IVC) involvement, unreconstructible SMV/PV occlusion, aortic
invasion, and metastases to distant lymph nodes beyond the locoregional resec-
tion field.

29.3.2 Preoperative Biliary Drainage

Preoperative biliary drainage in patients presenting with obstructive jaundice is not

routinely recommended and may be associated with an increased incidence of com-
plications and wound infections compared with upfront surgery, as shown in a meta-­
analysis that included 25 studies (22 retrospective and 3 randomized controlled
trials) and 6214 patients [16]. However, endoscopic biliary stenting is indicated in
patients with active cholangitis (a rare occurrence in malignant biliary obstruction)
and in those with a serum ≥250 μmol/L and is preferred to percutaneous drainage.
In this regard, plastic stenting is preferred to covered self-expanding metal stents;
the latter were associated with higher intraoperative blood loss and rates of surgery-­
related morbidity as well as longer postoperative hospital stays in a recent random-
ized trial of 70 patients with resectable PDAC [17].
29 Pancreatic Cancer in the UAE 479

29.3.3 Multidisciplinary Team (MDT)

The management of patients with PDAC is discussed at weekly MDT Oncology

meetings that include the participation of consultants within the following special-
ties: gastroenterologists, pathologists, radiologists, nuclear medicine specialists,
surgeons, medical and radiation oncologists, and palliative care team representa-
tives. All major cancer centers in the UAE have weekly MDTs. Smaller cancer
centers and solo practicing surgeons may not have access to MDT, which may com-
promise the care of PDAC and other cancers in the UAE.

29.3.4 Centralization of Cancer Services

There is ample evidence that supports the centralization of cancer services, particu-
larly high-risk surgeries such as those for pancreatic cancer, and demonstrates
improvements in the quality of the healthcare delivered. In the Netherlands, the
centralization of pancreatic surgery resulted in an increase in the resection rate for
patients with pancreatic head and periampullary cancer diagnosed in non-pancreatic
surgery centers that matched those reported in pancreatic surgery centers and
improved overall survival [11]. Centralization enables the establishment of high-­
volume centers and the delivery of better patient outcomes. In one study from the
United States, patients who underwent pancreaticoduodenectomy (PD) for pancre-
atic cancer at high-volume centers enjoyed improved perioperative outcomes, a
reduction in short-term mortality, and better overall survival compared to those
treated at low-volume centers [18].
In the UAE, the Oncology Task Force was founded in 2019 under the auspices of
the Emirates Oncology Society by practicing cancer care providers with a mandate
to fulfill the UAE national agenda, one of whose key performance indicators was to
reduce the number of cancer deaths. The Task Force recommended the establish-
ment of tertiary oncology centers that integrate the governmental and private sectors
of healthcare providers and that can be easily accessed from all cities within the
UAE; these will be supported by multiple affiliated satellite offices equipped with
chemotherapy facilities [19].

29.3.5 Neoadjuvant Chemoradiotherapy (NACR)

While upfront surgery is the standard of care for patients with resectable PDAC, the
concept of NACR is being tested in clinical trials [20] and is becoming more com-
mon in clinical practice in the UAE. On the other hand, neoadjuvant chemotherapy
regimens have become the standard of care in patients with borderline resectable
PDAC, followed by reevaluation of resectability [20]. Indeed, the PREOPANC
Dutch randomized trial showed that neoadjuvant gemcitabine-based chemoradio-
therapy followed by surgery and adjuvant gemcitabine improved overall survival
480 H. O. Al-Shamsi et al.

compared with upfront surgery and adjuvant gemcitabine in resectable and border-
line resectable pancreatic cancer [21].

29.3.6 Surgery

Surgery is performed within a month of completing the staging investigations

(which may include staging laparoscopy) at most and is conducted by specialty-­
trained surgeons. One month from surgery is the most widely practiced approach for
surgery post-neoadjuvant therapy, and up to 6 weeks in the UAE, based on the
patient’s recovery post-neoadjuvant therapy.
While traditional open surgery is used to remove exocrine pancreatic cancers, the
global adoption of minimally invasive approaches (laparoscopic, laparoscopic-­
assisted, or robotic-assisted) has seen selected surgeons in the UAE offer these tech-
niques at select centres. This is especially true for the less difficult distal
pancreatectomy with en block splenectomy, for which there is clear evidence from
the LEOPARD Dutch randomized controlled trial of clinical benefits to patients in
terms of reduced time to functional recovery and rates of delayed gastric emptying,
as well as a better quality of life with the minimally invasive approach compared to
open surgery and without increasing cost [22]. On the other hand, the complexity of
both the resection and the reconstruction in PD and the conflicting evidence from
the three randomized controlled trials regarding the potential advantages of the min-
imally invasive approaches over open surgery [23] have limited their adoption
among UAE surgeons. Nonetheless, the author has reported two comparative case-­
matched controlled trials of laparoscopic versus open PD, one from a U.K. centre
[24] and the other from a Middle Eastern centre [25], and consistently demonstrated
significant reductions in hospital stay while maintaining oncologic outcomes.

29.4 Radiation Oncology

Radiation therapy continues to play an important role for pancreatic cancer patients.
In the palliative setting, where tumors, either the primary tumor or metastatic sites,
are causing significant pain and affecting the patient’s quality of life, radiation can
be utilized to alleviate those symptoms [26].
Most cancer centers in the UAE adhere to the National Comprehensive Cancer
Network (NCCN) guidelines, which provide multiple different approaches, includ-
ing for patients diagnosed with locally advanced or borderline resectable pancreatic
cancer prior to surgery. Radiation options included are concurrent chemoradiother-
apy after induction chemotherapy, upfront concurrent chemoradiotherapy, stereo-
tactic ablative body radiotherapy (SABR), or enrollment in a clinical trial [27].
While most radiotherapy departments in the UAE are equipped with the latest radio-
therapy machines and upgrades, allowing image guidance and very precise treat-
ment, the utilization of radiation therapy for pancreatic cancer in the UAE remains
lower than estimated. This could be related to multiple factors, including the lack of
29 Pancreatic Cancer in the UAE 481

a proper referral pattern for those patients, the concern of potentially losing the
opportunity to operate on those patients, the lack of radiation oncologists or medical
physics expertise in advanced pancreatic cancer radiotherapy techniques, and the
lack of information about the presence of experienced gastroenterologists or inter-
ventional radiologists who can do the proper fiducial placements needed for image
guidance or stereotactic ablative radiotherapy. Finally, and perhaps most impor-
tantly, there is a lack of a dedicated center of excellence for treating pancreatic
cancer cases in the UAE, which would be ideal given the relatively small number of
cases scattered across the country [18]. Having a dedicated center of excellence for
nonmetastatic, borderline non-resectable pancreatic tumors would allow patients to
access a perhaps more experienced radiation facility, which could have more options
and even clinical trials to enroll those patients in and provide the best potential
outcome.
All advanced modalities for pancreatic cancer irradiation should be available
with the current and near-future expansion of UAE radiotherapy infrastructure and
expertise. Work must be done among centers to centralize cases or unresectable
nonmetastatic cases that might be a potential candidate for enrollment in a clinical
trial testing a novel agent with a novel or advanced radiation technique. Knowledge
sharing and collaboration in facing this disease are a must, and in our opinion, dedi-
cated radiation therapy workshops and meetings for such diseases should also be
more readily available to keep up with the rapid progress in pancreatic cancer
radiotherapy.

29.5 Palliative and Supportive Care for Pancreatic Cancer

in the UAE

PDAC carries significant morbidity for patients with a wide spectrum of commonly
reported symptoms, including nausea, pain, dyspnea, abdominal distension and
bloating, constipation, weight loss, malnutrition, steatorrhea, diarrhea, anxiety, and
depression. A thorough supportive care assessment is essential to minimize symp-
tom burden, including dietician input, treatment of pancreatic insufficiency, and a
low threshold for consideration of small bowel overgrowth if symptoms do not
improve with treatment of exocrine insufficiency. Nausea and vomiting are very
common and multifactorial, with multiple potential etiologies, including local and
systemic tumor effects, chemotherapy, medications, anxiety, and gastric outlet
obstruction.
The abdominal pain of PDAC has an adverse effect on the patient’s quality of
life, particularly when symptoms do not improve with systemic anticancer thera-
pies. PDAC is recognized as one of the most painful cancers with its characteristic
epigastric distribution, but there is more commonly a mixed picture at presentation:
a visceral component that is poorly localized, dull, colicky, and associated with
nausea and vomiting. Somatic pain, which is often sharp and well localized, and
neuropathic pain, which is referred to as pain in the back and is frequently exacer-
bated by lying flat, are two types of pain.
482 H. O. Al-Shamsi et al.

Somatic pain arises from local invasion and metastasis into the surrounding peri-
toneum, retroperitoneum, and bones. Visceral pain arises from the infiltration of
adjacent organs and the accumulation of ascites in patients with more advanced
stages of disease. The neuropathic pain component is attributed to the perineural
invasion. Extra-pancreatic nerve plexus invasion is responsible for the neuropathic
pain sensation. Similarities in growth factor receptors and adhesion molecules
between pancreatic cancer cells and neuronal cells explain the affinity to neural tis-
sue and lead to increased cancer cell proliferation, migration, and invasion along
nerve bundles. Nociceptive signals are carried along sympathetic fibers to the celiac
plexus nerves and ganglia (T12-L2) and are transmitted via the splanchnic nerves
(T5–T12) to the higher centers of the central nervous system [28].
In accordance with the World Health Organization (WHO) analgesic ladder
model [29], patients often receive simple analgesics (Step 1) like paracetamol or
nonsteroidal anti-inflammatory drugs for mild pain with the addition of adjuvant
analgesics like corticosteroids, gabapentinoids (Pregabalin and Gabapentin), tricy-
clic antidepressants (amitriptyline), and SNRIs (Duloxetine) for clearly neuropathic
pain. With increasing severity of pain, weak opioids (Step 2) (Codeine or Tramadol)
are trialed before escalating to Step 3 with strong opioids (Morphine, Oxycodone,
Hydromorphone, Methadone, and Fentanyl). The NMDA receptor antagonist, ket-
amine, is also utilized in specialized palliative care units for patients with refractory
neuropathic pain despite high-dose opioid therapy [30]. While all these named anal-
gesics are available within the UAE, availability and clinician familiarity with their
use vary from one Emirate to another.
When combinations of traditional opioid analgesics (oral or parenteral) fail to
provide adequate analgesia, interventional analgesic techniques may prove benefi-
cial. Celiac plexus blockade is the most commonly used intervention and involves
the disruption of visceral pain innervation from the pancreas and adjacent structures
by an injection of corticosteroids and/or local anesthetic. Celiac blocks can be per-
formed using either a percutaneous CT-guided (PC) or an endoscopic ultrasound
(EUS) approach, with some evidence suggesting that the EUS approach provided
better quality analgesia than the PC approach [31]. Likewise, celiac plexus neuroly-
sis, which entails permanent destruction of the plexus, has also been demonstrated
to be suitable for patients with a short life expectancy of 3–6 months, again with an
EUS approach giving better patient-reported outcomes. Celiac plexus blocks are
available at a small but growing number of hospitals across the UAE. Implanted
intrathecal drug delivery systems may be considered for patients with a longer pre-
dicted life expectancy (>6 months) who continue to have poorly controlled pain
refractory to high-dose opioids and celiac plexus blocks, but this is only available at
a small number of super-specialized facilities and is not covered by the majority of
health insurance policies.
The evidence for early palliative care integration into oncology care is now well
established [32], but we also have evidence that early palliative care for patients
with PDAC is also associated with reduced emergency department admissions and
healthcare costs [33].
29 Pancreatic Cancer in the UAE 483

29.6 Conclusion

In the UAE, treatment of pancreatic ducal adenocarcinoma, whether early or meta-

static, is advanced and largely follows NCCN guidelines. One of the major chal-
lenges is decentralized surgical care due to the large number of cancer care providers
in the UAE, which may affect the surgical outcome in lower-volume centers.

Conflict of Interest The authors have no conflict of interest to declare.

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Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society,
Full Professor of Oncology at the Ras Al Khaimah Medical
and Health Sciences University, Ras Al Khaimah, UAE, and
an Adjunct Professor of Oncology at the College of Medicine,
University of Sharjah. He is the first Emirati to be promoted as
a professor in oncology in the UAE. He is also the Chairman for
Colorectal Cancer in the MENA region, appointed by the pres-
tigious National Comprehensive Cancer Network®. He is also
the only member of Lung Cancer Policy Network in the MENA
region that aims to advance lung cancer research and screening
globally. He is the Chairman of the Oncology and Hematology
Fellowship Training Program for the National Institute for
Health Specialties in the United Arab Emirates. He is the only
member in GCC in the WIN Consortium which is comprised
of organizations representing all stakeholders in personalized
cancer medicine globally.
29 Pancreatic Cancer in the UAE 485

He is board-certified in both internal medicine and oncology

from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty fel-
lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fel-
lowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new dis-
tinct subgroup of CRC, NON V600 BRAF-mutated CRC. In 2022,
he published the first book about cancer research in the UAE and
also the first book about cancer in the Arab world, both of which
were launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to docu-
ment the cancer care in the UAE with many topics addressed for the
first time, e.g., neuroendocrine tumors in the UAE. He is passionate
about advancing cancer care in the UAE and the GCC and has
made significant contributions to cancer awareness and early detec-
tion for the public using social media platforms. He is considered
as the most followed oncologist in the world with over 300,000
subscribers across his social media platforms (Instagram, Twitter,
LinkedIn, and TikTok). In 2022, he was awarded the prestigious
Feigenbaum Leadership Excellence Award from Sheikh Hamdan
Smart University for his exceptional leadership and research and
the Sharjah Award for Volunteering. He was also named the
Researcher of the Year in the UAE in 2020 and 2021 by the Emirates
Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
of research training for medical trainees to enhance their clinical
and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.
486 H. O. Al-Shamsi et al.

Ms. Faryal Iqbal is the research associate at Burjeel Medical

City, Abu Dhabi, United Arab Emirates. She completed her under-
graduate studies in molecular biology and biotechnology. Following
that, she received a postgraduate qualification in molecular genet-
ics. She co-edited “Cancer in the Arab World,” the first extensive
book covering cancer care across all Arab countries. The book suc-
ceeded significantly, with over 450,000 downloads within just two
years. She has several peer-reviewed papers under her name. In
September 2023, Ms. Iqbal received the “EOS Research Award”
from the prestigious Emirates Oncology Society for her research
efforts. Moreover, she assists in different aspects of clinical trial
implementation at a research site. Her research interests and publi-
cations encompass oncology, hematology, and genetics.

Dr. Neil A. Nijhawan is a UK-trained consultant in Palliative

Medicine at Burjeel Medical City. After medical school at Kings
College London, he pursued speciality training in Palliative
Medicine in London, with rotations in acute general hospitals,
domiciliary visits, community hospices, and tertiary oncology cen-
tres. Prior to completing his palliative medicine training, Neil
returned to his childhood home, Trinidad in the West Indies, to help
set up and commission the new Caura Hospital Palliative Care
Unit, where he was the Medical Director. This unit was opened in
2014 and provides a comprehensive palliative care service, includ-
ing a 12-bed inpatient unit, weekly outpatient clinics, and a pallia-
tive care consult service at the local university hospital. After
completing his specialty training, Neil worked as a consultant in
palliative medicine at the Imperial College Healthcare NHS Trust
in London, where he was the clinical lead for palliative medicine.
His clinical area of interest is symptom control (including pain,
nausea, breathlessness, and fatigue) and assistance with complex
treatment decision-making at the end of life, and he is often called
on to provide an independent second opinion. He is active in pallia-
tive care education and palliative care advocacy and is currently the
UAE representative to the WHO Eastern Mediterranean Region
Palliative Care Expert Network. Neil holds adjunct faculty posi-
tions with both Khalifa University and Gulf Medical University
where he is Clinical Associate Professor in Hospice & Palliative
Medicine.
29 Pancreatic Cancer in the UAE 487

Dr. Hampig R. Kourie gained his medical doctor degree from

the Faculty of Medicine of Saint Joseph University in Beirut,
Lebanon, in 2010. He started his fellowship in Hôtel-Dieu de
France, Saint Joseph University Hospital in Beirut, Lebanon,
and he continued his medical oncology fellowship in Jules
Bordet Institute in Brussels, Belgium, from 2014 to 2016. Since
September 2016, he worked in the digestive oncology department
in Hôpital Européen Georges Pompidou (HEGP) in Paris as a
researcher in the Association des Gastro-entérologues Oncologues
en France (AGEO). He is also certified from Paris Diderot and
Paris Descartes universities in hereditary cancers and diges-
tive oncology. He gained his PhD in genetics from Saint Joseph
University of Beirut in 2023 and his MEMS from ESA Business
School in 2023. He is practicing as hematologist-oncologist in
Hôtel Dieu de France, Hôpital Saint Joseph des Soeurs de la Croix,
and Bellevue Medical Center.
He is actually an ESMO Faculty in the colorectal cancer group.
He founded and directed the Middle East Biomarkers course and
the Middle East and North Africa GI Oncology Summit. He has
more than 200 peer-reviewed articles, mainly in immunotherapy,
oncogenomics, and digestive oncology fields.

Dr. Nadia Abdelwahed With a solid foundation of medical stud-

ies, Dr. Nadia Abdelwahed specialized in the branch of medical
oncology and added valuable practical experience in the adminis-
tration of oncology intervention and therapy by addressing cases
from all stages and conditions of the disease. Her specialty practice
began in 2015 and continued for 3 years, making her an expert in
the diagnosis and screening of all cancer types, especially breast
cancer, and an expert in cancer treatment methods, qualifying her
through the school of medicine residency program. During this
period, she addressed both the inpatient and outpatient categories
of patients. After this academic training and practical performance,
Dr. Nadia secured a placement as a medical oncologist (special-
ist) in a leading university oncology hospital in Damascus, Syria.
After completing her tenure of office there, she joined another
multispecialty center as a medical oncologist from 2018 until
2021. Alongside her postgraduate studies and practical training,
Dr. Nadia conducted her independent research studies leading to
the master’s degree (Neoadjuvant Capecitabine in Rectal Cancer)
Research in 2018. In 2017, she passed the European Society of
Medical Oncology (ESMO) exam and was certified for a period
of 5 years. In 2021, she also excelled at the Immune Oncology
Course at Harvard Medical School in the United States, earning
a Certificate of Achievement. She is also a recipient of the FRON
Prize (Forum of Research in Oncology) for her research work
on “Impact of HER-2 Ratio on Efficacy of Trastuzumab in Early
Breast Cancer” in 2017. In 2021, Dr. Nadia relocated to the UAE
and qualified for the HAAD Licensing Exam as a Specialist in
Medical Oncology; soon after, she joined VPS Healthcare at the
Burjeel Cancer Institute of the Burjeel Medical City.
488 H. O. Al-Shamsi et al.

Dr. Ibrahim H. Abu-Gheida is the Clinical Director of the

department of radiation oncology at Burjeel Medical City. He
also serves as a regional Radiological Society of North America
(RSNA) committee representative for the Middle East and Africa.
Dr. Abu-Gheida completed his undergraduate training, where
he earned a Bachelor of Science with honors degree from the
American University of Beirut. Following this, Dr. Abu-Gheida
completed his Medical School training at the American University
of Beirut Medical Center. He continued and joined the Department
of Internal Medicine at the American University of Beirut. Then
he did his training in the Department of Radiation Oncology at
the American University of Beirut Medical Center, where he also
served as the chief resident. During his training, Dr. Abu-Gheida
completed a Harvard-affiliated NIH-funded research program as
well. After his residency, Dr. Ibrahim went to the Cleveland Clinic
in Ohio, where he was appointed as an Advanced Clinical Radiation
Oncology Fellow. Dr. Abu-Gheida went and joined the University
of Texas MD Anderson Cancer Center, where he sub-­specialized in
treating breast, gastrointestinal, and genitourinary cancers. Dr. Abu
Gheida played an instrumental role in establishing and heading the
radiation oncology facility and department at Burjeel Medical City.
He has chaired and co-chaired multiple international oncology
conferences. Dr. Ibrahim has more than 40 peer-reviewed papers
in prestigious medical journals, including the American Society of
Radiation Oncology official journal - the International Journal of
Radiation Oncology Biology and Physics, Nature, the Journal of
Clinical Oncology, and several others. He is also the primary author
and editor of several book chapters published in prestigious books.

Professor Dr. Basil Ammori graduated from Baghdad University

medical school in 1986, completed his surgical training in the
UK, obtained the CCST in 2000, and was granted a Hunterian
Professorship by the Royal College of Surgeons of England in
2000. Appointed a consultant surgeon, he led the laparoscopic
bariatric and HPB (hepato-pancreato-biliary) surgery service in
Manchester between 2002 and 2017 and was the first to introduce
laparoscopic Whipple’s procedure in the U.K. He was appointed
as an Honorary Professor at the University of Manchester in 2011
and later joined King Hussein Cancer Center, Amman, Jordan, as a
full member in November 2017 as a laparoscopic gastrointestinal
oncology surgeon before moving to Burjeel Hospital, Abu Dhabi,
in January 2020. He sat on the editorial boards of a number of
medical journals and has over 240 peer-reviewed publications and
book chapters.
29 Pancreatic Cancer in the UAE 489

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Hepatocellular Carcinoma (HCC)
in the UAE 30
Salman Wahib Srayaldeen
and Mohamed Ahmed Mohamed Elkhalifa

30.1 Introduction

There are two main types of liver cancer based on their etiology and the origin of the
tumor: primary and secondary, or metastatic.
Primary liver cancer: Most cases of primary liver cancer are caused by hepato-
cellular carcinoma (HCC), which accounts for 90% of all cases. In this case, hepa-
tocytes with liver cells are the main cause of cancer. It has been reported that about
10% of primary liver cancer cases are associated with cholangiocarcinoma. The bile
ducts of the liver are the first site where cholangiocarcinoma develops.
Metastatic or secondary liver cancer: Secondary liver cancer or metastatic liver
cancer occurs when cancer in another organ or body tissue migrates via the circula-
tory system to the liver. The liver is a common target for metastases from other
cancers, including colon, lung, breast, and other organs.
HCC is a more prevalent cancer among individuals who have certain previous
medical conditions, for instance, chronic liver disease (CLD) [1], which includes
patients who have chronic hepatitis and non-alcohol-related fatty liver disease
(NAFLD). However, it can also occur in individuals with no history of chronic liver
illness [1, 2].
According to the 2020 statistics of the World Health Organization (WHO), the
worldwide incidence of HCC estimation is 9.5 cases per 100,000 people, with over
905,000 new cases reported in 2020 [3], making it less frequent than breast, pros-
tate, lung, cervical, and other GI malignancies. However, the importance of HCC
comes from its being considered the third most notable cause of mortality associ-
ated with cancer globally, following lung and colorectal malignancies [4], which
explains the narrow difference between incidence and prevalence as 5-Year Relative
Survival statistics are very low, which represents and constitutes a major global
health problem [5, 6].

S. W. Srayaldeen (*) · M. A. M. Elkhalifa (*)

Sheikh Khalifa Specialty Hospital, Ras al Khaimah, United Arab Emirates

© The Author(s) 2024 491

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_30
492 S. W. Srayaldeen and M. A. M. Elkhalifa

30.2 Epidemiology

HCC is allocated as the seventh cancer in the worldwide statistics [7], with 905,677
new cases in 2020, and the estimated number of cancer-related deaths in 2020 was
830,180 cases [8]. In terms of disease prevalence, men are more likely than women;
the prevalence sex ratio varies between 2:1 and 4:1, depending on the geographic
region [9].
The global incidence varied by population and continent; Asia is thought to have
the highest incidence, accounting for approximately 72% of all new cases, followed
by Europe (10%) and Africa (8%) [5, 10].
When considering the incidence of HCC according to the geographical distribu-
tion, Mongolia has the highest incidence worldwide with about 71.3 cases per
100,000 people, followed by China with 29.2 cases per 100,000 people; however,
when comparing the number of populations between these countries, China is con-
sidered to have the highest frequency [3, 11].
Italy is the most common country in Europe, with 18.1 per 100,000 people, and
Egypt has 28.3 per 100,000 people in Africa [3, 7].
The Middle East and North Africa (MENA) and Gulf countries, excluding Egypt,
have the lowest incidence of HCC compared to other countries; for example, Syria
and Jordan have almost equal frequencies of HCC at around 2 per 100,000 peo-
ple [12].
According to GLOBOCAN 2020, in Gulf countries, the highest frequency of
HCC is 3.4 per 100,000 people in Saudi Arabia. In terms of the Gulf Cooperation
Council’s (GCC) countries age-standardized incidence rate (ASR), which was esti-
mated at 4.7 per 100,000 people in 2020 [7], Saudi Arabia ranks first with 5.2 per
100,000 people, followed by Kuwait, and the United Arab Emirates (UAE) ranks
last with 2.9 per 100,000 people [3, 11, 13].
The UAE recorded approximately 83 newly diagnosed cases of HCC in 2020 [5,
7], with an incidence of 0.9 per 100,000 people.
The liver cancer demographics are shown in Table 30.1. Figure 30.1 shows the
number of liver cancer (malignant) occurrences in the UAE across the years
2013–2021 by UAE- National Cancer Registry (NCR) [14].
The fifth-leading cause of death in the UAE was found to be cancer in the UAE-
NCR report, 2021. The number of deaths from all cancers in 2021 totaled 975
(506 in males and 469 in females) and accounted for 8.2% of all deaths, regardless
of nationality, type of cancer, or gender [14].
In 2021, the UAE National Cancer Registry reported a total of 5830 newly diag-
nosed cancer cases. Of these cases, 96% (5612) were invasive cancer cases, while
only 4% (218) were in situ cases. These statistics highlight the prevalence of inva-
sive cancer cases in the UAE and the need for continued efforts in cancer prevention
and treatment [14].
Cancer incidence rates in the UAE show that colorectal, breast, thyroid, leuke-
mia, and skin cancers are the five most frequently diagnosed types of disease among
males as well as females. While colorectal, skin, prostate, leukemia, and Non-
Hodgkin Lymphoma (NHL) were the top-ranked cancers among males, breast,
 30

Table 30.1 Liver cancer demographics among the UAE population during 2013–2021
UAE population Total malignant cases Liver cancer cases Crude incidence rate liver
Year (in millions) (in numbers) (in numbers) Percentage (%) cancer cases per 100,000
2013 8.66 3574 69 1.93 –
2014 8.79 3610 58 1.61 0.64
2015 8.93 3744 68 1.82 0.7
Hepatocellular Carcinoma (HCC) in the UAE

2016 9.12 3982 83 2.08 –

2017 9.3 4123 72 1.75 0.8
2019 9.5 4381 72 1.64 –
2021 – 5612 114 2.0 1.2
Source: UAE population: https://fcsc.gov.ae/ar-­ae/Pages/Statistics/Statistics-­by-­Subject; Ministry of Health and Prevention, Statistics and Research Center,
National Disease Registry—UAE National Cancer Registry Report
493
494 S. W. Srayaldeen and M. A. M. Elkhalifa

120 114
No. of liver cancer cases in the UAE

100

83
80 72 72
69 68
58
60

40

20

0
2013 2014 2015 2016 2017 2019 2021
Years

Fig. 30.1 Number of liver cancer (malignant) occurrences in the UAE across the years 2013–2021.
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2013–2021

thyroid, colorectal, uterus, and ovary were the top-ranked cancers among females.
However, HCC is not among the top ten causes of the common cancers’ death
[15–17].
According to UAE-NCR data collected in 2021, the number of patients with
HCC increased gradually from 69 new cases in 2013 to 114 new cases in all popula-
tions in 2021 [14], of which 30 are UAE nationality patients with a gender distribu-
tion of 19 males and 11 females, and 84 non-UAE national patients (62 males and
22 females) [14] (Figs. 30.2 and 30.4). Figure 30.3 shows the distribution of liver
cancer cases by surveillance, epidemiology, and end results (SEER) stages in the
UAE across the years.
In 2020, the UAE reported 83 new cases and 96 (0.49%) deaths of HCC. With a
crude rate of 0.84 and an ASR of 2.9 per 100,000 people [7], the incremental inci-
dence of HCC in the UAE could be justified by the increasing incidence of obesity,
alcohol consumption, and the aging of the population [18, 19].
In the UAE, the majority of patients at diagnosis are older (over 80 years old)
[20], and the majority of cases are advanced or unstaged [15, 21] (Fig. 30.3); the
male to female ratio for HCC incidence is 2.7:1. This is higher than the global aver-
age of 2.3:1. At an older age (80+ years), the male-to-female ratio is closer to 2:1
[20] (Fig. 30.4). Furthermore, males have a markedly higher risk of dying from
HCC than females [9, 22]. In the UAE, chronic hepatitis B or C forms are respon-
sible for and considered the leading risk factor for developing hepatocellular carci-
noma, rather than other potential causes [23].
 30 Hepatocellular Carcinoma (HCC) in the UAE 495

100

90
No. of liver cancer cases in the UAE

84
80

70
59
60
51 50
50 44 46
38
40
30
28 26
30 24
18 20 18
20

10

0
2013 2014 2015 2016 2017 2019 2021

Years
UAE Non-UAE

Fig. 30.2 The number of liver cancer cases (malignant) among the UAE population according to
nationality, 2013–2021. Source: Ministry of Health and Prevention, Statistics and Research Center,
National Disease Registry—UAE National Cancer Registry Report

100
No. of liver cancer cases in the UAE

90
80
70
39
60
27 40
50
40 14
11 18
30
13 15
20 18 13
7
10 17
7 10 10
0 2
2012 2015 2016 2017

Years
Localized Regional
Distant Metastasis / Systemic Disease Unstaged, Unknown, or Unspecified

Fig. 30.3 Distribution of liver cancer cases by SEER stages in the UAE across the years. Source:
Ministry of Health and Prevention, Statistics and Research Center, National Disease Registry—
UAE National Cancer Registry Report, 2012–2017
496 S. W. Srayaldeen and M. A. M. Elkhalifa

120

110
No. of liver cancer cases in the UAE

100
33
90

80

70 29
60 19
21 25
24
50 18
81
40

30 54 53
45 47 47
40
20

10
2013 2014 2015 2016 2017 2019 2021
Years

Male Female

Fig. 30.4 Distribution of liver cancer cases (malignant) according to gender, 2013–2021. Source:
Ministry of Health and Prevention, Statistics and Research Center, National Disease Registry—
UAE National Cancer Registry Report

30.3 Risk Factors

Factors that increase the risk of primary liver cancer include:

30.3.1 HBV Chronic Infection

Hepatitis B virus (HBV) infection has severe complications, starting with chronic
sequelae, which are associated with an increased lifetime risk of developing HCC
and cirrhosis of the liver (LC). Limited, extensive research and studies in the UAE
examine the burden of HBV-related hepatocellular carcinoma, which poses a sig-
nificant obstacle to understanding the disease comprehensively [24, 25].
In the UAE, chronic hepatitis B is the most prevalent risk factor for HCC, with
42% in 1990 and 41% in 2017. However, liver cancer rates related to the hepatitis B
virus are lower in the UAE than in most western nations [26], such as Spain, the
United Kingdom, and the United States [23]. As a result of comprehensive measures
to effectively control the spread of disease, beginning with a widespread vaccina-
tion program, HBV vaccination programs have been mandatory for all newborns
since 1991, and all infants receive four doses of the vaccine at 0 months, 2 months,
4 months, and 6 months. In addition, as part of the visa renewal process, all expatri-
ate residents in the UAE are periodically examined for hepatitis B, along with other
infectious diseases such as HIV [16, 17, 25].
30 Hepatocellular Carcinoma (HCC) in the UAE 497

The incidence of HBV was 0.23% in the most recent survey of blood donors. As
of the 2016 Population Census, an estimated 1.2 million people in the UAE hold
Emirati citizenship [25], a percentage of 0.23% would result in an estimated 2760
HBV cases. Assuming a prevalence of 1.5%, as reported among pregnant women in
2000, the country would have 18,000 HBV cases. According to estimations made
by medical experts, the prevalence of HBV in the general population of the UAE is
likely to range from 1 to 1.5%, leading to an anticipated number of cases ranging
from 12,000 to 18,000 cases, as illustrated in and [17, 23].
Chronic hepatitis B virus infection increases the risk of liver-related disorders
and end-stage liver diseases, including HCC, liver failure, and cirrhosis [27, 28].
According to the research, most patients with HBV who develop HCC have cirrho-
sis [29]. HBV infection was also associated with a greater annual incidence of HCC
in cirrhotic individuals compared to those without cirrhosis [29].
The quality of life of individuals with chronic hepatitis B declined along with the
severity of their disease [27]. Patients with untreated HBV chronic infection have an
increased risk of developing hepatocellular carcinoma with increasing chronologi-
cal age, proportional to both the presence or absence of liver disease and the degree
of liver disease progression status [30]. According to recent studies, individuals
with cirrhosis due to HBV have a significantly higher risk of developing HCC, with
a 31-fold increase compared to those without cirrhosis. The mortality rate is also
significantly higher, with a 44-fold increase in mortality for those with cirrhosis
[28, 31].
Over the course of 20 years, there has been a significant increase in mortality
rates for HCC caused by the HBV in the Arab population worldwide, specifically in
the UAE.
The mortality rate of HBV-associated HCC has increased by 137% in the
Arab population, leading to the deaths of 6447 Arabs. This increase was twice
as high as that observed in other worldwide statistics [32]. Additionally, the
population of the UAE experienced an increase in HBV-associated HCC deaths
of approximately 10% between 1990 and 2010, with males being affected at a
higher rate than females, with a rate of 3.2 per 100,000 males and 1.2 per
100,000 females.

30.3.2 The Dual Infection, Triple-Infection, and HCC

Hepatitis D virus (HDV) infection has been linked to developing severe decompen-
sated chronic viral hepatitis and liver end-stage, which are significant health con-
cerns [33, 34]. However, the replication and generation of complete virion fragments
of HDV are dependent on the presence of HBsAg [33]. Because of this, about
5–10% of patients with chronic hepatitis B are also infected with the delta hepatitis,
a condition known as “dual infection” due to the simultaneous presence of two dif-
ferent types of hepatitis viruses, the HBV and the HDV [35].
498 S. W. Srayaldeen and M. A. M. Elkhalifa

30.3.3 Metabolic Factors, Nonalcoholic Fatty Liver

Disease, and HCC

Diabetes and obesity are important risk factors for both hepatitis C virus (HCV)
infection and HCC. There are 240,000 cases of diabetes mellitus (D.M.) in the
UAE, of which 210,000 are expatriates (77.5%) with a prevalence rate of 15.2% and
47,000,000 are U.A.E. nationals (25.4%) with a prevalence rate of 25.4% [17, 21].
In 2008, cardiovascular risk factors were assessed among adult UAE nationals in
Abu Dhabi as a prerequisite for enrollment in national insurance. This examination
found that 33% of males and 38% of females were obese [12, 17]. This is equivalent
to the United States’ obesity rate [12]. In addition, according to the World Health
Organization’s definition of obesity, 40.2% of the 44,942 UAE students assessed in
2016 were overweight, 24.4% were obese, and 5.7% were very or morbidly obese
[12, 16, 17].
Furthermore, diabetes and hepatocellular carcinoma from a researcher’s view-
point. Forty observational studies from the MEDLINE, EMBASE, and Web of
Science databases between January 1, 2000, and June 24, 2020, investigate the links
between diabetic mellitus (DM), hypertension, dyslipidemia, and obesity and the
risk of HCC due to chronic HBV infection [29, 36]. When it came to meta-analysis,
only DM had enough studies to make it worthwhile. Diabetes mellitus is a very seri-
ous threat [29].
However, to completely comprehend the relationship between antidiabetic drugs,
glycemic management, and HCC, additional comprehensive studies are required to
draw firm conclusions [36, 37].

30.3.4 Nonalcoholic Fatty Liver Disease

CLD resulting from NAFLD affects a considerable proportion of the young and
elderly population [38], and its prevalence is increasing globally [12]. NFLAD
occurs in people who do not consume alcohol, distinguishing it from alcoholic liver
disease (ALD). Recently, the incidence of NFLAD has been increasing due to meta-
bolic diseases and lifestyle factors, with obesity, type 2 diabetes (T2DM) hyperlip-
idemia, and metabolic syndrome constituting the most prevalent risk factors for this
trend. Nonalcoholic fatty liver (NAFL) is pathologically separate from nonalcoholic
steatohepatitis (NASH) [38, 39].
NAFL clearly has a 5% lipid deposit in hepatocyte cells known as “hepatic ste-
atosis” without evidence of hepatocellular injury [38], whereas NASH is distin-
guished by an aggressive form of fatty liver disease steatosis with inflammation and
hepatocyte ballooning with or without liver fibrosis [38]; NASH is the most
advanced form of NAFLD and is more likely to lead to decompensated liver disease
and HCC [40]. In addition, liver cell cancer, or HCC, is prevalent. Due to nonalco-
holic steatohepatitis, an increasing number of HCC diagnoses are being made
[38–40].
30 Hepatocellular Carcinoma (HCC) in the UAE 499

Furthermore, NASH is the hepatic manifestation of the metabolic syndrome, in

which obesity and diabetes are independently related risk factors for HCC [40].
Fifty percent of patients with NASH develop HCC before cirrhosis [41]. Moreover,
as a result of chronic hepatitis C (CHC) and chronic hepatitis B (CHB), HCC mor-
tality is decreasing. NAFLD is increasing HCC mortality [40, 42].
The prevalence of NAFLD in the UAE was estimated to be 255,000 cases in
2017 (25%) and 372,000 cases (46%) by 2030 [43], with an overall prevalence rate
of 30.2%; the prevalence of NASH was estimated to be 4.1% in 2017 and to increase
to 86.0% by 2030 (78,300 cases) [43], with an overall prevalence rate of 30.2%.
Moreover, the number of nonalcoholic fatty liver disease cases in the UAE corre-
lated with the high prevalence of type 2 diabetes and obesity, with an average body
mass index (BMI) of 28.8; all of these factors, along with the aging of the popula-
tion, contributed to an increase in NFLAD and, consequently, an increase in the
prevalence of HCC [18].
Alswat et al. examined the clinical burden of NAFLD/NASH in Saudi Arabia
and the UAE and represented significant increases in advanced liver disease and
NASH-related mortality by 2030 [43]. The UAE had the highest prevalence of liver
cirrhosis related to NASH (1119.21%), followed by Qatar (776.90%) and Oman
(540.67%) as a result of the aforementioned variables [39]. The incidence of decom-
pensated liver cirrhosis and HCC was assessed at 60 cases in 2017 and is projected
to increase by 241% to 190 cases in 2030 [43]. The prevalence of HCC is estimated
to be 1% [43].

30.3.5 Chronic Infection with HCV

In the UAE, HCV infection is the second most important cause of HCC, with a 27%
prevalence rate in 1990 and a 27.3% prevalence rate in 2017 [26].
Infection with the HCV, also known as the hepatotropic RNA virus, is a leading
cause of severe hepatic fibrosis and cirrhosis, and it also significantly increases the
risk of developing HCC [44]. Morbidity and mortality from HCV-related HCC con-
tinue to be high as rates of HCV cirrhosis rise [44].
A comparative analysis of the incidence of hepatocellular carcinoma in America,
Europe, Japan, and Latin America shows that hepatocellular cancer is largely attrib-
uted to the HCV [45]. In contrast, the HBV is the leading etiology of HCC in most
of Asia and Africa [23]. Because of the visa regulation and the screening program
provided by the UAE’s Ministry of Health and Prevention (MOHAP) and other
UAE health facilities to all populations, local and nonlocal, the prevalence of HCV
in the UAE is relatively low at 0.1% [46].
Globally, HCV-infected people have a 15- to 20-fold higher significant risk of
HCC [44], with an annual incidence of 1–4% in cirrhotic patients older than 30 years
[44, 47]. Mortality related to HCV-associated HCC rose by 21.1% during the previ-
ous decade, whereas deaths attributable to factors other than HCV and alcohol
remained constant [48]. Within 20–30 years, approximately 20% of chronic
500 S. W. Srayaldeen and M. A. M. Elkhalifa

hepatitis C patients will develop liver cirrhosis, with a significant risk of progressing
to HCC. The annual rate of HCC due to HCV exposure is 1–4% [49].
Regarding the association between HCV genotype and the risk of HCC, geno-
type 3 was associated with an 80% higher risk of HCC than other genotypes [50]. In
the UAE, genotype 1 is the most prevalent, followed by genotypes 3 and 4, with
genotype 4 being the most widespread in Middle Eastern countries. Among expatri-
ates, genotype 1 was prevalent among Iranians, genotype 4 among Egyptians, and
genotype 3 among Pakistanis [51].
As with HBV and HCC, development risk is also connected with lifestyle habits
such as smoking, alcohol drinking, and coffee consumption [29, 36]. In addition,
HBV, smoking, and alcohol are correlated with the developing incidence of HCC,
as demonstrated by numerous studies and articles [37].
It has been proven that alcohol use exacerbates HCV-associated HCC, but coffee
consumption may be protective. Multiple studies show that drinking at least one cup
of coffee per day reduces the risk of developing HCC [44].
Both a decrease in the pace of hepatic fibrosis development and a decrease in the
risk of HCC have been associated with coffee use [52].
Diabetes and obesity are two important risk factors for HCV infection and
HCC. Chronic HCV becomes more comorbid with diabetes and obesity, increasing the
incidence of HCC by 2–3 folds with diabetes and 1.5–4 times with obesity [44]. Diabetes
mellitus-mediated HCC development is likely to involve elevated insulin levels and
insulin resistance, which lead to increased inflammation, cellular proliferation, apopto-
sis inhibition, and the generation of tumor-causing mutations [53], whereas obesity
leads to an increase in proinflammatory cytokines, adiponectin, and insulin resistance,
all of which are potential mediators of carcinogenesis in HCV-­related HCC [44].
Chronic HCV may be treated with either the standard treatment approach based
on interferon (IFN) or with direct-acting antiviral agents (DAAs), both of which
reduce the risk of HCC [54]. Studies comparing the rates of HCC occurrence and
recurrence in patients with HCV-related cirrhosis after DAA vs. interferon (IFN)-
based cure found no significant differences [44]. Studies comparing the rates of
HCC recurrence in patients who received DAA versus IFN-based regimens found
no difference in the rates of recurrence.
Results demonstrated no statistically significant difference in the incidence or
recurrence of HCC between patients treated with DAA or IFN [54].
According to a 2017 paper on the epidemiology of hepatitis C in the GCC coun-
tries, the prevalence of hepatitis C among nationals was 0.24% (95% CI 0.02–0.63)
in the UAE, 0.44% (95% CI 0.29–0.62) in Kuwait, 0.51% (95% CI 0.43–0.59) in
Qatar, and 1.65% (95% CI 1.40–1.91) in Saudi Arabia [55].
Bahrain and Oman have no accessible statistics. Among the entire resident popu-
lations, HCV prevalence was 0.30% (95% CI 0.23–0.38) in Bahrain, 0.41% (95%
CI 0.35–0.46) in Oman, 1.06% (95% CI 0.51–1.81) in Qatar, 1.45% (95% CI
0.75–2.34) in Kuwait, 1.63% (95% CI 1.42–1.84) in Saudi Arabia, and 1.64% (95%
CI 0.96–2.49) in the UAE. Expatriate communities, especially those of Egyptian
descent, demonstrated a higher incidence [55].
30 Hepatocellular Carcinoma (HCC) in the UAE 501

According to WHO statistics, it is estimated that there are 22 million people

infected with HCV in the WHO Eastern Mediterranean Region, with around 15.4
million of those individuals suffering from chronic infection. The WHO estimates
that the prevalence of HCV in the K.S.A. is between 0.6 and 2%, whereas in the
U.A.E. and Kuwait, it is less than 0.5% [46]. The World Health Organization has
tasked us with wiping out HBV and HCV by the year 2030.
The UAE has launched a micro-elimination program for the HCV with the aim
of providing HCV treatment to all nationalities residing in the seven Emirates. The
program has been successful in increasing the accessibility of HCV treatment by
making it covered under medical insurance. The main objective of the micro-­
elimination of HCV program is to reduce the prevalence of HCV infection and the
severity of the illness among high-risk populations [46].
To achieve this goal, the UAE government and the Ministry of Health have taken
a proactive approach to community engagement and action. Healthcare profession-
als in blood banks, clinics, hospitals, courts, and rehabilitation facilities have been
engaged to help achieve the goal of HCV micro-elimination. The government and
the Ministry of Health have also organized a workshop on the micro-elimination of
HCV to bring together stakeholders and provide a platform for discussion and col-
laboration [46].
In conclusion, the UAE’s micro-elimination program for HCV is a comprehen-
sive and collaborative effort aimed at reducing the prevalence of HCV infection and
the severity of the illness. By increasing access to treatment and engaging health-
care professionals and communities, the program aims to achieve HCV micro-­
elimination and improve the health of high-risk populations in the UAE. [46].

30.3.6 Cirrhosis

The UAE, followed by Qatar and the Philippines [56], has the most remarkable
increase in liver cirrhosis mortality. Furthermore, people with liver cirrhosis are
more likely to develop HCC [57]. Fattovich et al. (2004) discovered that approxi-
mately 98% of hepatocellular carcinoma patients had liver cirrhosis [58]. In the long
term, follow-up studies hypothesized that up to one-third of patients with cirrhosis
would develop HCC, with an incidence rate ranging from 1 to 8% per year.
Generally, hepatitis B virus-related liver cirrhosis is the best predictor of HCC inci-
dence and mortality, with a significantly increased risk of HCC of around 31-fold
and an increased mortality risk of about 44-fold compared to non-cirrhotic individu-
als [59, 60].

30.3.7 Exposure to Aflatoxins

The fungi Aspergillus flavus and Aspergillus parasiticus create mycotoxins

known as aflatoxins, potent hepatotoxins, and potential liver carcinogens [61].
502 S. W. Srayaldeen and M. A. M. Elkhalifa

Aflatoxins can infect a wide variety of foods, including cereals, seeds, herbs, and
nuts. In warm and humid climates, where mold thrives, the disease is most com-
mon [62].
An international study revealed that aflatoxin might play a role in 4.6–28.2% of
all HCC cases worldwide. In the same analysis, the rate of HCC attributable to afla-
toxin in Eastern Mediterranean nations, including the UAE, is approximately 10%.
Unfortunately [41], there are no recent studies about the risk of aflatoxin-related
HCC in the UAE. However, a 1999 article on aflatoxin contamination in the UAE
demonstrated that the rice stored in some homes in the UAE might contain aflatoxin
and increase the risk of HCC [63].

30.3.8 Excessive Alcohol Consumption

Consuming more than a modest quantity of alcohol on a regular basis may

cause permanent impairment to the liver and raise the probability of developing
liver cancer over time. Excessive alcohol consumption causes alcohol liver dis-
ease (ALD) and is responsible for more than half of all HCC cases in the east-
ern European nation [64]. Moreover, in the UAE, one paper published in 2020
indicates ALD causes HCC by 12.78%, compared to other countries in the
GCC and MENA [26]. This percentage is lower than in Sudan and Turkey but
higher than in other Gulf countries; another study examining the risk factor of
HCC within the WHO Eastern Mediterranean Region (EMR) found ALD to be
22% of the etiology of HCC in the UAE, the highest among neighboring coun-
tries [26].

30.4 Clinical Presentation and Diagnosis of HCC in the UAE

Based on the clinical approach, early-stage HCC can be separated from more
advanced stages. In the early stages of HCC [2, 65], many patients experience either
no symptoms or a variety of nonspecific ones, including mild to moderate pain in
the upper abdomen, early satiety (when you feel full when you’ve eaten less than
usual) [22], fatigue, unintentional weight loss, or a discernible lump around the
abdomen’s upper region. These are the hallmark symptoms of hepatocellular carci-
noma in 95% of patients. The appearance of signs and symptoms may vary based on
the severity, size, and site of the disease or damage; jaundice may be indicative of
severe disease [66]. Patients with HCC may also exhibit hypoglycemia, hypercalce-
mia, diarrhea, and cutaneous signs such as dermatomycosis and pemphigus folia-
ceus [66]. Typically, extrahepatic metastases move to the lungs, abdomen lymph
nodes, and bones [67] (Fig. 30.5).
30 Hepatocellular Carcinoma (HCC) in the UAE 503

30
Hepatocellular carcinoma age distrbuon from 2011 to 2017

25

20
2017
2016
15
2015
2014
10 2013
2012
2011
5

0
0-10 11_ 20 21- 30 31- 40 41- 50 51-60 61- 70 71-80 81-90 91-100

Fig. 30.5 The age distribution of hepatocellular carcinoma in the UAE from 60 to 80 years
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report

30.5 HCC Management in the UAE

One of the major performance metrics for the UAE National Agenda’s pillar of
world-class healthcare is the reduction of cancer-related mortality [12, 17]. To
achieve this objective on the ground, in the UAE, all health authorities have
adopted a comprehensive healthcare system for cancer screening, diagnosis, and
treatment provided to all citizens and residents through its preventive and curative
health services [12], beginning with the federal health authority level in the
Ministry of Health and Prevention healthcare and continuing to the local health
authority level as in Abu Dhabi, the Department of Health (DOH), and Dubai
Health Authority (DHA), through all hospitals in both the public and private sec-
tors, as well as primary health care centers and specialized health centers distrib-
uted all across the country [21].

30.6 Hepatocellular Carcinoma Diagnostic Approach

Hepatocellular carcinoma often develops and progresses silently, limiting and chal-
lenging its detection in the early stages before the appearance of advanced cancer
[68]. In numerous cases [69], HCC can be diagnosed with noninvasive imaging
techniques, eliminating the need to perform a biopsy. Even in cases where a biopsy
504 S. W. Srayaldeen and M. A. M. Elkhalifa

is necessary, imaging continues to be frequently recommended for guidance. HCC

staging approaches must consider liver function, tumor burden, and performance
status [70, 71] for comprehensive medical plan decision-making.

30.6.1 Hepatocellular Carcinoma’s Pathohistological Diagnosis

Pathohistological diagnosis is the most accurate method to identify HCC and its
differential diagnoses since the classification of liver cancer is based on morpho-
logical features and characteristics [72]. The WHO and the International Consensus
Group have collectively come up with cornerstone criteria and recommendations
for the diagnosis of HCC, which include pathohistological, histological, and immu-
nobiological methods [73]. Generally, patients with cirrhosis should be diagnosed
with HCC using noninvasive criteria, with or without pathological confirmation.
Nevertheless, pathology confirmation remains essential for validating the diagnosis
of HCC in patients without liver cirrhosis [66]. Patients with a significant possibility
of developing HCC undergo evaluation, and the diagnosis is made based on whether
the lesion size measurements are less or more than 1 cm [73]. The American
Association for the Study of Liver Diseases (ASLD) recommends monitoring
lesions less than 1 cm in diameter using ultrasonography (US) every 3–6 months.
However, larger than 1 cm in diameter should be monitored with additional diag-
nostic tools, such as four-phase computed tomography (CT) or magnetic resonance
imaging (MRI) [70, 73]. Meanwhile, the European Association for the Study of the
Liver (EASL) recommendations classify masses into three categories: less than
1 cm, between 1 and 2 cm, and more than 2 cm in size [68, 72], with each category
having its own set of diagnostic criteria. Nonetheless, the Asian Pacific Association
for the Study of the Liver (APASL) guideline does not take liver lesion size into
account [74].

30.6.2 Biopsy

In the majority of cases, a biopsy is unnecessary since a diagnosis can be made

based on radiological features and an increased alpha-fetoprotein (AFP) serum, par-
ticularly in individuals with a history of cirrhosis or other risk factors [66, 72, 73].
Liver biopsies have been shown to be 100% specific for diagnosing HCC. However,
due to the difficulty of wide-ranging differential diagnosis in highly differentiated
hepatocellular tumors, this may not be the case in routine diagnostic biopsies [68].
Reliable and accurate diagnosis of HCC through liver biopsy relies on many factors,
including biopsy site, tumor size, and differentiation, in addition to the expertise of
the biopsy specialist and the histopathologist [66, 74]. According to reports, it
ranges from around 90 to 95% across the board for tumor sizes. In addition, nodules
are notoriously challenging to identify pathologically, unlike some other masses
and lumps [75].
30 Hepatocellular Carcinoma (HCC) in the UAE 505

For patients without chronic liver disease, non-cirrhotic livers are more often
impacted by metastases from extrahepatic malignancy than cirrhotic livers; hence, a
biopsy is more likely to confirm the diagnosis [76]. The competence of the biopsy
expertise and the pathologist is crucial for an accurate diagnosis (Figs. 30.6 and 30.7).
Hepatocellular carcinoma CT and MR imaging reporting and data collection
have recently been standardized worldwide (HCC) [67, 72, 73]. However, prior
imaging-based criteria showed significant limitations [78]. Therefore, the Liver
Imaging Reporting and Data System (LI-RADS) has been created to improve accu-
racy for borderline patients, ranging from LR-1 (certainly benign) to LR-5 (likely
malignant) (inevitably HCC) [70, 72, 78].

30.6.3 Imaging Study

HCC is distinguished from other solid tumors by its unique reliance on imaging
modalities as the cornerstone for diagnosis. Notably, even in situations in which a
biopsy becomes necessary, imaging techniques are commonly used to guide the
procedure [70, 73].

30.6.3.1 Ultrasound Examination

Routine ultrasound (US) has the ability to effectively detect focal liver lesions in
their early stages with a high level of sensitivity. Moreover, it can accurately
classify these lesions as either cystic or parenchymal and determine whether they

Nodule
on US

< 1cm > 1 cm

Repeat US at 3 months Other contrast enhanced

4 phase MDCT/ contrast
enhanced MRI study (CT or MRI)

Growing/changing Stable Arterial hypervascularity AND Arterial hypervascularity AND

character
venous or delayed phase washout venous or delayed phase washout

Investigate
according to size
Yes No Biopsy No Yes

HCC

Fig. 30.6 The following text describes the diagnostic algorithm outlined in the American
Association for the Study of Liver Diseases (AASLD) guideline for the detection of nodules
through ultrasound (US) in patients who are at risk of HCC [77]
506 S. W. Srayaldeen and M. A. M. Elkhalifa

Nodule on US

< 1cm 1-2 cm > 2 cm

Repeat US at 4 months 4 phase CT/ contrast 4 phase CT or contrast

enhanced MRI enhanced MRI

Growing/changing Stable 1 or 2 positive techniques*: 1 positive techniques:

character HCC radiological hallmarks** HCC radiological hallmarks**

Yes No Yes No
Investigate
according to size

HCC Biopsy HCC Biopsy

Inconclusive

* One imaging technique only recommended in centers of excellence with high-end radiological equipment.
** HCC radiological hallmark arterial hypervascularity and venous/late phase washout.

Fig. 30.7 The diagnostic algorithm outlined in the European Association for the Study of the
Liver (EASL) guidelines is designed to aid in the diagnosis of liver nodules detected by ultrasound
(US) in patients at risk of HCC [77]

are benign or malignant [66, 75]. In addition, color Doppler flow US imaging
provides more information about the nature of the liver mass and its intricate
anatomical relationship with essential intrahepatic vascular structures [70, 72].
The sensitivity of ultrasound for HCC detection is 60%, and the specificity is
97%. The sensitivity increased to 79% when combined with the AFP assessment
[71, 75]. Contrast-enhanced ultrasonography (CEUS) demonstrates notable effi-
cacy in assessing the microvascular perfusion of hepatic neoplasms while simul-
taneously providing valuable assistance in the direction of interventional
procedures and appraising treatment efficacy.

30.6.3.2 CT and MRI

Patients with abnormal liver US and elevated blood alpha-fetoprotein (AFP) screen-
ing values should undergo dynamic contrast-enhanced CT and multimodal
MRI. These imaging methods successfully diagnose liver issues by displaying
blood flow and tissue characteristics of the liver. By illuminating abnormalities in
hepatic blood perfusion and tissue features, these cutting-edge imaging techniques
bring attention to liver illnesses. Imaging is helpful for both creating and continuing
to monitor the course of treatment [72].
A triphasic contrast CT scan of the liver is better than an ultrasound, with high
specificity compared to ultrasound findings. If there is an increased alpha-­fetoprotein
and an abnormal ultrasound with the focal liver lesion(s), the diagnosis of HCC
needs a more advanced workup. A CT four-phase liver (protocol) or
30 Hepatocellular Carcinoma (HCC) in the UAE 507

contrast-­enhanced magnetic resonance imaging of the abdomen is recommended

for diagnostic verification [70, 75]. Multimodal MRI detects and diagnoses smaller
liver cancers (2 cm in diameter) more effectively than dynamic contrast-enhanced
computerized tomography [79]. An MRI of the abdomen has a sensitivity and speci-
ficity of 81% and 85%, respectively, compared to 68% and 93% for a CT scan
[66, 75].
In recent years, numerous research conducted and meta-analyses on the determi-
nation of the diagnostic effectiveness of CTs and MRIs for the identification of
small HCC in high-risk patients have been published; MRI has stronger diagnostic
efficacy than CT, but there is no consensus recommendation to choose one method
over the other [67, 70, 72].
Gadoxetic acid is a gadolinium-based MRI contrast agent used to diagnose liver
lesions and abnormalities [70, 72]. The use of gadoxetic acid MRI has been added
to the most current revisions of the recommendations issued by the European
Association for the Study of the Liver (EASL) [68] and the American Association
for the Study of Liver Diseases (AASLD) [73]. HCC has been approved as a nonin-
vasive diagnostic criterion by these prestigious scientific bodies. However, there is
not enough evidence to recommend Gadoxetic MRI over extracellular contrast MRI
as the gold standard in diagnosis [67].

30.6.3.3 Serum Markers

The concentration of serum alpha-fetoprotein (AFP) is considered the most reliable
biomarker for the diagnosis of hepatocellular carcinoma [72]. The fetal liver and
yolk sac create a glycoprotein called alpha-fetoprotein (AFP) during pregnancy.
AFP levels may rise in noncancerous conditions such as pregnancy, chronic or
active liver illnesses, and cancerous conditions such as embryonal tumors of the
gonads and HCC [70, 79].
In clinical practice, a 20 ng/mL blood alpha-fetoprotein is often used as a thresh-
old to initiate an evaluation for HCC. However, this detection rate has a sensitivity
of less than 60% and a specificity of about 80% when it comes to HCC [80]. In
relation to sensitivity and specificity, the diagnostic threshold of 400 nanograms per
milliliter (ng/mL) for alpha-fetoprotein (AFP) demonstrates a considerably superior
level of accuracy compared to a threshold of 200 ng/mL, regardless of the presence
or absence of ultrasound [79]. Based on the findings, it can be concluded that in
individuals at a high risk of developing HCC, an AFP serum level exceeding 400 ng/
mL serves as a nearly definitive diagnostic criterion for HCC, exhibiting a specific-
ity exceeding 95% [70, 72].

30.7 Intermediate and Advanced Hepatocellular Carcinoma

Staging and Treatment Options for Respectable
and Unrespectable Patients

The development of hepatocellular carcinoma adds a new level of complexity to the

management of chronic liver disease, which already includes cirrhosis, fibrosis, and
esophageal varices [81]. A multidisciplinary team (MDT) including interventional
508 S. W. Srayaldeen and M. A. M. Elkhalifa

radiology, surgery, medical oncology, and radiology is essential for effective treat-
ment of HCC. Next comes staging and prognosis [67, 71]. The poor prognosis for
HCC results from the disease itself, its underlying cause, and the degree of impaired
liver function [82, 83]. The degree of liver dysfunction is measured by various
scores and classifications, including the Child-Pugh classification, the Model for
End-Stage Liver Disease (MELD) system, and the albumin-bilirubin (ALBI) clas-
sification [82, 83].
The classification ALBI, which includes albumin and bilirubin in its nomogram,
was developed to predict the evolution of patients with HCC [67, 82, 83]. However,
this ALBI classification has not been widely used in recent years and is separate
from the HCC treatment recommendation. Therefore, we used validated scales such
as the Eastern Cooperative Oncology Group (ECOG) performance status or the
Karnofsky index instead of this system [82, 83].
The characteristics of tumors and the spread of metastasis are described in exten-
sive detail in the Tumor-Node-Metastasis (TNM) Staging System developed by the
American Joint Committee on Cancer [69]. One of the most popular methods to
simplify HCC treatment is the Barcelona Clinic Liver Cancer (BCLC) staging
approach developed at the Barcelona Clinic. According to the BCLC methodology,
patients may be classified into one of five HCC stages: 0, A, B, C, or D. The recom-
mendations propose either curative or palliative treatment based on the patient’s
tumor status (number, size, vascular invasion, extrahepatic location), liver function
(Child-Pugh score), and performance status (PS, defined by the Eastern Cooperative
Oncology Group scale6). This strategy considers not only the kind of tumor but also
the severity of liver disease and the patient’s functional status, as shown by tests [68,
69, 82]. Treatment decisions are based on the results of an all-encompassing
appraisal of the disease called BCLC staging, which takes into account tumor char-
acteristics, liver function, and overall performance status.
The BCLC system has undergone consistent validation and is highly endorsed
for prognosticating and allocating treatment. The Barcelona Clinic Liver Cancer
(BCLC) system, initially introduced at the end of the 20th century, stands as the
predominant staging framework utilized for liver cancer across numerous interna-
tional regions, including the UAE and Western nations. BCLC’s latest revision, out-
lined in the January 2022 edition [84] of the Journal of Hepatology, reaffirms its
authoritative position in the field.
The first practice change in BCLC 2022 involves the endorsement of treatment
stage migration (TSM) [84]. The 2022 BCLC strategy encompasses a sophisticated
clinical decision-making module that allows for personalized treatment allocation
by considering precise patient and tumor profiles, leveraging local proficiency, and
optimizing technical resources. The subsequent modification in this update pertains
to the acknowledgement of liver transplantation (LT) as one of the principal objec-
tives. In comparison to the 2018 version [70, 84], where LT was suggested solely for
multifocal 3 cm HCCs [69], the current update identifies three arrows pointing
towards LT for small multifocal HCCs [84], an intermediate stage, or stage B, of
BCLC patients who have successfully undergone downstaging through trans arterial
30 Hepatocellular Carcinoma (HCC) in the UAE 509

chemoembolization (TACE) or trans arterial radioembolization (TARE), and suc-

cessful downstaging by TACE. The interventional radiology (IR) team will play a
decisive role in achieving the multidisciplinary team’s (MDT) objective of increas-
ing the number of transplanted patients [69, 70, 84, 85].
The BCLC framework incorporates variables associated with the tumor’s stage,
liver function, and symptomatic presence [68]. It establishes the prognosis by cate-
gorizing patients into five distinct stages that are indicative of appropriate treatment
approaches [70, 84].
Different forms of liver cancer, according to tumor size and invasion of other
parts of the liver and vessels, provide different therapeutic opportunities and diffi-
culties. Surgically interventional as resectable liver cancer, transplantable liver can-
cer, nonsurgically unresectable liver cancer, and metastatic liver cancer [81].
Ablation is the treatment of choice for BCLC 0, while resection and TACE are
also viable options. The findings of the LEGACY study [86], which compared
TARE to TACE, suggest that TARE is as effective but should only be used for soli-
tary HCCs less than 8 cm [86]. However, resection is favored in BCLC A for tumors
larger than 2 cm [69], because of the high incidence of tumor recurrence recorded
following ablation.
According to the updated 2022 guidelines from the BCLC, best clinical practice
is recommended for patients who are not eligible for LT or have multiple tumors.
The BCLC recommends a minimally invasive approach as a possible alternative to
liver resection for these patients. Current guidelines also suggest that minimally
invasive procedures for liver tumors should be based on tumor size. For HCC that is
less than 3 cm, ablation is recommended, whereas tumors larger than 3 cm should
undergo TACE [84].
Unfortunately, patients with significant liver dysfunction (Child-Pugh C or B
cirrhosis with concomitant decompensations such as chronic or recurrent hepatic
encephalopathy (HE), refractory ascites, or spontaneous bacterial peritonitis) or
patients whose general health has deteriorated dramatically to the point where they
are no longer candidates for LT can only be managed palliatively rather than cura-
tive therapy [87, 88].

30.8 Treatment Modality of HCC

30.8.1 Treatment for HCC Includes Surgery

Tumors that arise in a non-cirrhotic liver are effectively treated by surgical resection
because substantial resections can be carried out with a reduced risk of complica-
tions and a good chance of survival [89]; some underlying causes, such as NFLAD
and HBV, can lead to HCC in patients without a cirrhosis background [89], making
surgical resection the treatment of choice [68]. That is why assessing liver function
and reserve volume before any operation is crucial [68, 89]. However, a meta-­
analysis by Xu et al. comparing survival outcomes between the combined approach
510 S. W. Srayaldeen and M. A. M. Elkhalifa

(n = 197) and liver resection only (n = 269) in patients with primary HCC showed
that at 3 years, the overall and disease-free survival were comparable, despite the
fact that decompensated cirrhosis is a formal contraindication for a liver trans-
plant [68].
Since no adjuvant treatment has been shown to be effective in preventing recur-
rences after surgery in HCC, resection is recommended for patients with solitary
HCC arising in the non-cirrhotic liver or in a cirrhotic liver with preserved liver
function, normal bilirubin, and a hepatic venous pressure gradient of less than or
equal to 10 mmHg [90].
High rates of curable recurrence after resection with curative intent warrant
close monitoring (evidence high; recommendation strong). Follow-up intervals
need to be clearly defined. Three- to four-month intervals are reasonable in the
first year [68].

30.8.2 Role of Liver Transplant LT for HCC in the UAE

Theoretically, a liver transplant is the therapy of choice for HCC patients. However,
the danger of posttransplant recurrence makes this option limited [67]. Unfortunately,
a liver transplant is associated with a significant probability of tumor recurrence; on
average, 15–20% of patients transplanted for HCC relapsed within 2 years after
transplantation [91], although this percentage varies by center and disease degree
[92]. The presence of macroscopic vascular invasion and/or extrahepatic metastases
is a contraindication to LT [67].
In the GCC, which includes the UAE, when selecting candidates for LT, profes-
sionals use a strict set of criteria known as the Milan criteria [93]. Milan criteria
place restrictions on who can undergo a transplant due to their HCC based on the
following: there is no evidence of angioinvasion or extrahepatic spread; the tumor’s
total diameter is less than 5 cm; there are fewer than three tumor foci; and the largest
tumor site has a diameter of less than 3 cm [93].
On February 1, 2018, when the first liver transplant from a healthy donor was
carried out in the UAE at Cleveland Clinic Hospital (CCAD), Abu Dhabi, LT was
officially implemented in the UAE [94, 95].
In May 2017, a decision from the Ministry of Health and Prevention established
the legal definition of brain death in the UAE, opening the door for deceased donor
organ transplantation. This allowed for the successful introduction of solid organ
transplantation [95].
Fourteen liver transplants from living donors and 11 from deceased donors
were successfully completed at the Cleveland Clinic Hospital (CCAD), Abu
Dhabi, with 16% of patients diagnosed with HCC (four patients). Twenty recipi-
ents have had at least a year of follow-up, and both graft and patient survival have
been actuarially estimated to be 100% after 1 year. Patients, even those with HCC,
have not seen a recurrence. After a median follow-up of 647 days (range,
247–1002), a total of 24 patients and 25 grafts had a 100% and 96% survival rate,
respectively [94].
30 Hepatocellular Carcinoma (HCC) in the UAE 511

30.8.3 Ablation Treatment of HCC

Ablation techniques are used to treat HCC, and these techniques include radiofre-
quency ablation (RFA), microwave ablation (MWA), percutaneous ethanol injection
(PEI), and others [67].
Percutaneous radiofrequency ablation (RFA) has replaced surgery for small nod-
ules of HCC (less than 2 cm in diameter) [96]. It has become the standard of care
for unresectable early HCCs in recent years[97]. When compared to PEI, RF abla-
tion has exhibited superior ablative capacity and survival benefits [98].
A meta-analysis evaluates MWA with RFA based on data from seven studies
involving 774 patients: one randomized controlled trial (RCT) and six retrospective
studies [96]. Though the overall response rate (ORR) was similar between the two
treatment groups (OR 1.01, 95% CI 0.53–1.87, p = 0.98), MWA performed better
than RFA in the case of larger nodules (OR 0.46, 95% CI 0.24–0.89, p = 0.02).
Despite the apparent superiority of MWA in larger neoplasms, both percutaneous
methods have similar efficacy and a similar 3-year SR after RFA [99, 100].
Thermal ablation with radiofrequency is the gold standard for patients with
BCLC-0 and BCLC-A tumors who are not surgical candidates. However, technical
considerations (tumor location) and hepatic and extrahepatic patient circumstances
warrant consideration of thermal ablation as an alternative to surgical resection for
solitary tumors measuring 2–3 cm in size [68].
Radiofrequency ablation in suitable areas may be used as a first-line therapy,
even in surgical patients with extremely early-stage HCC (BCLC-0) [68]. When
thermal ablation is not viable, especially for tumors, ethanol injection may be used
as an alternative [96, 99].

30.8.4 Role of Locoregional Therapy for Patients with HCC

in the UAE

The American Association for the Study of Liver Diseases (AASLD) [73], the
European Association for the Study of the Liver (EASL) [68], and the Asian Pacific
Association for the Study of the Liver (APASL) (98), all recommend TACE for
patients with intermediate-stage HCC (BCLC stage B) [68, 69, 73], defined as
patients with multinodular disease, performance status 0, Child-Pugh class A or B
cirrhosis, and without portal vein invasion or extrahepatic disease [68, 101]. Major
contraindications include decompensated cirrhosis and/or multicentric involvement
of both liver lobes that prevent selective intervention and severely reduced portal
vein blood flow [67]; the most common adverse event of TACE is a post-­embolization
syndrome, while liver failure, abscesses, ischemic cholecystitis, or even death affect
less than 1% of patients. Fever is an indicator of tumor necrosis, and antibiotic pro-
phylaxis does not reduce the risk of infection [102].
A retrospective review of 150 patients with HCC in Qatar revealed that patients
who underwent TACE as first-line therapy had an enhanced median survival of
27 months (95% CI 20.3–33.7). In a separate retrospective analysis from a single
512 S. W. Srayaldeen and M. A. M. Elkhalifa

institution in Kuwait, 12.6% of patients underwent TACE, whereas 8.2% underwent

RFA [103, 104].
There are two forms of TACE used in clinical practice: conventional TACE
(cTACE) and TACE with drug-eluting beads (DEB-TACE). The conventional
method employs cytotoxic drugs such as doxorubicin (the most common cytotoxic
drug), mitomycin, or cisplatin, followed by the infusion of lipiodol, an oily radio-­
opaque agent [102, 105]. In contrast, DEB-TACE employs non-resorbable embolic
microspheres loaded with chemotherapy drugs that are capable of sustained
release [106].
Based on the results of a meta-analysis conducted by Zou et al., it was found that
DEB-TACE has shown a higher rate of complete response and overall survival (OS)
compared to conventional TACE [102]. However, there is yet to be a definitive
answer as to why DEB-TACE appears to produce better results in both ways. Also,
Chen et al. and Han et al. reached the same conclusion that more remarkable OS
was associated with DEB-TACE [105]. In contrast, numerous studies have found no
difference in overall response (OR) or adverse events between the two techniques
[102, 106].
TACE is presently regarded as the treatment of choice for selected individuals
with HCC at the intermediate stage (BCLC stage B) [67]. Although TACE is a via-
ble treatment option for HCC, it may not be effective in all patients in order to better
determine which patients will benefit from TACE. Medical professionals have
developed seven criteria. These criteria were initially used to predict the prognosis
of HCC patients undergoing LT and are now used to subclassify patients within the
BCLC-B stage, successfully assess, and maximize the potential benefits of TACE
for each case.
These criteria include tumor size, number of tumors, tumor marker, and liver
function (child bug), considering the heterogeneity of HCC tumors [107]. Current
studies suggest that intermediate-stage patients may benefit from TACE if they have
Child-Pugh scores of 7, a performance status of 0 (PS 0), a high multinodular tumor
burden that is not bulky, and no evidence of extrahepatic illness [108, 109].
Recent research indicates that TACE benefits early-stage HCC patients who are
not candidates for surgery or ablation therapy [110]. Additionally, TACE may also
be performed before LT to serve as a bridge therapy for candidates on the transplant
list, improving and increasing compliance with the Milan criteria leading to better
outcomes [111].
Numerous meta-analyses conclude that TACE is associated with increased OS
and tumor response in comparison to conservative treatment [110]. However, it is
advisable to avoid performing TACE on individuals who have decompensated liver
disease, poor renal function, macrovascular invasion of the portal or hepatic vein, or
extrahepatic spread. This is according to a study that highlights the potential risks
associated with the procedure [68].
Regarding the combined treatment between TACE and other modalities of treat-
ment, there is no benefit of combining TACE with RFA compared to RFA as mono-
therapy in small HCC tumors less than 3 cm, but patients may achieve benefit with
30 Hepatocellular Carcinoma (HCC) in the UAE 513

intermediate tumors (3–10 cm) or are ineligible for RFA monotherapy due to tumor
location [112, 113]. According to a randomized controlled trial by Peng et al., liver
failure, advanced cirrhosis (Child-Pugh C), total bilirubin >3 mg/dL, evidence of
extrahepatic disease, full portal vein thrombosis, and uncorrectable coagulopathy
are among the few contraindications to TACE therapy [114, 115]. Considered
related contraindications include severe atherosclerosis, renal failure, and an allergy
to contrast material [116, 117].
Following the initial TACE procedure, each patient must be reevaluated, and
because HCCs have predominantly arterial (hyper-) vascularization, modified
Response Evaluation Criteria in Solid Tumors criteria (mRECIST) are used. The
patient’s response to TACE can be characterized as a complete response (CR), a
partial response (PR), stable disease (SD), or progressive illness (PD) [118, 119].

30.9 Systemic Therapies Used for Patients with HCC

Before 2007, the United States Food and Drug Administration (FDA) had not autho-
rized any medicine for the treatment of advanced HCC. Sorafenib was the first and
only drug licensed for this purpose [120]. With the rapid development and approval
of novel molecularly targeted therapies and immune checkpoint inhibitors (ICIs)
[121] in the last 3 years, more options have become available for the treatment of
advanced HCC. The combination of an immune checkpoint inhibitor (IC) and a
vascular endothelial growth factor (VEGF) inhibitor is currently recommended in
guideline recommendations as first-line therapy for HCC [122, 123].
Moreover, the positive safety and effectiveness data from the phase III
IMbrave150 study represent a significant pivot in the first-line treatment of HCC
[121, 124]. The duration of the lines represents the study period, from its actual
inception to its eventual FDA registration. Therefore, the therapies in the green
boxes are regarded as “second-line,” while the treatments in the red boxes are “first-­
line” [121, 124] (Fig. 30.8).

30.9.1 Molecular Targeted Therapies

30.9.1.1 Sorafenib
Sorafenib is a form of medication that blocks certain signalling pathways respon-
sible for the growth and development of HCC. It primarily targets the Raf-MEK-­
ERK and VEGFR 1-3, as well as the PDGFR and PDGFR pathways [121]. Heart
and Renal Protection (SHARP) research (Sorafenib et al.; NCT00105443) found
that sorafenib increased OS and progression-free survival compared to placebo.
Sorafenib has been compared to various TKIs in the literature, including suni-
tinib and linifanib. However, driving failed to show superiority and was more dan-
gerous than sorafenib [126]. Patients from the GCC area with advanced HCC and
Child-Pugh A/B who had failed or were ineligible for local palliative ablation
514 S. W. Srayaldeen and M. A. M. Elkhalifa

Sorafenib Lenvatinib Regorafenib Cabozantinib Ramucirumab

vs. vs. vs. vs. vs.
placebo Sorafenib placebo placebo placebo
NCT00105443 NCT01761266 NCT01774344 NCT01908426 NCT02435433
(2005-2007) (2013-2018) (2013-2017) (2013-2019) (2015-2019)

2006 2010 2014 2018

2008 2012 2016 2020

Nivolumab Pembrolizumab Nivolumab + ipilimumab Atezolizumab + bevacizumab

progressing progressing progressing on/intolerant to vs.
on/intolerant to on/intolerant to sorafenib sorafenib
sorafenib sorafenib NCT01658878 NCT03434379
NCT01658878 NCT02702414 (2016-2020) (2012-2020)
(2012-2017) (2016-2018)

Fig. 30.8 Flowchart of a timeline demonstrates the timing of major clinical trials, including drugs
currently approved for advanced HCC. Dual lines on the timeline represent trial initiation and FDA
approval. First-line therapies are shown in red boxes, while second-line therapies are shown in
green boxes [125]

treatment were included in retrospective research undertaken by Rasul et al. in

Qatar, GCC, to evaluate the safety and effectiveness of sorafenib. Sorafenib was
safe and improved survival, especially in the high-risk Child-Pugh A [122] group.
The two most common sorafenib-related side events were fatigue and skin rash (237).
Furthermore, patients with the least liver damage (Child-Pugh A) had better sur-
vival rates when treated with sorafenib than patients with Child-Pugh B and C [123].
The most recent recommendations [121] recommend tyrosine kinase inhibitors
(TKIs), sorafenib, or lenvatinib as alternatives for patients who do not meet the
criteria for treatment with atezolizumab in combination with bevacizumab.

30.9.1.2 Lenvatinib
Lenvatinib is a potent small-molecule inhibitor that targets and binds to a range of
receptors with impressive selectivity. These receptors include retinoic acid, kinase
inhibitors, vascular endothelial growth factor (VEGF) 1–3, fibroblast growth factor
(FGFR) 1–4, and platelet-derived growth factor (PDGFR). Its ability to bind to mul-
tiple receptor types makes it a promising choice for therapeutic interventions target-
ing these pathways, highlighting its remarkable efficacy.
The efficacy of lenvatinib was evaluated in a primary clinical trial called
REFLECT (NCT01761266), which compared lenvatinib with sorafenib as first-line
therapy for patients with unresectable HCC and Child-Pugh disease, a liver disease
with adequate liver function. The primary objective of the study was to assess OS,
while the secondary endpoints included time to progression (TTP) and
30 Hepatocellular Carcinoma (HCC) in the UAE 515

progression-­free survival (PFS). The findings indicated that patients receiving len-
vatinib had a median survival time (OS) of 13.6 months, which was significantly
higher than the median survival time (OS of 12.0 months, TTP) observed in patients
receiving sorafenib.
The REFLECT study showed that the median survival OS with lenvatinib was
13.6 months, which was better than the 12.0 months observed with sorafenib (TTP).
Furthermore, the study showed a significantly improved progression-free survival
(PFS) of 7.4 months in patients treated with lenvatinib, compared with a PFS of
3.7 months in patients receiving sorafenib. These compelling results were noted and
documented in references [126–128]. Subsequently, the FDA granted approval for
lenvatinib as a first-line therapy for unresectable hepatocellular carcinoma [128].

30.9.1.3 Regorafenib
Regorafenib, a multi-kinase inhibitor that shares structural similarity with sorafenib,
was investigated in a randomized, double-blind, phase III clinical trial called the
RESORCE trial (NCT01774344). In this study, regorafenib effectively targeted
multiple kinases, including VEGFR2, VEGFR3, PDGFR, FGFR-1, Kit, Ret, and
B-Raf [103]. In particular, when administered as second-line therapy to patients
previously treated with sorafenib who had failed treatment, regorafenib showed a
significant improvement in OS compared with placebo [126]. The adverse effects of
regorafenib were comparable to those of placebo. These positive findings from the
RESORCE trial [121, 129] now authorize the use of regorafenib as a viable second-­
line treatment option for patients with sorafenib-resistant advanced HCC when no
other treatment alternatives are available.

30.9.1.4 Cabozantinib
Cabozantinib is classified as a small-molecule tyrosine kinase inhibitor that selec-
tively targets and blocks essential tyrosine kinases, which play important roles in
tumorigenesis due to their role in cellular processes, including cell growth, prolif-
eration, differentiation, and survival.
In addition, cabozantinib has a dual mechanism of action, blocking tumor angio-
genesis by preventing the growth of new blood vessels, thereby reducing the blood
supply the tumor needs to grow through VEGFR and effectively interfering with
tumor growth and metastasis-limiting activities through MET, resulting in a remark-
able antitumor effect [121, 126, 130].
To investigate its efficacy, a phase III clinical trial called CELESTIAL
(NCT01908426) was conducted in patients with unresectable HCC who had previ-
ously failed treatment with sorafenib and were unresponsive to curative therapies.
The results of the study showed significantly longer median OS in patients treated
with cabozantinib compared to those receiving a placebo [131].
In January 2019, the FDA issued an authorization for Cabozantinib to be a
second-­line therapeutic alternative for patients afflicted with advanced HCC who
had previously undergone sorafenib treatment. This approval was granted on the
grounds of the promising results observed in the CELESTIAL study [132].
516 S. W. Srayaldeen and M. A. M. Elkhalifa

30.9.1.5 Ramucirumab
Ramucirumab is a type of medication that belongs to the class of humanized recom-
binant monoclonal IgG1 antibodies. Its primary mechanism of action is selective
binding to VEGFR-2, effectively inhibiting activation of the VEGF pathway [126].
REACH (NCT01140347) is the name of the clinical trial conducted to discover
the effects of ramucirumab on the progression of advanced HCC among individuals
who were already treated with sorafenib. The participants in the study were all
receiving treatment for their disease with sorafenib. Interestingly, the results of this
study showed no increase in OS compared to the placebo group [121]. However,
patients with advanced HCC and high AFP levels (400 ng/mL) who had previously
been treated with sorafenib were enrolled in another study called REACH-2
(NCT02435433) to compare the efficacy of ramucirumab with placebo.
The results of this study indicated that the ramucirumab group had better OS and
median progression-free survival [121, 130]. Based on the results of the study
REACH-2, the FDA granted approval for the use of ramucirumab as second-line
therapy for HCC [133].

30.9.2 Monotherapy with Immune Checkpoint Inhibitors

30.9.2.1 Nivolumab
Nivolumab is an immunotherapeutic agent as a human immunoglobulin G4 anti-
body that inhibits the signalling pathway of programmed cell death protein 1.
Hence, the FDA has given its approval for this method of treatment to be used in
various types of tumors, such as metastatic non-small cell lung cancer, esophageal
cancer, and advanced renal cell carcinoma [121, 126].
CheckMate 040 is a non-comparative phase I/II (ClinicalTrials.gov Identifier:
NCT01658878) conducted to examine the efficacy of nivolumab as a monotherapy.
This drug was tested in patients with HCC, specifically patients who had previously
been treated with sorafenib.
The study showed an ORR of 20% (42 out of 214 patients, 95% CI: 15–26), with
39 patients showing a partial response (meaning their tumor shrank) and three
patients showing a complete response (meaning their tumors disappeared entirely).
In addition, a median progression-free survival of 4.0 months was observed in the
study, and the overall duration of response was 9.9 months [134].
Therefore, on September 22, 2017, these positive findings led to the FDA grant-
ing expedited authorization for administering nivolumab to patients with HCC who
had undergone sorafenib treatment for hepatocellular carcinoma [135].
Moreover, results from another randomized, multicentre phase III trial,
CheckMate 459 (NCT02576509), were published in Barcelona 2019 European
Society for Medical Oncology (ESMO) conference. Patients were randomly
selected to be treated with either nivolumab or sorafenib as first-line therapy. The
study failed to identify a significant increase in OS. However, the primary outcome
suggests that immunotherapy has a potential position as first-line therapy, which
could influence the current standard of medical management [136].
30 Hepatocellular Carcinoma (HCC) in the UAE 517

30.9.2.2 Pembrolizumab
Pembrolizumab, an immune checkpoint inhibitor that uses a monoclonal antibody
against programmed cell death protein 1 (PD-1), underwent investigation in the
Keynote 224 trial (ClinicalTrials.gov identifier: NCT02702414) [121, 126]. The
efficacy of pembrolizumab in treating these individuals was the focus of the study
conducted to understand the outcomes. Eligibility criteria for the HCC trial patients
receiving therapeutic sorafenib and with advanced or refractory disease were invited
to participate in this experiment to evaluate both the efficacy and risk of
pembrolizumab.
The trial findings demonstrated durable responses and favorable progression-­
free survival (PFS) of 4.8 months, median OS of 12.9 months, and TTP of 4.9 months
in the HCC patient population [137].
The keynote trial results led to the FDA’s approval of pembrolizumab on
November 9, 2018, as a treatment for patients with advanced hepatocellular carci-
noma resistant to sorafenib and experiencing disease progression [138].
Building upon the Keynote-224 trial, a phase III double-blind, randomized, con-
trolled trial known as the Keynote-240 was conducted. This study compared pem-
brolizumab with best supportive care to placebo and best supportive care as
second-line therapy for HCC patients previously receiving systemic therapy (250).
The study results indicated that pembrolizumab did not show statistically significant
improvements in OS and PFS compared to the placebo group [139].
ASCO 2021 added valuable information on both trials. It provided further
insights into pembrolizumab’s potential as a gold standard therapy for patients with
late-stage HCC, supported by recent study data [140].
The Keynote-224 trial’s second cohort, which enrolled advanced HCC
patients who had not undergone any previous comprehensive treatment, reported
an ORR of 16%, a median PFS of 4 months, and a median OS of 17 months.
Therefore,
The Keynote 240 trial findings were further elucidated at the 2021 American
Society of Clinical Oncology Gastrointestinal (ASCO GI) conference. The updated
data demonstrated a statistically significant improvement in the median OS within
the pembrolizumab cohort, which reached 13.9 months as opposed to 10.5 months
observed in the placebo arm. In addition, the median PFS was 3.3 months and the
ORR was 18.3% in the pembrolizumab group compared with 4.4% in the placebo
group [141].

30.9.3 Combination Therapy

30.9.3.1 Atezolizumab + Bevacizumab

Atezolizumab, an IgG1 monoclonal antibody, exhibits specificity in binding to
PD-L1, disrupting its interaction with PD-1 and reversing the suppression of T-cells.
On the other hand, bevacizumab, a humanized monoclonal antibody that targets
vascular endothelial growth factor (VEGF), functions by inhibiting angiogenesis
and impeding tumor growth in HCC [121, 126].
518 S. W. Srayaldeen and M. A. M. Elkhalifa

This combination therapy has emerged as a promising and preferred first-line

treatment approach for advanced HCC, supported by the IMbrave 150
(NCT03434379) clinical trial outcomes. IMbrave 150, a global, open-label, phase
III study, involved 501 patients randomly assigned to receive either atezolizumab +
bevacizumab or sorafenib. The cohort receiving the combination of atezolizumab
and bevacizumab demonstrated a statistically significant extension in both OS and
progression-free survival (PFS) when compared to the sorafenib group. However,
the median OS for the atezolizumab + bevacizumab group could not be evaluated
(NE), while it was 13.2 months in the sorafenib group. Additionally, based on the
response evaluation criteria in solid tumors (RECIST) version 1.1 criteria, the com-
bination therapy group demonstrated an ORR of 27.3% compared to 11.9% in the
sorafenib group [142].
In May 2020, the utilization of atezolizumab in conjunction with bevacizumab
received approval from the FDA for administering first-line therapy to patients diag-
nosed with advanced HCC.
This decision was based on the compelling safety and efficacy outcomes observed
in the IMbrave 150 clinical trial (Finn et al., 2021). Notably, Finn et al. presented
updated findings from the IMbrave 150 study during the 2021 ASCO Gastrointestinal
Cancer Symposium (p. 169). With an additional 12 months of follow-up, the com-
bination of atezolizumab + bevacizumab demonstrated sustained clinical efficacy
benefits compared to sorafenib.
This treatment regimen achieved the longest OS observed in first-line phase III
studies and is currently considered the standard of care for advanced HCC patients
who have not previously received systemic therapy [143].

30.9.3.2 Nivolumab + Ipilimumab

The combination of an anti-PD-1 antibody called nivolumab and a CTLA-4 inhibi-
tor known as ipilimumab was examined in a study called CheckMate 040. Fifty
patients in cohort 4 of CheckMate trial 040 (NCT01658878) received nivolumab
plus ipilimumab at a total of four dosages at 3-week intervals. As part of ongoing
treatment, patients received 240 mg single dosage of nivolumab every 14 days. This
regimen was carefully followed to ensure the continuity and efficacy of the patient’s
treatment.
According to the study, using RECIST v1.1 criteria yielded an ORR of 32%,
with four patients achieving a complete response and 12 patients showing a partial
response. Based on the data collected, it was found that the average response time
was 17.5 months. As a result, on March 10, 2020, the dose regimen of arms A was
approved for advanced HCC patients who had progressed on sorafenib treatment.
Recently, the revised CheckMate 040 result was released at ASCO 2021, and it
showed that the mOS length had improved to 22.2 months. This improvement
resulted in the 24-month OS rate increasing to 46%, while the 36-month OS rate
was 42%. Furthermore, recent studies on the combination of nivolumab and ipilim-
umab as second-line therapy have demonstrated significant improvements in clini-
cal outcomes and survival rates [144].
30 Hepatocellular Carcinoma (HCC) in the UAE 519

30.10 Supportive Management

The use of psychoactive medicines, in particular benzodiazepines, for the treatment

of psychological distress is leading to an increased risk of falls, accidents, and an
impaired mental state in patients with advanced cirrhosis [68].
The use of psychoactive medicines, in particular benzodiazepines, for the treat-
ment of psychological distress is associated with an increased risk of falls, acci-
dents, and an impaired mental state in patients with advanced cirrhosis. Patients
with HCC and liver cirrhosis should thus use these drugs with extreme caution [145].
According to the patient’s condition, psycho-oncological support and nutritional
supplementation are recommended [68]. Patients with cancer are presented with a
wide range of physical, nutritional, and psychosocial issues that require a patient-­
specific, integrated intervention and consistent follow-ups to secure and consolidate
the improved quality of life [146].
Because of the poor prognosis of patients with chronic HCC, as defined by the
Barcelona Clinic Liver Cancer (BCLC) criteria, with a life expectancy of around
3–4 months [68], the treatment of end-stage illness is limited to symptomatic care,
and there is no need for tumor-directed therapy. These patients should get palliative
care, which includes pain control, nourishment, and emotional support [145–147].

30.11 Hepatocellular Carcinoma Preventive Measurements

in the UAE

30.11.1 Vaccination

All newborns have been given four doses of the HBV vaccine at 0, 2, 4, and 6 months
of age as part of mandatory vaccination programs that have been in place since 1991
[25]; furthermore, the high-risk population receives additional HBV vaccine booster
shots [25].

30.11.2 Treatment for Viral Hepatitis

Numerous studies demonstrate that treating chronic HBV infection minimizes the
incidence risk of HCC [29]. The majority of doctors follow the guidelines of the
European Association for the Study of the Liver (EASL) [148]. By limiting disease
progression and mortality, the major objective of HBV treatment is to increase sur-
vival and quality of life. PEGylated interferon (Peg-IFN-alfa-2), lamivudine (LAM),
telbivudine, and adefavir are given much less often than entecavir (ETV) and teno-
fovir disoproxil fumarate (TDF) in the UAE [23, 25]. In 12 cohort studies and 1
RCT, CHB patients have been examined with entecavir (ETV), lamivudine (LAM),
telbivudine (LdT), and/or tenofovir disoproxil fumarate (TDF). The meta-analysis
demonstrated that ETV was better than LAM in terms of the incidence of HCC
520 S. W. Srayaldeen and M. A. M. Elkhalifa

(p = 0.001). We discovered no significant difference in HCC incidence between

ETV and TDF (p = 0.08) [148].
In addition, one study demonstrated the efficacy of tenofovir in lowering HCC
incidence relative to entecavir, and there is now a recommendation for the wide-
spread use of tenofovir in chronic hepatitis B patients [149, 150]. By reducing HBV
DNA levels, the long-term course of antiviral therapy effectively decreases the inci-
dence of HCC among people with chronic hepatitis B (CHB) [151].
According to a recent study, there is no significant difference between entecavir
(ETV) and tenofovir disoproxil fumarate (TDF) treatments when it comes to the
risk of HCC development in treatment-naive CHB patients, regardless of preexist-
ing cirrhosis [149]. In conclusion, antiviral treatments may minimize the develop-
ment of HCC and death in individuals with chronic hepatitis C, especially when a
sustained virological response (SVR) is established [152].

30.11.3 Other Medications

30.11.3.1 Statins
The statins class of medications has a major impact on lowering cholesterol levels,
thereby decreasing the possibility of cardiovascular disorders, including coronary
artery disease and stroke [153].
Meanwhile, elevated cholesterol levels are now recognized as a significant con-
tributor to liver cancer. The potential benefits of statins for preventing liver cancer
have been investigated in 24 randomized controlled trials with a total of 59,070
participants.
When comparing statin users with the non-statin group, patients on a statin medi-
cation course significantly had a lower chance of developing HCC (risk ratio: 0.55,
95% confidence interval: 0.47–0.61, I2 = 84.39%).
More importantly, the results of the effectiveness of statin therapy were sup-
ported by strong data, showing that statins lower the incidence of HCC in people
with nonalcoholic fatty liver disease [154] and in those with diabetes and liver cir-
rhosis. Additionally, statins could potentially lower the incidence of HCC in those
with chronic hepatitis B and hepatitis C viruses, specifically individuals with liver
cirrhosis [155].

30.11.3.2 Aspirin and Other Nonsteroidal Anti-Inflammatory Drugs

A meta-analysis and comprehensive review were conducted to evaluate the correla-
tion between aspirin as well as NSAIDs, or nonsteroidal anti-inflammatory drugs,
and the prevalence of HCC.
The analysis included 19 research projects with a total of 149,000 participants.
The results indicated that all categories of aspirin and NSAID treatment, including
aspirin only, nonaspirin NSAIDs only, and a combination of both, were associated
with a decreased risk of HCC incidence and improved liver-related mortality. The
study shows daily aspirin use specifically minimized the probability of liver cancer
for those diagnosed with HBV. These findings support the hypothesis that using
30 Hepatocellular Carcinoma (HCC) in the UAE 521

aspirin and NSAIDs may serve as a protective measure against HCC [156–158].
However, there was no statistically significant variance among aspirin users or non-
users in the rate of gastrointestinal bleeding.

30.11.3.3 Metformin
Big data was collected from April 2017 to January 2019 and published in 2020. A
combined collection of eight scientific research papers, consisting of four cohort
studies and four case-control studies, examines the potential role of metformin ther-
apy in minimizing the incidence of liver cancer. The metformin effect was most
pronounced with early-stage HCC or patients at potentially curative tumor stages
[159, 160].

30.11.4 Lifestyle Factor

30.11.4.1 Coffee Consumption

Consumption of coffee on a regular basis lowers incidences of both liver disease and
HCC.; this statistic, supported by numerous clinical and observational trials, reveals
that any coffee consumption declines the probability of developing hepatocellular
by 40% [161]. Coffee contains large amounts of antioxidants, suggesting biologic
plausibility for the protective effect [161, 162].

30.11.4.2 Diet
Consumption of a healthy diet has been found to have a positive impact on reducing
the risk of cancer as well as other chronic diseases such as cardiovascular disease
(CVD) [161]. Notably, studies have indicated that the intake of white meat, fish,
omega-3 fatty acids, and vegetables is remarkably related to a decreased risk of
HCC [162–164], while the consumption of red meat has been linked to an increased
risk of HCC [163].
The potential hepatoprotective effects of Vitamin E, functioning as an antioxi-
dant, have been suggested for mitigating oxidative stress-induced damage to the
liver and HCC. Patients with liver cirrhosis/fibrosis and some nonalcoholic steato-
hepatitis [97, 165] who were given vitamin E showed positive clinical outcomes,
indicating the beneficial effects of vitamin E supplements [97, 165].
Nevertheless, additional investigation is necessary to substantiate this hypothesis.

30.11.4.3 Physical Activity

Maintaining a healthy weight within the normal range, implementing dietary modi-
fications, and engaging in more physical exercise have all been shown to enhance a
person’s health and well-being over time.
One study from South Korea examines patients with chronic hepatitis B as a
high-risk group for developing hepatocellular carcinoma and the potential preven-
tion role of physical activity. The study analyzed data from 9727 patients’ treatment-­
naive with chronic hepatitis b. found that the engaging low to moderate physical
activity).
522 S. W. Srayaldeen and M. A. M. Elkhalifa

Specifically, patients with low to moderate physical activity ranging between 500
and 1500 (MET)-min/week demonstrated a significantly lower risk of HCC com-
pared to those who were inactive in both patients with and without cirrhosis.
Moreover, the highest outcomes of preventive measures and the biggest gains
from physical activities are shown in obese or high body mass index, male partici-
pants, non-diabetes participants, and young groups.
However, those with cirrhosis who continued to engage in vigorous exercise did
not achieve similar positive benefits in HCC prevention because high-intensity exer-
cise raises blood testosterone levels, which has been linked to an increased risk of
HCC in cirrhotic individuals.
Guidelines for physical activity need more research and investigation. That will
be appropriate for each group, taking into account the intensity, nature, duration,
and amount of physical exercise.

30.12 Conclusion

The incidence of HCC in the UAE has been stable, with 60–80 cases per year in the
UAE between 2013 and 2019, with a potential future increase in incidence with ris-
ing rates of obesity, diabetes, and excessive alcohol consumption, as well as hepati-
tis B virus, hepatitis C virus, and NASH.
The UAE has successfully implemented measures to keep the prevalence of
HCV infection low. The widespread availability of screening and treatment facili-
ties, coupled with effective public health campaigns, has helped to detect infected
individuals early and provide them with appropriate treatment, thus reducing the
overall prevalence of the disease. Additionally, a comprehensive vaccination pro-
gram targeting high-risk populations, such as healthcare workers, newborns, and
mothers, has contributed to the reduction of HBV infection rates in the country.
Despite the success in controlling viral hepatitis, the increasing rates of obesity
and diabetes in recent years could potentially lead to an escalation in the incidence
of liver cancer in the future.
To effectively address liver cancer prevention and management in the UAE, a
comprehensive and interdisciplinary approach is necessary, requiring the collabora-
tion of public health officials and healthcare providers in implementing preventive
measures and early detection strategies to reduce the burden of liver cancer in the
country. Public health interventions aimed at curtailing the prevalence of hepatitis B
and C virus infections have been effective in the UAE.
Furthermore, promoting healthy lifestyles and reducing modifiable risk factors,
such as excessive alcohol consumption, obesity, and diabetes, are pivotal in prevent-
ing and managing liver cancer in the UAE. It is crucial that the government, health-
care providers, and the public forge smart partnerships to achieve common goals.
These partnerships would facilitate the pooling of resources, expertise, and knowl-
edge, enabling the development of tailored interventions that consider the unique
cultural, social, and economic factors that influence liver cancer risk and outcomes
in the UAE.
30 Hepatocellular Carcinoma (HCC) in the UAE 523

The implementation of effective public health initiatives, including educational

campaigns, screening programs, and affordable access to treatment, is necessary to
lower the incidence and mortality rates of liver cancer further in the UAE.

Conflict of Interest The authors have no conflict of interest to declare.

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30 Hepatocellular Carcinoma (HCC) in the UAE 533

Dr. Salman Wahib Srayaldeen is a highly qualified and experi-

enced medical professional with a strong background in the fields
of hematology and medical oncology. He holds a Master’s degree
in hematology/medical oncology from Damascus University,
where he earned an M.D. degree as well with a very good grade
level. He has been practicing medicine for over a decade and has
held various positions in the medical field, including senior special-
ist in hematology/medical oncology at the Oncology Center.
Dr. Salman has a strong commitment to his field, as evidenced
by his active participation in various professional organizations,
including the Emirates Oncology Society (EOS), the Emirates
Hematology Society (EHSA), the Syrian Oncology Society (SOA),
the European Society of Medical Oncology (ESMO), the European
Hematology Society (EHA), and the American Society of Clinical
Oncology (ASCO). He has also published more than ten articles in
reputable journals, showcasing his research and knowledge in
the field.
Dr. Salman has extensive work experience in the fields of medi-
cal oncology and hematology. He has been working as a specialist
at Sheikh Khalifa Specialty Hospital in the UAE since May 2017,
where he provides specialized care to patients diagnosed with can-
cer and blood disorders. Before that, he held various positions,
including general practitioner, specialist in internal medicine/
hematology, and resident doctor in a stem cell transplantation unit.
In addition to his work experience, Dr. Salman has also attended
numerous workshops and conferences and has several certificates
of attendance, showing his commitment to continuously improving
his skills and knowledge in the field. He is excellent in reading,
writing, and speaking both Arabic and English, and he is good
at German.
Overall, Dr. Salman Wahib Sray Aldeen is a highly qualified
and experienced medical professional with a strong background in
the fields of hematology and medical oncology. He is dedicated to
providing high-quality care to his patients and is constantly work-
ing to improve his skills and knowledge in the field.

Dr. Mohamed Ahmed Mohamed Elkhalifa is a highly respected

healthcare professional with a broad range of expertise and accom-
plishments in the field. He holds a MBBS from the University of
Gezira in Sudan and is licensed by several healthcare organizations.
His research interests include liver, skin cancers, medical education
development, epidemiology, and health services research, as well
as continuous quality improvement in healthcare firms. His work in
these areas has earned him recognition through numerous publica-
tions, awards, and invitations to deliver keynote presentations at
international conferences.
In addition to his medical degree, Dr. Elkhalifa is a Certified
Professional in Healthcare Quality (CPHQ), a Certified Professional
in Healthcare Risk Management (CPHRM), and a Project
Management Professional (PMP) certified professional. He is also
a member of the Royal Colleges of Physicians in the UK
(MRCP (UK)).
534 S. W. Srayaldeen and M. A. M. Elkhalifa

Before his current role, Dr. Elkhalifa served as a Regional

Healthcare Accreditation Coordinator (RAC) in Saudi Arabia,
where he was responsible for overseeing accreditation processes
and ensuring compliance with accreditation standards. His exten-
sive experience in the field and commitment to quality made him a
valuable asset to the organization and helped him to make a positive
impact on the healthcare industry.
Dr. Mohamed Elkhalifa’s broad range of expertise and experi-
ence make him a valuable asset to any healthcare organization. His
dedication to improving healthcare quality, combined with his
excellent team-leading, administrative, and organizational skills,
makes him well-­suited to take on leadership roles and drive positive
change in healthcare firms. He has a strong commitment to improv-
ing healthcare outcomes and making a positive impact on the lives
of patients and communities.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Head and Neck Malignancies in the UAE
31
Ashish V. Chintakuntlawar, Hani Al-Halabi, and Aref Chehal

31.1 Introduction

Head and neck cancer is one of the most common cancers in the world and one of
the more prevalent malignancies among males in the United Arab Emirates (UAE)
[1]. Cancers of the head and neck comprise a variety of cancers, including mucosal
head and neck squamous cell carcinomas (HNSCC), nasopharyngeal carcinomas
(NPC), skin cancers (including melanomas, squamous, and basal cell carcinomas),
carcinomas of the paranasal sinus, and salivary gland carcinomas. In this chapter,
we will mainly focus on mucosal HNSCCs.
Although HNSCC is the term usually used to describe all mucosal head and neck
cancers, it is important to note that it comprises a variety of cancers from distinct
subsites, including the oral cavity, oropharynx, larynx, and hypopharynx. Although
tobacco and alcohol consumption are the main etiologic factors, cancers in these
subsites have variable pathophysiology and clinical outcomes, including rates of
distant metastasis and overall survival. In the western hemisphere, the rates of
human papilloma virus-associated oropharyngeal cancer (HPV-OPSCC) are also
changing demographic trends. Management of HNSCC remains a tough clinical
challenge all over the world and requires multidisciplinary collaboration amongst

A. V. Chintakuntlawar (*)
Division of Medical Oncology, Sheikh Shakhbout Medical City,
Abu Dhabi, United Arab Emirates
e-mail: Chintakuntlawar.ashish@mayo.edu
H. Al-Halabi
Gulf International Cancer Center, Abu Dhabi, United Arab Emirates
e-mail: hani@gulficc.ae
A. Chehal
Division of Medical Oncology, Sheikh Shakhbout Medical City,
Abu Dhabi, United Arab Emirates
e-mail: achehal@ssmc.ae

© The Author(s) 2024 535

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_31
536 A. V. Chintakuntlawar et al.

many specialties to optimally treat the patient. This is essential not only to achieve
better survival outcomes but also to reduce long-term treatment-related morbidity in
survivors.
In this chapter, we will discuss the epidemiology, pathogenesis, and management
of HNSCC. Our goal is to not only describe the current state of affairs as it relates
to therapy but also describe the challenges we face in order to define opportunities
for improvement.

31.2 Epidemiology

The data regarding the incidence of HNSCC in the UAE is limited and has previ-
ously been published in systematic reviews, published articles, or single institution
series. However, recently, data from registries has started to become available. Data
from the Ministry of Health and Prevention, UAE National Cancer Registry shows
that the absolute numbers of HNSCC (lip, oral cavity, pharynx, and larynx com-
bined) are increasing in the UAE (Fig. 31.1) [2]. This is also true for

180
No. of head & neck cancer* cases in the UAE

160

140

120

100

80

60

40

20

0
2013 2014 2015 2016 2017 2019 2021
Lip, Oral cavity, & Pharynx 103 114 117 135 151 142 154
Nasal cavity, middle ear,
4 8 6 10 10 9 12
accessory sinuses
Larynx 29 29 44 29 20 31 29

Fig. 31.1 Number of head and neck cancer (malignant) occurrences in the UAE across the years
2013–2021 (Source: Ministry of Health and Prevention, Statistics and Research Center, National
Disease Registry—UAE National Cancer Registry Report, 2013–2021).
* Head and neck cancer includes 1. Lip, Oral cavity, & Pharynx, 2. Nasal cavity, middle ear, acces-
sory sinuses, and 3. Larynx
31 Head and Neck Malignancies in the UAE 537

population-­adjusted ratios (Table 31.1) and holds true especially for non-UAE resi-
dents (Fig. 31.2), males (Fig. 31.3), and oral cavity and oropharyngeal cancers
(Fig. 31.1).
The data regarding HPV versus non-HPV oropharyngeal cancers is also lacking
in the registry. It will be critical to collect this data and monitor future trends with
respect to the native Emirati population as well as the expat population. The UAE is
unique with respect to immigration trends, and there are a significant number of
expats from both regions, such as the Indian subcontinent and Southeast Asia, where
oral carcinomas are common, and from the Western Hemisphere, where HPV-
positive OPSCC are on the rise.

Table 31.1 Head and neck cancer demographics among the UAE population during 2013–2021
Crude incidence rate
Head and neck of head and neck
UAE population Total malignant cancer cases (in cancera cases per
Year (in millions) cases (in numbers) numbers) 100,000 population
2013 8.66 3574 136 –
2014 8.79 3610 151 – Lip, Oral cavity &
pharynx: 1.25
– Nasal cavity, middle
ear, accessory
sinuses: 0.09
– Larynx: 0.32
2015 8.93 3744 167 – Lip, Oral cavity &
pharynx: 1.3
– Nasal cavity, middle
ear, accessory
sinuses: 0.1
– Larynx: 0.5
2016 9.12 3982 174 –
2017 9.3 4123 181 – Lip, Oral cavity &
pharynx: 1.6
– Nasal cavity, middle
ear, accessory
sinuses: 0.1
– Larynx:0.2
2019 9.5 4381 182 –
2021 – 5612 195 – Lip, Oral cavity &
pharynx: 1.7
– Nasal cavity, middle
ear, accessory
sinuses: 0.1
– Larynx:0.3
Source: UAE population: https://fcsc.gov.ae/en-us/Pages/Statistics/Statistics-by-Subject.
aspx#/%3Fsubject=Demography%20and%20Social; Ministry of Health and Prevention, Statistics
and Research Center, National Disease Registry—UAE National Cancer Registry Report; aHead
and neck cancer includes 1. Lip, Oral cavity, and Pharynx, 2. Nasal cavity, middle ear, accessory
sinuses, and 3. Larynx
 538 A. V. Chintakuntlawar et al.

160 152
141 141 139
No. of head and neck cancer* cases in the UAE

140 129

120 114
108

100

80

60
40 43 43
37 38
40 33
28

20

0
2013 2014 2015 2016 2017 2019 2021

Years

UAE Non-UAE

Fig. 31.2 The number of head and neck cancer cases (malignant) among the UAE population
according to nationality, 2013–2021 (Source: Ministry of Health and Prevention, Statistics and
Research Center, National Disease Registry—UAE National Cancer Registry Report).
* Head and neck cancer includes 1. Lip, Oral cavity, & Pharynx, 2. Nasal cavity, middle ear, acces-
sory sinuses, and 3. Larynx

250
Distribution of head and neck cancer* cases in the

200
39
45 43
38
150 38
36 156
35 136 136 139
129
UAE

100 115
101

50

0
2013 2014 2015 2016 2017 2019 2021
Years

Male Female

Fig. 31.3 Distribution of head and neck cancer cases (malignant) according to gender, 2013–
2021 (Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report).
* Head and neck cancer includes 1. Lip, Oral cavity, & Pharynx, 2. Nasal cavity, middle ear, acces-
sory sinuses, and 3. Larynx
31 Head and Neck Malignancies in the UAE 539

31.3 Diagnostic Techniques

The diagnosis of HNSCC requires expert evaluation using endoscopy by a trained

and experienced head and neck surgeon. Imaging should be reviewed by a radiolo-
gist with expertise in head and neck cancers. A concurrent evaluation by a radiation
oncologist and a medical oncologist, or at least a multidisciplinary tumor board
evaluation, is necessary for optimal treatment planning. Cross-sectional imaging
with CT scanning, MRI, and FDG-PET is also available in the UAE. Access to
FDG-PET is limited but is rapidly improving.

31.4 Current Treatment Paradigms

The treatment standards are largely commensurate with National Comprehensive

Cancer Network (NCCN) recommendations and Food and Drug Administration (FDA)
approvals. Oral cancers are treated with surgical resection, and often microvascular
reconstruction is required for locally advanced oral cancers. Although not available in
every tertiary care facility, access to microvascular reconstruction surgery is fair in the
emirates of Dubai and Abu Dhabi. The availability of experts in microvascular surgery
is limited in the northern Emirates. Transoral robotic surgery (TORS) is increasingly
being utilized in the surgical resection of OPSCC. Recently, ECOG 3311 and phase 2
and 3 trials from the Mayo Clinic have shown the feasibility and importance of de-
escalation therapy via TORS for HPV-OPSCC [3, 4]. On the other hand, the recent
randomized trial of TORS versus chemoradiotherapy had to be halted due to unexpected
deaths. Therefore, it will be critical to implement the TORS very carefully, and monitor-
ing the outcomes via a credentialing system as in ECOG3311 may be needed [3, 5].
Radiotherapy in the adjuvant or definitive setting (with or without concurrent che-
motherapy) is becoming more accessible. Radiotherapy has been available here in
the UAE for more than 30 years but was initially limited to one center. In the past
5–10 years, we have witnessed a revolution in the field of radiotherapy with the
development of multiple new centers across Abu Dhabi and Dubai. Advanced radio-
therapy techniques such as volumetric modulated arc therapy (VMAT), Intensity-
modulated radiation therapy (IMRT), and stereotactic radiation are now available to
treat HNSCC patients, and older 2D and 3D techniques are being phased out to
improve treatment efficacy and patients’ quality of life [6]. Proton therapy has shown
promise in further improving the therapeutic index of radiotherapy in HNSCC, but as
in many parts of the world, it is not yet available in the UAE or the Middle East.
Systemic therapy, administered concurrently with radiotherapy or palliative ther-
apy, is widely available. However, what is lacking is expertise specific to HNSCC
and access to clinical trials and novel experimental therapeutics. Cytotoxic chemo-
therapy agents such as platinum agents, taxanes, and methotrexate are all available.
Biologics such as cetuximab [7, 8] and immunotherapeutics such as nivolumab and
pembrolizumab are also available, and their use is commensurate with the current
guidelines [9, 10]. There are studies from India with innovative strategies keeping
in mind the low resource setting [11, 12]. Similar strategies could be tested in the
540 A. V. Chintakuntlawar et al.

UAE population with the goal of reducing not only the cost but also the symptom
burden on patients, who often work through the therapy.
There are a number of other supportive therapies needed for optimal manage-
ment of HNSCC patients. Access to dentistry for dental rehabilitation, speech
pathology, physical therapy, occupational therapy, dietician services, and audiologic
testing is limited and lacks specific expertise. Both access to devices and training
related to speech therapy and hearing impairment are limited due to a lack of insur-
ance coverage as well as a shortage of medical professionals.

31.5 Challenges

Even though there has been tremendous progress in terms of diagnostics as well as
available modalities of therapy, including chemotherapy, immunotherapy, IMRT,
VMAT, and reconstructive surgery, there remain significant challenges that preclude
optimal outcomes and the management of long-term morbidities.
Most of the patients with HNSCC in the UAE are from the lower socioeconomic
strata and have poor financial and social support. Many patients, especially those
with oral tongue, buccal, and oropharyngeal squamous cell carcinoma, belong to the
Indian subcontinent. They have extremely limited medical access, which often
delays the diagnosis and even therapy. They have almost nonexistent social support
and often lose their source of income upon diagnosis, making both therapy and
recovery an uphill task for both the patient and the providers. It is very well known
that interruptions or delays in therapy are associated with particularly poor out-
comes [13, 14]. There are no systematic studies from the UAE to determine how
many patients suffer from delays and interruptions during therapy.
There is emerging interventional trial data from India, especially from Tata
Memorial Hospital [15–17], but none from the UAE, and there is no comprehensive
molecular analysis of these cancers to determine if the genetic drivers are the same.
With a significant number of expats from the western hemisphere, it is likely that
we will see more HPV-OPSCC. It is critical that we identify the trends in the local
population and the expat population for this particular cancer and pay close attention
to the careful descaling of the therapy, preferably in a prospective trial, to reduce mor-
bidity. This makes it essential not to lump them with other HNSCCs and to continue
to offer them the same conventional therapies with significant long-term morbidity.
The incidence of depression and anxiety related to therapy and therapy-related
morbidity is very high in HNSCC survivors all over the world. HNSCCs is also one
of the leading causes of cancer-related suicide, particularly in rural areas [18]. The
burden of psychosocial symptoms could be decreased by better access to psychiatry
and psychology services as well as patient support groups. Currently, there are no
head-and-neck cancer-specific support groups in the UAE.
There is a significant number of patients from the lower socio-economic strata of
the UAE population who are disproportionately affected by HNSCCs. This poses
greater distress and financial hardship, resulting in delays in diagnosis and therapy and
often resulting in interruptions of therapy. All these factors have been shown to
31 Head and Neck Malignancies in the UAE 541

negatively affect the survival outcomes of HNSCC. It is critical that we have the means
to provide lodging closer to radiotherapy facilities, access to financial support and job
security while patients are on therapy and unable to work, and the availability of unin-
terrupted nutritional support, including tube feedings. All of these are as important as,
if not more important than, the pharmacologic therapies we provide to these patients.

31.6 Conclusion

In conclusion, head and neck cancer continues to be a challenge in the UAE, affect-
ing both the native Emirati and expat populations, with tobacco, alcohol, and HPV
as emerging etiologies. Access, diagnostic, and therapeutic challenges remain, but
steady progress is being made. Clinical trials and ancillary services, including phys-
ical, occupational, speech, dental, and psychosocial rehabilitation, need major
improvements and engagement.

Acknowledgments The authors are indebted to their patients and families.

Conflict of Interest The authors have no conflict of interest to declare.

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Dr. Ashish V. Chintakuntlawar is a certified medical oncologist

by the American Board of Internal Medicine with expertise in treat-
ing head and neck cancers as well as endocrine cancers such as
thyroid and adrenal carcinomas. His research interests include
translational research and early phase clinical trials in head and
neck and endocrine cancers.Dr. Chintakuntlawar is a member of
the American Society of Clinical Oncology (ASCO), the American
Thyroid Association (ATA), the international thyroid oncology
group (ITOG), and the American-Australian-Asian adrenal
Alliance (A5), an international cooperative group dedicated to
research related to adrenal diseases.

Dr. Hani Al-Halabi is an American and Canadian board-certi-

fied consultant radiation oncologist, currently practicing at the
Gulf International Cancer Center in Abu Dhabi. He has special
interests in the management of thoracic and head-and-neck oncol-
ogy patients and the use of SBRT and SRS for treating primary
and metastatic disease. Dr. Al-Halabi is the author of numerous
peer-reviewed publications and was the principal investigator of
several phase I and II clinical trials. Dr. Al Halabi is an active
member of the American Society for Therapeutic Radiation
Oncology (ASTRO) and the European Society of Radiation
Oncology (ESTRO).

Dr. Aref Chehal is a consultant medical oncologist and hematolo-

gist at Sheikh Shakhbout Medical City (SSMC) in Abu Dhabi. Dr.
Chehal has more than 20 years of experience in hematology and
oncology. He is a recognized and established adjunct professor of
medicine at both Khalifa University and Gulf Medical University in
the United Arab Emirates.
544 A. V. Chintakuntlawar et al.

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Thyroid Cancer in the UAE
32
Riyad Bendardaf , Iman M. Talaat , Noha M. Elemam ,
and Humaid O. Al-Shamsi

R. Bendardaf
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
University Hospital Sharjah, Sharjah, United Arab Emirates
e-mail: riyad.bendardf@uhs.ae
I. M. Talaat
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Research Institute for Medical and Health Sciences, University of Sharjah,
Sharjah, United Arab Emirates
Emirates Pathology Society, Dubai, United Arab Emirates
e-mail: italaat@sharjah.ac.ae
N. M. Elemam
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Research Institute for Medical and Health Sciences, University of Sharjah,
Sharjah, United Arab Emirates
e-mail: nelemam@sharjah.ac.ae
H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi, United Arab
Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 545

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_32
546 R. Bendardaf et al.

32.1 Introduction to Thyroid Cancer

The thyroid gland consists of two lobes connected by an isthmus and is located in
the neck below the larynx and in front of the trachea. Thyroid cancer (TC) starts as
a lump or nodule in the thyroid that is usually asymptomatic. Individuals with previ-
ous exposure to high doses of radiation and a genetic history of TC are more prone
to thyroid cancer development [1]. Radiotherapy used to treat serious cancers like
Hodgkin’s disease was found to be associated with an increased risk of developing
TC [1]. Another possible cause of TC development is exposure to radioactive iodine
released during a nuclear disaster [2].
Although the most common malignancy of the endocrine system is thyroid cancer,
it is still very rare, accounting for about 1% of all malignant tumors. However, it has
been increasing in frequency in recent years. Thyroid cancer is a malignant tumor of
the glandular tissue of the thyroid gland that can be classified based on the differentia-
tion status and affected cell types into differentiated TC (DTC), including papillary,
follicular, and Hurthle cell tumors, which make up 95% of TC cases. This is in addi-
tion to medullary TC (MTC) and anaplastic TC, as well as some rare subtypes [3].
Papillary thyroid cancer (PTC) is the most prevalent type, especially in well-­
differentiated TC, accounting for 70–80% of cases. It is the most common form of
thyroid cancer to result from radiation exposure. Also, it could occur at any age and
is most likely located at the lymph nodes in the neck. However, the prognosis for
younger (< 45 years) patients is significantly better than for older (> 45 years)
patients [4]. In particular, PTC looks like an irregular solid or cystic nodule within
normal thyroid parenchyma. Even though PTC is well-differentiated, it can be quite
invasive and spread quickly to other organs as well as the lymphatic system [5].
Follicular thyroid carcinoma (FTC) is the second most frequent thyroid malig-
nancy. On initial presentation, 11% of FTC patients develop metastases outside of
the cervical or mediastinal lymph nodes. The age of TC patients affects their life
expectancy, as people younger than 45 have a better prognosis. In comparison to
papillary cancer, FTC tends to affect older individuals and accounts for 10–15% of
all thyroid cancers [6, 7]. Despite having distinct features, the FTC may be invasive.
Like papillary cancer, FTC can invade the nearby neck lymph nodes. Additionally,
FTC has a higher propensity than PTC to metastasize into blood arteries and spread,
particularly to the lungs and bones, where bone metastasis was found to be osteo-
lytic [6, 7].
Neuroendocrine tumor medullary carcinomas of the thyroid (MTC) account for
less than 5% of thyroid cancers. It is triggered by the calcitonin-producing C cells
of the thyroid, which do not build up radioiodine. Around 75% of cases of MTC are
sporadic, while the remaining are associated with multiple endocrine neoplasia type
2 (MEN2), an autosomal-dominant condition caused by mutations in the RET proto-­
oncogene. A test of such a genetic mutation can indicate an initial analysis of the
MTC [8]. The clinical outcome of patients is affected by the severity of the disease,
tumor biology, and the overall success of the surgical resection [9].
The most aggressive and invasive type of thyroid cancer is anaplastic thyroid
carcinoma (ATC), which is also the least likely to respond to therapy. Fortunately, it
is a rare type and affects less than 2% of people, but it accounts for 40% of thyroid
32 Thyroid Cancer in the UAE 547

cancer mortality [10]. According to reports, the 5-year survival rate was less than
10%, and the majority of patients only survived a few months following diagnosis
[10]. A fast-growing neck mass is the typical initial sign of ATC in patients, with
metastasis in the lungs evident in 50% of the cases at the time of diagnosis [11].

32.2 Thyroid Cancer Classification

Many thyroid tumors are derived from follicular epithelial cells, while only a few
arise from calcitonin-secreting C cells. According to the World Health Organization
(WHO), follicular cell-derived neoplasms are categorically divided into benign,
low-risk, and malignant neoplasms. Another type of classification of thyroid tumors
was suggested to be based on the combination of classic histopathology and molec-
ular pathogenesis. For instance, most encapsulated thyroid tumors with follicular
cell growth exhibited a RAS-like molecular profile [12, 13]. On the contrary, thy-
roid tumors with papillary and/or infiltrative growth and nuclear atypia possessed a
BRAFV600E-like molecular profile. Thyroid tumors with BRAFV600E and RAS
mutations can undergo further genetic changes and result in the progression of high-­
grade malignancies [14]. The protooncogene RET codes for a transmembrane
receptor tyrosine kinase, whose activation could lead to oncogenesis. As mentioned
earlier, germline RET mutations result in MEN2 and MTC. RET mutations were
reported to be associated with more aggressive diseases in MTC [15]. Less than
10% of differentiated thyroid tumors and anaplastic carcinomas possess RET muta-
tions. When compared to thyroid tumors in older people, RET fusions are more
common in thyroid cancers identified in children and young adults. Also, they are
more common in patients with previous exposure to environmental radiation
[16–21].

32.3 Thyroid Cancer Statistics

On a global scale, an increase in screening methods has resulted in a rise in the

diagnosis of thyroid cancer. Also, besides the enhanced diagnosis of early tumors,
the greater prevalence of individual risk factors (such as obesity) and the increased
exposure to environmental risk factors (iodine levels) have been implicated in the
global increase of the TC [22].
According to the Global Cancer Observatory (GLOBOCAN), the age-­
standardized incidence rate (ASR) worldwide for thyroid cancer was 6.6 per
100,000 in 2020 and 9.1 per 100,000 in 2022. Notably, 586,202 and 821,173 newly
diagnosed thyroid cancer cases were reported in 2020 and 2022 across all genders
and ages, respectively. Also, the ASR per gender was 13.6 per 100,000 for females
and 4.6 per 100,000 for males in 2022. Additionally, the age-­standardized mortality
rate of thyroid cancer reached 0.57 per 100,000, which accounted for 47,485 cases
worldwide [1, 23].
In the United Arab Emirates (UAE), according to the UAE National Cancer
Registry (UAE-NCR) 2021, thyroid cancer ranks first among endocrine cancers and
 548 R. Bendardaf et al.

595

550
No. of thyroid cancer cases in the UAE

501

450 412
398

344
350 314
282

250

150

50
2013 2014 2015 2016 2017 2019 2021
Years

Fig. 32.1 Number of thyroid cancer (malignant) occurrences in the UAE across the years
2013–2021. (Source: Ministry of Health and Prevention, Statistics and Research Center, National
Disease Registry—UAE National Cancer Registry Report, 2013–2021)

is the second most prevalent cancer among the UAE population of all genders.
Furthermore, thyroid cancer is ranked as the second most prevalent cancer in
females and the fourth most common in males. Figure 32.1 shows that the number
of thyroid cancer cases rose from 2013 to 2021, where it surged from 7.89% in 2013
to 10.6% in 2021 (Table 32.1) [24].
In the UAE, a total of 3574 cancer cases were diagnosed in 2013, out of which
282 were thyroid cancer (Table 32.1). Interestingly, the percentage of thyroid cancer
patients in the UAE reached 10.6% (n = 595) from the total number of malignant
cancer cases (n = 5612) that were newly diagnosed in 2021. Females showed a
higher incidence of thyroid cancer, accounting for 77.1% and 74.8% of diagnosed
thyroid cancer cases in 2016 and 2019, respectively (Fig. 32.2). In comparison,
5612 cancer cases were diagnosed in 2021. It is worth mentioning that 595 (10.6%)
cases were reported to be thyroid cancer, where 402 were UAE nationals (Fig. 32.3).
The distribution of thyroid cancer cases by Surveillance, Epidemiology, and End
Results (SEER) stages in the UAE across the years is shown in Fig. 32.4 [24].
A study published by Alseddeeqi E. et al. described the incidence of thyroid
cancer in Abu Dhabi, the capital of the UAE, from 2012–2015 [25]. 89.9% of TC
patients were diagnosed with papillary thyroid cancer, followed by 22.2% of patients
with follicular thyroid cancer and 2% of patients with medullary thyroid cancer
[25]. Also, the same study reported the sharp increase in the incidence rate noted in
2013 [25], which is similar to the rapid rise seen from 2017 to 2019 (Table 32.1).
This could be attributed to an increase in previous exposure to ionizing radiation as
well as a rise in iodine deficiency status, especially in females [25, 26]. This empha-
sizes the significance of having an updated and detailed histological subtype of
thyroid cancer in the UAE. According to the UAE 2017 data, 44% of the thyroid
cancer cases were localized, while around 20% of the tumors were found to be
Table 32.1 Thyroid cancer demographics among the UAE population during 2013–2021
32 Thyroid Cancer in the UAE

UAE Population Total malignant Thyroid cancer Crude incidence rate of thyroid cancer
Year (in millions) cases (in numbers) cases (in numbers) Percentage (%) cases per 100,000 population
2013 8.66 3574 282 7.89 –
2014 8.79 3610 314 8.70 3.46
2015 8.93 3744 344 9.19 3.8
2016 9.12 3982 398 9.99 –
2017 9.30 4123 412 9.99 4.4
2019 9.50 4381 501 11.4 –
2021 – 5612 595 10.6 6.4
Source: UAE population: https://fcsc.gov.ae/en-us/Pages/Statistics/Statistics-by-Subject.aspx#/%3Fsubject=Demography%20and%20Social; Ministry of
Health and Prevention, Statistics and Research Center, National Disease Registry—UAE National Cancer Registry Report
549
 550 R. Bendardaf et al.

500

450
No. of thyroid cancer cases in the UAE

400
421
350
375
300

250 302
307
256
200 234
203
150

100
174
110 126
50 80 88 91
79
0
2013 2014 2015 2016 2017 2019 2021
Years

Male Female

Fig. 32.2 Distribution of thyroid cancer cases (malignant) according to gender, 2013–2021.
(Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2013–2021)

450
402
No. of thyroid cancer cases in the UAE

400
356
350
289
300

250 226 234

193
200
145
150 123
110
100 88

50

0
2014 2015 2017 2019 2021

Years
UAE Non-UAE

Fig. 32.3 The number of thyroid cancer cases (malignant) among the UAE population according
to nationality, 2014–2021. (Source: Ministry of Health and Prevention, Statistics and Research
Center, National Disease Registry—UAE National Cancer Registry Report, 2014–2019)

infiltrating the regional lymph nodes. A few cases (n = 8) were reported to possess
metastatic potential. For instance, 1.9% of thyroid cancer patients were staged as
metastatic in comparison to 2.04% in 2017. This could be attributed to early screen-
ing through the increased use of diagnostic imaging and surveillance [27–30].
32 Thyroid Cancer in the UAE 551

450
No. of tyroid cancer cases in the UAE 400
350 123 141
300 84
9 8
250 7
74 82
71
200
150
100 182 192 181
50
0
2015 2016 2017

Years
Localized Regional
Distant Metastasis / Systemic Disease Unstaged, Unknown, or Unspecified

Fig. 32.4 Distribution of thyroid cancer cases by SEER stages in the UAE across the years.
(Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2015–2017)

32.4 Thyroid Cancer Diagnosis and Treatment

Patients with well-differentiated TC showed a long-term survival rate of around

90%, while patients with poorly differentiated tumors had survival rates below 10%,
indicating their resistance to standard treatment options [31, 32]. The known stan-
dard therapeutic approaches for radioiodine-refractory and advanced TC are immu-
notherapy, chemotherapy, and tyrosine kinase inhibitors [33]. Therefore, new
research approaches and technologies are necessary in order to discover new targets
for therapy for TC.
Kinase inhibitors, such as vandetanib and cabozantinib, are indicated for medul-
lary thyroid cancer, while others, such as sorafenib and lenvatinib, are approved for
radioiodine-refractory differentiated thyroid cancer [34–37]. In addition to many
other kinases, RET is simultaneously targeted by these multitargeted kinase inhibi-
tors. The safety and longevity of responses to these drugs are partially constrained
by toxic side effects that are due to the inhibition of non-RET kinases, such as vas-
cular endothelial growth factor receptor 2 (VEGFR2) [38, 39].
All recommendations include measuring blood thyroid-stimulating hormone
(TSH) levels and performing an ultrasonographic assessment of thyroid nodules in
order to decide whether a fine needle aspiration biopsy is necessary. Typically, a
diagnosis of TC is made by investigating a fine needle aspiration biopsy of a thyroid
nodule or a surgically removed nodule [27, 40]. Multiple organizations released
guidelines for the diagnosis and/or management of thyroid cancer, such as the
American Thyroid Association (ATA) [41, 42], the National Comprehensive Cancer
Network (NCCN) [4], and the American Association of Clinical Endocrinologists/
552 R. Bendardaf et al.

American College of Endocrinology/Associazione Medici Endocrinologi (AACE/

ACE/AME) [43].
Surgery is the main gold-standard treatment for all types of TC, especially dif-
ferentiated types. The currently recommended treatment involves performing a
complete thyroidectomy, which involves extracting the whole thyroid gland and
affecting neighboring lymph nodes in the upper chest or neck. Post-surgical resec-
tion, patients might be subject to radioactive iodine (131I) and thyrotropin suppres-
sion for the destruction of any remnant thyroid cancer cells [4]. However, no curative
treatment exists for anaplastic thyroid cancer, as most patients present in an unre-
sectable or metastatic state [31]. All TC patients who have had a thyroidectomy will
require thyroid hormone replacement for the rest of their lives. Also, a blood test
showing the detection of thyroglobulin might indicate a recurrence of thyroid cancer.

32.5 Conclusion

TC is the most common malignancy of the endocrine system that can be classified
based on the differentiation status and affected cell types. Another type of classifica-
tion of thyroid tumors is based on histopathology and molecular pathogenesis. On a
global scale, there is a rise in the incidence of thyroid cancer that could be attributed
to the greater prevalence of risk factors such as obesity and exposure to iodine lev-
els. In the UAE, TC ranks first among endocrine cancers and is the second most
prevalent cancer among the UAE population. Until now, the standard therapeutic
approaches were surgery, radioactive iodine, chemotherapy, tyrosine kinase inhibi-
tors, and immunotherapy. Therefore, further research is needed to discover new
targets for therapy for different subtypes of TC.

Conflict of Interest The authors have no conflict of interest to declare.

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32 Thyroid Cancer in the UAE 555

Prof. Riyad Bendardaf has been a consultant Medical

Oncologist at University Hospital Sharjah in the UAE since 2013.
Before joining the University Hospital Sharjah, he worked as a
Medical Oncology Consultant at the Medical Oncology Unit,
Department of Medicine, Benghazi Medical Centre, Benghazi,
Libya, and as a Medical Oncology Consultant at the Department
of Oncology & Radiotherapy, Turku University Hospital, Turku,
Finland, where he initially started as an oncology resident. In
2013, he was appointed as a Clinical Professor in the Clinical
Sciences Department, College of Medicine, University of Sharjah,
UAE. He worked as a Docent (Associate Professor of Medical
Oncology) at the Department of Oncology and Radiotherapy,
Turku University Hospital, University of Turku, Finland. He is an
active member of different oncology societies, including the
European Society of Medical Oncology (ESMO), the American
Society of Clinical Oncology (ASCO), the European Society of
Digestive Oncology (ESDO), the European School of Oncology
(ESO), the Finnish Medical Society (Duodecim), and the European
Association of Cancer Research (EACR). He is also on the edito-
rial board of various international peer-reviewed journals. Prof.
Bendardaf has more than 60 scientific papers published in interna-
tional oncology and cancer peer-reviewed journals. He also pre-
sented his work at several local and international conferences.

Prof. Iman M. Talaat graduated from the Faculty of Medicine,

Alexandria University, Egypt, with the highest honors. She obtained
her MSc and Ph.D. degrees in Basic Medical Sciences in Pathology.
She is a Professor and Consultant Anatomic Pathologist at the
Clinical Sciences Department, College of Medicine, University of
Sharjah, UAE, and at the Pathology Department, Faculty of
Medicine, Alexandria University, Egypt. She specializes in
Anatomic and Cellular Pathology, with her work focused on Cancer
Research and Pathogenesis of different neoplastic and non-neo-
plastic diseases. She is the coordinator of the Immuno-oncology
research group at the Research Institute for Medical and Health
Sciences, University of Sharjah, UAE. She is a member of the
Emirates Medical Association (EMA) and a board member
(Cultural Committee Chairperson) of the Emirates Pathology
Society (EPS). She is also a member of the American Association
of Investigative Pathology (ASIP) and the European Association of
Cancer Research (EACR). She is an associate editor and review
editor in the pathology section of Frontiers in Medicine and in the
breast cancer section of Frontiers in Oncology. She was awarded
several grants with more than 100 publications in high-impact fac-
tor, peer reviewed journals.
556 R. Bendardaf et al.

Dr. Noha M. Elemam graduated from the German University of

Cairo with a bachelor’s degree in Pharmacy and Biotechnology
with Highest Honors. She obtained her master’s degree with
Excellence in Molecular Pharmacology. She was awarded a full-
granted scholarship to finally complete her Ph.D. degree with
Distinction in Molecular Medicine and Translational Research at
the University of Sharjah, along with a dual Ph.D. degree from
University of Lübeck, Germany in 2020. Currently, Dr. Noha is a
Senior Lecturer of Immunology at the College of Medicine at the
University of Sharjah, UAE. She is working on multiple projects in
the fields of immunology and viral infections as well as various
cancer types such as breast, colon, renal and prostate cancers. Dr.
Noha published more than 70 research and review papers in high
impact factor journals and participated in around 20 international
conferences with oral and poster presentations. Dr. Noha is a young
affiliate member of the Mohammed bin Rashed Academy of
Scientists (MBRAS). Dr. Noha was selected to be a winner of the
L’Oréal-UNESCO For Women in Science Middle East Regional
Young Talents 2023 Program-Postdoctoral category. She is an edi-
tor and expert reviewer in many prestigious international high
impact factor journals. Also, she is a co-inventor in a patent filed in
the US patent office, as well as a co-investigator in multiple grants
at the University of Sharjah.

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty fel-
lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fel-
lowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new dis-
tinct subgroup of CRC, NON V600 BRAF-mutated CRC. In 2022,
32 Thyroid Cancer in the UAE 557

he published the first book about cancer research in the UAE and
also the first book about cancer in the Arab world, both of which
were launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to docu-
ment the cancer care in the UAE with many topics addressed for the
first time, e.g., neuroendocrine tumors in the UAE. He is passionate
about advancing cancer care in the UAE and the GCC and has
made significant contributions to cancer awareness and early detec-
tion for the public using social media platforms. He is considered
as the most followed oncologist in the world with over 300,000
subscribers across his social media platforms (Instagram, Twitter,
LinkedIn, and TikTok). In 2022, he was awarded the prestigious
Feigenbaum Leadership Excellence Award from Sheikh Hamdan
Smart University for his exceptional leadership and research and
the Sharjah Award for Volunteering. He was also named the
Researcher of the Year in the UAE in 2020 and 2021 by the Emirates
Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
of research training for medical trainees to enhance their clinical
and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
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Lung Cancer in the UAE
33
Saeed Rafii, Batool Aboud, and Humaid O. Al-Shamsi

33.1 Introduction

In the United Arab Emirates (UAE), lung cancer is not as common as in other parts
of the world; however, the incidence of lung cancer is increasing, and most cases are
diagnosed at late stages. Smoking patterns and the unique young population of the
UAE could lead to an increasing number of lung cancers in the coming years.
Herein, we review the current state of lung cancer in the UAE and make recommen-
dations in order to reduce the incidence of lung cancer and the steps that need to be
taken towards early diagnosis.

S. Rafii
Department of Oncology, Mediclinic City Hospital, Dubai, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
e-mail: saeed.rafii@mediclinic.ae
B. Aboud
Department of Oncology, Saudi German Hospital, Ajman, United Arab Emirates
H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 559

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_33
560 S. Rafii et al.

33.2 Lung Cancer Statistics

Lung cancer is a major health challenge worldwide. It is estimated that 2.2 million
patients were diagnosed with lung cancer in 2020 [1]. From a mortality perspective,
globally, lung cancer accounts for almost 20% of all cancer-related deaths, more
than breast and colorectal cancers combined [1].
In the Arab Gulf Cooperation Council (GCC) countries, which include Bahrain,
Kuwait, Qatar, Saudi Arabia, Oman, and the UAE, the incidence of lung cancer is
significantly lower than in Europe, North America, and some Asian countries. Lung
cancer was identified as the seventh most common cancer among men and women
in the GCC, with an average number of 505 cases annually, which accounts for
4.6% of total cancer cases each year [2].
According to the UAE National Cancer Registry (UAE-NCR), 231 cases of lung
cancer were diagnosed in the UAE in 2021, which accounts for 3.9% of all diag-
nosed cancers. Lung cancer was the second common cause of cancer death in both
sexes, with an estimated average of 96 (9.85%) of cancer deaths per year. Based on
this, lung cancer was ranked the seventh most common cancer in men and women
in the UAE. In the same year, lung cancer was the sixth most common cancer in men
(161 cases; 6.3% of all cancer diagnosed in men) and the tenth most common in
women (70 cases; 2.3% of all cancer diagnosed in women) [3].

33.3 Lung Cancer Risk Factors in the UAE

33.3.1 Smoking

Tobacco smoking poses significant health risks ranging from cardiovascular disease
to stroke, chronic obstructive airway disease, and an increased risk of a variety of
cancers. Lung cancer is possibly the most well-known cancer associated with
tobacco smoking, although smoking is also a major risk factor in other malignancies
such as bladder and head and neck cancers. It is estimated that tobacco-associated
mortality reaches 8.7 million people worldwide, of which 7.4 million deaths are
attributed to direct tobacco use [4]. Lung cancer is possibly the most well-known
cancer associated with tobacco smoking. Lung cancer is the third most common
cause of death related to smoking after ischemic heart disease and chronic obstruc-
tive pulmonary disease (COPD) [5].

33.3.1.1 Smoking and Lung Cancer Risk

Smoking is the greatest risk factor and is responsible for more than 85% of all lung
cancers. The smoke in tobacco contains over 7000 chemicals and 60 different carci-
nogenic substances that are toxic and known to be cancer-producing. It is estimated
that 1.4 million people died worldwide due to tobacco-related lung cancer in 2019
[6]. With increasing rates of smoking in the Middle East, the incidence of the dis-
ease is on the rise. In 2015, the UAE reported 2569 deaths attributable to smoking,
with a mortality cost attribution of approximately US$ 1.7 billion [7].
33 Lung Cancer in the UAE 561

As well as cigarettes, other traditional methods of tobacco smoking, such as

midwakh and shisha, are commonly practiced in the UAE. These methods are
sometimes used to add other products, such as aromatic leaves, herbs, or flavored
oils, to tobacco. Such products are popular among youth and are commonly used
during social and family gatherings. In one study, cigarette smoking was the most
common form of tobacco use in the UAE (77.4% of smokers), followed by mid-
wakh (15.0%), shisha (waterpipe) (6.8%), and cigars (0.66%) [8]. The emerging
new electronic nicotine delivery systems (ENDS), including the e-cigarette and
vaping, will increase the burden of lung cancer attributed to the use of these new
tools. What we do know is that e-cigarettes contain 15 times the amount of form-
aldehyde found in traditional cigarettes and that this cancer-causing chemical is
associated with an increased risk of lung, oral, and bladder cancer. E-cigarettes
produce a number of dangerous chemicals, including acetaldehyde, acrolein, and
formaldehyde [9]. These aldehydes can cause lung disease as well as cardiovascu-
lar disease.

33.3.2 Air Pollution

Although smoking is still the single most common risk factor for lung cancer,
non-­smokers (who never smoked) are also at risk of developing lung cancer due
to polluted air. Outdoor pollution is thought to be responsible for over 300,000
lung cancer deaths [10]. Recent research, which was recently presented at the
European Society of Medical Oncology (ESMO) 2022 annual congress, showed
that exposure to fine 2.5 μm particulate matter (PM2.5) triggers the inflammatory
mediator interleukin-1β, which promotes carcinogenesis [11]. To our knowl-
edge, and at the time of writing this manuscript, there is no study showing an
association between air quality and lung cancer in the UAE or the region. The
UAE National Air Emissions Inventory Project published its final results in
2019 [12]. The report identifies emissions related to industrial processes and
product use (IPPU), energy, and transport as the major sources of PM2.5 in the
country [12]. Such emissions mainly arise from the metal and mineral indus-
tries, including aluminium, iron, steel, and cement production; stationary com-
bustions to produce energy; oil and gas production; road transport, including
passenger cars and heavy transportation; and the wear of tires and brake pads.

33.4 Preventative Measures for Lung Cancer in the UAE

The UAE government has made tremendous commitments in order to reduce the
health burden of smoking-associated disease through legislation. Tobacco control is
one of the most important priorities for health authorities in UAE.
Since the UAE’s ratification of the WHO Framework Convention on Tobacco
Control in November 2005, the Ministry of Health has developed an integrated
strategy to combat this epidemic through the National Tobacco Control Program. It
562 S. Rafii et al.

issued legislation supporting tobacco control measures, adopted international best

practices, and consequently, reducing tobacco consumption became one of the most
important indicators of the national agenda for the UAE Vision 2021. Federal Law
No.15 of 2009 forbids and penalizes the sale of tobacco products to those under the
age of 18. The law prohibits the sale of tobacco products near schools and places of
worship. The sale of sweets that resemble tobacco products, automatic vending
equipment and devices for tobacco distribution inside the country, tobacco advertis-
ing, and smoking in closed public spaces are also prohibited [13]. Each emirate may
have specific rules regarding smoking in public places. For example, the Emirate of
Sharjah banned all kinds of smoking in public areas in 2008, and Dubai Municipality
does not allow smoking shisha in parks, beaches, and all other public recreational
areas. The UAE’s National Tobacco Control Committee has indicated its intention
to implement a complete smoking ban in public areas in the country [13].
The UAE introduced an excise tax at a rate of 72% on tobacco products in 2017
and regulations for nicotine electronic products in 2019 in order to curb smoking,
combat diseases, and prevent the spread of electronic cigarettes and analog products
in the markets and outlets in the country [14]. According to the National Health
Survey 2018, the prevalence of tobacco use has been reduced from 11% in 2010 to
9% in 2018 [ 13].
The Ministry of Health and Prevention (MoHAP) held a workshop in April 2021
to develop a national policy to promote healthy lifestyles, with a focus on three
national indicators, including the prevalence of smoking any tobacco products.
Promoting a healthy lifestyle and reducing the rate of smoking is one of the
national key performance indicators of the UAE National Agenda, as set forth in
many documents, including the 2030 Agenda for Sustainable Development [15].
The UAE aims to reduce tobacco consumption from 21.6 percent to 15.7 percent
among men and from 1.9 percent to 1.66 percent among women by the year 2021
[13]. Such measures are recognized by the WHO, which has named the UAE as one
of the highest-achieving countries that enforce bans on tobacco advertising, promo-
tion, and sponsorship [16]. However, much more needs to be done in order to reduce
the burden of smoking-related disease in general and lung cancer in particular.
The UAE government has recognized the importance of improving air quality as
a key development priority in the UAE Vision 2021. The UAE government aims to
work on the following areas in order to improve the air quality in the country [17]:

• Defining the national standards for air pollution and compliance control.
• Implementation of the transition to a green economy.
• Encouraging the use of clean energy in different fields.
• The sustainability of the transport sector.
• The development of an air quality control network and the reliance on intelligent
technologies and solutions for monitoring types of pollutants.

The UAE and the 2030 Agenda for Sustainable Development, which underpins
the national sustainable development pillars, recognize the importance of preven-
tion and “seek to reduce cancer and lifestyle-related diseases in order to ensure
33 Lung Cancer in the UAE 563

longer, healthier lives for citizens and residents” [15]. Two of the national key per-
formance indicators are the prevalence of smoking and the rate of deaths from can-
cer. This underlines the commitment of the UAE to reducing cancer mortality by
promoting preventative measures.

33.5 Lung Cancer Screening Program in the UAE

Despite being ranked as the seventh most common cancer, lung cancer is the second
leading cause of cancer-related death, accounting for 9.85% of cancer-related mor-
talities in both men and women in the UAE [3]. This data highlights the fact that the
majority of lung cancer cases are diagnosed at late stages when curative therapy
options are no longer available. It is estimated that around 80% of lung cancer
patients in the UAE are diagnosed at advanced stages [18, 19]. It is well known that
the advanced stage at diagnosis carries a poor survival outcome for patients [20].
While 5-year survival for stage IA1 is estimated to be around 92%, no patient with
stage IVb lung cancer is expected to live 5 years after diagnosis [21]. Recognizing
the importance of early detection of lung cancer and its positive impact on reducing
mortality, in 2017, the Department of Health (DoH) in Abu Dhabi launched a lung
screening service based on a low-dose CT scan for high-risk individuals aged 55 to
75 with the following risk factors [22]:

• 30 pack-year history of smoking and/or tobacco cessation for less than 15 years.
• 20 pack-year history of tobacco use and/or tobacco cessation for less than
15 years and one additional risk factor.
• 20-year history of water pipe (shisha) and/or dokha, medwakh, and/or all other
forms of smoked tobacco use.

This screening service is based on opportunistic recruitment and not on a call-­

and-­recall system. As such, there is currently no official data on the uptake rate of
lung cancer screening in the UAE. In August 2022, the Lung Cancer Policy Network
(a global multi-stakeholder initiative set up by the Lung Ambition Alliance) pub-
lished a document titled “Lung cancer screening: learning from implementation”
which outlines valuable lessons learned from lung cancer screening programs
around the world [23].
Because of the UAE’s smoking pattern, eligibility criteria in the UAE may need
to be adjusted to target younger, high-risk individuals. Additionally, instead of
opportunistic recruitment, targeted outreach may be a better strategy in order to
reduce barriers to participation in the screening program. Also, in order to ensure
the success of the screening program, an effective referral pathway for patients with
abnormal findings is highly important [18, 23, 24]. Lastly, it is of the utmost impor-
tance that the screening program be integrated into the health system and covered
by the insurance companies.
564 S. Rafii et al.

33.6 Treatment of Lung Cancer in the UAE

Much investment has been made in the UAE in order to achieve world-class health-
care services. As such, the healthcare system in the country is one of the best in the
region and among the best worldwide. Various diagnostic and therapeutic resources
are available in the UAE to diagnose and treat lung cancer effectively. Many public
and private healthcare facilities and hospitals are equipped with diagnostic imaging
hardware such as X-rays, CT scans, MRI machines, and PET CT scanners.
Currently, more than 30 cancer centers and clinics and at least four comprehen-
sive cancer centers are operating across the UAE [25, 26].
There is a significant number of specialists, including pulmonologists, radiolo-
gists, thoracic surgeons, and medical and radiation oncologists, working in the
UAE, both in the public and private sectors, many with specialized training in west-
ern countries [26].
Emirates Oncology Society and Emirates Thoracic Society are among the active
medical societies in the UAE that promote public awareness, education, and local
research in lung cancer [27, 28].

33.6.1 Access to Medicine in the UAE

Access to medicine in the UAE is comparable to many modern western countries.

Many modern anticancer therapies, including chemotherapy, the latest targeted
therapies, and immunotherapies, are available in the UAE. Approval of cancer med-
icine in the UAE is among the fastest in the world, which reduces the registration
period to around 30 days [29]. In 2020, the UAE became the first country in the
Middle East to approve osimertinib as an adjuvant treatment for early non-small
lung cancer. The UAE is the leading country in the GCC in the approval of immune
checkpoint inhibitors for cancer therapy [29].

33.7 Conclusion and Recommendations

Lung cancer is a deadly disease that incurs a large health and economic burden. A
significant proportion of lung cancer patients are diagnosed at advanced stages,
when curative treatment is no longer possible. A low-dose CT scan is proven to be
effective in identifying lung cancer at earlier stages. We commend the DoH for
identifying the need for lung cancer screening and implementing a screening pro-
gram. In order to have an effective lung cancer screening program that fits the needs
of the UAE population, we recommend:

1. Adjusting eligibility criteria for lung cancer screening based on local criteria and
population composition. In addition, we recommend a national level of research
on the rate of lung cancer among never smokers in order to explore the need for
expanding eligibility criteria beyond age and smoking.
33 Lung Cancer in the UAE 565

2. Instead of an opportunistic recruitment strategy, we recommend lung cancer

screening programs that are based on proactive identification of at-risk groups,
with particular attention to disadvantaged individuals, including those with less
understanding of the importance of screening or those with language barriers.
3. We recommend paying particular attention to cultural barriers that may hinder
the participation of women in the lung cancer screening program.
4. We appreciate the UAE government’s efforts to reduce smoking rates in the
country and encourage a comprehensive, inclusive screening program that sup-
ports smoking cessation as well as an integrative referral pathway for patients
with abnormal findings and is covered by insurance companies.

Conflict of Interest The authors have no conflict of interest to declare.

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Dr. Saeed Rafii is a board-certified consultant medical oncologist.

After completion of his primary medical degree, he was trained in
internal medicine, followed by subspecialty training in medical
oncology in two of the most prestigious cancer hospitals in the UK,
Queen Elizabeth Hospital Birmingham and the Royal Marsden
Hospital, London. He then completed a clinical fellowship in
early-phase clinical trials at the Royal Marsden Hospital, London,
and received his CCT (certificate of completion of training) from the
UK general medical council. Dr. Rafii was subsequently appointed
as an associate professor and consultant in medical oncology at the
University of Manchester and the Christie Hospital, where he helped
establish and expand the experimental cancer medicine centre. He
then moved to University College London Hospital and the Oxford
Cancer Network as a consultant medical oncologist.
He has extensive expertise in clinical trials and has been chief,
principal or co-investigator on over 100 early and late-phase
oncology clinical trials. Dr. Rafii also holds a PhD and a postdoc-
toral fellowship in molecular cancer genetics. He is a member of
the Royal College of Physicians of the UK, the European Society
of Medical Oncology (ESMO), and the American Association for
Clinical Oncology (ASCO). In 2018, he was elected as Fellow of
the Royal College of Physicians of UK (FRCP) for his outstand-
ing medical and research activities.
33 Lung Cancer in the UAE 567

Dr. Batool Aboud is a specialist in medical oncology. She

received her master’s degree in medical oncology from Damascus
University and is a member of the Syrian Board of Medical
Oncology. She practices at the Saudi German Hospital in Ajman,
UAE, since 2020, and is a lecturer at Ajman University, where she
teaches fifth-year medical school students.

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty fel-
lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral fel-
lowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new dis-
tinct subgroup of CRC, NON V600 BRAF-mutated CRC. In 2022,
he published the first book about cancer research in the UAE and
also the first book about cancer in the Arab world, both of which
were launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to docu-
ment the cancer care in the UAE with many topics addressed for the
first time, e.g., neuroendocrine tumors in the UAE. He is passionate
about advancing cancer care in the UAE and the GCC and has
568 S. Rafii et al.

made significant contributions to cancer awareness and early

detection for the public using social media platforms. He is
considered as the most followed oncologist in the world with
over 300,000 subscribers across his social media platforms
(Instagram, Twitter, LinkedIn, and TikTok). In 2022, he was
awarded the prestigious Feigenbaum Leadership Excellence
Award from Sheikh Hamdan Smart University for his excep-
tional leadership and research and the Sharjah Award for
Volunteering. He was also named the Researcher of the Year in
the UAE in 2020 and 2021 by the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan,
Vice President of the United Arab Emirates, awarded him the
first place in UAE Nafis program for outstanding leadership in
private sector across all business and medical disci-
plines. Beside his clinical and administrative duties, he is
engaged in education and various levels of research training for
medical trainees to enhance their clinical and research
skills. His mission is to advance cancer care in the UAE and the
MENA region and make cancer care accessible to everyone in
need around the globe.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Gynecologic Malignancies in the UAE
34
Saladin Sawan , Faryal Iqbal , and Humaid O. Al-Shamsi

34.1 Introduction

The United Arab Emirates (UAE) was formed as a constitutional federation of seven
emirates: Abu Dhabi, Dubai, Sharjah, Ajman, Umm Al Quwain, Ras Al Khaimah,
and Fujairah, which came together as one state in December 1971. It is located in
the Arabian Peninsula’s southeast [1]. According to the United Nations Development
Programme (UNDP) in their most recent Human Development Report 2020, the
UAE is distinguished as the foremost nation in the Arab world with a “Very High
Human Development Index.” It holds the 31st position among a total of 189 coun-
tries worldwide [2, 3]. The Federal Competitiveness and Statistics Centre published
demographic data for the UAE, showing a total population of 9.5 million in 2019,
with 3.2 million females (33.7%) [4, 5].

S. Sawan (*)
University of Manchester, Manchester, UK
e-mail: saladin.sawan@manchester.ac.uk
F. Iqbal
Burjeel Medical City, Abu Dhabi, United Arab Emirates
e-mail: faryal.iqbal@burjeelmedicalcity.com
H. O. Al-Shamsi
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi, United Arab
Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 569

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_34
570 S. Sawan et al.

34.2 Cancer Care in the UAE

With the objective of accessing medical data while safeguarding patient confidenti-
ality, the Ministry of Health and Prevention (MOHAP) initiated the creation of the
“UAE National Cancer Registry” (UAE-NCR). This registry, designed for both
UAE nationals and expatriates, serves as a population-based record of cancer cases
in the country [6]. The UAE National Cancer Registry (UAE-NCR) is the exclusive
and reliable resource for acquiring accurate information regarding cancer incidence
and mortality rates in different regions of the country. It offers valuable insights into
the data gathered from all healthcare providers throughout the UAE.

34.2.1 Overall Cancer Incidence Rate in the UAE

In 2021, the UAE-NCR recorded 5830 newly diagnosed cancer cases (malignant
and in-situ) in both genders. Out of them, the number of malignant cases was 5612
(96%), whereas 218 (4%) were in situ cases. The cancer affected a greater number
of women than men; the number of affected males was 2620 (44.9%), whereas the
number of females diagnosed with cancer was 3210 (55.1%) in 2021 [6]. Taken
into account the proportion of female and male population, the crude incident rate
of cancer in 2021 was 108.7/100,000, 39.5/100,000, and 60.5/100,000 in female,
male, and overall crude incidence rates for both genders, respectively. The total
number of overall newly diagnosed cancer cases in 2021 was divided according to
UAE citizenship: 1493 cases were newly diagnosed with cancer among UAE citi-
zens, whereas 4337 newly diagnosed cancer cases among non-UAE citizens were
reported [6]. Hence, 25.6% of newly diagnosed cancers affected Emirati citi-
zens [6].

34.3 Gynecologic Malignancies in the UAE

Any cancer that initiates in a female’s reproductive organs is broadly termed

“Gynecologic Cancer”.

1. Uterine cancer initiates in the uterus.

2. Cervical cancer initiates in the cervix.
3. Ovarian cancer initiates in the ovaries.
4. Vaginal cancer initiates in the vagina.
5. Vulvar cancer initiates in the Vulva [7].
34 Gynecologic Malignancies in the UAE 571

34.4 Gynecologic Cancer Incidence Rate in the UAE

In 2021, there were a total of 490 gynecologic cancer cases (including both malig-
nant and in-situ) among the population of the UAE, out of a total of 3210 newly
diagnosed cancer cases in women, representing 15.2% of the total. The data pre-
sented in Table 34.1 demonstrates that non-UAE citizens within the UAE popula-
tion had a higher number of gynecologic cancers, specifically 367 cases, compared
to UAE citizens, who accounted for 123 cases [6].
According to the “Cancer Incidence in the United Arab Emirates: Annual Report
of the UAE-National Cancer Registry 2021,” the UAE population experiences the
highest number of malignant cases in the cervix uteri, uterus, and ovaries within the
age groups of 40–49, 60–69, and 50–59, respectively. Table 34.2 presents the break-
down of gynecologic cancer cases by age group for the entire UAE population.
Furthermore, Table 34.3 displays the distribution of malignant gynecologic cancers
by age group, specifically among UAE citizens, while Table 34.4 illustrates the
distribution among non-UAE citizens [6].

Table 34.1 The sum of gynecologic cancers out of the total number of newly diagnosed cancer
cases among the UAE population according to primary site (malignant and in situ) and national-
ity, 2021
Primary site UAE Non-UAE Total
All invasive cancers (malignant cases)
C53 cervix uteri 23 118 141
C54-C55 uterus 60 113 173
C56 ovary 23 85 108
Non-invasive cancers (in-situ cases)
D06 carcinoma in situ of cervix uteri 17 51 68
Total 123 367 490
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021

Table 34.2 Primary site (malignant) distribution of gynecologic cancers by age group among all,
(UAE and non-UAE Citizens), 2021

Primary Site 0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80+ Total
C53 cervix 0 0 5 38 45 34 14 4 1 141
uteri

C54-C55 0 0 2 21 37 42 46 24 1 173
uterus
C56 ovary 0 1 4 19 27 33 12 9 3 108

Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021
572 S. Sawan et al.

Table 34.3 Primary site (malignant) distribution of gynecologic cancers by age group among
UAE citizens, 2021
Primary
Site 0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80+ Total
C53 0 0 2 0 9 7 3 1 1 23
cervix
uteri
C54- 0 0 0 5 12 12 18 12 1 60
C55
uterus
C56 0 1 0 3 4 9 1 3 2 23
ovary
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021

Table 34.4 Primary site (malignant) distribution of gynecologic cancers by age group among
non-UAE citizens, 2021
Primary
Site 0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80+ Total
C53 0 0 3 38 36 27 11 3 0 118
cervix
uteri
C54-C55 0 0 2 16 25 30 28 12 0 113
uterus
C56 0 0 4 16 23 24 11 6 1 85
ovary
Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2021

34.5 Recent Incidence of the Most Common Gynecologic

Cancers in Among the UAE Population

34.5.1 Cervix Uteri

This particular form of cancer primarily affects women over the age of 30 [8]. The
total number of malignant cervix uteri cases among the UAE population in 2021 is
presented in Table 34.1. It ranked as the fifth most prevalent cancer among women
in the UAE. Specifically, there were 141 cases of cervix uteri cancer, accounting for
4.6% of all female cancer diagnoses in 2021. The stage distribution of cervix uteri
cancer cases in 2017, as documented by the UAE-National Cancer Registry (UAE-­
NCR), is depicted in Fig. 34.1. Table 34.2 highlights that the age group of 40–49
had the highest number of reported cervix uteri cases in 2021 according to the
UAE-­NCR [6].
34 Gynecologic Malignancies in the UAE 573

9 Unstaged; 1 localized
Not Stated 27%
35%

5 Regional,
Nos
7 Distant
33%
5%

1 localized 5 Regional, Nos 7 Distant 9 Unstaged; Not Stated

Fig. 34.1 Stage distribution of cervix uteri cancer cases among the UAE population, 2017.
(Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2017)

34.5.2 Uterus

Among the population of the UAE, uterus cancer is the prevailing gynecologic can-
cer. The total count of malignant uterus cancer cases among the UAE population in
2021 is provided in Table 34.1. It ranked as the fourth most prevalent cancer among
women in the UAE. In 2021, there were 173 reported cases of uterus cancer, consti-
tuting 5.7% of all cancer diagnoses in females. As indicated by Table 34.2, the UAE
National Cancer Registry (UAE-NCR) recorded the highest number of uterus can-
cer cases within the age group of 60–69 in 2021 [6].

34.5.3 Ovary

Ovarian cancer is a type of cancer that develops in the ovaries or in adjacent regions
such as the fallopian tubes and the peritoneum [9]. Mutations in the BRCA1 and
BRCA2 genes, as well as those associated with Lynch syndrome, have the potential
to increase the risk of ovarian cancer in women [9]. Table 34.1 provides an overview
of the total number of malignant ovary cancer cases within the UAE population in
2021. It ranked as the seventh most prevalent cancer among women in the
UAE. Specifically, there were 108 reported cases of ovary cancer, representing
3.5% of all female cancer diagnoses in 2021. According to Table 34.2, the UAE
National Cancer Registry (UAE-NCR) documented the highest number of ovarian
cancer cases in the age group of 50–59 [6].
574 S. Sawan et al.

50%

40%
Percentage %

30%

20%

11.49%
9.85% 9.64%
10%
4.92% 4.31%
1.33% 1.33%
0%
Malignant Malignant Malignant Leukemia Malignant Malignant Malignant
Neoplasm of Neoplasm of Neoplasm of Neoplasm of Neoplasm of Neoplasm of
Colon Trachea, Breast Stomach Cervix Uteri Rectum
bronchus &
Lung
Underlying Cause of Death

Fig. 34.2 Distribution of cancer mortality rates by type in the UAE in 2021. (Source: Ministry of
Health and Prevention, Statistics and Research Center, National Disease Registry—UAE National
Cancer Registry Report, 2021)

34.6 Mortality Rate in the UAE Due to Gynecologic

Cancer in 2021

Cancer is the fifth-leading cause of death in the UAE [6]. Malignant neoplasm of the
cervix uteri contributed to 1.33% of all cancer-related deaths within the UAE popu-
lation in 2021. It held the sixth position in terms of mortality rates among the UAE
population during that year. Figure 34.2 presents the breakdown of malignant can-
cer deaths by cancer type in the UAE, as reported by the UAE National Cancer
Registry (UAE-NCR) in 2021 [6].

34.7 Overall Malignant Gynecologic Cancers in the UAE

Based on the report from the UAE National Cancer Registry (UAE NCR) 2021,
uterus cancer has the highest number of overall malignant gynecologic cancer cases,
i.e., 173, while the second-highest is cervix uteri, with 141 cases in 2021, and the
third is ovarian cancer, with 108 cases. Figure 34.3 provides an overview of the total
count of malignant gynecologic cancer cases in the UAE from 2013 to 2021 [6].
Figure 34.4 shows the trendline of total malignant gynecologic cancer cases
among UAE population from the year 2013–2019 [6].
 34 Gynecologic Malignancies in the UAE 575

200
180 173

160
Number of malignant cases

141
140 127 125
120 106 111 108
97 99 100
100 94 90
87 82
77 78 74
80 69 69 70
62
60
40
20
0
2013 2014 2015 2016 2017 2019 2021
Years

C53 Cervix Uteri C54-C55 Uterus C56 Ovary

Fig. 34.3 Overall malignant gynecologic cancer cases in the UAE for the years 2013–2021.
(Source: Ministry of Health and Prevention, Statistics and Research Center, National Disease
Registry—UAE National Cancer Registry Report, 2013–2021)

460

422
Number of gynecologic cancer cases

410

360

315
310
290

261 263
253
260 235

210
2013 2014 2015 2016 2017 2019 2021
Years

Fig. 34.4 The trendline of total malignant gynecologic cases in the UAE population between
2013 and 2021. (Source: Ministry of Health and Prevention, Statistics and Research Center,
National Disease Registry—UAE National Cancer Registry Report, 2013–2021)
576 S. Sawan et al.

34.8 Cervical Cancer Prevention and Control Program

In the UAE, cervix uteri ranks as the fifth most common cancer among women [6].
Almost 99% of cervical cancer cases are attributed to Human Papillomavirus (HPV)
infection in the cervix area. Vaccinations are highly effective in preventing HPV
infection among females [10].
The cervical cancer awareness campaign is a component of the Department of
Health’s larger initiative titled “Live healthily & simply check” campaign. This par-
ticular campaign spans six months, starting from October 2017 and concluding in
March 2018. It coincides with the global observance months dedicated to raising
awareness about cancer prevention initiatives [11].
DOH launched the “Cancer Wave Health Promotion Project” in 2012. The objec-
tive of the campaign was to raise community awareness about the importance of
regular screening and early detection of the top three cancers, namely breast, cervi-
cal, and colorectal [12].
Friends of Cancer Patients (FoCP) collaborated with the United Nations
Population Fund (UNFPA) to create guidance programs for the Ministry of Health
and partner agencies, aimed at developing and updating their programs for prevent-
ing and controlling cervical cancer. FoCP organized its inaugural forum titled
“Turning the Tide on HPV and Cervical Cancer” in January 2019, followed by the
second forum “Accelerating Action on HPV and Cervical Cancer” in January 2021,
in Sharjah, UAE [13].
Due to these significant and commendable measures taken to prevent cervical
cancer, the UAE has observed a decline in the number of cervix uteri cases in
recent years.
Figure 34.5 shows the trendline of newly diagnosed carcinoma in situ of the
cervix uteri for the years 2015, 2016, 2017, 2019, and 2021 [6]. This illustrates the
decrease in the number of cervix uteri (one of the most common gynecologic can-
cers in the UAE).
The UAE needs to set up more screening and prevention campaigns for the
sake of other common gynecologic cancers in the UAE, i.e., uterus and ovary
cancers among the female population. Physicians have a vital role to play in pro-
moting community awareness campaigns among women in the country. These
campaigns aim to mitigate the risk of developing cancer and promote the adop-
tion of healthy lifestyles. It is crucial for physicians to actively engage in these
efforts.
34 Gynecologic Malignancies in the UAE 577

90
81
Number of in situ cervix uteri cancer
80
66 68
70
60
60
50
cases

38
40
30
20
10
0
2015 2016 2017 2019 2021
Years

Fig. 34.5 The trendline of D06 carcinoma in situ of the cervix uteri for the years 2015, 2016,
2017, 2019, and 2021. (Source: Ministry of Health and Prevention, Statistics and Research Center,
National Disease Registry—UAE National Cancer Registry Report)

34.9 Conclusion

The UAE boasts a sophisticated healthcare system. The significantly high rate of
female cancer incidence in the UAE has prompted health authorities to take proac-
tive measures in providing gynecologic cancer care services. These initiatives
include the establishment of the National Cancer Registry, the implementation of an
HPV vaccination drive, organizing workshops and training for healthcare profes-
sionals, conducting awareness campaigns, and launching screening campaigns for
females nationwide. To further enhance the multidimensional care for gynecologic
cancer patients in the UAE, it is important to foster collaborations with other coun-
tries. Such collaborations would help in bringing together various cancer specialties
and advanced technologies available within the country.

Conflict of Interest The authors have no conflict of interest to declare.

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Dr. Saladin Sawan is currently a consultant surgeon in gynaeco-

lgoy oncology in Manchester University NHS Foundation Trust in
England. He had worked recently in the United Arab Emirates
when he gained an insight into the burden of gynaecological can-
cers in the UAE.
Saladin is a vice-chair of the Scientific Advisory Committee,
the Royal College of Obstetricians and Gynaecologists, UK. He is
an honorary lecturer, The University of Manchester, UK.

Ms. Faryal Iqbal is the research associate at Burjeel Medical

City, Abu Dhabi, United Arab Emirates. She completed her under-
graduate studies in molecular biology and biotechnology.
Following that, she received a postgraduate qualification in molec-
ular genetics. She co-edited “Cancer in the Arab World,” the first
extensive book covering cancer care across all Arab countries. The
book succeeded significantly, with over 450,000 downloads within
just two years. She has several peer-reviewed papers under her
name. In September 2023, Ms, Iqbal received the “EOS Research
Award” from the prestigious Emirates Oncology Society for her
research efforts. Moreover, she assists in different aspects of clini-
cal trial implementation at a research site. Her research interests
and publications encompass oncology, hematology, and genetics.
34 Gynecologic Malignancies in the UAE 579

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow)
in 2024. He is the only physician in the UAE with a subspecialty
fellowship certification and training in gastrointestinal oncology
and the first Emirati to train and complete a clinical post-doctoral
fellowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new
distinct subgroup of CRC, NON V600 BRAF-mutated CRC. In
2022, he published the first book about cancer research in the UAE
and also the first book about cancer in the Arab world, both of
which were launched at Dubai Expo 2020. Cancer in the Arab
World has been downloaded more than 450,000 times in its first 18
months of publication and is the ultimate source of cancer data in
the Arab region. He also published the first comprehensive book
about cancer care in the UAE which is the first book in UAE his-
tory to document the cancer care in the UAE with many topics
addressed for the first time, e.g., neuroendocrine tumors in the
UAE. He is passionate about advancing cancer care in the UAE
and the GCC and has made significant contributions to cancer
awareness and early detection for the public using social media
platforms. He is considered as the most followed oncologist in the
world with over 300,000 subscribers across his social media plat-
forms (Instagram, Twitter, LinkedIn, and TikTok). In 2022, he was
awarded the prestigious Feigenbaum Leadership Excellence
Award from Sheikh Hamdan Smart University for his exceptional
leadership and research and the Sharjah Award for Volunteering.
He was also named the Researcher of the Year in the UAE in 2020
and 2021 by the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
580 S. Sawan et al.

across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various lev-
els of research training for medical trainees to enhance their clini-
cal and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Genitourinary Malignancies in the UAE
35
Mohammed Shahait, Hosam Al-Qudah,
Layth Mula-­Hussain , Ibrahim H. Abu-Gheida,
Thamir Alkasab, Ali Thwaini, Rabii Madi,
Humaid O. Al-Shamsi , Syed Hammad Tirmazy,
and Deborah Mukherji

M. Shahait · R. Madi · D. Mukherji (*)

Department of Urologist, Clemenceau Medical Center, Dubai, United Arab Emirates
e-mail: mohammed.shahait@cmcdubai.ae; rabii.madi@cmcdubai.ae;
deborah.mukherji@cmcdubai.ae
H. Al-Qudah
Department of Urology, Fakeeh University Hospital, Dubai, United Arab Emirates
L. Mula-Hussain
Radiation Oncology, Dalhousie University, Halifax, NS, Canada
e-mail: layth.mula-hussain@dal.ca; lmulahussain@aol.com
I. H. Abu-Gheida
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Burjeel Medical City, Abu Dhabi, United Arab Emirates
T. Alkasab
Uro-Oncology Specialist, Alzahra Hospital, Dubai, United Arab Emirates
e-mail: Thamir.Alkasab@azhd.ae
A. Thwaini
Department of Urologist, Mohammed Bin Rashid University of Medicine and Health
Sciences, Dubai, United Arab Emirates
e-mail: Ali.thwaini@mediclinic.ae
H. O. Al-Shamsi
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca
S. H. Tirmazy
Department of Oncology, Dubai Hospital, Dubai, United Arab Emirates
e-mail: SHTirmazy@dha.gov.ae

© The Author(s) 2024 581

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_35
582 M. Shahait et al.

35.1 Introduction

The genitourinary malignancies encompass kidney and bladder cancer, diagnosed

in both men and women; prostate cancer, testicular germ cell tumors, and penile
cancer, diagnosed exclusively in men.
Since the establishment of the United Arab Emirates-national cancer registry
(UAE-NCR), it has captured cases of prostate cancer, kidney and renal pelvis can-
cer, bladder cancer, and germ cell tumors in men, but not penile cancer cases due to
the rarity of this disease. Prostate cancer ranked as the second most common malig-
nancy in men, Kidney and Renal pelvis ranked ninth, and bladder cancer ranked as
the tenth most common malignancy detected in men in the 2021 UAE-NCR report.
The majority of the GU malignancies registered in this time period were diagnosed
in expats [1] Table 35.1.

Table 35.1 Genitourinary cancer demographics among the UAE population during 2013–2021
UAE Total
population malignant GU cancera Crude incidence rates of GU
(in cases (in cases (in Percentage cancera cases per 100,000
Year millions) numbers) numbers) (%) population
2013 8.66 3574 369 10.32 –
2014 8.79 3610 425 11.77 Prostate: –
Testis: –
Kidney and renal pelvis: 1.06
Urinary bladder: 1.35
2015 8.93 3744 390 10.41 Prostate: –
Testis: –
Kidney and renal pelvis: 0.9
Urinary bladder: 1.1
2016 9.12 3982 402 10.09 –
2017 9.3 4123 394 9.5 Prostate: –
Testis: –
Kidney and renal pelvis: 0.9
Urinary bladder: 1.2
2019 9.5 4381 437 9.9 –
2021 – 5612 588 10.4 Prostate: –
Testis: –
Kidney and renal pelvis: 1.6
Urinary bladder: 1.4
Source: UAE population: https://fcsc.gov.ae/en-us/Pages/Statistics/Statistics-by-Subject.
aspx#/%3Fsubject=Demography%20and%20Social; Ministry of Health and Prevention, Statistics
and Research Center, National Disease Registry—UAE National Cancer Registry Report
a
GU cancer cases include: (1) Prostate (2) Testis (3) Kidney and renal pelvis (4) Urinary bladder
35 Genitourinary Malignancies in the UAE 583

35.2 Prostate Cancer in the UAE

According to Global cancer statistics 2020: GLOBOCAN, the age-standardized rate

(ASR) of new prostate cancer cases in the UAE is 13.4 cases per 100,000 population
per year, while worldwide it is 30.7 cases per 100,000 population per year. Moreover,
the ASR of prostate cancer-related mortality in the UAE is 3.4 cases per 100,000
population per year, compared to the worldwide rate of 7.7 cases per 100,000 popu-
lation per year. The mortality-to-incidence ratio of prostate cancer in the UAE is
similar to that in the world (25%), but it is higher compared to the USA (16.6%) [2].
The differences in the incidence and mortality rates between the UAE and USA
might be explained by several factors, such as the age of the population, genetic
predisposition, PSA screening penetrance, diet, accessibility to novel medications,
and stage at diagnosis [3–5]. For example, 16.8% of the USA population is older
than 65 years, compared to 1.9% of the UAE population. In the UAE, there is no
established prostate cancer screening program at the national level; even more
opportunistic PSA testing is not widespread due to a lack of awareness, and in most
instances, it is not covered by private insurance.
To better understand the genomic diversity of prostate cancer among different
ancestries, Albawardi et al. compared the mutational profiles of Mediterranean
patients with prostate cancer treated at Tawam Hospital to those of prostate cancer
patients from different ancestries and found that the tumors of patients of ME ances-
try had fewer gene-level copy number aberrations than those in men of other ances-
tries [6]. In addition, somatic amplification of the glutathione S-transferase family
on chromosome 1 (GSTM1, GSTM2, GSTM5) and the IQ motif-containing family
on chromosome 3 (IQCF1, IQCF2, IQCF13, IQCF4, IQCF5, IQCF6) was noted
more frequently in patients of ME ancestry. The findings of this study are in line
with other studies that showed differences in clonal evolution between the Middle
Eastern and Western populations [4].
A recent bibliometric analysis of prostate cancer research in the Arab world showed
that most Arab-based studies did not involve collaborations and were categorized as
low-level evidence [7]. However, prostate cancer health providers in the UAE are
actively involved in regional consensus on prostate cancer management, the translation
and validation of quality-of-life questionnaires, and multi-­institutional studies [8, 9].
Patients diagnosed with prostate cancer in the UAE have good access to diagnos-
tic and treatment modalities and physicians with sub-specialist training. Specialist
imaging modalities such as multi-parametric MRI and PET-PSMA are examples of
diagnostic modalities. Treatment modalities available for localized disease include
robotic surgery, external beam radiation therapy, brachytherapy, and theranostics
(including lutetium-PSMA). Access to novel systemic therapies, germline, and
somatic genetic testing is excellent.
Recommendations for improving prostate cancer outcomes in the UAE

1. Implementation of population-based PSA screening as well as improving public

awareness of prostate cancer symptoms and the importance of screening, includ-
ing earlier screening, in men with a family history of prostate cancer.
584 M. Shahait et al.

2. Training and awareness for primary healthcare physicians.

3. Implementation of fast-track referral pathways for patients with suspected can-
cer that include targets.
4. Improved the data documentation process at the hospital level on prostate cancer
diagnosis, stage at diagnosis, and treatment outcome data.
5. Encourage multidisciplinary management of prostate disease by sub-specialist
teams to ensure optimal patient outcomes.
6. Encourage multidisciplinary management of treatment-related toxicity for men
treated with systemic therapy, including cardiovascular and bone health.
7. Early access to specialist palliative care for men with advanced disease.
8. Engagement in context-specific research with improved data collection on popu-
lation genetics, barriers to screening, patient preferences for treatment, and
treatment-­related toxicity.

35.3 Bladder Cancer in the UAE

According to Global Cancer Statistics 2020: GLOBOCAN, the age-standardized

rate (ASR) of new bladder cancer cases in the UAE is 6.4 cases per 100,000 popula-
tion per year, while worldwide it is 5.6 cases per 100,000 population per year.
Moreover, the ASR of bladder cancer-related mortality in the UAE is 2.7 cases per
100,000 population per year, compared to the worldwide rate of 1.9 cases per
100,000 population per year [2]. The high incidence of bladder cancer in the UAE
compared to the rest of the world might be explained by the fact that a substantial
number of expats are originally from countries with high bladder cancer incidence,
such as Lebanon and Egypt [10].
Although bladder cancer is a disease of the elderly, as the average age at diagno-
sis of bladder cancer in the USA is 73 years, most bladder cancer cases in the UAE
are in patients younger than 65 years [10]. The occurrence of cancer at a younger
age in Arab countries compared to western countries is well described in different
malignancies that include breast and colorectal cancer [11, 12]. This observation is
very crucial for practicing physicians in the UAE, as western guidelines for micro-
scopic hematuria stratify patients based on age according to the age-standardized
rate observed in their population [13]. As such, physicians in the UAE should be
vigilant about adopting these guidelines into their practice.
There are several identified modifiable risk factors for bladder cancer, such as
obesity and smoking [14, 15]. The UAE has a comparable obesity rate compared to
the USA, with a trend toward having a higher rate of childhood obesity [16]. Another
risk factor is smoking; the overall smoking rate among the UAE population is
18.20%, with a high male-to-female ratio of 44:1 [17].The highest prevalence was
reported in males aged 20–39 years. Several forms of tobacco consumption are
observed in the UAE, which include cigarette smoking (77.4%), followed by 15.0%
midwakh use (a small pipe used for smoking tobacco), 6.8% waterpipe use, and
0.66% cigar use [18]. The UAE Government’s efforts to curb smoking consisted of
bundled policies, which include but are not limited to raising the cost of smoking
through taxation, mounting sustained social marketing campaigns, and ensuring
35 Genitourinary Malignancies in the UAE 585

that health professionals routinely advise smokers to stop smoking, accompanied by

behavioral and pharmacological support for cessation and smoking cessation
clinics.
Patients in the UAE have excellent access to all diagnostic and treatment modali-
ties for bladder cancer, including sub-specialist surgical expertise, external beam
radiation, and recently approved systemic therapies, including immune checkpoint
inhibitors.
Recommendations for improving bladder outcomes in the UAE are as follows:

1. Improved the data documentation process at the hospital level, on bladder cancer
diagnoses, risk factors, stage at diagnosis, and treatment outcome data.
2. Advocate for improved tobacco control policies and improved public awareness
of bladder cancer risks and symptoms.
3. Encourage multidisciplinary management of bladder cancer by sub-specialist
teams to ensure optimal patient outcomes.
4. Early access to specialist palliative care for men with advanced disease.
5. Engagement in context-specific research with improved data collection on blad-
der cancer risk factors, treatment response, barriers to early diagnosis, and
patient preferences for treatment.

35.4 Kidney Cancer in the UAE

According to Global cancer statistics 2020: GLOBOCAN, the age-standardized rate

(ASR) of new kidney cancer cases in the UAE is 2.3 cases per 100,000 population
per year, while worldwide it is 4.6 cases per 100,000 population per year. Moreover,
the ASR of kidney cancer-related mortality in the UAE is 0.95 cases per 100,000
population per year, compared to the worldwide rate of 1.8 cases per 100,000 popu-
lation per year [2]. The number of kidney cancer cases diagnosed in the UAE is low,
and it is difficult to infer any conclusions; however, the widespread use of axial imag-
ing led to an increase in the number of early-stage cases between 2013 and 2017.
Patients in the UAE have excellent access to diagnostic and treatment modalities,
including sub-specialist expertise in laparoscopic and robotic surgery for localized
disease. Patients have access to all recently approved systemic therapies, including
targeted therapy and immune checkpoint inhibitors for use in adjuvant and advanced
disease settings.
Recommendations for improving kidney cancer outcomes in the UAE are as
follows:

1. Improved the data documentation process at the hospital level on kidney cancer
diagnoses, risk factors, stage at diagnosis, and treatment outcome data.
2. Encourage multidisciplinary management of kidney cancer by sub-specialist
teams to ensure optimal patient outcomes.
3. Early access to specialist palliative care for men with advanced disease.
4. Engagement in context-specific research with improved data collection on kid-
ney cancer risk factors, treatment response, and patient preferences for treatment.
586 M. Shahait et al.

35.5 Testicular Cancer in the UAE

According to Global Cancer Statistics 2020: GLOBOCAN, the age-standardized

rate (ASR) of new testicular cancer cases in the UAE is 0.49 cases per 100,000
population per year, while worldwide it is 1.8 cases per 100,000 population per year.
Moreover, the ASR of kidney cancer-related mortality in the UAE is 0.02 cases per
100,000 population per year, compared to the worldwide rate of 0.22 cases per
100,000 population per year [2]. The incidence and mortality of testicular cancer in
the UAE follow the global pattern of low incidence and mortality of testicular can-
cer observed in Asia [19]. Patients have access to fertility clinics both in the public
and private sectors.
Recommendations for improving testicular cancer outcomes in the UAE are as
follows:

1. Improved the data documentation process at the hospital level on testicular can-
cer diagnoses, risk factors, stage at diagnosis, and treatment outcome data.
2. Encourage multidisciplinary management of testicular cancer by sub-specialist
teams to ensure optimal patient outcomes. Due to the rarity of the disease and
excellent treatment outcomes with appropriate treatment, it is recommended that
there be cross-­institutional collaboration and discussion of all advanced cases.
3. Access to fertility centers and insurance coverage for this young patient
population.
4. Engagement in context-specific research with improved data collection on treat-
ment outcomes and long-term data to monitor rates of relapse.

35.6 Conclusion

The incidence of GU malignancies in the UAE is expected to rise significantly due

to population and demographic change in the coming decade. There is an urgent
need to establish population-based screening for prostate cancer and raise public
awareness regarding the risk factors and symptoms of GU cancers. Other recom-
mendations include strengthening the UAE cancer registry to include treatment out-
come data, mechanisms to audit adherence to guidelines, multidisciplinary
sub-specialist care for all patients regardless of location or financial resources, early
access to specialist palliative care for patients with advanced disease, and the pro-
motion of context-specific research collaboration.

Conflict of Interest The authors have no conflict of interest to declare.

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Dr. Mohammed Shahait is a doctor of urology and minimally

invasive surgery with extensive experience in the management of
complex genitourinary tumors and robotic surgery. Dr.Shahait has
performed the first robotic surgery in the Kingdom of Jordan. After
receiving his medical degree from the Jordanian University of
Science and Technology, he completed his residency at the division
of urology and kidney transplant at the American University of
Beirut Medical Center (AUBMC). Dr. Shahait afterwards com-
pleted a 2-year fellowship in Endourology laparoscopic and robotic
surgery at the University of Pittsburgh Medical Center, followed
by a prestigious 1-year fellowship in advanced robotic surgery at
the University of Pennsylvania. He later joined the King Hussein
Cancer Center in Amman, Jordan as a consultant in uro-oncology.
Dr. Shahait’s research focus is on the outcomes of patients under-
going robot-assisted radical prostatectomy for prostate cancer and
has more than 45 peer-reviewed articles.

Dr. Hosam Al-Qudah is a consultant urologist with fellowship

training in the United States of America. He has been on the
Jordanian and Arab Boards of Urology since 2003 and 2004.
He started his residency training in 1998 at the Jordan
University of Science and Technology and the American University
Hospital of Beirut. After that, he worked in private practice for one
year and then moved to the United States of America to receive
subspecialty training in reconstructive urology from Wayne State
University from July 2004 until June 2005. In July 2005, he moved
to do transplant surgery at the University of Maryland, which is
one of the pioneering programs in transplant, especially in laparo-
scopic donor nephrectomy. After that, he did his third fellowship in
uro-oncology and advanced laparoscopy at Moffitt Cancer Center
in Tampa, Florida, from July 2006 until June 2007.
After finishing this training, he was appointed as an assistant
professor of urology at the Jordan University of Science and
Technology (King Abdullah University Hospital). At the end of
2008, he moved to Saudi Arabia and worked as a consultant urolo-
gist and transplant surgeon at Saad Specialist Hospital for almost 8
years. During these years, he was the surgeon in charge of the
transplant service in the hospital.
On July 24th, 2016, he joined Alzahra Hospital in Dubai as
head of the division of urology and consultant urologist. During
these years, he has performed a good number of complicated
oncology and laparoscopic cases.
On June 1st, 2021, he moved to Fakeeh University Hospital to
lead the urology service in this hospital. It is a state-of-the-art new
hospital that aims to raise health standards in Dubai.
He did the first laparoscopic donor nephrectomy, the first lapa-
roscopic partial nephrectomy, and the first laparoscopic radical
prostatectomy in Jordan.
35 Genitourinary Malignancies in the UAE 589

Dr. Layth Mula-Hussain was born, raised and gained his medical
degree from the University of Mosul, Ninevah – Iraq. He travelled to
Jordan to do a residency in radiation oncology at the King Hussein
Cancer Center, then to Germany to do an M.Sc. in advanced oncol-
ogy at Ulm University. Then he completed four years of clinical fel-
lowships in Canada. Besides many professional memberships, he is a
lifetime ESTRO Fellow & IAHPC member, ESCO Graduate,
Certified Clinical Investigator, Fellow and the “Regional Adviser for
Eastern Canada” of the Royal College of Physicians of Edinburgh,
and an ESO Ambassador by the European School of Oncology.
During his 20+ years in oncology, Dr. Mula-Hussain served as
a consultant physician in radiation oncology at the King Hussein
Cancer Center in Jordan, Zhianawa Cancer Center in Iraq, and
Sultan Qaboos Comprehensive Cancer Centre in Oman. He is cur-
rently an attending physician at the Cape Breton Cancer Centre, an
assistant professor at Dalhousie University in Nova Scotia, Canada,
and a visiting professor at Ninevah University in Iraq.
Dr. Mula-Hussain was the founding director of Iraq’s first radia-
tion oncology certification board program (2013–2017). He acted as
an Expert within imPACT IAEA teams for Pakistan (2013) & Syria
(2022), a member of the ASCO International Affairs Steering
Committee (2016–2019), and a reviewer in the IAEA curriculum for
radiation oncology education and training (2024). He authored / co-
authored 80+ manuscripts/ books/ books’ chapters, did 100+ scien-
tific presentations, and his efforts were cited over a thousand times
with an H-index of 17 “https://www.researchgate.net/profile/
Layth-Mula-Hussain”.

Dr. Ibrahim H. Abu-Gheida is the Clinical Director of the

department of radiation oncology at Burjeel Medical City. He also
serves as a regional Radiological Society of North America (RSNA)
committee representative for the Middle East and Africa. Dr. Abu-
Gheida completed his undergraduate training, where he earned a
Bachelor of Science with honors degree from the American
University of Beirut. Following this, Dr. Abu-Gheida completed his
Medical School training at the American University of Beirut
Medical Center. He continued and joined the Department of Internal
Medicine at the American University of Beirut. Then he did his
training in the Department of Radiation Oncology at the American
University of Beirut Medical Center, where he also served as the
chief resident. During his training, Dr. Abu-Gheida completed a
Harvard-affiliated NIH-funded research program as well. After his
residency, Dr. Ibrahim went to the Cleveland Clinic in Ohio, where
he was appointed as an Advanced Clinical Radiation Oncology
Fellow. Dr. Abu-Gheida went and joined the University of Texas
MD Anderson Cancer Center, where he sub-specialized in treating
breast, gastrointestinal, and genitourinary cancers. Dr. Abu Gheida
played an instrumental role in establishing and heading the radia-
tion oncology facility and department at Burjeel Medical City. He
has chaired and co-chaired multiple international oncology confer-
ences. Dr. Ibrahim has more than 40 peer-reviewed papers in pres-
tigious medical journals, including the American Society of
Radiation Oncology official journal - the International Journal of
Radiation Oncology Biology and Physics, Nature, the Journal of
Clinical Oncology, and several others. He is also the primary author
and editor of several book chapters published in prestigious books.
590 M. Shahait et al.

Dr. Thamir Alkasab is a distinguished uro-oncologist at Al

Zahra Hospital Dubai. He graduated as a uro-oncologist from
Princess Margret Cancer Center/University of Toronto in 2016.
Renowned for his expertise in urological cancer surgery, he spe-
cializes in using robotic/laparoscopic tools for precise interven-
tions. Dr. Thamir has authored many publications in the
uro-oncology field. His commitment to advancing treatment
options and improving outcomes for cancer patients underscores
his dedication to excellence in healthcare.

Dr. Ali Thwaini is a consultant urologist in Dubai with a special

interest in urological cancers, namely renal cancers. He was the
lead for renal cancers in the Belfast health and social care trust
(Belfast City Hospital). His main skills are in advanced laparos-
copy, renal cancer, and renal reconstruction procedures.He is also
an adjunct clinical professor at Mohammed bin Rashid University
in Dubai and an honorary clinical lecturer at Queen’s University,
Belfast.

Dr. Rabii Madi is a urologic oncologist with 20 years of aca-

demic and clinical experience in urologic oncology and minimally
invasive surgery. He is serving as the Director of Urology and
Robotic Surgery at CMC-Dubai. He was the director of robotic
surgery at Case Western Reserve in Cleveland before moving to
Georgia and heading the urologic oncology and robotic surgery
programs at Augusta University Health for 9 years.
Dr. Madi is among the most experienced robotic surgeons in
the USA. He has performed more than 2300 robotic surgeries and
has more than 50 peer-reviewed publications and 120 presenta-
tions in national and international meetings. He has pioneered
new techniques and approaches in urologic oncology and robotic
surgery.
35 Genitourinary Malignancies in the UAE 591

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer of

Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow)
in 2024. He is the only physician in the UAE with a subspecialty
fellowship certification and training in gastrointestinal oncology
and the first Emirati to train and complete a clinical post-doctoral
fellowship in palliative care. He was an assistant professor at the
University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new
distinct subgroup of CRC, NON V600 BRAF-mutated CRC. In
2022, he published the first book about cancer research in the UAE
and also the first book about cancer in the Arab world, both of
which were launched at Dubai Expo 2020. Cancer in the Arab
World has been downloaded more than 450,000 times in its first 18
months of publication and is the ultimate source of cancer data in
the Arab region. He also published the first comprehensive book
about cancer care in the UAE which is the first book in UAE his-
tory to document the cancer care in the UAE with many topics
addressed for the first time, e.g., neuroendocrine tumors in the
UAE. He is passionate about advancing cancer care in the UAE
and the GCC and has made significant contributions to cancer
awareness and early detection for the public using social media
platforms. He is considered as the most followed oncologist in the
world with over 300,000 subscribers across his social media plat-
forms (Instagram, Twitter, LinkedIn, and TikTok). In 2022, he was
awarded the prestigious Feigenbaum Leadership Excellence
Award from Sheikh Hamdan Smart University for his exceptional
leadership and research and the Sharjah Award for Volunteering.
He was also named the Researcher of the Year in the UAE in 2020
and 2021 by the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
592 M. Shahait et al.

across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various lev-
els of research training for medical trainees to enhance their clini-
cal and research skills. His mission is to advance cancer care in
the UAE and the MENA region and make cancer care accessible
to everyone in need around the globe.

Dr. Syed Hammad Tirmazy is a consultant clinical oncologist

and head of oncology at Dubai Hospital, DHA. He has substantive
experience in managing adult solid cancers and has been involved
in multiple international clinical trials. Before moving to Dubai in
2016, he worked as a consultant clinical oncologist in the West
Midlands region, UK. After completing his graduation, he moved
to the UK in 2003. He initially completed internal medicine train-
ing and MRCP and subsequently attained training in clinical
oncology and worked in internationally renowned oncology cen-
ters in the UK, including Queen Elizabeth Hospital Birmingham.
He has a master’s in clinical oncology from the University of
Birmingham, an FRCR in Clinical Oncology from RCR London,
and a CCT in Clinical Oncology. He also attained FRCP Glasgow.

Dr. Deborah Mukherji completed her advanced specialty train-

ing in Medical Oncology at Guys and St Thomas’s NHS
Foundation Trust, London UK and was awarded a Post-Graduate
Diploma in Oncology from the Institute of Cancer Research,
University of London, in 2011. On completion of her advanced
specialty training, Dr. Mukherji joined the Royal Marsden
Hospital London specializing in clinical research and drug devel-
opment with a focus on prostate cancer. Dr. Mukherji joined the
faculty of the American University of Beirut, Lebanon, in June
2012 and is currently an associate professor of clinical medicine.
She joined Clemenceau Medical Center Dubai, UAE as a consul-
tant medical oncologist in October 2022.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
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the copyright holder.
Sarcoma in the UAE
36
Aydah Al-Awadhi and Philipp Berdel

36.1 Background

According to the World Health Organization (WHO), soft tissue sarcoma is an

uncommon and rare type of malignancy in adults, accounting for approximately 2%
of all malignancies (primarily malignant bone tumors account for only 0.2% in
adults and more than 3% in children and adolescents). By definition, primary bone
and soft tissue sarcomas are non-epithelial malignancies. These are characterized
by rapid, locally infiltrative growth and show a high risk of metastasis. The most
common primary malignant bone tumors are osteosarcomas (approximately 35%),
chondrosarcomas (25%), and tumors of the Ewing sarcoma group (16%) [1, 10].
According to the 2020 WHO Classification of Tumors—Soft Tissue and Bone
Tumors, bone sarcoma (BS) and soft tissue sarcoma (STS) encompass roughly 100
distinct pathologic entities, many of which are ultrarare (incidence 1 per million) [2,
3]. Sarcomas are uncommon, and as a result, they frequently lack information about
their epidemiology, biology, natural history, prognostic and predictive indicators,
and sensitivity to standard treatment. This makes diagnosis and clinical decision-­
making difficult.

A. Al-Awadhi (*)
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Tawam Hospital, Al Ain, United Arab Emirates
e-mail: ayawadhi@seha.ae
P. Berdel
Tawam Hospital / STMC, Al Ain, United Arab Emirates
United Arab Emirates University, Al Ain, United Arab Emirates
e-mail: phberdel@seha.ae

© The Author(s) 2024 593

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_36
594 A. Al-Awadhi and P. Berdel

36.2 Burden of Sarcoma in the UAE

As expected, due to the rarity of the disease, there is limited information on STS and
bone sarcomas in the United Arab Emirates (UAE). In this chapter, we aim to shed
light on all available published data on sarcoma in the UAE and discuss available
services for STS and bone tumors, as well as the unmet needs.
According to the UAE National Cancer Registry Report (UAE-NCR) of 2021,
connective and soft tissue sarcomas in adult patients accounted for 47 cases out of
the total 5612 cancer cases diagnosed in 2021 across the country, representing
0.83% of all malignancies [4]. In the same report, bone and cartilage sarcomas were
documented to account for 34 cases out of all cancer cases in 2021, accounting for
0.6% of all cancer cases. In the pediatric population, UAE-NCR reported 4.5% of
bone and articular cartilage sarcomas.
Both bone (BS) and soft tissue sarcomas (STS) should ideally be treated at spe-
cialized facilities from the start because they require a comprehensive and sophisti-
cated therapeutic strategy involving pathologists, radiologists, specialized surgeons,
radiation oncologists, and medical oncologists [5].
Despite recent advances in pathology, there are still diagnostic difficulties that
must be acknowledged. Given the rarity of the disease, the significant forms of sar-
comas with dynamically changing nomenclature, the morphological heterogeneity
within the same class of sarcoma and different types of sarcomas, the pathological
overlap between benign and musculoskeletal tumors, and the availability of ade-
quate biopsy material for diagnosis, the task of pathology in sarcoma diagnosis is
complex [6]. Research on sarcomas has advanced significantly, and molecular tech-
niques such as next-generation sequencing have been utilized to identify the sub-
types of sarcomas [7, 8]. However, these molecular methods are not available in the
UAE and are often sent by large cancer centers abroad to be tested. A second opin-
ion from an anatomic pathologist specializing in musculoskeletal tumors should be
required prior to making a final treatment decision [7]. For diagnostic, predicative,
and prognostic purposes, specialized pathology centers are beginning to incorporate
molecular diagnostics into their histopathological reports. Since there is no highly
specialized sarcoma pathologist available in the UAE, many centers have collabo-
rated with large centers abroad, mainly in the United States, for a second patholo-
gist’s opinion [9].
To guarantee that all patients should receive the best care possible from a multi-
disciplinary team at a specialized facility. Usually, highly specialized orthopedic
oncology surgeons operate on patients with bone and soft tissue sarcomas, and only
a few with this expertise are available in the UAE, like in Tawam Hospital, the larg-
est tertiary cancer center in the UAE. For the resection of sarcomas, a wide resection
(R0) with a resection margin outside the reactive zone of the tumor (a safety margin
within ​​the cancellous bone of 3 cm) and entrainment of the existing biopsy channel
are required [10].
Also, only a few oncologists have dedicated, specialized sarcoma training and
interest. Therefore, strong cooperation within the community of physicians treating
36 Sarcoma in the UAE 595

sarcoma patients outside and within a sarcoma center is needed. The reconstruction
of the bones and joints after bone sarcoma resection is usually done by the implanta-
tion of megaprostheses. It is worth mentioning that in some highly specialized cen-
ters, the post-operative reconstruction of the bony defect can be done with recycled
bone grafts, e.g., by extracorporeal irradiation (ECI) or liquid nitrogen, when appro-
priate for the management of primary malignant bone tumors. Usually, National
Comprehensive Cancer Network (NCCN) guidelines direct the management of STS
and bone sarcomas in the UAE, and when chemotherapy or targeted agents are
needed, the standard regimens per National Comprehensive Cancer Network
(NCCN) guidelines are utilized. High-dose ifosfamide of more than 12 g/m2 with
mesna per dose is rarely utilized, partly due to a lack of experience with toxicity.

36.3 Conclusion

In conclusion, there is a great unmet need for expertise in the management of differ-
ent types of sarcomas. Therefore, strong cooperation among the physicians treating
sarcoma patients outside and within a sarcoma center is needed.

Conflict of Interest The authors have no conflict of interest to declare.

References
1. Siegel RL, et al. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7–33.
2. Miller KD, et al. Cancer statistics for adolescents and young adults, 2020. CA Cancer J Clin.
2020;70(6):443–59.
3. Italiano A, et al. Clinical effect of molecular methods in sarcoma diagnosis (GENSARC): a
prospective, multicentre, observational study. Lancet Oncol. 2016;17(4):532–8.
4. Cancer incidence in United Arab Emirates, Annual Report of the UAE - National Cancer
Registry, 2021. Statistics and Research Center, Ministry of Health and Prevention. (Accessed
on 28 Mar 2024).
5. Siegel GW, et al. The multidisciplinary management of bone and soft tissue sarcoma: an essen-
tial organizational framework. J Multidiscip Healthc. 2015;8:109–15.
6. Liegl-Atzwanger B. The role of pathology in sarcoma. Memo - Mag Eur Med Oncol.
2020;13(2):159–63.
7. Fletcher C, et al. WHO classification of tumours of soft tissue and bone: WHO classification
of tumours, vol. 5. World Health Organization; 2013.
8. Szurian K, Kashofer K, Liegl-Atzwanger B. Role of next-generation sequencing as a diagnos-
tic tool for the evaluation of bone and soft-tissue tumors. Pathobiology. 2017;84(6):323–38.
9. Randall RL, et al. Errors in diagnosis and margin determination of soft-tissue sarcomas ini-
tially treated at non-tertiary centers. Orthopedics. 2004;27(2):209–12.
10. Berdel P. In: Ruchholtz S, Wirtz DC, editors. Orthopädie und Unfallchirurgie essentials.
Intensivkurs zur Weiterbildung. 4th ed. Stuttgart New York: Georg Thieme Verlag; 2021.
p. 169–218.
596 A. Al-Awadhi and P. Berdel

Dr. Aydah Al-Awadhi is a consultant medical oncologist who

graduated from medical school at the United Arab Emirates
University in 2012, then completed her internal medicine residency
in the United States and completed her medical oncology and
hematology fellowship at the University of Texas, MD Anderson
Cancer Center, in 2019. She is American Board certified in internal
medicine, hematology, and medical oncology. She was awarded the
Emirates Oncology Society (EOS) Member of the Year Award for
2021 and the Emirates Oncology Society Women in Oncology of
the Year Award. She is also currently the scientific chairperson of
the Emirates Oncology Society and the chair of the Breast Cancer
Working Group. Dr. Al-Awadhi has published many articles and
book chapters on breast cancer and oncology, with her main exper-
tise in breast cancer and sarcoma.

Prof. Dr. Philipp Berdel FRCS received his medical degree at the
University of Bonn in Germany and then started his residency as an
orthopaedic surgeon in 1997 in the Department of Orthopaedic and
Trauma Surgery of the University Hospital Aachen, Germany.
After finishing his training as an orthopaedic surgeon in 2005
and fellowships in orthopaedic rheumatology (2006) and pediatric
orthopaedic surgery (2008), he received training authorization in
both fields in 2008 and 2010, respectively.
In 2011, he reached the highest level of orthopaedic training in
Germany, Advanced Orthopaedic Procedures, from the Medical
Board Nordrhein, Germany.
Since 2013, he has lived and worked in Al Ain, Abu Dhabi, UAE.
In 2017, he became one of only 45 certified orthopedic oncol-
ogy surgeons on the German Medical Board (out of 13.400 ortho-
pedic surgeons).
Since 2017, he has been an adjunct professor in the Department
of Surgery, College of Medicine and Health Science, United Arab
Emirates University (UAEU); since February 2021, he has been a
full professor.
He is a member of the German Orthopaedic Society (DGOOC)
and of its scientific working group for orthopaedic oncology. On
May 1, 2015, he joined the Emirates Medical Association/Emirates
Orthopaedic Society as well.
He is a Fellow of the Royal College of Surgeons of England
(FRCS) and holds the German, GMC (UK), DOH (Abu Dhabi),
and MOH (Oman) licenses.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Neuroendocrine Tumors (NETs)
in the UAE 37
Aydah Al-Awadhi and Humaid O. Al-Shamsi

37.1 Introduction

Neuroendocrine neoplasms (NEN) are uncommon and can develop anywhere in the
body, most commonly in the gastrointestinal tract, lung, and pancreas [1, 2].
Although most neuroendocrine tumors (NETs) are neuroendocrine tumors (NETs)
with a slow-progressing disease biology, 10–20% of NENs are neuroendocrine car-
cinomas (NECs), which are highly proliferative tumors. Neuroendocrine tumors
occur at a rate of 2.5 to 5 per 100,000 per year [3].
The approach to neuroendocrine neoplasms usually includes extensive clinical
assessment, both clinically and chemically, radiological imaging, nuclear scans, and
pathological evaluation to reach a definitive diagnosis and treatment plan.

A. Al-Awadhi
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
e-mail: ayawadhi@seha.ae
H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 597

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_37
598 A. Al-Awadhi and H. O. Al-Shamsi

37.2 NETs Prevalence in the UAE

In a survey conducted by Al-Shamsi et al. through the Emirates Oncology Society

(EOS) in September 2021, this is the first survey to assess the current burden of
NET in the United Arab Emirates (UAE). The survey was distributed to oncologists,
surgeons, and endocrinologists through direct emails and WhatsApp groups. The
estimated number of invited participants was 110 physicians who potentially treat
neuroendocrine tumors. The survey aimed to get a snapshot of the status and burden
of NET in the UAE at the time of the survey, which may also reflect the overall
burden of NET in the UAE.
Forty-three respondents (39%) completed the survey: 31 were medical oncolo-
gists, 3 were general surgeons, 4 were radiation oncologists, 2 were endocrinolo-
gists, and only 1 was a gastroenterologist.
Thirty-one respondents (72.1%) had active patients with neuroendocrine tumors
at the time of the survey. Sixteen (37.2%) had between 1 and 3 NET patients at the
time of the survey, and 11 (25.6%) had 4–6 NET patients. Six (14%) had seven to
nine patients, and only four had more than ten patients, which may reflect the refer-
ral patterns to some oncologists or centers.
Thirty-one respondents (73.8%) indicated that GI NET was the most common
NET in their practice. Six (14.3%) respondents selected lung and two (4.8%)
selected gynecological NETs as the most common NETs in their practices.
The pancreas was the top answer for the most common gastro-entero-pancreatic
NET, with pancreas 22 (30.6%), stomach 17 (23.6%), small intestine 13 (18.1%),
appendix 12 (16%), and lastly, colon 8 (11.1%). According to the responses, the
following NETs are the least common in their practice, with the rectum being the
least common, followed by the stomach, and then the colon.
Forty-one (95.3%) of the respondents agreed that general practitioners, gastroen-
terologists, and general surgeons need more education about NETs to better diag-
nose NETs. 31 (72.1%) reported delays in the diagnosis of their NET patients.
The most used modalities in imaging NETs were Dota-PET with 26 (29.2%),
followed by octreotide scan with 22 (24.7%), CT with 17 (19.1%), and PET/CT
with 14 (15.7%). Twenty-three (53.5%) respondents reported ordering chromo-
granin and 5-HIAA as their initial workup for NET patients. Twenty-two (51.2%)
agreed that the number of NET patients is increasing over time in their practice.
Thirty-five (81.4%) reported not having access to the NET multidisciplinary
tumor board (MDT) in their hospital or practice. 23 respondents (54.8%) reported
they needed more experience using peptide receptor radionuclide therapy (PRRT)
for the management of NETs.
Unfortunately, there is no data to illustrate the prevalence of NEN in the UAE. An
IRB-approved study conducted in a single high-volume center (Tawam hospital)
found that from 2010 to 2020, approximately 149 patients were diagnosed with
NEN, the majority of whom originated in the GI tract (N = 67), followed by the lung
(N = 43), pancreas (N = 23), cervix (N = 9), and others with unknown primary origin
(N = 7) [4]. Interestingly, most of the patients were also metastatic at presentation
37 Neuroendocrine Tumors (NETs) in the UAE 599

(102/149). The median age at diagnosis was 56. Females comprised 51 patients of
the total population, whereas men were 98. Interestingly, a good number of patients
presented and were diagnosed with carcinoid syndrome (N = 63) [4].
Also, in another study conducted by the University of Sharjah and published in
2014 that investigated the clinicopathological characteristics of appendiceal carci-
noid in Sharjah, out of the 964 patients who underwent surgery for acute appendici-
tis from January 2010 through December 2010 in a single center, 9 were found to
have an appendiceal carcinoid [5]. The median age is 28.7 years, with male inci-
dence being higher than female incidence. The incidence reported in this study is
apparently higher than that reported from other regions in the Gulf countries [5].
In terms of diagnostic workup, most of the modalities are available in large can-
cer centers, including octreotide SPECT, CT, and SSTR-PET. Also, peptide recep-
tor radionuclide therapy (PRRT) with 177 Lu-DODATE is available in limited
centers in the UAE. Other liver-directed modalities, including TACE and TARE, are
available as well, but in fewer centers based on the availability of experienced inter-
ventional radiologists.
Most of the medications indicated for use in metastatic neuroendocrine tumors
or carcinomas are available in the UAE, from chemotherapy to targeted medications
and hormonal therapy. There is, however, a high unmet need in terms of public
awareness of this tumor, which the Emirates Oncology Society (EOS), in collabora-
tion with different companies and institutions, is working hard to shed light on. For
example, EOS and Ipsen, which is a global biopharmaceutical company, have cre-
ated the largest awareness ribbon displaying the zebra print associated with the
condition’s awareness activity, which measures 4.8 m2, breaking the previous record.
Finally, more research is needed to better understand the prevalence and charac-
teristics of NEN in the UAE, as well as to raise public awareness of this disease
entity, its implications, and its clinical presentation.

37.3 Conclusion

Despite their increasing incidence, NETs are considered to be rare tumors. There is
no published data about the prevalence of NETs in the UAE. In a survey in 2021 for
oncologists in the UAE, 43 respondents completed the survey. Thirty-one respon-
dents (72.1%) had active patients with neuroendocrine tumors at the time of the
survey. Thirty-one respondents (73.8%) indicated that GI NET was the most com-
mon NET in their practice. Six respondents (14.3%) selected lung and two (4.8%)
selected gynecological NETs as the most common NETs in their practices. This is
the first study to address the potential burden of NETs in the UAE. More education
for family physicians, endocrinologists, and gastroenterologists in the UAE is
needed to facilitate early diagnosis. More research is needed to assess the burden of
NET in the UAE.

Conflict of Interest The authors have no conflict of interest to declare.

600 A. Al-Awadhi and H. O. Al-Shamsi

References
1. Yao JC, Hassan M, Phan A, Dagohoy C, Leary C, Mares JE, et al. One hundred years after
"carcinoid": epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases
in the United States. J Clin Oncol. 2008;26(18):3063–72.
2. Sorbye H, Strosberg J, Baudin E, Klimstra DS, Yao JC. Gastroenteropancreatic high-grade
neuroendocrine carcinoma. Cancer. 2014;120(18):2814–23.
3. Oronsky B, Ma PC, Morgensztern D, Carter CA. Nothing but NET: a review of neuroendocrine
tumors and carcinomas. Neoplasia. 2017;19(12):991–1002.
4. Cancer Registry, Tawam Hospital, SEHA, Al Ain, United Arab Emirates.
5. Anwar K, Desai M, Al-Bloushi N, Alam F, Cyprian FS. Prevalence and clinicopathologi-
cal characteristics of appendiceal carcinoids in Sharjah (United Arab Emirates). World J
Gastrointest Oncol. 2014;6(7):253–6.

Dr. Aydah Al-Awadhi is a consultant medical oncologist who

graduated from medical school at the United Arab Emirates
University in 2012, then completed her internal medicine residency
in the United States, and completed her medical oncology and
hematology fellowship at the University of Texas, MD Anderson
Cancer Center, in 2019. She is American Board-certified in internal
medicine, hematology, and medical oncology. She was awarded the
Emirates Oncology Society (EOS) Member of the Year Award for
2021 and the Emirates Oncology Society Women in Oncology of
the Year Award. She is also currently the scientific chairperson of
the Emirates Oncology Society and the chair of the Breast Cancer
Working Group. Dr. Al-Awadhi has published many articles and
book chapters on breast cancer and oncology, with her main exper-
tise in breast cancer and sarcoma.

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer

of Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty fel-
lowship certification and training in gastrointestinal oncology and
the first Emirati to train and complete a clinical post-doctoral
37 Neuroendocrine Tumors (NETs) in the UAE 601

fellowship in palliative care. He was an assistant professor at the

University of Texas MD Anderson Cancer Center between 2014
and 2017. He has published more than 140 peer-reviewed articles
in JAMA Oncology, Lancet Oncology, The Oncologist, BMC
Cancer, and many others. His area of expertise includes precision
oncology and cancer care in the UAE. In 2016, he published with
his group from MD Anderson the JCO paper describing a new dis-
tinct subgroup of CRC, NON V600 BRAF-mutated CRC. In 2022,
he published the first book about cancer research in the UAE and
also the first book about cancer in the Arab world, both of which
were launched at Dubai Expo 2020. Cancer in the Arab World has
been downloaded more than 450,000 times in its first 18 months of
publication and is the ultimate source of cancer data in the Arab
region. He also published the first comprehensive book about can-
cer care in the UAE which is the first book in UAE history to docu-
ment the cancer care in the UAE with many topics addressed for
the first time, e.g., neuroendocrine tumors in the UAE. He is pas-
sionate about advancing cancer care in the UAE and the GCC and
has made significant contributions to cancer awareness and early
detection for the public using social media platforms. He is consid-
ered as the most followed oncologist in the world with over
300,000 subscribers across his social media platforms (Instagram,
Twitter, LinkedIn, and TikTok). In 2022, he was awarded the pres-
tigious Feigenbaum Leadership Excellence Award from Sheikh
Hamdan Smart University for his exceptional leadership and
research and the Sharjah Award for Volunteering. He was also
named the Researcher of the Year in the UAE in 2020 and 2021 by
the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
of research training for medical trainees to enhance their clinical
and research skills. His mission is to advance cancer care in the
UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Hematological Malignancies in the UAE
38
Shahrukh Hashmi

38.1 Introduction

Hematologic malignancies, like solid tumors, are an extremely heterogeneous group of

diseases. Apart from chemotherapy, immunotherapy, surgery, and radiation therapy,
hematologic malignancies have an added arm of cellular therapies (bone marrow trans-
plant, CAR-T cells, and gene therapy), making the patient’s journey very complex. The
classification of hematologic malignancies is also very problematic, as many different
systems exist concurrently and different countries utilize different classifications,
which in turn affects the overall national statistics of diseases with respect to incidence
rate. Some of the systems existents are the Gall and Mallory classification, Rappaport
classification, Kiel classification, Lukes-Collins classification, Working Formulation,
Revised European-American classification (REAL), French-American-British system,
World Health Organization (WHO) classification 2001, and World Health Organization
(WHO) classification 2008, revised in 2016. Though earlier classification systems
were based on tissue architecture and the cytologic appearances of neoplastic cells, the
current era of genomics is driving the newer classification systems.
Since there are more than 200 countries in the world, it is imperative to know
which classification is being used in a particular region. In 2016, the WHO classifi-
cation was updated and expanded upon the use of objective diagnostic criteria (e.g.,
particularly for genomics) for clearly defined entities and is now widely accepted in
some countries. However, unfortunately, it takes years for the diffusion of

S. Hashmi (*)
Mayo Clinic, Rochester, MN, USA
Department of Health, Abu Dhabi, United Arab Emirates
Khalifa University, Abu Dhabi, United Arab Emirates
e-mail: hashmi.shahrukh@mayo.edu

© The Author(s) 2024 603

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_38
604 S. Hashmi

innovation or updated practice in healthcare, and thus one needs to be careful when
comparing the epidemiology of hematologic malignancies if different classification
systems are being used.

38.2 UAE Statistics

Bearing in mind the critically important differences in the classification of hemato-

logic malignancies, let’s focus on the paradigm of hematologic malignancies in the
United Arab Emirates (UAE), which is a country of approximately ten million peo-
ple. Fortunately, the data in the UAE on hematologic malignancies is assimilated
based on the latest WHO classification, and the last published data was the sixth
annual report of the UAE National Cancer Registry, in which the UAE National
Cancer Registry (UAE-NCR) records demographic, cancer, staging, clinical, and
treatment information for all cancers diagnosed in the UAE in accordance with
internationally accepted registration and coding standards, which are WHO-based
unless otherwise specified [1–3]. For UAE and non-UAE citizens in the country, all
malignant and in situ cases diagnosed in the UAE during 1 January–31 December
2021 were notified and registered to the UAE National Cancer Registry [1].
There is a striking difference in the incidence rates of invasive cancers between
the North American statistics and those of the UAE. The ratio of solid cancers to
hematologic malignancies is tilted, with a higher proportion of hematologic malig-
nancies in the UAE. As per the 2021 data of the UAE National Cancer Registry by
the Ministry of Health and Prevention (MOHAP), leukemias and non-Hodgkin’s
lymphomas (NHL) are the fourth and eigth leading cancers in the UAE, respec-
tively. This contrasts with the data from the registry in the United States, where only
one hematologic malignancy is in the top 10 cancers [1, 2].
This trend of a higher proportion of hematologic malignancies in the UAE is also
found in geographically nearby locations, e.g., in Saudi Arabia, where the last report
by the Saudi Cancer Registry (2016) indicates the presence of the NHL and leuke-
mias as the fifth and sixth most common malignancies, respectively.
The current data cannot explain why there is a disparity in a higher incidence of
hematologic incidence.

38.3 Healthy Worker Effect in the UAE with Respect

to Hematologic Malignancies

Median age (in years) in the UAE is 32.8. The main reason is that 65% of the popu-
lation is between 25 and 54 years old and represents mainly the workers coming
from different countries for work and the majority of them return to their native
countries at the time of retirement. Thus, traditional methods of projecting cancer
incidence rates have an inherent bias because not only are cancers that are prevalent
at a younger age different in the overall sample, but it is also impossible to predict
38 Hematological Malignancies in the UAE 605

trends given expatriates belong to over 200 countries, thus causing a healthy worker
effect [4, 5].

38.4 Consanguinity

In the current genomics era, there is an increased propensity for the diagnosis of
genetic conditions predisposing to hematologic malignancies. With targeted next-­
generation sequencing (NGS) for hematologic cancers and immunodeficiencies, a
wide variety of inheritable syndromes are being diagnosed that cause various hema-
tologic malignancies, especially leukemias; e.g., in a large study by the Center for
International Blood and Marrow Transplant Research (CIBMTR), the post- and pre-­
transplant samples of patients with myeloid malignancies were evaluated for inher-
itable mutations, and though the sample was consistent of adults and elderly patients,
4% of the patients were found to have the SBDS mutation, which is the hallmark of
Shwachman-Diamond syndrome (SDS).
Given that Arab populations and some expatriate populations that are prevalent
in the UAE (particularly Pakistan, Saudi Arabia, and Nigeria) have a high rate of
consanguinity, a higher incidence of inheritable hematologic malignancies is esti-
mated, particularly for leukemias, which can arise from a number of inherited (auto-
somal recessive) conditions.

38.5 Diagnostic Issues and the Current Paradigm

Since a critically important decision in high-risk hematologic malignancies is

hematopoietic stem cell transplantation (HSCT), chimeric antigen receptor T cells
(CAR-T cells), and gene therapy, one must have a clear picture of which patients not
to take for these very complex and high-risk procedures. For decision-making, one
needs a targeted NGS panel, cytogenetics, fluorescence in situ hybridization (FISH)
panel, and minimal residual disease (MRD) for assessments of acute leukemias,
multiple myeloma, lymphomas, and myelodysplastic syndromes [6].
Some real-world issues that are prevalent in the UAE for diagnostics are the
unavailability of these genomic testing panels. If they are available at a particular
institution, the denial of approval for these tests is commonly observed in hemato-
logic malignancies, especially if these are send-out tests (out of the country). Some
of the testing has been the standard of care for decades, e.g., MRD testing for B-cell
acute lymphoblastic leukemia (B-ALL), and unfortunately, it is unavailable in the
majority of the hospitals in the UAE as an in-house test.
Similarly, most large healthcare institutions still (as of the writing of this in 2022)
do not perform in-house NGS myeloid or lymphoid panels, which is a critical piece
of information when deciding on HSCT. For example, some of the known driver
mutations in acute leukemias have an almost 0% chance of cure with chemotherapy
alone and require an immediate transplant. Unlike solid cancers, the morphology of
606 S. Hashmi

the cancer and cytopathology have become less important in hematologic malignan-
cies, where the primary driver clone may drive the progression of cancer, but over
time, there could be many sub-clones that become dominant and proliferate, and
thus genomics is the primary driver of the oncogenesis in hematologic cancers.

38.6 Management Issues

Cellular therapies are not new in the treatment paradigm of hematologic malignan-
cies, as HSCT was performed in the 1950s. About a decade ago, the first reports of
successful CAR-T cells were published. In 2017, the first CAR-T cells were
approved for leukemias and subsequently for lymphomas in the United States. Since
then, at least six CAR-T products have been approved, but all for hematologic
malignancies (B-ALL, NHL, and multiple myeloma). As of now, neither the
US-FDA nor the EMA have approved a CAR-T product for solid cancers, and the
role of autologous HSCT (auto-SCT) is limited to a few solid cancers (germ cell
tumors, Wilms tumors, and neuroblastomas). Lastly, gene therapy has been approved
by the EMA and the FDA for certain hematologic conditions (e.g., hemophilia and
thalassemia), and there is no known role for gene therapy for solid cancers currently.
All three treatment modalities—HSCT, CAR-T cells, and gene therapy— require
extensive infrastructure in the form of a transplantation unit, dedicated and skilled
personnel, and extensive quality management systems. Furthermore, these therapies
are expensive, with average costs significantly higher than the annual costs of
immunotherapies, chemotherapies, radiotherapies, or oncologic surgeries. For
example, CAR-T cell therapy in the United States typically costs between USD
375,000 and 500,00, an allogeneic HSCT is typically priced between USD 400,000
and 750,000, and gene therapy pricing is above a million dollars per treatment [7].
In the UAE, at least four facilities are licensed by the regulatory authorities to
perform HSCTs (three in Abu Dhabi and one in Dubai). These are likely going to be
the facilities that are also going to be involved in future CAR-T cell therapies and
gene therapy. The coverage issues for both the local population and the expatriate
population need to be solved in order to provide smooth and optimal care for
patients’ journeys with hematologic malignancies.
Acute leukemias (particularly acute lymphoblastic leukemia and acute myeloid
leukemias) and Burkitt lymphoma are true medical emergencies and need urgent
admission and treatment. There are few centers that perform “acute leukemia induc-
tion” for acute leukemias, and these centers are present in Dubai, Abu Dhabi, and Al
Ain. There is a networked ecosystem for the referral of these patients to these large
facilities managing acute leukemias. However, post-leukemia induction, the insur-
ance coverage for both local patients and expatriates needs to improve for pre-­
transplant requisites, e.g., HLA typing for both the recipient and the donor.
According to the 2021 UAE cancer registry report, there were 304 cases of leu-
kemia and 228 cases of NHL diagnosed in the preceding year [1]. Some cases could
be either due to non-reporting bias or emigration/immigration bias. Nonetheless,
only a minority of these received HSCT, and data is only available for UAE citizens
who traveled abroad for the receipt of the transplant. Now better systems are being
38 Hematological Malignancies in the UAE 607

placed to track the patient journal, i.e., cancer survivorship, which begins from the
time of diagnosis until death, and thus it is imperative that long-term data, both pre-
and post-transplant, be captured.
A robust ecosystem of research is being developed in the UAE, which is impera-
tive for hematologic malignancies given the complexity of cellular therapies. CAR-T
clinical trials and various stem cell therapy products will likely be tested in human
trials, which will help improve both the clinical outcomes and the mortality statistics.
Some issues pertaining specifically to the hematologic malignancies in the UAE
are presented in Table 38.1.

Table 38.1 Hematologic malignancies in the UAE

Current situation Issues Mitigation strategies
Statistics Eighty-five percent are Immigration and Age-adjusted rates with
tracking expatriates with majority emigration bias the removal of healthy
of them being Healthy worker effect worker bias
20–65 years of age
Diagnosis of  (a) Most hematologic  (a) Absence of  (a) Develop in-house
hematologic malignancies targeted NGS capabilities for both
malignancies require panels NGS panels and also
cytogenetics, (lymphoid and for MRD testing for
FISH, and targeted myeloid) in the acute leukemias
NGS panels for majority of the  (b) Influence insurance
decision-­making hospitals in the companies to
about treatment UAE approve the standard
 (b) Acute leukemias  (b) Absence of diagnostics for
and myeloma need MRD testing hematologic
MRD testing post-induction malignancies, which
post-induction for chemotherapy include genomic
treatment decisions for acute testing
leukemias
Cellular  (a) Bone marrow  (a) HSCT has been  (a) Gain accreditation
therapies transplant started in the through the FACTa/
(hematopoietic UAE, but there JACIEb for the
stem cell is no FACTa- or HSCT programs in
transplant, HSCT) JACIEb- the UAE
plays a vital role in accredited  (b) Start the CAR-T
cure of most of the center in the program by
hematologic country yet establishing robust
malignancies  (b) No CAR-T cell infrastructure in the
 (b) CAR-T cells are therapy facility UAE, including a
being used as a is ready to start state- of-the-art
curative treatment commercial quality management
in some cancers CAR-T cell system (QMS)
and as a bridge to therapy
transplant for some  (c) Gene therapy
cancers infrastructure is
 (c) Gene therapy is not available
being used to cure
certain
hematologic
conditions
(continued)
608 S. Hashmi

Table 38.1 (continued)

Current situation Issues Mitigation strategies
Hematologic  (a) For hematologic  (a) Absence of  (a) Establishment of
malignancies malignancies and dedicated dedicated loss to
survivorship HSCT, long-term cancer follow-up (LTFU) or
follow-up clinics survivorship survivorship clinics
are required and BMT for leukemia,
survivorship lymphoma, and
clinics myeloma
 (b) Establish a
multidisciplinary
clinic for HSCT/
BMT and graft-
versus-host disease
(GVHD)
Clinical  (a) Given the poor  (a) No in-house (by  (a) Establishing a
trials prognosis of UAE state-of-the-art
certain investigators) clinical trials unit
hematologic interventional  (b) Establish funding
malignancies, clinical trial has mechanisms
novel drug testing started in the specifically for
is necessary to field of hematologic
improve outcomes hematologic malignancies and
 (b) the etiology of malignancies stem cell therapies
most of the  (b) Gene editing (including CAR-T
hematologic trials for cells and gene
malignancies is various therapy)
unknown hematologic
conditions have
not started yet
a
FACT Foundation for the Accreditation of Cellular Therapy
b
JACIE Joint Accreditation Committee ISCT-Europe & EBMT

38.7 Conclusion

The presence of hematologic malignancies in the UAE is proportionately (com-

pared to solid cancers) higher than that in the United States. The exact causes are
unknown. Moreover, the complex management of hematologic malignancies
includes stem cell transplantation, CAR-T cells, and gene therapies, besides the
traditional chemotherapies and immunotherapies. We need to pay attention to
immigration and emigration bias, besides the healthy worker effect in the
UAE. Lastly, now there is a great movement toward the establishment of cellular
therapy centers in the UAE, which include the only potentially curable treatments
for many cancers.

Conflict of Interest The author has no conflict of interest to declare.

38 Hematological Malignancies in the UAE 609

References
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3. Khoury JD, Solary E, Abla O, Akkari Y, Alaggio R, Apperley JF, Bejar R, Berti E, Busque
L, Chan JK, Chen W. The 5th edition of the World Health Organization classification
of haematolymphoid tumours: myeloid and histiocytic/dendritic neoplasms. Leukemia.
2022;36(7):1703–19.
4. https://fcsc.gov.ae/en-us/Pages/Statistics/Statistics-by-Subject.aspx#/%3Ffolder=​Demography%20
and%20Social/Population/Population&subject=Demography%20and%20Social.
5. Kirkeleit J, Riise T, Bjørge T, Christiani DC. The healthy worker effect in cancer incidence
studies. Am J Epidemiol. 2013;177(11):1218–24.
6. El Achi H, Kanagal-Shamanna R. Biomarkers in acute myeloid leukemia: leveraging next gen-
eration sequencing data for optimal therapeutic strategies. Front Oncol. 2021;11:3997.
7. Gene therapies should be for all. Nat Med. 2021. 27, 1311.

Dr. Shahrukh Hashmi is the Director of Research at the

Department of Health, Abu Dhabi, UAE. He graduated from Baqai
Medical University, Pakistan, as the top graduate, receiving a gold
medal from the president of Pakistan. He received a master’s degree
(MPH) from Yale University, Connecticut, USA. He is a diplomat
of the American Board of Preventive Medicine/public health, inter-
nal medicine, and hematology. He is a Professor of Medicine at the
Mayo Clinic, Rochester, Minnesota, US. He started the Mayo
Clinic’s first BMT survivorship program. He has served as PI or
co-PI on many industry-­sponsored and NIH-sponsored trials. His
research interests include premature aging, artificial intelligence,
and GVHD. He is also involved in stem cell therapeutics, particu-
larly in regenerative hematology. He has authored >300 articles in
peer-reviewed journals, including JAMA, Lancet, and The NEJM,
and has an H-index of>50, and has >10,000 citations. He chairs
many national or international professional committees or groups,
including being the chair of the Worldwide Network for Blood and
Marrow Transplant’s Nuclear Accident Committee (Geneva,
Switzerland), the founding chair of the American Society for Blood
and Marrow Transplant Society’s Survivorship SIG (Chicago,
Illinois), and the co-chair of the Center for International Blood and
Marrow Transplant Registry’s (CIBMTR) Health Services
Committee (Milwaukee, Wisconsin).
610 S. Hashmi

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
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the copyright holder.
Hematopoietic Stem Cell
Transplantation (HSCT) in the UAE 39
Humaid O. Al-Shamsi , Amin M. Abyad,
Zainul Aaabideen Kanakande Kandy, Biju George,
Mohammed Dar-Yahya, Panayotis Kaloyannidis,
Amro El-Saddik, Shabeeha Rana, and Charbel Khalil

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca
A. M. Abyad
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
Department of Oncology, Burjeel Medical City, Abu Dhabi, United Arab Emirates
Z. A. Kanakande Kandy
Department of Oncology, Burjeel Medical City, Abu Dhabi, United Arab Emirates
e-mail: zainul.aabideen@burjeelmedicalcity.com
B. George · P. Kaloyannidis
Department of Haematology, Burjeel Medical City, Abu Dhabi, United Arab Emirates
Department of Bone Marrow Transplant and Cell Therapy, Burjeel Medical City,
Abu Dhabi, United Arab Emirates
e-mail: biju.george@burjeelmedicalcity.com; panagiotis.kalogiannidis@burjeelmedicalcity.com
M. Dar-Yahya
Department of Bone Marrow Transplant and Cell Therapy, Burjeel Medical City,
Abu Dhabi, United Arab Emirates
e-mail: mohammed.hamid@burjeelmedicalcity.com
A. El-Saddik
Department of Oncology, Burjeel Medical City, Abu Dhabi, United Arab Emirates
Department of Bone Marrow Transplant and Cell Therapy, Burjeel Medical City,
Abu Dhabi, United Arab Emirates
e-mail: amro@burjeelholdings.com

© The Author(s) 2024 611

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_39
612 H. O. Al-Shamsi et al.

S. Rana
Genesis Healthcare centre, Dubai, United Arab Emirates
e-mail: Shabeeha@doctors.org.uk
C. Khalil
Department of Bone Marrow Transplant and Cell Therapy, Burjeel Medical City,
Abu Dhabi, United Arab Emirates
Reviva Regenerative Medicine center, Middle East Institute of Health University Hospital,
Bsalim, Lebanon
School of Medicine, Lebanese American University, Beirut, Lebanon
e-mail: charbel.khalil@burjeelmedicalcity.com

39.1 Introduction

Hematopoietic stem cell transplantation (HSCT) has become an essential and poten-
tially life-saving or curative choice for various non-cancerous and cancerous blood-
related conditions, solid tumors, and immune system disorders [1]. Over time, there
has been a gradual shift in the perception of hematopoietic stem cell transplantation
(HSCT) as a treatment option. Initially viewed as a last resort, it has now become an
integral part of the international treatment guidelines for both malignant and non-
malignant diseases mentioned earlier. The decision to recommend HSCT involves a
meticulous evaluation of the risks and benefits by a team of experts. Factors consid-
ered include the disease stage, duration, presence of other medical conditions, indi-
vidual patient characteristics, transplant protocol, donor type, source of stem cells,
conditioning regimen, and more. This comprehensive assessment helps determine
whether the benefits of HSCT outweigh those of non-­transplant strategies for each
patient [1, 2]. Proficiency and knowledge in HSCT play a crucial role in the imple-
mentation of cellular therapy and gene therapies, which hold immense potential for
revolutionizing the landscape of treatment choices for a wide range of illnesses [3–
5]. The effectiveness of any HSCT or cellular therapy program relies heavily on the
creation and implementation of a well-structured and specialized unit comprising
experienced multidisciplinary teams who adhere to the highest global standards. In
this section, we will discuss the advancements made in HSCT services within the
United Arab Emirates (UAE) and share our valuable insights and knowledge gained
from establishing the first all-encompassing pediatric and adult HSCT service in the
country. This service has been specifically designed to address the needs of UAE citi-
zens, residents, and individuals from neighboring countries who encounter similar
difficulties in accessing HSCT treatments.

39.2 Historical Background of the Unmet Need for HSCT

in the UAE

In December 1971, the UAE was formed as a union of seven Emirates. With its
rapid economic growth, the UAE has emerged as one of the world’s fastest-growing
economies, thanks to visionary leadership, strategic planning, significant
39 Hematopoietic Stem Cell Transplantation (HSCT) in the UAE 613

investments, and exceptional infrastructure development. The healthcare sector has

also experienced remarkable progress in recent decades, marked by the establish-
ment of advanced governmental and private healthcare institutions in collaboration
with regional and international partners. However, despite these advancements, a
significant number of local patients still travel abroad, particularly for cancer treat-
ment [6]. Over the past few years, numerous pediatric and adult patients from the
UAE have sought medical treatment overseas, primarily in countries such as the
USA, Germany, Korea, the UK, and Singapore. These patients have received care
for both cancerous and non-cancerous ailments, with the expenses being covered by
the UAE government [7]. A similar situation can be observed with expatriate resi-
dents, as they frequently choose to go back to their home countries to receive medi-
cal treatment. This decision is influenced by a range of logistical and economic
factors, such as inadequate insurance coverage or loss of employment due to ill-
ness [8].
Given the prevalence and occurrence of both non-cancerous and cancerous
blood-related diseases in the UAE, there is a pressing need for local approaches like
HSCT. To address this, the Ministry of Health and Prevention (MOHAP) took the
initiative to establish the UAE National Cancer Registry (UAE-NCR) in 2014. This
population-based cancer registry encompasses data from both UAE citizens (local
Emirati patients) and non-UAE citizens (expatriate residents) [9]. The most recent
annual report released by the UAE National Cancer Registry (UAE-NCR) in 2022
provides data on newly diagnosed cases in the year 2019. This includes information
on 220 cases of leukemia (comprising 168 expatriate and 52 Emirati patients), 42
cases of multiple myeloma (32 expatriate and 10 Emirati patients), 215 cases of
non-Hodgkin’s lymphomas (151 expatriate and 64 Emirati patients), and 76 cases of
Hodgkin’s lymphomas (51 expatriate and 25 Emirati patients) [9]. Regarding non-­
cancerous reasons for HSCT, the UAE exhibits notably elevated rates of various
hereditary blood disorders that have been historically prevalent in the region. These
disorders, including thalassemia, impose a substantial burden on public health and
healthcare resources in terms of both prevalence and the medical care required
[10, 11].
Before the year 2020, the lack of comprehensive HSCT centers in the UAE
meant that seeking transplant services abroad became unavoidable. It is estimated
that hundreds of patients, both adults and pediatrics, travel abroad annually to seek
HSCT treatment. This situation presents several challenges, including limited cov-
erage, logistical difficulties, high costs, and the need for meticulous peri- and post-­
HSCT procedural management. It not only impacts the psychological well-being of
patients and their families but also disrupts the essential continuity of care. Many
returning patients often have an inadequate understanding of their medical condi-
tion and the treatment they received abroad, and they may lack important medical
documentation and reports. These factors can potentially lead to treatment interrup-
tions or discrepancies between local and overseas medical teams due to communi-
cation gaps that commonly exist [11, 12]. The overall quality of care for patients is
frequently affected by difficulties arising from cultural disparities, ethical and reli-
gious considerations, and language barriers, which can compromise their experi-
ences [15]. We have observed that medical tourism is made more complex by factors
614 H. O. Al-Shamsi et al.

such as restricted mobility and the added risk of COVID-19 infection during travel.
These circumstances necessitate stringent travel arrangements, which are particu-
larly concerning for an already immunocompromised patient population that
requires continuous medical care. Therefore, the COVID-19 pandemic and travel
restrictions have emphasized the critical need for locally based and self-sufficient
HSCT programs within the UAE [12].
Considering all these factors, we have come to realize the significant demand for
establishing a comprehensive HSCT unit that can cater to both adult and pediatric
patients within the UAE. This would address the unmet needs of a substantial num-
ber of patients who can benefit from HSCT without the need to travel abroad. Such
a local unit would bring various advantages in terms of clinical care, logistics, and
cost-effectiveness. Additionally, it would provide a convenient option for patients
from neighboring countries facing similar challenges, offering them the opportunity
to seek HSCT in a nearby country that has consistently welcomed foreigners and
facilitated their transition and integration.
Currently, there are 3 centers that provide HSCT for the UAE: 2 in Abu Dhabi
and 1 in Dubai.

39.3 Abu Dhabi Stem Cell Center (ADSCC)

In July 2020, the Abu Dhabi Stem Cell Center completed the first autologous HSCT
case in the UAE [13, 14].

39.4 Conceptualization and Journey Through

the Establishment of the Comprehensive HSCT Program
at Burjeel Medical City

Our objective was to create a fully fledged HSCT unit for both adults and children,
adhering to international standards set by the European Society for Blood and
Marrow Transplantation (EBMT). This initiative aligns with the vision of the Abu
Dhabi Department of Health and the UAE government, aiming to deliver top-­quality
healthcare to UAE citizens and residents. Additionally, our goal is to establish Abu
Dhabi and the UAE as a burgeoning center for global medical tourism, with a spe-
cific focus on cancer care.
The HSCT unit at Burjeel Cancer Institute within Burjeel Medical City (BMC)
was established as part of a comprehensive cancer center. BMC’s inception took
place in 2015, positioning it as the flagship medical facility of Burjeel Holding
Healthcare (formerly VPS Healthcare). Spanning over 1.1 million square feet in the
capital city of Abu Dhabi, BMC has undergone significant development in the past
two years. The oncology department has transformed into a state-of-the-art facility
that provides comprehensive cancer care, encompassing medical and radiation
oncology, nuclear medicine, surgical oncology, and the first palliative care service in
39 Hematopoietic Stem Cell Transplantation (HSCT) in the UAE 615

Abu Dhabi city. A team of highly skilled experts with international training and
expertise is dedicated to delivering these specialized services [11]. It is the only cen-
ter in the UAE that has received a European Society of Medical Oncology (ESMO)
designation as an integrated oncology and palliative care services provider [11].
The HSCT initiative at BMC commenced in February 2021, marked by the
establishment of a taskforce comprising experienced clinical hematologists and
oncologists specializing in adult and pediatric HSCT. The taskforce also included a
chief nursing officer, oncology and hematology pharmacists, a human resources
representative, pediatric and adult infectious disease specialists, a quality director, a
laboratory director, and international advisors with prior involvement in setting up
HSCT services in Saudi Arabia and Italy [16]. The initial phase involved evaluating
the available workforce and infrastructure, as well as determining any resource
requirements. Our primary focus was to augment the manpower by filling any gaps
to ensure the full participation and commitment of the experts directly involved in
the HSCT project [11].
A specialized unit was constructed, featuring 13 private inpatient rooms
equipped with high-efficiency particulate absorbing (HEPA) filters. To oversee the
management of the HSCT unit, experienced pediatric and adult HSCT nurse spe-
cialists were recruited, with expertise in handling stem cell products, infection
control, and administering chemotherapy. Dedicated outpatient clinic rooms were
established to facilitate pretransplant evaluations, consultations, patient education,
and follow-up, overseen by a knowledgeable HSCT coordinator. Additionally,
clinical care pathways were developed in collaboration with various medical
departments, including an active emergency room with a capacity of 14 beds, an
intensive care unit, pulmonary, gastroenterology, cardiology, and adult and pediat-
ric infectious disease departments. Representatives from these units were desig-
nated to ensure alignment with the acute and chronic care requirements of HSCT
patients. To address infection control and manage infectious complications related
to HSCT, the expertise of a US-trained specialist in solid and HSCT infectious
diseases was enlisted [11].
A dedicated collection room on the HSCT floor was equipped with a newly pur-
chased apheresis machine to facilitate stem cell collection. To oversee the apheresis
and processing of stem cells, a PhD clinical scientist with expertise in stem cell
therapies was appointed. The CD34+ cell count is performed on-site using flow
cytometry, and the collected cells are stored in a specialized refrigerator within our
facility, maintained at a temperature range of 2–6 °C. Currently, efforts are under-
way to establish a complete stem cell laboratory and cellular therapy unit for stem
cell processing and cryopreservation. In the meantime, the cryopreservation of stem
cell products is outsourced to an externally accredited laboratory [11].
In accordance with health regulations in the UAE, hospital-based blood banks
are not permitted. Instead, the central Abu Dhabi blood bank ensures round-the-­
clock availability of irradiated blood products for HSCT patients [11].
The laboratory, imaging facilities (including the PET scanner), interventional
radiology services, and radiation department at BMC met all the necessary criteria
616 H. O. Al-Shamsi et al.

to complete the remaining requirements for the launch of the HSCT service. With
these additions, the HSCT program at BMC successfully fulfilled the recommended
criteria for establishing a HSCT program, as outlined by the Worldwide Network
for Blood and Marrow Transplantation workshop [11, 17].
The operations of the HSCT unit are regulated by institutional guidelines and
protocols, supported by standard operating procedures (SOPs). To ensure adherence
to these protocols, regular audits of HSCT procedures and patient treatment out-
comes are carried out. Daily rounds are conducted by the HSCT specialist or con-
sultant, while a multidisciplinary team, including specialists such as infectious
disease specialists, nutritionists, psychologists, nurses, and other necessary person-
nel, conducts comprehensive weekly audits [11]. In August 2021, the HSCT unit at
BMC obtained the approval of the Abu Dhabi Department of Health after achieving
a perfect score of 100% in the audit process [11].

39.5 Adult HSCT Cases Completed at BMC

To initiate our efforts, we chose to prioritize autologous HSCT for multiple myeloma
(MM) as our starting point. This decision was based on the fact that MM is the most
common indication for transplantation and offers a relatively straightforward proto-
col, which aids in medical staff training and adaptability. We began by assessing ten
cases and adopted the strategy of selecting candidates with the lowest risk for
HSCT. Ultimately, two cases were scheduled for October 2021 [11]. The first patient
was a 46-year-old Sudanese male who had been diagnosed with MM over 16 years
ago. The second patient, a 53-year-old male from Lebanon, was referred to our
facility after recently being diagnosed with high-risk MM. Following initial treat-
ment with daratumumab and the VRd protocol, the patient was intended to undergo
autologous HSCT after achieving the first remission [11]. However, due to the
financial crisis and lack of insurance coverage in Lebanon, the patient could no
longer receive autologous transplantation as an intensification treatment [18, 19].
Ultimately, both patients underwent a non-cryopreserved autologous HSCT proce-
dure using melphalan conditioning [11].
To the authors’ knowledge, the HSCT program at BMC was the first center in the
UAE to complete an HSCT using the cryopreservation technique. The median
engraftment time for multiple myeloma was 11 days, and the median engraftment
time for lymphoma was 10 days (unpublished data on file).
To the authors’ knowledge, the first adult allogeneic (haploidentical) HSCT case
in the UAE was also completed at BMC in September 2022. The case was for an
AML case involving a 27-year-old male referred from KSA to our facility with poor
disease characteristics after receiving intensive remission induction therapy.
Unfortunately, due to the financial crisis and lack of insurance coverage, the patient
was no longer able to receive his allogeneic transplant. Although the patient did not
have a full-match sibling donor, which is considered the optimal donor, the only
donor available was his 24-year-old brother with a 50% match, so we have decided
39 Hematopoietic Stem Cell Transplantation (HSCT) in the UAE 617

to perform the first allo-haploidentical stem cell transplant. The patient received
5.6 × 106/kg CD34 cells, engrafted on day 19, but subsequently expired on Day + due
to idiopathic pneumonia syndrome. Since then, four more adult patients have under-
gone an allogeneic stem cell transplant (unpublished data on file).
Over 100 patients who underwent HSCT from the initiation of the transplant in
2021 at BMC to December 2023 were included in the adult and pediatric categories.
Out of 100 patients, most underwent autologous transplantation; others underwent
allogeneic transplantation during this period. Patients who underwent allogeneic
transplants were haploidentical, full-matched, and related stem cell transplants. The
most common malignancies for which patients underwent HSCT at our center were
multiple myeloma, followed by Hodgkin’s lymphoma, non-Hodgkin lymphoma,
amyloidosis, thalassemia, germ cell tumors, chronic myeloid leukemia, acute
myeloid leukemia, myelodysplastic syndrome, neuroblastoma, and premature
immunodeficiency. The majority of patients who underwent stem cell transplants
were in complete remission at the time of the transplant. Acute graft versus host
disease (GvHD) was rarely observed in our patients. The majority of patients sur-
vived post-transplant (unpublished data on file).

39.6 Pediatric HSCT Cases Completed at BMC

The pediatric HSCT service at BMC is the first and only pediatric HSCT service in
the UAE. The service started in March 2022.
The median day of engraftment for thalassemia is 29 days. The median day of
engraftment for sickle cell anemia is also 29 days. Severe combined immunodefi-
ciency had 11 days of engraftment. Primary immunodeficiency (PID) had 32 days
for engraftment (unpublished data on file).

39.7 HSCT-BMC Outreach Activity and Building

Community Trust

In partnership with local print and digital media outlets and designated medical
societies, the BMC-HSCT team launched several campaigns to enhance public
awareness about hematologic malignancies, their diagnosis, and available treat-
ments. These initiatives aimed to inform the local community about advancements
in cancer care within the UAE and to emphasize the availability of HSCT services
locally. To reach hematologists and oncologists across the UAE and the GCC region,
we directly communicated and shared information about our HSCT program, while
also establishing a hotline referral and transfer system. Additionally, we initiated the
first comprehensive UAE-wide HSCT weekly virtual multidisciplinary team (MDT)
meeting, facilitating discussions on potential HSCT cases and fostering the exchange
of experiences and expertise among the oncology and hematology communities in
the UAE [11].
618 H. O. Al-Shamsi et al.

In 2023, and to the authors’ knowledge, the BMT program at BMC was the first
center to obtain membership in the European Society for Bone Marrow
Transplantation in the UAE.

39.8 American Hospital Dubai (AHD)

The American Hospital Dubai launched the city’s first comprehensive autologous
stem cell transplant program in Dubai. The program received a detailed Dubai Health
Authority inspection and approval in September 2021. In October 2021, the program
performed the first autologous BMT on one of BMC’s Nigerian dialysis-­dependent
high-risk myeloma patients in October 2021. The standard operating procedures,
policies, and protocols adapted at American Hospital are based on international stan-
dards with reference to specific disease-related entities. So far, the program has per-
formed 10 autologous stem cell transplantations. The program has been moving
forward successfully, with excellent patient feedback and satisfaction.
The BMT team includes a consultant hematologist as clinical program director,
a specialist hematologist, a BMT quality manager, an apheresis team leader, dedi-
cated transplant-trained nurses, and specialized laboratory staff for stem cell collec-
tion, processing, cryopreservation, and thawing prior to transplant. The cases are
discussed and agreed upon by the transplant multidisciplinary team, which includes
international participation in the form of virtual attendance. The cases performed so
far are within standard guidelines for multiple myeloma and relapsed lymphoma.
Being one of the most comprehensive cancer centers in Dubai, American Hospital
is ideally suited for medical tourism and is fulfilling this role with great success.
Having a specialized service like stem cell transplantation at American Hospital
Dubai, which caters to Dubai and the Northern Emirates within the home country,
has also opened easy access for UAE nationals and residents to avail themselves of
this service without having to travel far and beyond. More recently, Dubai hosted a
formal Dubai Health Authority inspection for accreditation, with extremely positive
feedback.

39.9 Conclusion

This review outlines the progress that the HSCT programs have made in the UAE
over the last two years. From no programs providing HSCT service in the UAE to
three programs in ADSCC, BMC, and the AHD. The BMC-HSCT program cur-
rently leads HSCT in the UAE, with the most allogeneic and autologous HSCT
procedures performed. It is the only program that also provides pediatric HSCT in
the UAE, and currently, as of May 2023, it is the only program providing allogenic
adult HSCT. This progress would not have been possible without very strong sup-
port from the health regulators in the UAE and the UAE government to enhance
access to all modalities for cancer care for UAE citizens and residents. The next
39 Hematopoietic Stem Cell Transplantation (HSCT) in the UAE 619

chapter of the HSCT programs in the UAE is to gain more experience and get inter-
national accreditations, e.g., FACT accreditations. The HSCT providers should also
continue to gain the trust of patients from the local community and neighboring
countries.

Conflict of Interest The authors have no conflict of interest to declare.

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620 H. O. Al-Shamsi et al.

Prof. Humaid Obaid Al-Shamsi is the Chief Executive Officer of

Burjeel Cancer Institute in Abu Dhabi, UAE, President of the
Emirates Oncology Society, Lead of the Gulf Cancer Society, Full
Professor of Oncology at the Ras Al Khaimah Medical and Health
Sciences University, Ras Al Khaimah, UAE, and an Adjunct
Professor of Oncology at the College of Medicine, University of
Sharjah. He is the first Emirati to be promoted as a professor in
oncology in the UAE. He is also the Chairman for Colorectal
Cancer in the MENA region, appointed by the prestigious National
Comprehensive Cancer Network®. He is also the only member of
Lung Cancer Policy Network in the MENA region that aims to
advance lung cancer research and screening globally. He is the
Chairman of the Oncology and Hematology Fellowship Training
Program for the National Institute for Health Specialties in the
United Arab Emirates. He is the only member in GCC in the WIN
Consortium which is comprised of organizations representing all
stakeholders in personalized cancer medicine globally.
He is board-certified in both internal medicine and oncology from
the UK, USA (ABIM), and Canada (FRCPC). He has also been
awarded the FRCP (London) in 2023 and FRCP (Glasgow) in
2024. He is the only physician in the UAE with a subspecialty fellow-
ship certification and training in gastrointestinal oncology and the first
Emirati to train and complete a clinical post-doctoral fellowship in pal-
liative care. He was an assistant professor at the University of Texas
MD Anderson Cancer Center between 2014 and 2017. He has pub-
lished more than 140 peer-reviewed articles in JAMA Oncology,
Lancet Oncology, The Oncologist, BMC Cancer, and many others. His
area of expertise includes precision oncology and cancer care in the
UAE. In 2016, he published with his group from MD Anderson the
JCO paper describing a new distinct subgroup of CRC, NON V600
BRAF-mutated CRC. In 2022, he published the first book about can-
cer research in the UAE and also the first book about cancer in the
Arab world, both of which were launched at Dubai Expo 2020. Cancer
in the Arab World has been downloaded more than 450,000 times in its
first 18 months of publication and is the ultimate source of cancer data
in the Arab region. He also published the first comprehensive book
about cancer care in the UAE which is the first book in UAE history to
document the cancer care in the UAE with many topics addressed for
the first time, e.g., neuroendocrine tumors in the UAE. He is passion-
ate about advancing cancer care in the UAE and the GCC and has
made significant contributions to cancer awareness and early detection
for the public using social media platforms. He is considered as the
most followed oncologist in the world with over 300,000 subscribers
across his social media platforms (Instagram, Twitter, LinkedIn, and
TikTok). In 2022, he was awarded the prestigious Feigenbaum
Leadership Excellence Award from Sheikh Hamdan Smart University
for his exceptional leadership and research and the Sharjah Award for
Volunteering. He was also named the Researcher of the Year in the
UAE in 2020 and 2021 by the Emirates Oncology Society.
In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan, Vice
President of the United Arab Emirates, awarded him the first place
in UAE Nafis program for outstanding leadership in private sector
across all business and medical disciplines. Beside his clinical and
administrative duties, he is engaged in education and various levels
of research training for medical trainees to enhance their clinical
39 Hematopoietic Stem Cell Transplantation (HSCT) in the UAE 621

and research skills. His mission is to advance cancer care in the

UAE and the MENA region and make cancer care accessible to
everyone in need around the globe.

Dr. Amin M. Abyad earned his medical degree, Bachelor in

Medicine and Surgery (MBChB), from Beirut Arab University.
After completing his internship, he joined the Internal Medicine
Residency at Makassed Hospital in Beirut, Lebanon, which is affil-
iated with the American University of Beirut Medical Center
(AUBMC). Dr. Amin was appointed as Chief Resident of Internal
Medicine (2017–2018). Then Dr. Amin started his fellowship in
hematology and medical oncology at Makassed Hospital, where he
received intensive training in hematology and medical oncology.
Dr. Amin joined Burjeel Medical City in July 2021. Dr. Amin is
highly interested in malignant hematology and solid malignancies.
He has been highly involved in clinical research, being involved in
multiple research projects and publishing in multiple peer-reviewed
journals.
Dr. Abyad believes in patient-centered care, trying to enhance
patient outcomes through the application of the latest evidence-
based practice and personalized medicine.

Dr. Zainul Aaabideen Kanakande Kandy is highly skilled and

experienced in paediatric haematology, oncology, and bone mar-
row transplants. He received his degree in Medicine at Calicut
University in Kerala, India; subsequently, he took his post-graduate
degree in paediatrics from the University of Mumbai.In 2001, Dr.
Zainul moved to the United Kingdom, where he specialized and
undertook further training and experience in paediatric haematol-
ogy, paediatric oncology, and paediatric bone marrow transplanta-
tion in various hospitals in the UK such asRoyal Marsden Hospital,
London, UK;University College Hospitals of London, UCLH,
London;Imperial College London, UK; Manchester Children
Hospital, Manchester, UK; Alder Hey Children Hospital, Liverpool,
UK; and Great North Children Hospital, Newcastle, UK.
Dr. Zainul gained his master’s degree in paediatric oncology at
Birmingham University as well as a certificate in medical education
at Manchester University. Subsequently, he completed his
International Fellowship in paediatric bone marrow transplantation
at Great North Children’s Hospital in Newcastle.He worked previ-
ously as a consultant pediatric at University Hospital of Coventry
and Warwickshare and Royal Oldham Hospital before moving to
the UAE.In the UAE, he had worked at the department of pediatric
hematology and oncology at Tawam Hospital as a consultant, Al
Ain, before joining at Burjeel Medical City as head of pediatric
hematology, oncology and BMT.Aside from his commitment to
further advance his experience and knowledge in the field of paedi-
atrics, paediatric haematology, oncology, and bone marrow trans-
plantation in the United Kingdom, he also published articles and
actively supported the community by sharing his knowledge and
participating in international conference across countries.
622 H. O. Al-Shamsi et al.

Dr. Biju George earned his medical degree, Bachelor in

Medicine and Surgery (MBBS), from Christian Medical College,
Vellore, India. After completing his internship, he completed his
internal medicine residency and his higher specialty training in
haematology at the same hospital. He had additional training in
Westmead Hospital Sydney for 3 years in the field of unrelated
and haploidentical stem cell transplantation and helped establish
the haploidentical programme in CMC Vellore. He has published
more than 250 articles in international peer-reviewed journals and
is a reviewer for journals such as Transplant and Cellular Therapy,
Bone Marrow Transplantation, and British Journal of
Haematology. Dr. George joined Burjeel Medical city in
September 2022 and heads the adult Bone Marrow Transplant
programme.

Mohammed Dar-Yahya is a highly skilled nursing profes-

sional with a rich educational and professional background. He
began his journey in healthcare by earning a Bachelor of Science
in Nursing from the University of Jordan (2004–2008). Shortly
thereafter, Mohammed joined the King Hussein Cancer Center,
where he served from 2008 to 2021. During his tenure, he
worked as a registered nurse in the bone marrow transplant unit
and progressed through various roles, eventually becoming a
nurse manager.
Committed to advancing his expertise, Mohammed completed
his Master’s degree in Palliative Nursing Care between 2016 and
2019. In 2021, he took a significant step by joining Burjeel
Medical City. There, he has been instrumental in establishing the
first bone marrow transplant unit in the UAE, Abu Dhabi, show-
casing his leadership and pioneering contributions to the field of
nursing.

Dr. Panayotis Kaloyannidis has joined Burjeel Medical City as

specialist hematologist in the adult hematology and bone marrow
transplant department. He has 25 years of experience, mainly in
the field of malignant hematological diseases and their treatment
with conventional chemotherapy and cellular therapies, including
hemopoietic stem cell transplantation. Since 1998 he has been
actively involved in more than 2000 hematopoietic stem cell trans-
plants (autologous and allogeneic) from any source of hematopoi-
etic cells (bone marrow, peripheral blood, and umbilical cord
blood). In 2012–2013, he was trained in cellular therapies with
chimeric antigen receptors T cells (CAR T cells) and specific T
cells against viral infections and relapse post allogeneic stem cell
transplantation. His expertise and areas of interest include diagno-
sis and treatment of malignant hematological diseases, hematopoi-
etic stem cell transplantation, post-transplantation complications
(graft vs. host disease, infections, relapsed disease), cellular thera-
pies, and immunotherapy for malignant hematological diseases.
Dr. Kaloyannidis has held a senior Consultant Hematologist posi-
tion at the Department of Hematology and Bone Marrow
Transplantation Unit at the “G. Papanicolaou” General Hospital in
39 Hematopoietic Stem Cell Transplantation (HSCT) in the UAE 623

Thessaloniki, Greece, from 1998 to 2014 and as a senior

Consultant Hematologist at the Adult Oncology/Hematology and
SCT department at King Fahad Specialist Hospital-Dammam,
S. Arabia from June 2014 to March 2023. Dr. Kaloyannidis is a
member of the Hellenic Society of Hematology, the European
Society for Bone Marrow Transplantation (EBMT), and the Saudi
Society of Blood and Marrow Transplantation (SSBMT). His
areas of expertise include,

• iagnosis and treatment of malignant hematological

D
diseases
• Hematopoietic stem cell transplantation and post-transplan-
tation complications (graft vs. host disease, infections,
relapsed disease).
• Cellular therapies, and immunotherapy for malignant

hematological diseases.

Dr. Amro El-Saddik is the Oncology Excellence Lead and the

Cell Therapy Program Director at Burjeel Holdings. His role is to
lead the team that will make Burjeel Medical City a Center of
Excellence in Oncology and Hematology, and a state of the art in
patients’ healing. He is also responsible for bringing high-quality
oncology products to be locally manufactured and packaged in
LIFEPharma, aiming to help healthcare authorities and regulators
provide more health for the money and keep head room for innova-
tion.He worked as the Oncology Senior Medical Manager for the
Gulf States at Pfizer from July 2018 until January 2021. And prior
to that, he was a Global Medical Manager for Cell and Gene
Therapy at GSK, responsible for the Middle East and North Africa
since June 2016. He is also an assistant professor of clinical pathol-
ogy at Mansoura University, Egypt.

Dr. Shabeeha Rana is a distinguished Consultant Hematologist,

trained in the United Kingdom. Her commitment to excellence
extends to her dual passions for teaching and clinical research in hae-
matological disease management. With an impressive track record
spanning over two decades, Dr. Shabeeha has solidified her reputation
as the foremost haematologist in the field, specializing in myeloma,
lymphoma, leukemia, and stem cell transplantation, earning the trust
of patients and colleagues alike in the United Arab Emirates.
Dr. Shabeeha’s career includes contributions to the healthcare
landscape of Dubai, such as Dubai’s bone marrow and haematopoi-
etic stem cell transplantation program; she has left an indelible
mark on the medical community. Notably, she established the first
center for Autologous Stem Cell Transplantation at the prestigious
American Hospital Dubai, raising the standard of care for patients
in the region.In recognition of her outstanding achievements, Dr.
Shabeeha has been selected as the first representative from the Gulf
region to participate in the European Haematology Association
Annual Meeting in 2023, an esteemed distinction within the
“Women in Lymphoma” group. Her leadership and contributions
continue to shape the future of haematology, making her a trail-
blazer in her field and a trusted advocate for patients seeking the
highest standards of medical care.
624 H. O. Al-Shamsi et al.

Dr. Charbel Khalil received his PhD in cellular therapy and

regenerative medicine from Saint Joseph University in Lebanon. I
pursued a fellowship in cellular therapy at the University of Paris
Diderot and was appointed as a full-time supervisor in the depart-
ment of cellular therapy at the Institute Gustave Roussy (IGR)—
Villejuif/University of Paris XI. I also hold a Master of Science in
biobanking from Luxembourg University and a Master in wound
management from ICW Germany, a Master in cellular therapy and
regenerative medicine from Saint Joseph University, a university
diploma in cellular therapy from Paris Diderot, Paris, and he is cur-
rently doing a diploma in Immuno-Oncology at Paris XI (Ecole du
Cancer—Paris, France). He is the cellular therapy director at the
Reviva stem cell platform for the Research and Applications Center-
Middle East Institute of Health University Hospital. Reviva has been
considered the leading stem cell treatment and research center in the
Middle East. It holds the first national cord blood bank, cellular
therapy, reconstructive medicine, and regenerative medicine for
clinical trials, and it won the Innovation Award in 2014.
Dr. Charbel contributed to the establishment and development
of the center’s infrastructure and services and supervised the
accreditation process in collaboration with Hospital Saint Louis—
Paris, France, for JACIE international regulation. This made me an
expert in the establishment and direction of any stem cell research
center and cord blood bank. He contributed again to the establish-
ment of the first bone marrow transplantation in the United Arab
Emirates at Burjeel Medical City in Abu Dhabi and the establish-
ment of the bone marrow transplantation unit at the Lebanese
American University Rizk Hospital in Lebanon. He is an assistant
professor at the Lebanese American University of Beirut School of
Medicine, Beirut, Lebanon.
Dr. Charbel has also been a teacher and researcher at Saint
Joseph University of Beirut, Faculty of Dental Medicine and
Pharmacy. He’s also an active member of the European, Eastern
Mediterranean, and Lebanese societies for blood and marrow trans-
plantation and the French society for stem cell and research. He has
published and contributed to more than 20 articles, mentored stu-
dents in the Master’s program at Paris XIII, and lectured in univer-
sities across Lebanon.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Cancer Survivorship Programs
in the UAE 40
Aydah Al-Awadhi , Ramanujam A. Singarachari,
and Rita A. Sakr

40.1 Introduction

Due to demographics, greater early detection, and improved treatment, there are
more cancer survivors today. However, current models of care, which are mostly
provided by specialists, fall short of meeting the physical, emotional, and supportive
care needs of cancer survivors. A survivorship care plan includes tailored check-ups
and routine follow-ups to ensure adequate health maintenance to address the physi-
cal, psychosocial, and possible long-term effects of the disease and the treatments
on the patient [1–3].

40.2 Cancer Survivorship Programs in the UAE

In the United Arab Emirates (UAE), cancer survivorship programs and dedicated
clinics have yet to be established as an integral part of caring for cancer patients. To
the best of our knowledge, there is no established certified survivorship program or
clinic for oncology patients in the UAE. However, some institutions are in the pro-
cess of facilitating a dedicated track for cancer survivors. Most of the post-treatment
surveillance is conducted at their regular follow-up clinics, with possible limitations

A. Al-Awadhi (*)
Tawam Hospital, Al Ain, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
e-mail: ayawadhi@seha.ae
R. A. Singarachari
Mediclinic Airport Road Hospital, Abu Dhabi, United Arab Emirates
R. A. Sakr
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
King’s College Hospital London, Dubai, United Arab Emirates

© The Author(s) 2024 625

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_40
626 A. Al-Awadhi et al.

due to funding and insurance coverage for screening tests. Regular follow-up for
those patients includes a full history and physical examinations, laboratory and
imaging investigations as needed, counseling for lifestyle modifications, and psy-
chosocial support.
Ideally, survivorship clinics should be carried out in the primary care setting, but
there is also a lack of dedicated training programs for primary care physicians to
master oncology survivorship tracking and health maintenance. This is all based on
international guidelines [1].

40.2.1 Cancer Survivors’ Role in Survivorship Programs

Many cancer survivors in the UAE have participated in their own efforts and joined
cancer societies and hospitals to raise awareness about the disease through cam-
paigns, as well as to share their experiences in the local newspaper, magazine, TV,
social media, and radio and support other cancer patients either directly or through
established support groups.

40.3 Challenges and Recommendations

Finally, cancer survivors’ numbers are likely to increase in the next few years, and
nationally dedicated guidelines and strategies on long-term survivorship planning
and related issues for cancer survivors of various ages have yet to be developed.
Efforts by cancer care professionals and non-profit organizations to promote survi-
vor awareness are on the horizon. To optimize holistic cancer care delivery, a
national survivorship strategy tailored to cancer, cultural, and population character-
istics is required.

40.4 Conclusion

With the anticipated rise in the numbers of cancer survivors in the country due to
improved early detection, treatment options, and outcomes, it becomes important to
establish a tailored cancer survivorship program to ensure the physical and psycho-
social well-being of the patients and mitigate the long-term consequences of disease
and treatment.

Conflict of Interest The authors have no conflict of interest to declare.

40 Cancer Survivorship Programs in the UAE 627

References
1. Shapiro CL. Cancer survivorship. N Engl J Med. 2018;379(25):2438–50.
2. van Kalsbeek RJ, Mulder RL, Skinner R, Kremer LCM. The concept of cancer survivorship
and models for long-term follow-up. Front Horm Res. 2021;54:1–15.
3. Hill RE, Wakefield CE, Cohn RJ, Fardell JE, Brierley ME, Kothe E, et al. Survivorship care
plans in cancer: a meta-analysis and systematic review of care plan outcomes. Oncologist.
2020;25(2):e351–e72.

Dr. Aydah Al-Awadhi is a consultant medical oncologist who

graduated from medical school at the United Arab Emirates
University in 2012, then completed her internal medicine residency
in the United States and completed her medical oncology and
hematology fellowship at the University of Texas, MD Anderson
Cancer Center, in 2019. She is American Board certified in internal
medicine, hematology, and medical oncology. She was awarded the
Emirates Oncology Society (EOS) Member of the Year Award for
2021 and the Emirates Oncology Society Women in Oncology of
the Year Award. She is also currently the scientific chairperson of
the Emirates Oncology Society and the chair of the Breast Cancer
Working Group. Dr. Al-Awadhi has published many articles and
book chapters on breast cancer and oncology, with her main exper-
tise in breast cancer and sarcoma.

Dr. Ramanujam A. Singarachari received his post-doctoral

medical degree DM (oncology-­medical) from the Regional Cancer
Treatment and Research Centre—Cancer Institute (WIA), based in
Chennai, India. He is also certified by the European Society of
Medical Oncology, the Federation of Royal Colleges of Physicians
of the United Kingdom, and the Association of Cancer Physicians—
Medical Oncology MRCP UK.
He has a vast experience of 24 years in training and working in
a number of eminent and reputable cancer centers in India, New
Zealand, and the United Arab Emirates. In the last 20 years in the
United Arab Emirates, he worked as a medical oncologist at large
hospitals like Sheikh Khalifa Medical City (SKMC) and Sheikh
Shakhbout Medical City (SSMC), jointly operated by Cleveland
Clinic, Mayo Clinic (USA), and SEHA (a government healthcare
provider in the UAE).
His areas of interest are GI cancers, breast cancers, CNS can-
cers, palliative care, and cancer survivorship.
628 A. Al-Awadhi et al.

Dr. Rita A. Sakr is a French/European board-certified, American

fellow, consultant breast oncoplastic surgeon, and Ob-gynecologist
with over 20 years of surgical, clinical, academic, and research
experience in the field. After training in both France and the USA,
Dr. Rita Sakr was appointed consultant breast oncoplastic surgeon
and Ob-gynecologist in several institutions, including the Institut
Curie, Paris; the Memorial Sloan Kettering Cancer Centre,
New York; and Assistance Publique—Hôpitaux de Paris. She also
held the position of associate professor and co-head of the Breast
and Gynecology Care Unit for high-risk patients at Pierre & Marie
Curie/Sorbonne University, France. She later relocated to Dubai as
a consultant breast surgeon and Ob-gynecologist in the Dr.
Sulaiman Al-Habib Hospital and then the American hospital.
Dr. Rita Sakr is a member of various clinical societies such as the
American Society of Clinical Oncology, the American Association
for Cancer Research, the Lebanese Society of Obstetrics and
Gynecology, the Collège National des Gynécologues et
Obstétriciens Français, Société Française de Sénologie et
Pathologie Mammaire, the New York Academy of Sciences, the
European Society of Surgical Oncology, the Emirates Oncology
Society, the Europa Donna, etc. Dr. Rita Sakr has more than 100
publications and abstracts in peer-reviewed journals and interna-
tional conferences and has been awarded many international rec-
ognitions, such as the American Association for Cancer Research
Award and the San Antonio Breast Cancer Symposium Award.
In addition to her wide surgical, clinical, and academic experi-
ence, Dr. Rita Sakr has a passion for patient advocacy and has been
actively involved in multiple associations for breast cancer survi-
vorship in Europe, the USA, and the UAE.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Suggested Quality Control Measures
for Cancer Care in the UAE 41
Humaid O. Al-Shamsi

41.1 Introduction

Cancer care in the UAE has evolved dramatically over the last few decades [1].
There are nearly 30 cancer centers that provide everything from basic cancer care to
more advanced and complex cancer therapy [1, 2]. In the UAE, there are nearly
90–100 medical oncologists, hematologists, radiation oncologists, and surgical
oncologists from various backgrounds and trainings in oncology [2]. This leads to
variation in cancer care without consistency or quality measures.
In this chapter, we will discuss the practical recommendations to improve
the quality of cancer care in the following domains: pathology, medical oncol-
ogy, genomic and molecular testing, radiation, surgical oncology, insurance
limit and renewal, cancer screening, and other general recommendations
(Fig. 41.1).

H. O. Al-Shamsi (*)
Burjeel Cancer Institute, Burjeel Medical City, Burjeel Holdings, Abu Dhabi,
United Arab Emirates
Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
Gulf Medical University, Ajman, United Arab Emirates
Emirates Oncology Society, Emirates Medical Association, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Gulf Cancer Society, Alsafa, Kuwait
e-mail: alshamsi@burjeel.com; humaid.al-shamsi@medportal.ca

© The Author(s) 2024 629

H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0_41
630 H. O. Al-Shamsi

Fig. 41.1 The potential

domains of cancer care
quality in the UAE

41.2 Cancer Care Quality Council and Cancer System

Quality Index

Oncologists in the UAE have diverse training backgrounds. Research has demon-
strated that receiving specialized training in oncology enhances the results of cancer
treatment [3–5]. Ensuring the quality of cancer care in the UAE is a complex task
due to the need for standardized delivery. To meet this challenge, it is necessary to
establish a cancer system quality index that can guarantee the excellence of care
provided [1]. When considering generic quality indicators, it is important to priori-
tize specific metrics that encompass various aspects of cancer care. These metrics
may include waiting times for surgeries, utilization of chemotherapy, 30-day mor-
tality rate after initiating chemotherapy, planning of radiation treatment, adoption of
a multidisciplinary approach, advance care planning, end-of-life care, and docu-
mentation of cancer care, including pain management.
Our suggestion is to create an autonomous Advisory Cancer Care Quality
Council responsible for overseeing the quality of care provided in both government
and private hospitals throughout the UAE. We propose adopting a cancer system
quality index that bears resemblance to the well-established index implemented in
Ontario, Canada, since 2002, recognized as one of the longest-standing indexes of
its kind [6–8]. Before adopting and implementing the Ontario cancer system quality
index or any other similar quality index, it is crucial to assess its suitability for our
healthcare system. It is recommended to foster collaboration between the newly
established UAE cancer system quality index and other regional or international
41 Suggested Quality Control Measures for Cancer Care in the UAE 631

organizations focused on cancer care quality. This collaboration aims to facilitate

the exchange of knowledge and experiences in order to enhance the overall quality
of cancer care [1].
Additionally, we propose the implementation of a centralized multidisciplinary
tumor board, which can convene either on-site or virtually on a weekly basis. This
tumor board should receive approval and oversight from the Department of Health
(DOH), Dubai Health Authority (DHA), and the Ministry of Health and Prevention
(MOHAP). It is essential to establish a mandatory rule that requires every confirmed
cancer case to be thoroughly discussed and documented at an accredited multidisci-
plinary tumor board. Subsequent management decisions should be based on the
recommendations made during these meetings [1].

41.3 General Recommendations

• Establishment of quality control and auditing for cancer in the UAE in all disci-
plines: medical oncology, radiation, surgery, pathology, imaging, and pallia-
tive care.
• Limit cancer treatment to accredited cancer centers that meet minimum require-
ments (availability of core MDT members, e.g., medical oncology, radiation
therapy, surgical oncology, and palliative care).
• Accreditation of centers providing cancer-related treatments.
• Cancer centers should follow internationally accredited guidelines [9, 10].
• A multidisciplinary team (MDT) recommendation for all newly diagnosed can-
cer cases. The major challenge is that many cancer cases are misdiagnosed or
inaccurately treated, leading to poor outcomes. Regulators must officially recog-
nize MDT, which consists of a consultant (not a specialist) medical oncologist, a
consultant radiation oncologist, a consultant general surgeon, a consultant
pathologist trained in oncology, and a preferred surgical oncologist.
• The approved MDT must also agree to accommodate other oncologists so
they have access to their MDT, as many small hospitals do not have full
oncology services and must be paired with an approved MDT to treat cancer
patients.
• Insurance only approves surgery for cancer or suspected cancer if MDT recom-
mendations are provided, except in emergency situations. (This cannot be listed
as there are many situations in which listing conditions may cause limitations in
access to emergency surgeries).
• Adoption of international cancer treatment guidelines in Dubai: We recommend
the following:
–– The National Comprehensive Cancer Network® (NCCN) is an alliance con-
sisting of 31 prominent cancer centers that operate as a not-for-profit organi-
zation. Their primary focus lies in patient care, research, and education. The
NCCN is committed to enhancing and enabling the provision of high-quality,
effective, efficient, and easily accessible cancer care, with the ultimate goal of
improving the quality of life for patients [10].
632 H. O. Al-Shamsi

–– European Society for Medical Oncology (ESMO): The ESMO Clinical

Practice Guidelines offer a collection of recommendations crafted by
renowned experts and grounded in evidence-based medicine research. These
guidelines serve as a valuable resource, equipping patients with a range of
suggestions to aid them in making informed decisions about their optimal
care choices [9].

41.4 Pathology

• Only an accredited oncology-designated lab can diagnose cancer; rare types of

cancer, like sarcoma, must be double-read by two pathologists.
• The regulators need to assign a designated pathology laboratory for cancer
diagnosis.

41.5 Medical Oncology

• Chemotherapy options must be given to patients. For example, locally advanced

breast cancer with HER2 positive for treatment with neoadjuvant chemotherapy
can be treated with 6 cycles of chemotherapy, but instead many are treating
patients with 16 cycles. Both are acceptable, but many patients are not informed
about the lighter option with similar efficacy.
• Auditing of all the chemotherapy protocols and deliveries should be done by
oncologists and oncology pharmacists.
• Flag system should be implemented for excessive use of chemotherapy in the last
2 weeks before death.

41.6 Genomic and Molecular Testing

• Mandate OncotypeDx© coverage for all breast cancer patients who are clinically
eligible as per the NCCN guidelines. This will reduce the use of chemotherapy
in early breast cancer [11].
• Mandate insurance coverage for molecular testing for cancers as per the NCCN
guidelines.

41.7 Radiation

• Quality control and auditing should be done for indications of radiation.

• Change the payment method from per fraction (per day) to per site; this will
reduce the excessive use of higher fractions and side effects.
• All radiotherapy patient plans must be peer-reviewed by two radiation oncolo-
gists; an exception will be made for urgent or emergency cases. All IMRT/VMAT
41 Suggested Quality Control Measures for Cancer Care in the UAE 633

plans must have a QA done by a physicist and verified by another physicist with
a minimum pass rate of 95%, a tolerance of 3% for the 3 mm gamma pass rate,
and for SBRT, 3% between 1 and 2 mm depending on PTV expansion. All 3D
plans must undergo RadCalc with a maximum accepted difference of 3%, unless
for small fields or off-axis treatment. All plans with a passing QA rate should be
checked, and plans signed and PDFs signed should be checked by the radiation
therapists before radiotherapy is delivered. All LINACs must undergo daily,
weekly, monthly, and yearly QA (this is standard). Independent external audits
for LINACs must be conducted before going live and on a yearly basis. For
brachytherapy, daily, monthly, quarterly, and yearly quality assurance should be
done. CT/MRI-based treatment planning should be done for all patients when
possible. Radiation safety and emergency training for all radiotherapy and
nuclear medicine staff are mandatory. Image guidance therapy should be used
whenever and as much as possible. CT simulation and daily, monthly, and annual
QA should be done.

41.8 Surgical Oncology

• All surgeries are approved by MDT except emergency surgeries, and this must
be audited regularly.
• Surgical oncology must be done by a trained surgeon in oncology.
• Rectal surgeries must be done by colorectal surgeons.
• Sarcoma surgeries must be done by orthopedic surgeons with special training in
oncology.
• Appropriate reimbursement should be ensured for minimally invasive surgery
when it is an evidence-based standard of care (for example, robotic-assisted sur-
gery for prostate cancer).

41.9 Palliative Care

• Make palliative care available in all cancer centers and mandatory.

• Insurance coverage should be ensured for palliative home care and hospices.
• Opioid infusion pump approval should be used in the outpatient setting.

41.10 Insurance Limit and Renewal

• Develop a mechanism to cover cancer patients who have reached their financial
limit as cancer treatment becomes more expensive.
• Renewal of insurance for cancer patients, as many patients are unable to renew
their insurance due to the high premium requested if diagnosed with cancer. The
increase should be limited to, say, 20%.
634 H. O. Al-Shamsi

41.11 Cancer Screening

• Establish a cancer screening task force.

• Review and update the current screening guidelines.
• Ensure insurance or third-party coverage for recommended screening tests.
• Educate the GPs and the public about screening by forming pathways for
screening.

41.12 Other

• The use of off-label medications should be audited regularly. Patients should be

aware of and fully consent to off-label drugs.
• Promote clinical trials in the UAE and make approval and access to international
trials easier.

41.13 Conclusion

Cancer care in the UAE has undergone significant advancements in recent decades.
However, despite this progress, there is a noticeable absence of implemented quality
indicators to ensure the consistent and standardized delivery of cancer treatment
across the country. One of the primary challenges stems from the varying levels of
experience and training among oncologists who come from diverse backgrounds to
practice in the UAE. While some adhere to the NCCN guidelines, others continue
to practice independently, potentially impacting the outcomes for cancer patients. In
this chapter, we examine recommendations aimed at improving the quality of can-
cer care in the UAE. Firstly, we recommend the establishment of an independent
Advisory Cancer Care Quality Council, responsible for monitoring the quality of
care provided in both government and private hospitals throughout the
UAE. Additionally, we suggest adopting a cancer system quality index and conduct-
ing regular audits of cancer centers to ensure adherence to quality measures. These
measures should encompass all aspects of cancer care, including radiation, surgical
procedures, palliative care, and others. It is crucial to emphasize quality control
measures that address the current cancer screening programs and enhance accessi-
bility for patients.

Conflict of Interest The author has no conflict of interest to declare.

Acknowledgements We thank Dr. Ibrahim Abu-Gheida for his help in writing the manuscript.
41 Suggested Quality Control Measures for Cancer Care in the UAE 635

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636 H. O. Al-Shamsi

Prof. Humaid Obaid Al-Shamsi is the Chief Executive

Officer of Burjeel Cancer Institute in Abu Dhabi, UAE, President
of the Emirates Oncology Society, Lead of the Gulf Cancer
Society, Full Professor of Oncology at the Ras Al Khaimah
Medical and Health Sciences University, Ras Al Khaimah, UAE,
and an Adjunct Professor of Oncology at the College of
Medicine, University of Sharjah. He is the first Emirati to be
promoted as a professor in oncology in the UAE. He is also the
Chairman for Colorectal Cancer in the MENA region, appointed
by the prestigious National Comprehensive Cancer Network®.
He is also the only member of Lung Cancer Policy Network in
the MENA region that aims to advance lung cancer research and
screening globally. He is the Chairman of the Oncology and
Hematology Fellowship Training Program for the National
Institute for Health Specialties in the United Arab Emirates. He
is the only member in GCC in the WIN Consortium which is
comprised of organizations representing all stakeholders in per-
sonalized cancer medicine globally.
He is board-certified in both internal medicine and oncology
from the UK, USA (ABIM), and Canada (FRCPC). He has also
been awarded the FRCP (London) in 2023 and FRCP (Glasgow)
in 2024. He is the only physician in the UAE with a subspecialty
fellowship certification and training in gastrointestinal oncology
and the first Emirati to train and complete a clinical post-doc-
toral fellowship in palliative care. He was an assistant professor
at the University of Texas MD Anderson Cancer Center between
2014 and 2017. He has published more than 140 peer-reviewed
articles in JAMA Oncology, Lancet Oncology, The Oncologist,
BMC Cancer, and many others. His area of expertise includes
precision oncology and cancer care in the UAE. In 2016, he
published with his group from MD Anderson the JCO paper
describing a new distinct subgroup of CRC, NON V600 BRAF-
mutated CRC. In 2022, he published the first book about cancer
research in the UAE and also the first book about cancer in the
Arab world, both of which were launched at Dubai Expo 2020.
Cancer in the Arab World has been downloaded more than
450,000 times in its first 18 months of publication and is the
ultimate source of cancer data in the Arab region. He also pub-
lished the first comprehensive book about cancer care in the
UAE which is the first book in UAE history to document the
cancer care in the UAE with many topics addressed for the first
time, e.g., neuroendocrine tumors in the UAE. He is passionate
about advancing cancer care in the UAE and the GCC and has
made significant contributions to cancer awareness and early
detection for the public using social media platforms. He is con-
sidered as the most followed oncologist in the world with over
300,000 subscribers across his social media platforms
(Instagram, Twitter, LinkedIn, and TikTok). In 2022, he was
awarded the prestigious Feigenbaum Leadership Excellence
Award from Sheikh Hamdan Smart University for his excep-
tional leadership and research and the Sharjah Award for
Volunteering. He was also named the Researcher of the Year in
the UAE in 2020 and 2021 by the Emirates Oncology Society.
41 Suggested Quality Control Measures for Cancer Care in the UAE 637

In May 2024, HH Sheikh Mansour bin Zayed Al Nahyan,

Vice President of the United Arab Emirates, awarded him the
first place in UAE Nafis program for outstanding leadership in
private sector across all business and medical disciplines. Beside
his clinical and administrative duties, he is engaged in education
and various levels of research training for medical trainees to
enhance their clinical and research skills. His mission is to
advance cancer care in the UAE and the MENA region and
make cancer care accessible to everyone in need around
the globe.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
 ppendix A: The National Guideline for Breast
A
Cancer Screening and Diagnosis

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 639
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
640 Appendix A: The National Guideline for Breast Cancer Screening and Diagnosis
Appendix A: The National Guideline for Breast Cancer Screening and Diagnosis 641

National Breast Cancer Screening Task Force

Dr. Huda Obaid Al Abdouli—Head of Task Force

Coordinator of National Cancer Screening Program—MOHAP
Dr. Buthaina Bin Belaila—Member
Head of Non-communicable Disease and Mental Health—MOHAP
Prof. Humaid Obaid Al Shamsi—Member
Director of the Burjeel Cancer Institute
President of the Emirates Oncology Society
Dr. Mona Al Ayyan—Member
Consultant General Surgeon/Breast Surgeon
Head of Surgery Department
Saqr Hospital Director
Dr. Lamia Safieldin—Member
Comprehensive Screening Specialist
Department of Health, Abu Dhabi
Dr. Asma Saeed Khammas—Member
Consultant Radiologist and Interventional Breast Imager—EHS
Head of Breast Imaging Unit—Fujairah Hospital
Dr. Nehad Kazim Albastaki—Member
Consultant Breast Radiology
Private Healthcare Sector—Abu Dhabi
Dr. Ola Aldafrawy—Member
Consultant Family Medicine
Dubai Health Authority
Dr. Aydah Al Awadhi
Consultant Physician
TWM-Oncology Clinic-TWM-Medical Affairs
Tawam Hospital
Scientific Chairperson of Emirates
Oncology Society

1. Purpose

1.1. To stipulate the service requirements to deliver the National Breast Cancer
Screening Program in the United Arab Emirates.
1.2. To set out the minimum Clinical Care Standards and frequency for breast can-
cer screening as per international evidence-based guidelines.
1.3. To set out the case mix, eligibility criteria and data reporting requirement for
breast cancer screening.
1.4. To ensure the population receives quality and safe care and timely referral for
diagnosis and/or treatment where appropriate.
642 Appendix A: The National Guideline for Breast Cancer Screening and Diagnosis

2. Scope

2.1. This guideline applies to all healthcare providers (facilities and professionals)
in the United Arab Emirates, providing, breast cancer screening and assess-
ment and diagnosis services; including mobile units.

3. Definitions

3.1. Case mix: Refer to all females, 40–69 years, determined as eligible for breast
cancer screening services, in accordance with the criteria detailed in this
guideline.
3.2. Screening mammograms: Are carried out for healthy women, who have no
symptoms of breast cancer and negative clinical breast examination.
3.3. Diagnostic mammograms: Are performed to evaluate a breast complaint or
abnormality detected by clinical breast examination or routine screening
mammogram.
3.4. Clinical breast examination (CBE): Is an exam conducted by healthcare pro-
fessional and involves inspection and palpation of all breast tissue including
lymph nodes basins.
3.5. Breast awareness: Women, 20 years and older, should be encouraged and
educate on how to conduct breast self-exam to become aware of the feeling and
shape of their breasts, and to report any changes immediately to their health-
care provider.
3.6. Breast assessment and diagnosis: Further imaging, clinical breast exam and
needle biopsy. The aim of assessment is to obtain a definitive and timely diag-
nosis of all potential abnormalities detected during screening.
3.7. First degree relatives: Parents, siblings, and children
Second degree relatives: Grandparents, aunts, uncles, nieces, nephews, grand-
children, and half siblings
Third degree relatives: Great-grandparents, great-aunts, great-uncles, great-
grandchildren, and first cousins (refer to Appendix D)
3.8. Initial screening: First screening examination of individual women within the
screening program, regardless of the organisational screening round in which
women are screened.
3.9. Subsequent screening: All screening examinations of individual women
within the screening program following an initial screening examination,
regardless of the organisational screening round in which women are screened.
There are two types of subsequent screening examinations:
3.9.1. Subsequent screening at the regular screening interval, i.e. in accor-
dance with the routine interval defined by the screening policy
(SUBS-R).
3.9.2. Subsequent screening at irregular intervals, i.e. those who miss an invi-
tation to routine screening and return in a subsequent organizational
screening round (SUBS-IRR).
Appendix A: The National Guideline for Breast Cancer Screening and Diagnosis 643

4. Duties for Healthcare Providers

All licensed healthcare providers facilities and professionals engaged in pro-

viding breast cancer screening and diagnosis services must:
4.1. Provide clinical services and patient care in accordance with this guideline and
in accordance with Policies and Standards, Laws and Regulations of the United
Arab Emirates; including developing effective recording systems, maintaining
confidentiality, privacy and security of patient information.
4.2. Comply with the Federal requirements; laws and policies for patient education
and consent. The licensed provider must provide appropriate patient education
and information regarding the screening test and must ensure that appropriate
patient consent is obtained and documented on the patient’s medical record.
4.3. Comply with Federal requirements; laws, policies and standards on managing
and maintaining patient medical records, including developing effective
recording systems, maintaining confidentiality, privacy and security of patient
information.
4.4. Comply with Federal requirements; laws, policies and standards for Information
Technology (“IT”) and data management, electronic patient records and dis-
ease management systems, sharing of screening and diagnostic test, and where
applicable pathology results.
4.5. Comply with relevant policies on cultural sensitivity; in particular, providers
must ensure:
4.5.1. That only female radiographers, mammographers or technologists are
allowed to perform mammographic examination for women.
4.5.2. That the timing of screening appointment for women seeking the ser-
vice is not delayed beyond 15 working days, due to the limited number
of same sex appropriately licensed professionals.
4.5.3. Where delays are likely to occur due to limited availability of same sex
licensed professionals at the employing facility, or where there is no
female radiographer, that the provider communicates this to the patient
and refers/recommends that the patient seeks screening services from
another provider.
4.6. Comply with MOHAP requests to inspect and audit records and cooperate
with authorized auditors as required.
4.7. Collect and submit data on screening visits and outcomes, as per Appendix B,
to the National Cancer Screening Registry; at MOHAP.
4.8. Comply with Federal laws, policies and standards on cancer case reporting and
report all confirmed screening-detected cancers to the National Cancer Registry
at MOHAP.

5. Enforcement and Sanctions

5.1. Healthcare providers, payers and third-party administrators must comply with
the terms and requirements of this guideline. MOHAP may impose sanctions
in relation to any breach of requirements under this guideline.
644 Appendix A: The National Guideline for Breast Cancer Screening and Diagnosis

6. Payment for Screening and Follow Up of Breast Cancer

6.1. Eligibility for reimbursement under the Health Insurance Scheme must be in
accordance, with local insurance laws for each Emirate.

7. Standard 1: Clinical Services Specifications

7.1. Breast Cancer Screening Service

All licensed healthcare facilities providing breast cancer screening ser-
vices must:
7.1.1. Follow best practice for breast cancer screening and diagnosis care pathways
and recommendation of breast cancer screening per Appendices C and D.
7.1.2. Adhere to the clinical performance indicators and timelines for referral
in accordance with Appendix E; and ensure availability of evidence of
compliance with these indicators.
7.1.3. Comply with requirement of breast screening unit, detailed in
Appendix F.
7.1.4. Have an approved referral protocol for referral of women with screen
detected abnormalities for further breast assessment unit or treatment.
7.1.5. Establish and maintain record of mammogram outcomes, audit program
to follow up positive mammography assessments and to correlate
pathology results with the interpreting physician’s findings.
7.1.6. Assign a breast cancer facility program coordinator/director who will be
accountable to:
7.1.6.1. Report and submit screening visits and outcome data, specified
in Sect. 4.
7.1.6.2. Establish internal audit policies and procedures and conduct
regular audits, monitoring and evaluation to demonstrate com-
pliance with this guideline and other associated regulatory
policies and standards.
7.2. Breast Assessment and Diagnosis Services
7.2.1. Breast assessment and diagnosis services must be carried out in
Diagnostic Breast Assessment Unit.
These unit must:
7.2.2. Comply with the requirements of Diagnostic Breast Assessment Unit,
described in Appendix F.
7.2.3. Comply with breast cancer screening and diagnosis care pathways, clin-
ical quality indicators, and timelines for referral in accordance with
Appendices B and E.
7.2.4. Have approved written protocols for the screening assessment and diag-
nosis; that clearly define the methods of assessment and the diagnostic
pathways for all possible assessment outcomes.
7.2.5. Women who require further assessment must be managed in accordance
with internationally best practices and recommended guidelines such
those of the National Health System Breast Screening Program
(NHSBSP) clinical guidelines for breast cancer screening assessment or
Appendix A: The National Guideline for Breast Cancer Screening and Diagnosis 645

the National Comprehensive Cancer Network NCCN Breast Cancer

Screening and Diagnosis.
7.2.6. Establish internal audit procedures to demonstrate compliance with this
guideline and other associated regulatory policies and standards.
7.3. All licensed healthcare professionals participating in breast cancer screen-
ing and diagnosis must:
7.3.1. Have knowledge of the principles of breast cancer screening, assess-
ment, diagnosis and management.
7.3.2. Participate in continuing medical education and take part in any recog-
nized external quality assessment schemes concerning radiologists and
radiographers; to allocate 40% of annual recommended CME for breast
imaging.
7.3.3. Conduct breast cancer risk assessment. Detailed history, such as that
described in, Appendix B, must be evaluated and completed, each time
a woman visits for screening. The purpose of this is to identify risk sta-
tus, as per risk categories specified in Appendix C and referral women
to appropriate screening tests.
7.3.4. Inform all individuals of the procedures and expected time frame to be
screened and to receive results.
7.3.5. Ensure that the outcome of screening for breast cancer is reviewed by a
multi-disciplinary team involving a full range of specially trained pro-
fessionals including a radiologist, radiographer, pathologist, surgeon,
nurse counselor and medical oncologist/radiotherapist.
7.3.6. Follow up and timely referral of women with abnormal results to further
assessment or treatment.

8. Standard 2: Recruitment for Screening

Women eligible for breast cancer screening may be recruited by the healthcare facil-
ities, through the following:
8.1. Targeted invitation
8.1.1. All facilities providing breast cancer screening and diagnosis services
must establish an invitation system to ensure identification, successful
participation and retaining of eligible population.
8.1.2. Targeted invitation may be established via an electronic or manual invi-
tation system.
8.2. Opportunistic
8.2.1. Physician consultation for related or unrelated reason
8.2.2. Engagement in a health promotion campaign

9. Standard 3: Breast Cancer Screening

9.1. Breast cancer screening must be provided in accordance with the breast
screening and diagnosis care pathway as provided in Appendix B, including
the following activities:
646 Appendix A: The National Guideline for Breast Cancer Screening and Diagnosis

9.1.1. History and risk assessment

9.1.2. Screening mammogram
9.2. Periodical screening must be carried out as specified in breast cancer screening
recommendations in Appendix C.
9.3. Detailed history, such as that described in Appendix B, must be evaluated and
completed by the screening facility nurse, each time a woman visits for screen-
ing. The purpose of that is to identify patient at increased risk and determine
the appropriate screening tests.
9.4. Screening mammography must involve two X-ray images for each breast; cra-
niocaudal (CC) and mediolateral oblique (MLO).
9.5. Digital breast tomosynthesis is recommended as adjunct to screening mam-
mogram. for women with high mammographic breast density and to be consid-
ered for women at increased risk in accordance with Appendix C (Reference:
European Commission Initiative on Breast Cancer (ECIBC). https://ecibc.jrc.
ec.europa.eu/recommendations/. 23 Mar 2023.)
9.6. Women must be provided with (oral and written) education and information,
regarding benefits, risk and limitation of breast cancer screening, and about the
screening test, associated procedures and expected time frames to receive
results.
9.7. Adequate attention must be given to the level of literacy, diversity and linguis-
tic requirements of different populations.

10. Standard 4: Breast Assessment and Diagnosis

10.1. Breast cancer assessment and diagnosis must be provided in accordance with
the clinical care pathway and timelines for referral (Appendices B and C).
10.2. Women with abnormal mammogram, who require further assessment and
diagnosis must be recalled/referred to Diagnostic Breast Assessment Unit
within 15 working days of screening mammogram.
10.3. Assessment and diagnostic work up of screen detected abnormality is best
achieved using the triple assessment:
10.3.1. Imaging; usually diagnostic mammography and ultrasound
10.3.2. Clinical examination
10.3.3. Image-guided needle biopsy for histological examination, if indicated
10.3.4. Cytology alone must not be used to obtain a non-operative diagnosis
of breast cancer
10.3.5. Clinical examination is mandatory for every woman with a confirmed
mammographic or ultrasound abnormality that needs needle biopsy
and for all women recalled because of clinical signs or symptoms
10.4. Clinical examination is not mandatory for women whose further imaging is
entirely normal.
10.5. Core needle biopsy must be performed under image guidance.
Appendix A: The National Guideline for Breast Cancer Screening and Diagnosis 647

10.6. A clip must be placed at site of biopsy during the procedure of needle sam-
pling to identify the lesion/s location; especially in non-palpable lesions.
10.7. Results of assessments must be evaluated and considered by a multidisci-
plinary team (MDT). Particular attention must be given to address radiology-
pathology correlation.
10.8. Early recall for repeat mammography either in screening or diagnostic set-
tings is not recommended and must never be used as a substitute for inexpert
or inadequate assessment.
10.9. Early recall rate must be recorded, monitored and audited.

11. Standard 5: Reporting of Screening Mammogram

11.1. Double reading of screening mammogram is mandatory. Mammograms must

be interpreted by two independent radiologists.
11.2. In case of discordant opinions between two radiologists, either consensus or
preferably arbitration using a third expert screening radiologist can be car-
ried out.
11.3. The final assessment must be reported using the FDA-approved Breast
Imaging, Reporting and Data System (BI-RADS®) Final Assessment
Categories as described in Appendix G.
11.4. Screening mammograms that require additional assessment tools/imaging
should be rated as BI-RADS® 0, 4 or 5 depending on initial evaluation and
readers experience.
11.5. Only after full assessment, with additional imaging and/or comparison with
prior mammogram; BI-RADS® 1, 2, 4 or 5 can be assigned.
11.6. One final mammogram report to be issued, A synoptic breast imaging report
must be used by radiologists containing at least the following information:
11.6.1. Interpreting physicians’ names
11.6.2. Date of examination
11.6.3. Patient identification
11.6.4. Reason for examination
11.6.5. Breast density
11.6.6. Description of significant imaging lesions: mammographic charac-
teristics of the lesion; location (in quadrants); distance from the nip-
ple (in mm); and size (maximum diameter in mm)
11.6.7. Final assessment (BI-RADS®)
11.6.8. Detailed recommendations should be included in the report

12. Standard 6: Screening Outcomes

12.1. All women must be informed about the results of screening within 3 weeks
(15 working days) from date of screening mammogram.
648 Appendix A: The National Guideline for Breast Cancer Screening and Diagnosis

12.2. Women with screening mammogram of normal/benign (BI-RADS® 1/2), are

discharged to routine screening. Screening frequency will follow recommen-
dation specified in Appendix G.
12.3. If a woman requires further assessment for abnormal screening mammogram
(BI-RADS® 0) or clinical breast exam, referral must be to a Diagnostic Breast
Assessment Unit within 5 days of screening mammogram result.
12.4. Women must be notified with assessment results within 5 days of assess-
ment tests.
12.5. At the end of the screening, women must be provided with one final written
mammogram report.
12.6. It is the responsibility of the radiologist/referring physician (at the screening
or assessment facilities) to inform women regarding her screening and assess-
ment results. Also, send feedback to referring physician at the primary health-
care clinic.
 ppendix B: Breast Cancer Screening
A
Pathways

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650 Appendix B: Breast Cancer Screening Pathways

Key
1. Women at increased risk of breast cancer are defined in Appendix C of the stan-
dard for the screening and diagnosis of breast cancer.
2. Indication for MRI is stipulated in Appendix C of the standard for the screening
diagnosis of breast cancer.
3. Criteria for referral to genetic counselor is detailed in Table C.2.
4. Women with the following criteria should be excluded from screening mam-
mogram: pregnant, breast feeding, had bilateral mastectomy, and had recent
mammogram within 24–12 months, under the age of 40, unless she is at
increased risk.
5. Triple assessment must be performed in diagnostic breast assessment unit.
Requirement of a diagnostic breast assessment unit is detailed in Appendix B.
6. Clinical examination is mandatory for every woman with a confirmed mam-
mographic or ultrasound abnormality that needs needle biopsy.
7. Further imaging usually involves further diagnostic mammography and/or
ultrasound.
8. Needle biopsy should be performed under image guidance. Clip placement is
done at the time of core needle biopsy to identify lesion locations.
9. Cytology should no longer be used alone to obtain a non-operative diagnosis of
breast cancer.
10. Result of assessments are recommended to be discussed by a multidisciplinary
team. Women must be informed about results within 5 working days.
11. Early recall is exceptional screening outcome and should be monitored and
audited.
12. Screening frequency will follow recommendation specified in Appendix C.
13. Referral of histologically confirmed cancer cases to treatment must be made
within 10 working days, following diagnosis.

References

1. NCCN Clinical Practice Guidelines in Oncology, Breast Cancer Screening and

Diagnosis. V.1.2022.
2. NHS Clinical Guidelines for Breast Cancer Screening Assessment, NHSBSP
publication no. 49.
3. The National Health System (NHS) Cancer Screening Programmes. Technical
guidelines for magnetic resonance imaging for the surveillance of women at
higher risk of developing breast cancer, NHSBSP publication no. 68.
4. The National Comprehensive Cancer Network (NCCN) Clinical Practice
Guidelines in Oncology, genetic/familial high-risk assessment: breast and ovary.
 ppendix C: National Breast Cancer Screening
A
Recommendation (Table C.1)

Women at Increased Risk/High Risk

A woman is considered at higher risk of developing breast cancer if she has one or
more of the following criteria:
• Previous history of breast cancer.
• Previous treatment with chest radiation at age younger than 30.
• Lobular carcinoma in situ (LCIS) or atypical ductal hyperplasia (ADH) or atypi-
cal lobular hyperplasia (ALH), on previous breast biopsy.
• Strong family history or genetic predisposition.
Criteria of personal or family history of a woman to be categorized as high
risk and to follow the high-risk protocol:
A woman is considered at higher risk of developing breast cancer if she has one
or more of the following criteria:

Table C.1 A summary of the national breast cancer screening recommendation

Screening
category Age Screen assessment tools
Women at 40–69 years • Mammogram every 2 years
average risk 70 years and above • Self-referred
Women at Age of initiation is • Annual mammogram screening
increased/high individualized according to • Begin 10 years prior to the youngest
risk risk (Table C.2) affected family member but not prior to
25 years
• Consider tomosynthesis
• Annual MRI screening—as indicated not
prior to 25 years
• Referral to genetic counselor for strong
familial/genetic predisposition
Adapted from: NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and
Diagnosis. V.1.2022

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652 Appendix C: National Breast Cancer Screening Recommendation (Table C.1)

Table C.2 National screening recommendations for women at increased risk

Previous treatment with chest Age <25 • Screening begin 10 years after
radiation at a young age (between years radiotherapy
age of 10 and 30) Age ≥25 • Annual mammography screening
(begin 10 years after radiotherapy but
not prior to age of 30 years)
• Consider tomosynthesis
• Annual MRI screening (begin 10 years
after radiotherapy but not prior to age
of 25 years)
Strong family history or genetic Age <25 • Referral to genetic risk assessment
predispositiona years
Age ≥25 • Annual mammography screening 10
years years before the youngest family
member but 25
• Youngest family member but not prior
to 10–25
Previous history of breast cancer Surveillance protocol
 • Annual mammography screening
Lobular carcinoma in situ (LCIS) or atypical Annual mammogram screening:
ductal hyperplasia (ADH) or atypical lobular  • To begin at diagnosis of LCIS or
hyperplasia (ALH) on previous breast biopsy ADH/ALH but not prior to age of 25
years
 • Consider annual MRI screening to
begin at diagnosis of LCIS or ADH/
ALH but not prior to age of 25 years
NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and Diagnosis. V.1.2022
a
Screening and assessment of women with genetic/familial high risk are individualized and should
be in accordance with recognized international guidances such as NCCN guideline

Personal History
• History of breast cancer
• History of ovarian cancer
• Gene mutation: BRCA1, BRCA2, TP 53, or PTEN mutation
• Previous treatment with chest radiation at age younger than 30
• Lobular carcinoma in situ (LCIS) or atypical ductal hyperplasia (ADH) or atypi-
cal lobular hyperplasia (ALH), on previous breast biopsy
Family History
• One first degree female relative with
–– Breast cancer diagnosed <50 years
–– Ovarian cancer at any age
–– Bilateral breast cancer where the first diagnosed <50 years
• Two or more first degree relatives, with breast cancer
• One of first-degree or second-degree relative diagnosed with breast cancer or
ovarian cancer at any age
• One first-degree male relative with breast cancer at any age
• Having a first-degree relative with gene mutation (BRCA1, BRCA2, TP 53,
or PTEN)
Appendix C: National Breast Cancer Screening Recommendation (Table C.1) 653

References

1. NICE, familial breast cancer. V.1.2022.

2. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and
Diagnosis. V.1.2022.
Criteria of use of MRI as adjunct to mammogram for high-risk women:
• Having BRCA1, 2 mutation
• Having a first-degree relative with BRCA1, 2 mutation
• Received chest radiation between age 10 and 30
• Carry or have a first-degree relative who carries mutation in TP 53 or PTEN genes
Criteria to merit referral for genetic risk evaluation:
• Ovarian cancer
• Male breast cancer
• Personal history of three or more of the following (especially if diagnosed before
age of 50 and can include multiple primary cancers in the same individual)
• Breast cancer
• Colon cancer
• Diffuse gastric cancer
• Pancreatic cancer
• Prostate cancer
• Thyroid cancer
• Brain tumors
• Endometrial cancer
• Brain tumors
• Adrenocortical carcinoma
• Melanoma
• Sarcoma
• Leukemia
• Kidney cancer
• Hamartomata’s polyps of GI tract
An individual with a breast cancer diagnosis meeting any of the following:
• A known mutation in a cancer susceptibility gene within the family (BRAC1/2,
TP 53, or PTEN)
• Early age-onset breast cancer ≤45
• Triple negative (ER-, PR-, HER-) breast cancer and age ≤60
• Two breast cancer primaries in a single individual
• Breast cancer at any age
–– >One close blood relative with breast cancers 50 years
–– >One close blood relative (first or second or third degree) with invasive ovar-
ian cancer at any age
–– >Two close blood relative with breast cancer, prostate cancer and/or pancre-
atic cancer at any age
654 Appendix C: National Breast Cancer Screening Recommendation (Table C.1)

–– Personal history of pancreatic cancer at any age

An individual with no personal history of cancer but with:
• A close relative with any of the following:
–– >Two breast cancer primaries in a single individual
–– >Two different individuals with breast cancer primaries from the same side of
the family maternal or paternal with at least one diagnosed before 50
–– Ovarian cancer
–– Male breast cancer
• First-or second-degree relative with breast cancer ≤45 years
• Family history of three or more of the following (especially if diagnosed before
age of 50 and can include multiple primary cancers in the same individual)
–– Breast cancer
–– Colon cancer
–– Diffuse gastric cancer
–– Pancreatic cancer
–– Prostate cancer
–– Thyroid cancer
–– Brain tumors
–– Endometrial cancer
–– Brain tumors
–– Adrenocortical carcinoma
–– Melanoma
–– Sarcoma
–– Leukemia
–– Kidney cancer
–– Hamartomata’s polyps of GIT
N. B. Maternal and paternal sides of the family should be considered indepen-
dently for familial pattern of cancer. First degree: mother, sister, daughter, brother,
and father—second degree: grandmother, aunt, niece, and nephew.

References

1. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and

Diagnosis. V.1.2022.
2. The National Comprehensive Cancer Network (NCCN) Clinical Practice
Guidelines in Oncology. Genetic/familial high-risk assessment: breast and ovary.
V.1.2022.
 ppendix D: Pedigree: First-, Second-,
A
and Third-Degree Relatives of Proband

First-degree relatives: parents, siblings, and children

Second-degree relatives: grandparents, aunts, uncles, nieces, nephews, grandchil-
dren, and half siblings
Third-degree relatives: great-grandparents, great-aunts, great-uncles, great-­
grandchildren, and first cousins

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 ppendix E: National Breast Cancer Screening
A
Clinical Performance Indicators

Clinical quality
indicators Definition Calculation Acceptable level Desirable level
1. Participation Percentage of Number of women >70% >75%
rate women 40–74 screened at least
years who have a once (per 2 years
screening period)/target
mammogram population
(calculated [(first- and
biennially) as a second-year
proportion of the populations
eligible population averaged from
census/forecast)]
× 100
2. Retention The estimated Kaplan–Meier Auditable outcome >75%
Rate percentage of methoda
women 40–74
years who are
re-screened within
30 months of their
previous screen
3. Technical Proportion of [Number of women <3% <1%
repeat rate women undergoing a
undergoing a technical repeat/
technical repeat Number of women
screening screened] × 100
examination
4. Abnormal Proportion of [Number of recalls At initial Auditable <7–10%
recall rate women recalled due to abnormal screening outcome
for further screens/Number of At subsequent Auditable <5–7%
assessment women screened] × screening outcome
100
5. Early recall Proportion of [Number of <1% 0%
rate women subjected for early
undergoing a recall/Number of
technical repeat women screened]
screening × 100
examination
6. Positive Proportion of [Number of screen At Initial screening >5%
predictive value abnormal cases detected/Number of At subsequent screening >6%
with completed abnormal screens
follow-up found to with complete
have breast cancer work-up] × 100

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658 Appendix E: National Breast Cancer Screening Clinical Performance Indicators

Clinical quality
indicators Definition Calculation Acceptable level Desirable level
7. Invasive Number of [Number of invasive At Initial screening >5 per 1000
cancer invasive cancers cancers detected/ At subsequent screening >3 per 1000
detection rate detected per 1000 Number of
screens screens] × 1000
8. In situ Number of ductal [Number of DCIS At initial screening >0.4 per 1000
cancer carcinomas in situ detected/Number of subsequent screening >0.4 per 1000
detection rate (DCIS) detected screens] × 1000
per 1000 screens
9. Invasive Proportion of [Number of invasive Initial screening 20%
cancer tumor invasive tumor ≤10 mm/ ≥25%
size screen-detected Total number of Subsequent screening ≥25%
cancers that are invasive tumors] × ≥30%
<10 mm in size 100
10. Invasive Number of women [Number of cancers Within the first year (0–11 <Per 10,000
cancer with diagnosis of detected in the months)
detection rate invasive breast 0–12-month interval Within the second year (12–23 12 per 10,000
cancer after a after a normal months)
normal screening screening episode/
within 12 and 24 Total person-years
months of screen at risk (0–12 months
date post screen)] ×
10,000
11. Time – Screening mammography and result within 15 working 95% >95%
interval days (wd)
– Screening and offered assessment within 5 working days 90% >90%
(wd)
– Assessment and issuing of results within 5 working days 90% >90%
(wd)
– Non-operative (needle) biopsy and result 5 working days >90% 100%
(wd)

a
Refer to Ref. [2] for calculation

References

1. European guidelines for quality assurance in breast cancer screening and diag-
nosis. Update Mar 2023.
2. Public Health Agency of Canada. Report from the Evaluation Indicators Working
Group. Guidelines for monitoring breast screening program performance.
Update 2022.
 ppendix F: Requirement for Breast Screening
A
and Diagnosis Services

Requirement for Breast Screening Unit

1. General
1.1. Assign a screening program director/coordinator who will be in charge of
overall performance, quality assurance of the unit and will be responsible
for submitting data on screening visits and outcomes to MOHAP.
1.2. Perform at least 1000 mammograms a year.
1.3. Be able to perform risk assessment, physical examinations, and screening
mammogram.
1.4. Monitor data and feedback of results. Keep a formal record of mammogram
results, assessment processes, and outcomes.
2. Invitation system
2.1. Operate a successful personalized invitation system and/or a promotional
campaign as well as an organized system for re-inviting all previously
screened women.
3. Mammography equipment
3.1. Specifications must meet recognized standards such as the MQSA final rule
published by the FDA.
3.2. Subject to regular radiographic and physicist quality-controlled tests, in
concordance with MQSA rule.
3.3. Equipment must be maintained and serviced in accordance with the manu-
facturer’s guidelines and service specifications, records must be maintained
by providers.
4. Radiographers
4.1. Radiographers, mammographers, or technologists performing the mammo-
graphic examination must have had at least 40 h of training specific to the
radiographic aspects of mammography
4.2. Regularly participate in external quality assessment schemes and radio-
graphic update courses.

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660 Appendix F: Requirement for Breast Screening and Diagnosis Services

5. Radiologists
5.1. Must have at least 60 h of training specific to mammography.
5.2. Must read mammograms from a minimum of 1000 screening mammo-
grams annually. Have centralized reading or, in a case of a decentralized
programmer, centralized double.
5.3. This radiologist must take full responsibility for the image quality of the
mammograms reported and ensure that where necessary images are
repeated until they are of satisfactory standard. The number of all repeated
examinations should be recorded.
6. Referral, assessment and feedback
6.1. Keep a formal record of mammogram results, assessment processes, refer-
rals, and outcomes.
6.2. Maintain record of mammogram results, referrals, assessment processes,
and outcomes.
6.3. Have an approved protocol for referral of women with screen detected
abnormalities to diagnostic breast assessment unit.

Requirement for a Breast Assessment/Diagnostic Unit

1. General
1.1. Perform at least 2000 mammograms a year.
1.2. Be able to perform physical examinations and ultrasound examinations as
well as the full range of radiographic procedures. Provide cytological
examination and/or core biopsy.
1.3. Sampling under radiological (including stereotactic) or sonographic
guidance.
1.4. Monitor data and feedback of results.
1.5. Keep a formal record of mammogram results, assessment processes, and
outcomes.
2. Physic-technical
2.1. Have dedicated equipment specifically designed for application in diagnos-
tic mammography, e.g., mammography system with magnification ability
and dedicated processing, and be able to provide adequate viewing condi-
tions for mammograms.
2.2. Have dedicated ultrasound and stereotactic system and needle biopsy
device for preoperative tissue diagnosis.
2.3. Comply with specifications of recognized standards such as the MQSA
final rule published by the FDA.
3. Radiographers
3.1. The radiographers, technologists, or other members of staff performing the
mammographic examination must have had at least 40 h of training specific
to the radiographic aspects of mammography and regularly participate in
external quality assessment schemes and radiographic update courses.
These persons must be able to perform good quality mammograms. There
should be a nominated lead in the radiographic aspects of quality control.
Appendix F: Requirement for Breast Screening and Diagnosis Services 661

4. Radiologists
4.1. Employ a trained radiologist, i.e., a person who has had at least 60 h of
training specific to mammography and who in volume reads at least 1000
mammograms per year.
5. Pathology support
5.1. Have organized and specialist cyto / histopathological support services.
6. Multidisciplinary activities
6.1. Participate in multidisciplinary communication and review meetings with
others responsible for diagnostic and treatment services.
 ppendix G: BI-RADS® Final Assessment
A
Categories

CPT—
evaluation BI-RADS
code score Description Definition
3340F 0 Incomplete. Need The mammogram or ultrasound didn’t
additional imaging give enough information to make a clear
diagnosis; follow-up imaging is necessary
and/or prior mammogram for comparison
3341F 1 Negative Negative, continue biannual screening
mammography (for women 40 and older)
3342F 2 Benign Benign (non-cancerous) finding, same
statistics and plan of follow-up as level 1.
This category is for cases that have a
finding that is characteristically benign
such as cyst of fibro adenoma
3343F 3 Probably benign Probably benign finding, there is less than
2% chance if cancer, additional
examinations done to clear the situation
at once
3344F 4 Suspicious Suspicious abnormality. Findings do not
4A have the classic appearance of
AB malignancy. But are sufficiently
4C suspicious to justify recommended
biopsy. Carry 2–95% chance of being
malignant finding.
4A: finding with a low suspicion of being
cancer (>2% and ≤10%)
4B: finding with an intermediate
suspicion of being cancer (>10% and
≤50%)
4C: finding of moderate concern of being
cancer but not as high category 5 (>50%
and <95%)

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664 Appendix G: BI-RADS® Final Assessment Categories

CPT—
evaluation BI-RADS
code score Description Definition
3345F 5 Highly suggestive of Highly suggestive of malignancy.
malignancy Classic sign of cancer is seen on the
mammogram. All category 5
abnormalities typically receive biopsy
and if the biopsy results are benign, the
abnormality usually receives re-biopsy
since the first biopsy may not have
sampled the correct area. Depending on
how category 4 and 5, the percentage of
category 5 abnormalities that will be
cancer may vary between 75% and 99%
3350F 6 Known biopsy Lesions known to be malignant that are
proven malignancy being imaged prior to definitive
treatment; assure that treatment is
completed

References

1. NCCN breast cancer risk reduction V.1.2023.

2. NICE, familial breast cancer, V.3. 2023.
3. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Screening and
Diagnosis. V.1.2022.
4. The National Comprehensive Cancer Network (NCCN) Clinical Practice
Guidelines in Oncology. Genetic/familial high-risk assessment: breast and ovary.
V.1.2022.
5. European guidelines for quality assurance in breast cancer screening and diag-
nosis, Nov 2022.
6. International Agency for Research on Cancer Handbook Working Group, vol.
33(3), 2 Mar 2021
7. Guidelines for Monitoring Breast Screening Program Performance, vol. 20.
2020. p. 795.
Appendix H: The National Guideline for
Cervical Cancer Screening and Diagnosis

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 665
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
666 Appendix H: The National Guideline for Cervical Cancer Screening and Diagnosis
Appendix H: The National Guideline for Cervical Cancer Screening and Diagnosis 667

National Cervical Cancer Screening Task Force

Dr. Huda Obaid Al Abdouli—Head of Task Force

Coordinator of National Cancer Screening Program—MOHAP
Dr. Buthaina Bin Belaila—Member
Head of Non-communicable Disease—MOHAP
Head of National Cancer Screening Program
Prof. Humaid Obaid Al Shamsi—Member
Director of the Burjeel Cancer Institute
President of the Emirates Oncology Society
Dr. Lamia Safieldin—Member
Comprehensive Screening Specialist
Department of Health—Abu Dhabi
Dr. Saad Ghazal Aswad—Member
Chair of Department
General-Obs/Gyno Clinic—Medical Affairs
Tawam Hospital
Dr. Wafa Adel Albayati—Member
Consultant and Head of Department Ob/Gyn
Khorfakan Hospital, EHS
Dr. Suad Hashim Ahmad—Member
Consultant Family Physician
Dubai Health Authority
Dr. Kauser Mansoor Baig—Member
Sr. Consultant in Obstetrics and Gynecology
Prof. and Head of the Department
Sharjah University Hospital
Dr. Saba Alsayari—Member
Consultant in Obstetrics and Gynecology
Head of the Department—Dubai
Dr. Sahar Ibrahim Yassa—Member
Specialist Obstetrics and Gynecology—EHS
The National Cervical Cancer Screening Program

1. Purpose

1.1. This guideline mandates the clinical service specifications and data reporting
for National Cervical Cancer Screening Program in the UAE.
1.2. It specifies the clinical care pathway and minimum service standards and spec-
ifications to ensure that women screened for cervical cancer receive quality
and safe care and timely referral for diagnosis and/or treatment.
668 Appendix H: The National Guideline for Cervical Cancer Screening and Diagnosis

2. Scope

2.1. This guideline applies to all healthcare providers (facilities and professionals)
licensed in UAE and providing cervical cancer screening services.
2.2. Participating healthcare providers should offer the following services as appli-
cable based on their license category:
2.2.1. Risk assessment and physical examination.
2.2.2. Specimen collection and preparation of adequate cervical smear.
2.2.3. Handling and reporting of cervical smears.
2.2.4. Follow-up and referral.
2.3. Follow reporting terminologies defined as per Appendix I.

3. Duties of the Healthcare Providers

All licensed healthcare providers; facilities and professionals engaged in pro-

viding cervical cancer screening services must:
3.1. Provide clinical services and patient care in accordance with this guideline and
in accordance with Policies and Standards, Laws and Regulations of the United
Arab Emirates; including developing effective recording systems, maintaining
confidentiality, and privacy and security of patient information.
3.2. Comply with the federal requirements; laws and policies for patient education.
The National Cervical Cancer Screening Program and consent. The licensed
provider must provide appropriate patient education and information regarding
the screening test and must ensure that appropriate patient consent is obtained
and documented on the patient’s medical record.
3.3. Comply with Federal requirements, laws, policies, and standards on managing
and maintaining patient medical records, including developing effective recording
systems, maintaining confidentiality, privacy and security of patient information.
3.4. Comply with Federal requirements; laws, policies, and standards for
Information Technology (“IT”) and data management, electronic patient
records and disease management systems, sharing of screening and diagnostic
test, and where applicable pathology results.
3.5. Comply with MOHAP requests to inspect and audit records and cooperate
with authorized auditors as required.
3.6. Collect and submit data on screening visits and outcomes, to the National
Cancer Screening Registry, at MOHAP.
3.7. Comply with Federal laws, policies, and standards on cancer case reporting
and report all confirmed screening-detected cancers to the National Cancer
Registry at MOHAP.

4. Enforcement and Sanctions

4.1. Healthcare providers must comply with the terms and requirements of these
guidelines MOHAP may impose sanctions in relation to any breach of require-
ments under this guideline.
Appendix H: The National Guideline for Cervical Cancer Screening and Diagnosis 669

5. Payment for Screening and Follow-Up of Cervical

Cancer Screening

5.1. Eligibility for reimbursement under the Health Insurance Scheme must be in
accordance, with local insurance laws for each Emirate.

6. Standard 1: Clinical Service Specifications

6.1. Screening facilities responsible for providing screening services must:

6.1.1. Be licensed according to licensing policies and regulations of the
United Arab Emirates.
6.1.2. Fulfill the eligibility criteria for a cervical cancer screening facility as
per clinical best practices in accordance with Appendix J.
6.1.3. Comply with the cervical cancer screening care pathways, clinical
quality indicators, and timelines for referral in accordance with
Appendices K–M respectively.
6.1.4. Assign a screening program coordinator responsible for submitting
data on screening visits and outcomes to MOHAP and who will fulfill
the responsibilities in accordance with Appendix N.
6.1.5. Collect and submit data on screening visits and outcomes within 3
weeks of the screening date to MOHAP.
6.1.6. Report all screen-detected cancer cases to MOHAP, through Cancer
Case Notification Form.
6.1.7. Maintain records for screening tests and outcomes.
6.1.8. Establish internal audit procedures to demonstrate compliance with
these guidelines and other associated regulatory policies and standards.
6.1.9. Ensure the availability of evidence of compliance with the Cervical
Cancer Screening Program Clinical Quality Indicators specified in
Appendix L including:
6.1.9.1. Collection and preparation of adequate cervical smear.
6.1.9.2. Handling and transporting of specimens to labs assigned by
MOHAP to deliver the service.
6.1.10. Have an approved protocol for referral of women with abnormal
results or physical examination to a diagnostic or treatment center.
6.2. Laboratories providing screening services must:
6.2.1. Be licensed according to licensing policies and regulations of the United
Arab Emirates.
6.2.2. Comply with the applicable elements of the clinical quality indicators in
accordance with Appendix M and ensure availability of evidence of
compliance with these indicators; such as laboratory records required
for accreditation purposes.
6.2.3. Establish internal audit procedures to demonstrate compliance with this
guideline and with other associated regulatory policies and standards.
6.2.4. Develop, implement, and monitor policies and standard operating pro-
cedures for management of smears in accordance with International
670 Appendix H: The National Guideline for Cervical Cancer Screening and Diagnosis

Clinical Laboratory standards including: processing, workload, storage,

documentation, and reporting.
6.2.5. Attain accreditation by an internationally credible body recognized by
MOHAP such as CAP, IOS 15189(2007), JCI/Lab.
6.2.6. Participate in an international external proficiency test by all personnel
involved in screening and reporting Pap test.
6.3. Healthcare professionals involved in providing cervical cancer screening ser-
vices must:
6.3.1. Be licensed according to licensing policies and regulations of the United
Arab Emirates.
6.3.2. Comply with the clinical standards detailed in this guideline to provide
the most appropriate care, taking responsibility for deciding the best
care options for managing cervical cancer cases.
6.3.3. Provide women with culturally and socially relevant education on wom-
en’s health and with information (oral and written) regarding the screen-
ing benefits and limitations of cervical screening, potential outcomes,
and next steps that may be required for care management.
6.3.4. Participate in continuing medical education (CME).

7. Standard 2: Screening Test

7.1. Papanicolaou test, (also called Pap test) is the standard test for screening for
cervical cancer.
7.2. Liquid-based cytology (LBC) is the accepted standard method for Pap test
specimen collection.
7.3. HPV test, as co-testing, for women aged 30 years and above (only internation-
ally approved test is accepted).

8. Standard 3: Frequency of Screening

8.1. The frequency of repeat screening for average-risk, symptom-free women is:
8.1.1. Every 3 years for women aged 25–29 years.
8.1.2. Every 5 years for women aged 30–65 years.
8.2. Women who are immune-compromised due to disease or medication.
8.2.1. Annual screening.

9. Standard 4: Eligibility for Screening

9.1. All sexually active women, symptom-free, aged 25–65 years old (married,
divorced, widowed) residing in the UAE, are eligible criteria for screen-
ing apply.
9.2. Women are excluded from screening if:
Appendix H: The National Guideline for Cervical Cancer Screening and Diagnosis 671

9.2.1. They have received a total hysterectomy for benign indications.

9.2.2. They are over 65 years (provided that the last two previous smears: US
cervical were negative).
9.3. Women who have had subtotal hysterectomy (preserving the cervix), or hyster-
ectomy due to cervical cancer or precancerous condition should continue to
have cervical screening.
9.4. Screening recommendations remain the same regardless of whether or not they
have received the HPV vaccination.

10. Standard 5: Recruitment to Screening

Recruitment of eligible women for screening can be made through:

10.1. Targeted invitation from eligible screening facilities.
10.2. Opportunistic by:
10.2.1. Approaching women who are enrolled in other existing screening
programs; e.g. breast cancer.
10.2.2. Physician consultation for related or unrelated reason.
10.2.3. As an outcome of a health promotion campaign.

11. Standard 6: Risk Assessment and Physical Examination

11.1. Women must receive adequate information regarding the screening, Pap test
procedure and expected outcomes and timeframe to receive results.
11.2. Detailed history, must be taken to assess risk and frequency of repeating
screening, including at least:
11.2.1. Menstrual status (LMP, hysterectomy, pregnant, postpartum, use of
contraceptive or hormone therapy).
11.2.2. Previous screening, results of screening, (negative, abnormal, or pos-
itive) and any previous treatment, (biopsy, chemotherapy, radiother-
apy, or surgery).
11.2.3. Immune-compromised status due to diseases (including HIV) or
medication.
11.3. Full clinical examination must be performed including visual inspection of
the cervix.

12. Standard 7: Specimen Collection and Preparation of

Adequate Pap Test

12.1. The following categories of licensed healthcare physicians are eligible to per-
form a Pap test:
12.1.1. Licensed gynecologists and obstetricians.
12.1.2. Physicians are already privileged to do so by their institution.
672 Appendix H: The National Guideline for Cervical Cancer Screening and Diagnosis

12.2. Eligible physicians must:

12.2.1. Complete the required form with relevant clinical information in
accordance with Standard 6 including any clinical findings e.g.
abnormal bleeding or visible lesions etc.
12.2.2. Collect and manage specimens in accordance with the facility inter-
nal policies and procedures for:
12.2.2.1. Labelling
12.2.2.2. Storage
12.2.2.3. Transportation
12.2.3. Smear-taking must be avoided in the following circumstances and
women must be advised when to return for a Pap test:
12.2.3.1. Menstruation
12.2.3.2. Vaginal inflammation/infection
12.2.3.3. Pregnancy (unless a previous smear was abnormal and in
the interim the woman becomes pregnant, then the follow-
up smear must not be delayed)

13. Standard 8: Cytology Smear Management and Reporting

Clinical laboratories handling and reporting of cytology specimens and cytol-

ogy smears testing must:
13.1. Manage cervical cytology smears and perform the cytopathology testing as
indicated in 6.2.4 and in accordance with laws, regulation, and Clinical
Laboratory Standards.
13.2. Make final reports of cervical cytology smear using the Bethesda System
(The Bethesda System for Reporting Cervical Cytology).
13.3. The report must be verified by a pathologist for all abnormal and reactive
cases, while negative cases can be verified by licensed cytotechnologists
using standard synoptic reporting format and containing minimum elements
consistent with those of internationally reputable accrediting bodies. The
report must include at least the following details:
13.3.1. Patient’s name.
13.3.2. Age/date of birth.
13.3.3. Menstrual status (LMP, hysterectomy, pregnant, postpartum, and
hormone therapy).
13.3.4. Relevant clinical information; such as if the patient had previously
positive test or had other types of cancer, etc.
13.3.5. Specimen description (source).
13.4. Reports for specimen adequacy and cytological findings must be returned to
the referring physician at the screening center within 8 working days of
receiving the specimen.
13.5. The reporting pathologist is the professional responsible for informing the
referring physician of the positive cancer results.
Appendix H: The National Guideline for Cervical Cancer Screening and Diagnosis 673

13.6. MOHAP may, at its discretion, conduct third-party independent quality assur-
ance testing of laboratories providing cervical smear laboratory test service.
Where it does so, providers must comply with MOHAP’s direction and coop-
erate with the MOHAP appointed party.

14. Standard 9: Screening Outcomes and Referrals

14.1. All women must be notified in writing about their results.

14.2. It is the responsibility of the physician at the screening facility to notify and
provide a written report to a woman regarding her screening results within 15
working days (3 weeks) of the date of specimen taken.
14.3. If the test outcome is normal the woman is discharged to routine screening as
per frequency mentioned in this guideline.
14.4. If the test outcome is unsatisfactory, it must be repeated within 6–12 weeks,
treating infection, if present, as indicated.
14.5. If the Pap test outcome is abnormal or positive for intraepithelial lesion or
malignancy, the woman’s test is managed according to Appendix K.
14.6. If a suspicious visible abnormality is identified during visualization of cervix;
the woman must be referred immediately to a Gynecologist Oncologist with-
out receipt of her test results.
14.7. If a woman requires referral for colposcopy or treatment they must be referred
to an appropriately licensed healthcare professional, privileged to provide the
specialty/oncology services, patients must be seen within the timeframe spec-
ified in Appendix M.
14.8. All colposcopy services should be carried out by accredited colposcopist and
if the facility has no accredited doctor then arrangements should be made to
refer the patient to facility with accredited colposcopist.
Appendix I: Definitions

Term Definition
The Bethesda system Is a system reporting for cervical or vaginal cytological diagnoses,
(TBS) used for reporting Pap smear results. The name comes from the
location (Bethesda, Maryland) of the conference that established the
system of reporting
HPV Human papilloma virus
HPV co-testing Is a test is done along with the Pap test in women aged 30 years and
above, to screen for a high-risk HPV viral type. Only internationally
approved test is accepted
ASC-US Atypical squamous cells of undetermined significance. It is a finding
of abnormal cells in the tissue that lines the outer part of the cervix
ASC-H Suspicious for high-grade dysplasia
LGSIL or LSIL Low-grade squamous intraepithelial lesion
HGSIL or HSIL High-grade squamous intraepithelial lesion
AIS Adenocarcinoma in situ
AGC Atypical glandular cells

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 ppendix J: Eligibility Criteria for a Facility
A
to Participate National Cervical Cancer
Screening Program

1. General
In addition to the requirements of this standard, the healthcare facility must fulfill
the following criteria:
1.1. Plan capacity to match the demand for screening and the facility capacity
1.2. Allocate appointment slots for cervical cancer screening linked to the
online booking system (when available)
1.3. Have available adequate equipment to provide safe and quality screening
1.3.1. Send cervical cytology smears only to licensed Laboratories that
meet the requirements of this standard.
1.3.2. Ensure patient privacy, comfort, and confidentiality at all times.
2. Human resources
2.1. The core team must include at least:
2.1.1. A program coordinator.
2.1.2. A licensed physician, gynecologist, or obstetrician, physician privi-
leged to deliver cervical screening care and services.
2.1.3. A licensed nurse for each clinic with a minimum of 2 years of expe-
rience in gynecology or obstetric nursing.
2.2. Training of licensed health professionals must be delivered using CME/
CPD courses accredited by CME department including:
2.2.1. For physicians; training for Pap smear taking in accordance with
international evidence-based training standards and guidelines.
3. Registration as screening facilities
Facilities meeting cervical cancer screening requirements should consider follow-
ing points:
3.1. Establish communication with cancer control team
3.2. Fill service provision form
3.3. Return filled form back to cancer control team
3.4. Wait until receive confirmation from cancer control team
3.5. Receive username and password for data reporting after orientation session
with cancer team
3.6. Commence screening and reporting of screening data to MOHAP

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Appendix K

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Appendix L

Acceptable Desirable
Quality indicators level level
Coverage
Retention rate Percentage of 40% 50%
eligible women
re-screened with 3
years after a
negative Pap test in
a 12-month period
Specimen adequacy unsatisfactory Percentage of Pap 4.7% 1.3%
proportion tests that are
reported as
unsatisfactory in a
12-month period
Screening test results negative Percentage of 90% 97%
women by their
most severe Pap
test result in a
12-month period
Cytology turn around time 2 weeks The average time >80% >90%
from the date the
specimen is taken
to the date the
finalized report is
issued over a
12-month period
Time to colposcopy Percentage of 80% 88%
women with a
positive Pap test
(HSIL+/ASC-H)
who had follow-up
colposcopy within
9, 6, and 12
months subsequent
to the index Pap
test

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682 Appendix L

Acceptable Desirable
Quality indicators level level
Follow-up
Biopsy rate Percentage of To be 11%
women with a determined
positive screening
test result (HSIL+/
ASC-H) who
received a
histological
diagnosis in a
12-month period
Cytology-histology agreement Proportion of
positive Pap tests
with histological
work-up found to
have a pre-
cancerous lesion or
invasive cervical
cancer in a
12-month period A
Outcome indicators
Pre-cancer detection rate Number of 7.1 per 1000
pre-cancerous
lesions detected
per 1000 women
who had a Pap test
in a 12-month
period
 ppendix M: Cervical Cancer Screening
A
Program—Timeframes for Appointments

Cytological pattern Priority Appointment

HSIL or ASC-H Urgent 1–2 weeks
LSIL/ASC-US Routine 2–6 weeks

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 ppendix N: Responsibilities of the Facility
A
Cancer Screening Program Coordinator

The healthcare facility cervical cancer screening program coordinator must:

1.1. Be a licensed healthcare professional.
1.2. Have comprehensive and high-quality knowledge in cervical cancer as a dis-
ease and its prevention.
1.3. Be responsible for:
1.3.1. Recruitment of eligible women.
1.3.2. Follow-up and tracking of screening results to ensure the timeliness and
completeness of follow-up.
1.3.3. Assessing relationships between planned care and approved protocols
for care.
1.3.4. Assessing women’s needs for support to remove barriers to screening
and follow-up.
1.3.5. Developing and promoting recall systems that include reminders to
patients as appropriate.
1.3.6. Submitting data on screening visit and outcomes to MOHP via the (can-
cer screening e-notification system).

References

1. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, et al.
Screening for cervical cancer: U.S. Preventive Services Task Force recommen-
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Available at: https://jamanetwork.com/journals/jama/fullarticle/2697704.
Retrieved 12 Apr 2021.
2. Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J,
et al. American Cancer Society, American Society for Colposcopy and Cervical
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2012;137:516–42. Available at: https://academic.oup.com/ajcp/arti-
cle/137/4/516/1760450. Retrieved 27 Sept 2022.

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3. American College of Obstetricians and Gynecologists. Updated guidelines for

management of cervical cancer screening abnormalities. Practice Advisory.
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advisory/articles/2020/10/updated-­guidelines-­for-­management-­of-­cervical-­
cancer-­screening-­abnormalities. Retrieved 12 Apr 2021.
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ASCCP_Risk_Based_Management_Consensus.3.aspx. Retrieved 12 Apr 2021.
5. Fontham ET, Wolf AM, Church TR, Etzioni R, Flowers CR, Herzig A, et al.
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6. Kim JJ, Burger EA, Regan C, Sy S. Screening for cervical cancer in primary
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jama/fullarticle/2697702. Retrieved 12 Apr 2021.
7. Centers for Disease Control and Prevention. HPV-associated cervical cancer
rates by race and ethnicity. Available at: https://www.cdc.gov/cancer/hpv/statis-
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8. Buskwofie A, David-West G, Clare CA. A review of cervical cancer: incidence
and disparities. J Natl Med Assoc. 2020;112:229–32. Available at: https://www.
sciencedirect.com/science/article/abs/pii/S0027968420300432. Retrieved 3
Mar 2022.
9. Yeh PT, Kennedy CE, de Vuyst H, Narasimhan M. Self-sampling for human
papillomavirus (HPV) testing: a systematic review and meta-analysis. BMJ
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e001351.long. Retrieved 12 Apr 2021.
10. Elam-Evans LD, Yankey D, Singleton JA, Sterrett N, Markowitz LE, Williams
CL, et al. National, regional, state, and selected local area vaccination coverage
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Mortal Wkly Rep. 2020;69:1109–16. Available at: https://www.cdc.gov/mmwr/
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11. Agénor M, Pérez AE, Peitzmeier SM, Borrero S. Racial/ethnic disparities in
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12. Johnson NL, Head KJ, Scott SF, Zimet GD. Persistent disparities in cervical
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sagepub.com/doi/10.1177/0033354920925094.
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tee.48.aspx.
 ppendix O: The National Guideline for
A
Colorectal Cancer Screening and Diagnosis

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H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
690 Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis
Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis 691

National Colorectal Cancer Screening Task Force

Dr. Huda Obaid Al Abdouli—Head of Task Force

Coordinator of National Cancer Screening Program
Ministry of Health and Prevention
Dr. Buthaina Bin Belaila—Member
Head of Non-communicable Disease
Ministry of Health and Prevention
Prof. Humaid Obaid Al Shamsi—Member
Director of the Burjeel Cancer Institute
President of the Emirates Oncology Society
Dr. Sara Al Bastaki—Member
Consultant Colorectal Surgeon Founder and President of Emirates Society of Colon
and Rectal Surgery
Sheikh Khalifa Medical City
Dr. Lamia Safieldin—Member
Comprehensive Screening Specialist
Department of Health, Abu Dhabi
Dr. Maryam Al Khatry—Member
Consultant Gastroenterology—Member
Obaidullah Hospital—Emirates Health Services—EHS President of the Emirates
Gastroenterology Society
Dr. Sameer Al Awadhi—Member
Consultant Gastroenterology—Member
Dubai Health Authority—DHA
Dr. Thomas Cherukara—Member
Consultant Gastroenterology—Member
Kuwait Hospital—Emirates Health Services—EHS
Dr. Taha Kadir—Member
Consultant Colorectal Surgeon
Private Sector
Dr. Makki Fayadh—Member
Consultant Gastroenterology
Private Sector
Dr. Salim Awadh—Member
Consultant Gastroenterology
Private Sector

1. Purpose

1.1. To stipulate the service requirements to deliver the National Colorectal Cancer
(CRC) Screening Program in the United Arab Emirates.
1.2. To set out the minimum Clinical Care Standards and frequency for CRC
screening as per international evidence-based guidelines.
692 Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis

1.3. To set out the case mix, eligibility criteria and data reporting requirements for
colorectal cancer screening.
1.4. To ensure the population receives quality and safe care and timely referral for
diagnosis and/or treatment where appropriate.

2. Scope

2.1. This guideline applies to all healthcare providers (facilities and professionals)
in the United Arab Emirates, providing CRC screening services, including
mobile units.

3. Definitions

3.1. Colorectal cancer screening: Means looking for polyps or cancer in the colon
and rectum in people who have no symptoms of the disease. CRC screening
includes the following services:
3.1.1. Colorectal cancer screening services
3.1.2. Colorectal cancer assessment and follow-up
3.2. Colonoscopy: Colonoscopy is the endoscopic examination of the large bowel
and the distal part of the small bowel with a Charge Coupled Device (CCD), a
camera or a fiber optic camera, on a flexible tube passed through the anus. It
can provide a visual sight to detect adenomatous polyps and cancer diagnosis
(e.g., ulceration and polyps). It also grants the opportunity for biopsy or
removal of suspected colorectal cancer lesions.
3.3. Fecal immunochemical test (FIT): FIT is a test that investigates by using
antibodies to detect blood in the stool sample for signs of cancer.
3.4. Case mix: Includes males and females aged 40–75 years determined eligible
for colorectal cancer screening services, in accordance with the criteria detailed
in this guideline. For people ages 76–85, the decision to be screened should be
based on a person’s preferences and healthcare professional judgment consid-
ering life expectancy, overall health, and prior screening history.

4. Duties for Healthcare Providers

All licensed healthcare providers, facilities, and professionals engaged in pro-

viding CRC screening services must:
4.1. Provide clinical services and patient care in accordance with this guideline and
in accordance with laws and regulations, policies, and standards of the United
Arab Emirates, including developing effective recording systems, maintaining
confidentiality, privacy, and security of patient information.
4.2. Comply with the federal requirements, laws, and policies for patient education
and consent. The licensed provider must provide appropriate patient education
Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis 693

and information regarding the screening test and must ensure that appropriate
patient consent is obtained and documented on the patient’s medical record.
4.3. Comply with federal requirements; laws, policies, and standards on managing
and maintaining patient medical records, including developing effective
recording systems, maintaining confidentiality, privacy, and security of patient
information.
4.4. Comply with federal requirements; laws, policies, and standards for Information
Technology (IT) and data management, electronic patient records and disease
management systems, sharing of screening and diagnostic test, and where
applicable pathology results.
4.5. Comply with MOHAP requests to inspect and audit records and cooperate
with authorized auditors as required.
4.6. Collect and submit data on screening visits and outcomes, as per Appendix P,
to the National Cancer Screening Registry at MOHAP.
4.7. Comply with federal laws, policies, and standards on cancer case reporting and
report all confirmed screening-detected cancers to the National Cancer Registry
at MOHAP.

5. Enforcement and Sanctions

5.1. Healthcare providers, payers, and third party administrators must comply with
the terms and requirements of this guideline. MOHAP may impose sanctions
in relation to any breach of requirements under this guideline.

6. Payment for Screening and Follow-Up of Colorectal Cancer

6.1. Eligibility for reimbursement under the health insurance scheme must be in
accordance, with local insurance laws for each Emirate.

7. Standard 1: Clinical Service Specifications

7.1. All licensed healthcare screening facilities scheme providing colorectal cancer
screening services must:
7.1.1. Follow best practice for colorectal cancer screening as per Appendix P.
7.1.2. Adhere to the clinical performance indicators and timelines in accor-
dance with Appendix Q.
7.1.3. Coordinate referral of individuals with positive screening for further
assessment or treatment with diagnostic and oncology centers and
develop an agreed protocol and clear process for referrals.
7.1.4. Maintain records for screening tests, outcomes, and clinical perfor-
mance indicators.
694 Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis

7.1.5. Assign a colorectal cancer facility program coordinator who will be

accountable to:
7.1.5.1. Reports and submits screening visits and outcome data, speci-
fied in Sect. 4.
7.1.5.2. Establish internal audit policies and procedures and conduct
regular audits, monitoring and evaluating to demonstrate com-
pliance with this guideline and other associated regulatory
policies and standards.
7.1.6. Endoscopy unit providing colorectal cancer screening must meet the
criteria for a competent unit infrastructure, equipment, and personnel,
as per Appendix R.
7.1.7. Have an approved protocol for referral of individuals with screen
detected abnormalities for further assessment or treatment.
7.2. All licensed laboratories providing diagnostic histopathology and genetic
testing services must:
7.2.1. Have in place the systems, policies, and operating procedures in accor-
dance with the requirements of relevant policies and laboratory
standards.
7.2.2. Use specimen identification and labeling in accordance with relevant
policies and standards and industry best practices.
7.2.3. Establish internal audit policies and procedures and conduct regular
audits, monitoring and evaluating to demonstrate compliance with this
guideline and other associated regulatory policies and standards.
7.2.4. Laboratory should be accredited by an internationally credible accredit-
ing body such as CAP, ISO 15189 (2007), JCI/Lab for colorectal cancer.
7.2.5. MOHAP may, at its discretion, conduct third-party independent quality
assurance testing of laboratories providing colorectal cancer screening
test service. Where it does so, providers must comply with the direction
and cooperate with the appointed party.
7.2.6. Labs performing FIT test must:
7.2.6.1. Follow the manufacturer’s instructions for use of the FIT
testing kit.
7.2.6.2. Use an explicit definition for cut-off levels for hemoglobin
concentration.
7.2.6.3. Make provision to record the information concerning the actual
amount of hemoglobin, both for tests classified as negative and
for those classified as positive.
7.2.6.4. Labs performing genetic testing must have organized and spe-
cialist cyto/histopathological support services who can demon-
strate compliance with related policies and laboratory
standards.
7.3. All licensed healthcare professionals participating in colorectal cancer
screening must conduct CRC risk assessment. Detailed history must be evalu-
ated and completed, each time an individual visits for screening. The purpose
of this is to identify individuals’ risk status, as per risk categories specified in
Appendix S, and referral to appropriate screening tests.
Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis 695

7.3.1. Obtain informed patient consent prior to screening. Where consent is

granted or refused, the treating physician must document and retain
signed consent forms on individuals’ medical records.
7.3.2. Inform all individuals of the procedures and expected timeframe to be
screened and to receive results.
7.3.3. Ensure that the outcome of screening for colorectal cancer is reviewed by
a multi-disciplinary team including gastroenterologist, colorectal surgeon,
gastrointestinal oncologist, pathologist, radiologist, physician, and a nurse.
7.3.4. Follow-up and timely referral of individuals with abnormal results to
treatment.

8. Standard 2: Screening Tests and Frequency

8.1. Screening tests for individuals at average risk of colorectal cancer, as specified
in Appendix S, are as follows:
8.1.1. Colonoscopy, every 10 years.
8.1.2. Fecal Immunochemical Test (FIT) every year.
8.1.3. Eligible population must be offered colonoscopy screening as per
Appendix P, in case of refusal, the patient should be offered a FIT.

9. Standard 3: Recruitment for Screening

Population eligible for colorectal cancer screening may be recruited by the health
care facilities, through the following:
9.1. Recruitment for screening
9.1.1. All CRC screening facilities must establish an invitation system to
ensure identification, successful participation, and retaining of eligible
population.
9.1.2. Targeted invitation may be established via an electronic or manual invi-
tation system.
9.2. Opportunistic
9.2.1. Physician consultation for related or unrelated reason.
9.2.2. Engagement in a health promotion campaign.

10. Standard 4: Screening with Colonoscopy

10.1. Pre-colonoscopy assessment

10.1.1. Pre-colonoscopy documentation must include:
10.1.1.1. Patient demographics.
10.1.1.2. Anticoagulant and antiplatelet use.
10.1.1.3. History of diabetes mellitus and use of insulin.
10.1.1.4. Presence of implantable defibrillators or pacemakers.
10.1.1.5. Previous gastrointestinal procedures, including surgeries.
696 Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis

10.1.2. Assessment of patient risk: Physical status of the patient must be

documented in accordance with the American Society of
Anesthesiology (ASA), Appendix T.
10.1.3. ASA class 3 or higher is at higher risk for cardiopulmonary events,
and appropriate measures must be taken in this respect.
10.1.4. Colonic cleansing: Type of bowel preparation must be documented
including documentation of careful preparation in accordance with
international standards and guidelines. Written instructions to be
given to the patient concerning colonic cleansing and need to be
mentioned in the report.
10.1.5. Inadequate bowel preparations must not exceed 10% of
examinations.
10.2. Colonoscopy procedure
10.2.1. Facility-specific policies and procedures must be in place for the
following:
10.2.1.1. Colonoscopy decontamination including infection control.
10.2.1.2. Sedation of patient, considering the patient’s status and
preferences and recording of all sedation methods and out-
comes; consider involving anesthesia service in patients
with significant comorbidities such as patients with ASA 3,
4, and 5 (Appendix T).
10.2.1.3. Patient support and comfort, including positioning during
the colonoscopy.
10.2.2. To achieve high-quality colonoscopy examination, complete intuba-
tion of the colon and careful inspection of the mucosa during with-
drawal is necessary.
10.2.2.1. If a complete colonoscopy is not achieved, imaging for
documentation of incomplete intubation may be necessary
and reasons must be clearly documented.
10.2.2.2. Auditable photo documentation of colonoscopy comple-
tion must be available including a panoramic image of the
appendiceal orifice, ileocecal valve, and cecum with a
video clip with a respective image.
10.2.2.3. Documentation of completion of rectal retroflexion (retro-
flexion of the endoscope during colonoscopy to increase
diagnostic yield) must be recorded.
10.2.2.4. Withdrawal times of the colonoscopy from cecum to anus
must be documented and must be not less than 6 min (when
no biopsies or polypectomies are performed). The times to
be documented include when:
10.2.2.4.1. Endoscope is inserted into the rectum.
10.2.2.4.2. Withdrawal from cecum was started.
10.2.2.4.3. Endoscope is withdrawn completely.
10.2.2.5. A record of the actual model and instrument number used
must be maintained by the unit staff to track procedure vol-
ume, problems, and infection transmission and instrument
repairs.
Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis 697

10.2.2.6. Any adverse clinical events (fall in blood pressure,

unplanned reversal of sedation medications, oxygen desat-
uration, etc.) that occur during colonoscopy as well as all
serious events (perforation, bleeding requiring blood trans-
fusion, and/or surgery) must be documented with hard cop-
ies attached to the colonoscopy report and reported in
accordance with standards for adverse events management
and reporting.
10.3. Post-colonoscopy procedures
10.3.1. Patients must be contacted 24 h post-procedure or on the next work-
ing day to monitor any complications; this contact must be
documented.
10.3.2. Before colonoscopy each patient must receive instructions about
management of any potential adverse events following discharge and
must be informed that complications may occur within 1–4 weeks
post-procedure.
10.3.3. A contact number must be provided to the patient for this purpose
and documented in the patient records.
10.3.4. Post-procedure complications must be tracked over a 30-day interval
after a colonoscopy.
10.3.5. Discharge instruction form should be given to patient instructing him
to call endoscopy unit or the gastroenterology physician on call or to
come to ER in case there is any abdominal pain or any complication
or concerns after the procedure. Patients should sign this form
acknowledging that he understood the post-colonoscopy and the pre-
discharge instructions.
10.4. Colonoscopy findings and reporting
10.4.1. Avoid using vague terms to describe polyps in the report.
10.4.2. An estimation of the size and dimension of all polyps must be docu-
mented, terms such as “large” or “small” must not be used.
10.4.3. Tattoos preferably be placed for all lesions >10 mm and those with
concerning appearance for cancer to mark the location of colon
lesions for repeat colonoscopy or surgery.
10.4.4. Lesions that are too large be safely removed must be biopsied and a
tattoo injection performed in the vicinity of the lesion and not into
the lesion.
10.4.5. Specimen identification and labeling must be in accordance with rel-
evant clinical laboratory standards and industry best practices.
10.4.6. Procedures and protocols for adequate specimen collection, han-
dling, labeling, and reporting must be in accordance with relevant
clinical laboratory standards and must be communicated to clinical
staff and other clients who are involved in the procedures for process-
ing of colorectal specimens.
10.4.7. Each facility must develop a patient colonoscopy report form,
retained on the patient’s medical record and made available to audi-
tors. A recommended sample of a standard report is provided.
698 Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis

10.4.8. A standard colonoscopy report must include at least the following

information:
10.4.8.1. Patient demographics and history
10.4.8.2. Assessment of patient risk and comorbidity
10.4.8.3. Procedure indications
10.4.8.4. Procedure: technical description
10.4.8.5. Colonoscopy findings
10.4.8.6. Interventions/unplanned events
10.4.8.7. Assessment
10.4.8.8. Follow-up plan
10.4.8.9. Pathology

11. Standard 5: Screening with Fecal Immunochemical

Test (FIT)

11.1. FIT test must be offered where the average risk patient refuses the screening
colonoscopy.
11.2. Patient must be provided with clear and simple instructions regarding collec-
tion of sample.
11.3. No drug or dietary restriction is required for FIT, and only one stool sample
is needed.
11.4. The quality of the sample must be reproducible and representative of the
stool, to be of the required volume and be adequately preserved.
11.5. The samples must be analyzed without delay and kept cool to avoid further
sample denaturation and a potential increase in false negative results; and the
proportion of unacceptable tests received for measurement must not exceed
3% of all kits received; less than 1% is desirable.

12. Standard 6: Screening Outcomes and Referrals

12.1. At the end of the screening, the screening unit must provide the individuals
with a written report with a clear instruction on follow-up plan and next steps,
including referral for treatment or next screening dates. Also, send feedback
to the referring physician at the primary or ambulatory healthcare clinic.
12.2. It is the sole responsibility of the colonoscopist (in case of screening colonos-
copy), or the referring physician (in case of FIT) to inform the individuals
with their results and next steps.
12.3. The time between completion of a screening test and receipt of results by the
participant must be less than 15 working days (acceptable standard >90%
within 15 days).
12.4. Screening with colonoscopy
Appendix O: The National Guideline for Colorectal Cancer Screening and Diagnosis 699

12.4.1. In case of normal results, negative for polyps, individuals must be

re-invited for screening in accordance with the frequencies specified
in Sect. 8.
12.4.2. In case of presence of adenoma, colonoscopy must be repeated in
accordance with Appendix P.
12.4.3. Adenoma detection rate must be monitored and audited. It is limited
to screening colonoscopies; surveillance procedures and repeat endo-
scopic procedures are excluded.
12.4.4. Individuals with a positive colonoscopy, cancer, must be urgently
referred for treatment, within 2 weeks of receiving colonos-
copy report.
12.4.5. The time interval between a positive colonoscopy (cancer) and defin-
itive management must be monitored. (Acceptable standard ≥95% of
cases must be no more than 31 days).
12.4.6. Death within 30 days after colorectal cancer screening, attributed to
complications caused by colonoscopy, must be recorded by
e-notification.
12.5. Screening with FIT test:
12.5.1. Individuals with a negative test result are re-invited for screening as
per frequencies specified in Sect. 8.
12.5.2. Individuals with a positive test result must be urgently referred for
follow-up colonoscopy within 15 working days.
12.5.3. The FIT test must be repeated if results are unclear or spoilt in accor-
dance with Appendix P.
 ppendix P: Colorectal Cancer Screening
A
and Diagnosis Pathway

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702 Appendix P: Colorectal Cancer Screening and Diagnosis Pathway
 ppendix Q: Colorectal Cancer Clinical
A
Performance Indicator

Indicator Acceptable level Desirable level

Screening uptake (participation) rate >45% >65%
Minimum number of screening colonoscopies >150 per annum >250
undertaken annually by each screening
colonoscopist
Inadequate FIT rate (proportion of people <3% <1%
screened with one or more FIT returned none
of which were adequate)
Maximum time between screening FIT test >90% >95%
and receipt of result should be 7 days from
sample’s dispatch
Rate of referral to follow-up colonoscopy 90% >95%
after positive FIT test (detects cancer)
Maximum time between referral after positive >90% >95%
screening FIT test and conducting follow-up
colonoscopy should be within 31 working
days
Cecal intubation rate (CIR). Follow-up and >90% >95%
screening colonoscopies to be recorded
separately (unadjusted CIR with video
recorded and photographic evidence)
Adenoma detection rate (ADR) ≥35% of Auditable outcome
colonoscopies
Cancer detection rate ≥2 per 1000 Auditable outcome
screened by FIT
≥11 per 100
colonoscopies
Withdrawal time in negative colonoscopies ≥6 min
(withdrawal from cecal pole to anus)
Polyp retrieval rate (retrieval of polypectomy >90% per 100 >95% per 100 polyps
specimens for histological analysis per polyps excised excised
colonoscopist)b
Rate of high-grade neoplasia reported by <5%
pathologists in a colonoscopy screening
program
Rate of high-grade neoplasia reported by <10%
pathologists in a FIT screening program

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704 Appendix Q: Colorectal Cancer Clinical Performance Indicator

Indicator Acceptable level Desirable level

Endoscopic complications of colonoscopy Bleeding <1:150
screening programs Perforation <1:1000
Post polypectomy perforation rate <1:500 Auditable outcome
Time interval between positive colonoscopy >90% >95%
and start of definitive management within 31
days
a
Excellent: no or minimal solid stool and only clear fluid requiring suctionAdequate: collections
of semi-solid debris that are cleared with washing/suctionInadequate: solid or semi-solid debris
that cannot be cleared effectively
b
Numerator: number of polyps with histological tissue retrieved for analysisDenominator: number
of polyps recorded during lower GI endoscopies

References

1. NHS Cancer Screening Programmes. Quality assurance guidelines for colonos-

copy. NHS BCSP Publication No. 6 Feb 2011.
2. European guidelines for quality assurance in colorectal cancer screening and
diagnosis. 1st ed. 2010.
 ppendix R: Colorectal Cancer Screening
A
Endoscopy Unit Infrastructure, Equipment
and Personnel

Endoscopy unit infrastructure and equipment must:

1. Include facilities for adequate pre-colonoscopy assessment, recovery, and be
designed to allow efficient patient flow.
2. Match the demand with respect to unit capacity (e.g., equipment and personnel).
3. Provide video-endoscopes with high resolution and image enhancement that
facilitate focal application of the dye for the detection and assessment of high-­
risk colorectal lesions and documentation.
4. Provide adequate supply of accessories suited to the endoscopic interventions
undertaken and documentation.
5. Provide properly maintained resuscitation equipment in the endoscopy rooms
and recovery areas.
6. Conduct a regular review of all the functioning and cleansing of the colonoscopies.
The review should be available at all times in the unit including infection control.
7. Plan capacity that matches demand for screening. Referral to colonoscopy to be
within 31 days from a positive FIT test (detects the presence of occult blood in
the fecal sample).
8. Referral to colonoscopy to be within 31 days from positive FIT test (detects the
presence of occult blood in the fecal sample).
Criteria colorectal cancer screening core team to include:
All members in the colorectal cancer core team should participate in regular
multidisciplinary team meetings to discuss each patient with colorectal cancer.
1. At least two gastroenterologists: each conduct a volume of minimum 150 per
colonoscopist per year with a cecal completion rate of >90%.
2. Nurse: Two nurses trained to provide support, assistance, information, and
advice to every patient. An in-depth understanding of colorectal cancer (diagno-
sis, treatment, prognosis, staging, and importance of stage at diagnosis), an in-­
depth understanding of the colorectal screening process (including screening
theory and particularly the potential benefits and harms of screening, and the
prime importance of quality assurance), and advanced communication skills.
3. Regular training and evaluation for colorectal cancer screening core team accord-
ing to international guideline.

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 ppendix S: Risk Assessment for Colorectal
A
Cancer

No low risk.
Average age risk:
1. Age ≥40
2. No history of inflammatory bowel disease
3. Negative family history
4. No history of adenoma or colorectal cancer
Increased risk:
1. Personal history of adenoma, sessile serrated polyp (SAP),1 colorectal cancer,
inflammatory bowel disease
2. Positive family history of first or second degree relative with colorectal cancer
(screening recommendations vary depending on family history, begin screening
at an age approximately 10 years earlier than the age at which the youngest per-
son in family was diagnosed with colorectal polyps or cancer).
High risk:
1. Family history of a hereditary colorectal cancer syndrome such as familial ade-
nomatous polyposis (FAP) or Lynch syndrome (also known as hereditary non-­
polyposis colon cancer or HNPCC).
2. Polyposis syndromes (Classical Familial Adenomatous Polyposis (FAP1-),
Attenuated Familial Adenomatous Polyposis (AFAP1-), MYH associated

1
Increased risk based on personal history of adenoma(s)/sessile serrated polyp(s) found at
colonoscopy:
(a) Low-risk adenoma: ≤2 polyps, <1 cm, tubular.
(b) Advanced or multiple adenomas: high-grade dysplasia, ≥1 cm, villous (>25% villous), between
3 and 10 polyps (fewer than 10 polyps in the setting of a strong family history or younger age
(<40 years) may sometimes be associated with an inherited polyposis syndrome).
(c) More than 10 cumulative adenomas (fewer than 10 polyps in the setting of a strong family his-
tory or younger age (<40 years) may sometimes be associated with an inherited polyposis
syndrome).
(d) Incomplete or piecemeal polypectomy (ink lesion for later identification) or polypectomy of
large cancer.
© The Editor(s) (if applicable) and The Author(s), under exclusive license to 707
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708 Appendix S: Risk Assessment for Colorectal Cancer

Polyposis (MAP1-), Peutz-Jeghers syndrome (PJS1-), Juvenile polyposis syn-

drome (JPS1-), hyperplastic polyposis syndrome (HPP1-))
Colorectal cancer screening and surveillance, in high-risk disease family group
High-­risk Screening
disease procedure and
groups Screening procedure Time of initial screen interval
Colorectal cancer
Consultation, CT, LFTs, and Colonoscopy within CT liver scan within
colonoscopy 6 months of 2 years post-op.
resection only if Colonoscopy 5
colon evaluation yearly until
pre-op is incomplete co-morbidity
outweighs
Colonic adenomas
Low risk 1–2 adenomas, both <1 cm Colonoscopy 5 years or no
surveillance
Intermediate 3–4 adenomas, OR at least one Colonoscopy Every 3 years
risk adenoma ≥1 cm
High risk ≥5 adenomas or ≥3 with at least Colonoscopy Yearly 3 months
one ≥1 cm piecemeal Colonoscopy or consider open
polypectomy flexi-si (depending surgical resection if
on polyp location) incomplete healing
of polypectomy
scar
Ulcerative colitis and Crohn’s colitis
Low risk Extensive colitis with no Pancolonic dye spray Every 10 years
inflammation or left-sided colitis with targeted biopsy. from onset of
or Crohn’s colitis of <50% colon If no dye spray then symptoms
Intermediate Extensive colitis with mild active 2–4 random biopsies After surgery by 10
risk disease or post-inflammatory every 10 cm years
polyps or family history of
colorectal cancer in a FDR <50
years
Extensive at least moderate
colitis or stricture in past 5 years
or dysplasia in past 5 years
(declining surgery) or PSC or
OLT for PSC) or colorectal
cancer in a FDR <50 years
Ureterosigmoidostomy
Acromegaly
Acromegaly Colonoscopy At 40 years
Appendix S: Risk Assessment for Colorectal Cancer 709

Colorectal cancer screening and surveillance in moderate risk disease family groups: initial
screening 10 years earlier than the youngest affected FDM
Screening
Family history procedure Screening interval
One first-degree relative Colonoscopy Start at 40 years of age or 10 years younger
with CRC or advanced than the earliest diagnosis in the patient’s
adenoma diagnosed before family, whichever comes first; colonoscopy
60 years of age, or two should be repeated every 5 years
first-degree relatives
diagnosed at any age
One first-degree relative Colonoscopy Start screening colonoscopy at 40 years of
with CRC or advanced age; colonoscopy should be repeated every
adenoma diagnosed at 60 10 years
years or older, or two
second-degree relatives
with CRC
One second- or third- Colonoscopy Average-risk screening (e.g., start at 40)
degree relative with CRC
Individuals who have Colonoscopy Colonoscopy screening should begin 8–10
Crohn disease with colonic years after the onset of symptoms
involvement or ulcerative
colitis. Screening-repeated
every 1–3 years
In individuals with Colonoscopy Colonoscopy should begin at 25 years of age
hereditary nonpolyposis and be repeated annually
colorectal cancer
Individuals with Colonoscopy Colonoscopy between 10 and 20 years of age
adenomatous polyposis and be repeated every 1–2 years
syndromes
Individuals with Peutz- Colonoscopy Esophagogastroduodenoscopy, colonoscopy,
Jeghers syndrome. If and video capsule endoscopy should begin at
results are, negative, 8 years of age. If results are negative,
testing-repeated every 3 testing-repeated every 3 years
years
Individuals with sessile Colonoscopy Colonoscopy should begin as soon as the
serrated adenomatous diagnosis is established and be repeated
polyposis annually

Affected relatives who are first-degree relatives of each other AND at least
one is a first-degree relative of the patient.
• Combinations of three affected relatives in a first-degree kinship include parent
and aunt/uncle and/or grandparent; OR 2 siblings/1 parent; OR 2 siblings/1 off-
spring. Combinations of two affected relatives in a first-degree kinship.
• Include a parent and grandparent, or >2 siblings, or >2 children, or child + sib-
ling. Where both parents are affected, these count as being within the first-degree
kinship.
• Clinical genetics referral recommended.
• Centers may vary depending on capacity and referral agreements. Ideally, all
such cases should be flagged systematically for future audit on an emirate level.
710 Appendix S: Risk Assessment for Colorectal Cancer

Colorectal cancer screening and surveillance in high-risk disease family groups

Screening Screening interval
Family history categoriesa procedure Age at initial screen and procedure
At-risk HNPCC (fulfils MMR gene Colonoscopy from age Colonoscopy every
modified Amsterdam criteria, testing of 25 years 18–24 months
or untested FDR of proven affected OGD from age 40 years (OGD every 2 ears
mutation carrier) relative or screening 10 years from age 40 years)
colonoscopy earlier than the youngest
± OGD affected FDM
MMR gene carrier Colonoscopy
± OGD
At-risk FAP (member of FAP APC gene Puberty Annual
family with no mutation testing of Flexible approach colonoscopy or
identified) affected Important making until aged 30 years
relative allowance for variation Thereafter 3–5
colonoscopy in maturity yearly until 60
years
proctocolectomy
or colectomy if
positive
Fulfils clinical FAP criteria, Colonoscopy Usually at diagnosis Recommendation
or proven APC mutation Colonoscopy/ Otherwise puberty for procto-
carrier opting for deferred OGD Flexible approach colectomy and
surgery prophylactic surgery important for making pouch/colectomy
normally strongly allowance for variation before age 30
recommended in maturity years
Cancer risk
increases
dramatically age
>30 years
Twice yearly
colonoscopy
FAP postcolectomy and IRA Colonoscopy After surgery Colonoscopy every
OGD OGD from age 30 years 3 years forward
and side-viewing
OGD
FAP post procto-colectomy DRE and After surgery Annual exams
and pouch pouch OGD from age 30 years alternating
endoscopy Flexible/rigid
Forward and pouch
side-viewing Endoscopy every 3
OGD years
Forward and
side-viewing OGD
Appendix S: Risk Assessment for Colorectal Cancer 711

Screening Screening interval

Family history categoriesa procedure Age at initial screen and procedure
MUTYH-associated Genetic Colonoscopy from age Mutation carriers
polyposis (MAP) testing 25 years should be
Colonoscopy OGD from age 30 years counselled about
± OGD the available
limited evidence;
options include
prophylactic
colectomy and
ileorectal
anastomosis; or
biennial
colonoscopy
surveillance
Every 3–5 years
gastro-
duodenoscopy
FDR with MSI-H colorectal Colonoscopy Colonoscopy from age Colonoscopy every
cancer and IHC shows loss of ± OGD 25 years OGD from age 2 years (with OGD
MSH2, MSH6 or PMS2 40 years aged >40 years)
expression
MLH1 loss and MSI
specifically excluded (MLH1
loss in elderly patient with
right sided tumor is usually
somatic epigenetic event)
Peutz-Jeghers syndrome Genetic Colonoscopy from age 2 yearly
testing of 25 years colonoscopy/
affected OGD from age 25 years consider
relative Small bowel MRI/ colectomy and
Colonoscopy enteroclysis IRA for colonic
± OGD cancer
Small bowel VCE
or MRI/
enteroclysis
2–4 yearly
OGD 2 yearly
Juvenile polyposis Genetic Colonoscopy from age Every 2 years
testing of 15 years colonoscopy and
affected OGD from age 25 years OGD. Extend
relative interval >35 years
Colonoscopy
± OGD

1. The Amsterdam criteria for identifying HNPCC are three or more relatives with
colorectal cancer:
• One patient a first degree relative of another.
• Two generations with cancer.
• One cancer diagnosed under the age of 45 or other HNPCC-related cancers,
e.g., endometrial, ovarian, gastric, upper urothelial, and biliary tree.
712 Appendix S: Risk Assessment for Colorectal Cancer

2. Clinical genetics referral and family assessment required, if not already in place
or if clinical genetics did not initiate referral.
3. FAP, familial adenomatosis polyposis; FDR, first-degree relative (sibling, par-
ent, or child) with colorectal cancer; HNPCC, hereditary non-polyposis colorec-
tal cancer; IHC, immunohistochemistry of tumor material from affected proband;
MSI-H, micro-satellite instability high (two or more MSI markers show instabil-
ity); OGD, esophagogastroduodenoscopy endoscopy; VCE, video capsule
endoscopy.
 ppendix T: American Society
A
of Anesthesiology Classification System

Class Description
1 Patient has no organic, physiologic, biochemical, or psychiatric disturbance (healthy, no
comorbidity).
2 Mild-moderate systemic disturbance caused either by the condition to be treated
surgically or by other pathophysiologic processes (mild-moderate condition, well
controlled with medical management; for examples include diabetes, stable coronary
artery disease, stable chronic pulmonary disease).
3 Sever, systemic disturbance or disease from whatever cause, even though it may not be
possible to define the degree of disability with finality (disease or illness that severely
limits normal activity and may require hospitalization or nursing home care; examples
include severe stroke, poorly controlled congestive heart failure, or renal failure).
4 Severe systemic disorder that is already life threatening, not always correctable by the
operation (examples include coma, acute myocardial infarction, respiratory failure
requiring ventilator, support renal failure requiring urgent dialysis, bacterial sepsis with
hemodynamic instability).
5 The moribund patient who has little chance of survival.

References

1. Updated guidelines on the management of colon cancer were published on

February 1, 2022 by the American Society of Colon and Rectal Surgeons
(ASCRS).
2. de Kanter C, Dhaliwal S, Hawks M. Colorectal cancer screening: updated guide-
lines from the American College of Gastroenterology. Am Fam
Physician. 2022;105(3):327–9.
3. Lin JS, Perdue LA, Henrikson NB, Bean SI, Blasi PR. Agency for Healthcare
Research and Quality (US); 2021.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 713
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
 ppendix U: DOH Standard for Center
A
of Excellence in Hematopoietic Stem Cell
Transplantation (HSCT) Services for Adults
and Pediatrics

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 715
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
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716 Appendix U: DOH Standard for Center of Excellence in Hematopoietic Stem Cell…

DOH STANDARD FOR CENTER OF EXCELLENCE IN

HEMATOPOIETIC STEM CELL TRANSPLANTATION
(HSCT) SERVICES FOR ADULTS AND PEDIATRICS

NOVEMBER 2019

https://doh.gov.ae/-/media/66699F4904F642EF8C3432F69E10084A.ashx
Appendix U: DOH Standard for Center of Excellence in Hematopoietic Stem Cell… 717

Document Title: DOH Standard for Centers of Excellence in Hematopoietic Stem Cell
Transplantation (HSCT) Services for Adults and Pediatrics
Document type Standard
Document Ref. DOH/HPI/COEHSCT/0.9/2019
Number:
Effective Date: November 2019
Previous None
versions
Document Healthcare Planning and Investment
Owner:
Applies to: All DOH Licensed Healthcare Providers who seek to be recognized as
Centers of Excellence in Hematopoietic Stem Cell Transplantation Services
Classification: • Public
Note: Read this Standard in conjunction with related UAE Laws, DOH Policies, Standards and
Manuals including but not limited to:
 • DOH Clinical Privileging Framework Standard
 • DOH Data Standards and Procedures
 • DOH Standard on Human Subjects Research

1. Purpose

1.1. This Standard defines the service specifications and minimum requirements
for healthcare providers to be designated by DOH as Hematopoietic Stem Cell
Transplantation Centers of Excellence (COE) in the Emirate of Abu Dhabi.
1.2. The Standard defines the eligibility criteria for all HSCT services in line with
DOH Standard for Centers of Excellence—DOH/SD/COE/0.9, evidence based
and international guidelines.

2. Definitions

2.1. Centers of Excellence (COE): Specialized and distinguished programs within

DOH licensed Healthcare facilities, which can provide an exceptionally high
level of expertise and multidisciplinary resources centered on particular ser-
vice lines and/or services and delivered in a comprehensive, interdisciplinary
fashion to achieve the best patient outcomes possible.
2.2. Foundation for the Accreditation of Cellular Therapy—Joint Accreditation
Committee (FACT-JACIE): Foundation for the Accreditation of Cellular
Therapy (FACT-JACIE) identifies and establishes standards for high quality
medical and laboratory practice in cellular therapies.
718 Appendix U: DOH Standard for Center of Excellence in Hematopoietic Stem Cell…

2.3. Autologous: Derived from and intended for the same individual.
2.4. Allogenic: The biologic relationship between genetically distinct individuals
of the same species.
2.5. Pediatrics Patient: Pediatric age as defined by DOH.

3. Abbreviations

3.1. HSCT: Hematopoietic stem cell transplantation

3.2. HEPA: High efficiency particulate air “an efficiency standard of air filter”
3.3. HLA: Human leukocyte antigen

4. Scope

This standard applies to all healthcare providers, public and private, licensed by
DOH who seek to qualify as a “Center of Excellence” in Hematopoietic Stem Cell
Transplantation (HSCT) services.

5. Implementation Arrangements

DOH shall:
5.1. Ensure that the requirements set out in this Standard are met through its regula-
tory powers and where necessary, set out further regulatory measures to address
the current and future health system needs for developing HSCT Centers of
Excellence.
5.2. Ensure that the COE comply with Federal Law and DOH regulations.
5.3. Develop Jawda key performance indicators (Jawda KPI’s) to monitor the
HSCT COE’s performance.
Healthcare providers shall:
5.4. Meet the requirements as set out by DOH in this standard along with the DOH
Standard for Centers of Excellence—DOH/SD/COE/0.9 to qualify as a “Center
of Excellence” in HSCT services.
5.5. Have in place their own operational guidelines, policies, and procedures.
5.6. Contribute to eliminating International Patient Care (IPC) transfers related to
HSCT services.

6. Duties for Healthcare Providers

6.1. The COE in HSCT has to ensure equal access to all patients based on medical
needs. The designated COE in HSCT must:
6.1.1. Ensure and provide evidence that their practices reflect updated interna-
tional best practices.
Appendix U: DOH Standard for Center of Excellence in Hematopoietic Stem Cell… 719

6.1.2. Document and monitor quality and safety of clinical care and outcomes
of surgical and non-surgical intervention performed on patients, and
make these available to DOH for auditing, as and when requested
to do so.
6.1.3. Provide records of HSCT related Jawda—Quality Metrics to DOH
inspectors.
6.1.4. Maintain Accreditation by a recognized International Accreditation
body aligned with DOH and COE and report the findings to DOH (see
Appendix V).
6.1.5. Aim to achieve recognized international accreditation in HSCT within
2–5 years.
6.1.6. Follow the clinical and regulatory requirements of this Standard irre-
spective of provision of COE services to patients who opt not to use
health insurance coverage (pre-authorization for coverage and health
insurance does not apply in this case).

 . Hematopoietic Stem Cell Transplantation (HSCT) COE

7
Service Requirements and Specifications

7.1. Facilities
7.1.1. Healthcare facilities seeking the COE designation in HSCT should
ensure the availability of:
7.1.1.1. A designated inpatient unit that minimizes airborne microbial
contamination ideally high efficiency particulate air filtration
(HEPA) with positive pressure or laminar airflow for alloge-
neic transplants.
7.1.1.2. Provisions for prompt evaluation and treatment of patients with
complications on a 24-h basis.
7.1.1.3. Access to stem cell lab services that is having international
accreditation for stem cell harvest, enumeration; processing
and cryopreservation shall be available within the vicinity. The
stem cell laboratory shall conform to the National Standards of
stem cell procurement, storage, and allocation.
7.1.1.4. Centers performing allogenic HSCT shall have access to HLA-­
testing laboratory with the capability to carry out DNA-based
HLA typing. This HLA-Laboratory shall seek international
accreditation.
7.1.1.5. Laboratory support with availability of microbiological tests,
monitoring of drug levels, chimerism study, and histopathol-
ogy services is important. The pathologist shall have experi-
ence in the histopathological interpretations of graft versus
host disease.
7.1.1.6. A transfusion service to provide irradiated blood products on a
24-h basis.
7.1.1.7. A pharmacy to provide essential medications on a 24-h basis.
720 Appendix U: DOH Standard for Center of Excellence in Hematopoietic Stem Cell…

7.1.1.8. A radiotherapy service shall be available within the vicinity.

7.1.1.9. Supportive services including specialists in the field of radiol-
ogy, intensive care, neurology, nephrology, respiratory medi-
cine, gastroenterology, cardiology, and infectious disease shall
be available for consultations.
7.2. Healthcare professionals
Healthcare facilities seeking the COE designation in HSCT must fulfil the follow-
ing requirements related to healthcare professionals:
7.2.1. Valid DOH license in their specialty.
7.2.2. The Head of Clinical Transplant Services shall be a consultant who has
at least 1-year specific training in HSCT.
7.2.3. The adult HSCT transplant center shall have at least one physician certi-
fied in Internal Medicine and accredited in Hematology or Medical
Oncology or Immunology.
7.2.4. Centers performing pediatric transplants shall have at least one physi-
cian certified in pediatrics and accredited in hematology/oncology or
immunology.
7.2.5. The transplant nurses must have appropriate certification in the manage-
ment of HSCT patients.
7.2.6. Other supportive staff members shall include a transplant coordinator,
pharmacy staff, dietary staff, social worker and physiotherapy staff, and
a data manager.
7.3. HSCT services provided in an authorized healthcare facility seeking recogni-
tion as a COE in HSCT must include a range of integrated clinical services
surgical and non-surgical intervention for its patients in accordance with this
Standard including the requirements of FACT-JACIE.

8. Performance Management

Health care provider including those providing pharmacological, surgical, and non-­
surgical intervention will be required to ensure the following from their services and
management systems:
8.1. Are capable of Tracking Performance, including trends in Clinical Quality/
Outcomes for patients by documenting the related JAWDA—Quality Metrics
(https://www.doh.gov.ae/resources/jawda-­a bu-­d habi-­h ealthcare-­
quality-­index).
8.2. Provide seamless care in partnership with other providers, including primary
care and hospitals, as required for holistic patient care.
8.3. A Center of Excellence in HSCT shall be required to maintain volumes of
greater than or equal to ten (10) new patients/year for autologous transplanta-
tion and ten (10) new patients/year for allogeneic transplantation.
Appendix U: DOH Standard for Center of Excellence in Hematopoietic Stem Cell… 721

9. Clinical Research and Education

9.1. The COE must demonstrate a commitment to education, research, and training
focusing on HSC and HSCT-related sciences.

10. Data Management

10.1. Data collection

10.1.1. Clinical programs shall submit clinical outcomes and specified regis-
try data elements to a national or international database in alignment
with related DOH standards.
10.2. The clinical program shall define staff responsible for collecting data main-
taining the database.
10.2.1. Defined data management staff should participate in continuing edu-
cation annually.

11. Payment Mechanism

11.1. The appropriate compensation model will be adjusted with additional cost
associated with clinical leadership, research, education, and technology.

12. Enforcement and Sanctions

12.1. DOH may impose sanctions in relation to any breach of requirements under
this standard in accordance with chapter on complaints, investigations, regu-
latory action, and sanctions, the DOH healthcare regulator manual.
Appendix V: Accredited of HSCT Program

• Foundation for the Accreditation of Cellular Therapy (FACT-JACIE) is the only

accrediting organization that addresses all quality aspects of cellular therapy
treatments:
1. Clinical care.
2. Donor management.
3. Cell collection.
4. Cell processing.
5. Cell storage and banking.
6. Cell transportation.
7. Cell administration.
8. Cell selection.
9. Cell release.
• Staffing requirements for the clinical unit shall meet the FACT requirements:
1. Clinical program director
2. Attending physicians
3. Mid-level practitioners
4. Clinical coordinator
5. Nurses
6. Consulting specialists
7. Quality management supervisor/data management
8. Support services staff (dietitian, psychology, social service)
• The support service staffs are as follows:
1. Pharmacy staff knowledgeable in the use and monitoring of pharmaceuti-
cals used by the clinical program.
2. Dietary staff capable of providing dietary consultation regarding the nutri-
tional needs of the transplant recipient, including enteral and parenteral
support, and appropriate dietary advice to avoid food-borne illness.
3. Social services staff.
4. Psychology services staff.
5. Physical therapy staff.
6. Data management staff.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 723
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
724 Appendix V: Accredited of HSCT Program

References

1. DOH Standard for Centers of Excellence—DOH/SD/COE/0.9.

2. DOH Healthcare Regulator Manual Version 1.0.
3. FACT-JACIE International Standards for Hematopoietic Cellular Therapy
Product Collection, Processing, and Administration.
4. National guidelines for hemopoietic stem cell therapy published 2009 and
updated 2011. ISBN: 978-983-3433-62-9 (need to get permission to use).
5. NHS standards contract for hematopoietic stem cell transplantation adult NHS
commissioning Board. 2013.
6. HSCT charter for KSU (Hematopoietic Stem cell Transplant (HSCT) Program at
the Oncology Centre, King Saud University Medical City (KSUMC)).
 ppendix W: Cervical Cancer Screening
A
Program Requirements

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 725
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
726 Appendix W: Cervical Cancer Screening Program Requirements

CERVICAL CANCER
SCREENING PROGRAM
REQUIRMENTS

MARCH 2022

https://www.doh.gov.ae/-/media/51BDF280150B4AD481064B8E945BDB1D.ashx
Appendix W: Cervical Cancer Screening Program Requirements 727

Document Title: Cervical Cancer Screening Program

Requirements
Document Ref. Number: DOH/CCSC/SD/1.1 Version: 1.2
Last Reviewed: March 2021 Next Review: March
2024
Approval Date: 3rd, March 2022 Effective 16th,
Date: March
2022
Document Owner: Cancer Prevention and Control Section, NCD,
Abu Dhabi Public Health Center
Applies to: All Licensed Healthcare Providers in the
Emirate of Abu Dhabi participating in DOH’s
Cervical Cancer Screening Program
Classification: • Public
This Standard should be read in conjunction • Federal laws on Medical Liability and the
with related UAE laws, DOH standards, Practice of Human Medicine
policies, and circulars including but not • DOH Providers Manual-Chapter on
limited to: Standards of Care
• DOH Professionals Manual-Chapter on
Professional Duties and Obligations
• DOH Regulator Manual-Chapter on Data
Management
• DOH Standard for Clinical Privileging
Framework
• DOH Standard for Adverse Events reporting
and Management
• Federal Charter on Patient’s Rights and
Responsibilities
• DOH Standard for Complaints Management
in Healthcare Facilities
• DOH Data Management Policy and DOH
Data Standards
• DOH Standard on Telemedicine
• DOH Policy on Cultural Sensitivity

1. Purpose

1.1. This document mandates the clinical service specifications and data reporting
for DOH’s Cervical Cancer Screening Program in the Emirate of Abu Dhabi.
1.2. It specifies the clinical care pathway and minimum service specifications to
ensure that women screened for cervical cancer receive quality and safe care
and timely referral for diagnosis and/or treatment.
728 Appendix W: Cervical Cancer Screening Program Requirements

2. Scope

2.1. These program specifications apply to all healthcare providers (facilities, labo-
ratories, professionals) licensed by DOH in the Emirate of Abu Dhabi who are
participating in DOH’s Cervical Cancer Screening Program.
2.2. Participating healthcare providers are to provide the following services as
applicable based on their license category:
2.2.1. Risk assessment and physical examination
2.2.2. Specimen collection and preparation of adequate cervical smear
2.2.3. Handling and reporting of cervical smears
2.2.4. Follow-up and referral
2.3. Follow reporting terminologies defined by DOH as per Appendix X.

3. General Duties of the Health Care Providers

All licensed and eligible healthcare providers participating in DOH’s Cervical

Cancer Screening Program must:
3.1. Provide clinical services and patient care in accordance with DOH Policies and
Standards, and the laws and regulations of the Emirate of Abu Dhabi.
3.2. Submit data to DOH via e-Claims in accordance with the DOH Reporting of
Health Statistics Policy and as set out in the DOH Data Standards and
Procedures (found online at https://www.doh.gov.ae/en/Shafafiya/dictionary).
3.3. Comply with relevant DOH Policies and Standards with special attention to:
3.3.1. Policies and standards on Patient Education and Consent: The licensed
provider must provide appropriate patient education and information
regarding the screening test and must ensure that appropriate patient
consent is obtained and documented on the patient’s medical record.
3.3.2. Policies and standards on managing patient medical records including
developing effective recording systems, maintaining patient records,
confidentiality, and privacy and security of patient information; educat-
ing patients on services provided; and satisfying the requirements of
patient informed consent and patient rights and responsibilities charter.
3.3.3. DOH data standards and procedures.
3.4. Comply with DOH’s requests to inspect and audit records and cooperate with
DOH authorized auditors as required by DOH.
3.5. Comply with requirements for information technology (IT) and data manage-
ment including sharing of screening/diagnosis and where applicable, pathol-
ogy results, electronic patient records and disease management systems.

4. Enforcement and Sanctions

4.1. Healthcare providers, professionals, and laboratories participating in the

DOH’s Cancer Screening Program must comply with the terms and require-
ments of this document.
Appendix W: Cervical Cancer Screening Program Requirements 729

4.2. Health care providers must comply with the DOH Standard Provider Contract.
4.3. DOH may impose sanctions in relation to any breach of requirements under
this program specification in accordance with the [DOH Policy on Inspections,
Complaints, Appeals and Sanctions].

5. Payment Mechanism

Eligibility for reimbursement under the Health Insurance scheme is as follows:

5.1. For Thiqa holders, reimbursement must be consistent with the DOH Standard
for Thiqa Preventive List of Interventions available at www.doh.gov.ae.
5.2. For non-Thiqa holders, payment must be consistent with the individual’s health
insurance product/plan.

 . Cervical Cancer Screening Program Specifications

6
for Facilities

Facilities participating in DOH’s Cervical Cancer Screening Program must:

6.1. Be licensed by the DOH.
6.2. Fulfill the eligibility criteria for a cervical cancer screening program participat-
ing facilities in accordance with Appendix Y and approved by DOH as eligible
cervical cancer screening program facilities.
6.3. Comply with DOH cervical cancer screening care pathways, clinical quality
indicators, and timelines for referral in accordance with Appendices Z–AB,
respectively.
6.4. Assign a screening program coordinator responsible for submitting data on
screening visits and outcomes to DOH, who will fulfill the responsibilities in
accordance with Appendix AC.
6.5. Collect and submit data on screening visits and outcomes within 3 weeks of the
screening date, to DOH through the Electronic Cancer Screening Notification
(e-cancer notification) that can be accessed at: https://www.doh.gov.ae/
en/e-­services.
6.6. Report all screen-detected cancer cases to DOH, through Cancer Case
Notification Form, of the e-cancer notification, specified in 4.2.
6.7. Maintain records for screening tests and outcomes.
6.8. Establish internal audit procedures to demonstrate compliance with this docu-
ment and other associated regulatory policies and standards.
6.9. Ensure availability of evidence of compliance with the Cervical Cancer
Screening Program Clinical Quality indicators specified in Appendix AA
including:
6.9.1. Collection and preparation of adequate cervical smear.
6.9.2. Handling and transporting of specimens to DOH licensed clinical
laboratories.
6.9.3. Have an approved protocol for referral of women with abnormal results
or physical examination to a diagnostic or treatment centers.
730 Appendix W: Cervical Cancer Screening Program Requirements

 . Cervical Cancer Screening Program Specifications

7
for Laboratories

Laboratories participating in DOH Cervical Cancer Screening Program must:

7.1. Be licensed by the DOH.
7.2. Comply with the applicable elements of the Screening Program and other
DOH clinical quality indicators in accordance with Appendix AA and ensure
availability of evidence of compliance with these indicators such as laboratory
records required for accreditation purposes.
7.3. Comply with the DOH Clinical Laboratory Standards.
7.4. Attain accreditation by an international body recognized by the DOH such as,
CAP-ISO 15189(2007), or JCI/Lab.
7.5. Participate in an international external proficiency test by all personnel involved
in screening and reporting Pap test.
7.6. Establish internal audit procedures to demonstrate compliance with this pro-
gram specification and with other associated regulatory policies and standards.
7.7. Develop, implement, and monitor policies and standard operating procedures
for management of smears in accordance with DOH clinical laboratory
standards.

 . Cervical Cancer Screening Program Specifications

8
for Healthcare Professionals

Health professionals participating in the DOH’s Cervical Cancer Screening Program

must be:
8.1. Licensed by the DOH.
8.2. Comply with the clinical standards detailed in this program specification to
provide the most appropriate care, taking responsibility for deciding the best
care options for managing cervical cancer cases.
8.3. Provide women with culturally and socially relevant education on women’s
health and with information (oral and written) regarding the screening benefits
and limitations of cervical screening, potential outcomes, and next steps that
may be required for care management.
8.4. Participate in continuing medical education (CME) in accordance with DOH
requirements.

 . Cervical Cancer Screening Program Screening Tests

9
and Frequency

9.1. Screening tests:

9.1.1. Papanicolaou test (also called Pap test). Liquid-based cytology (LBC) is
the accepted standard method for Pap test specimen collection.
9.1.2. HPV test, as co-testing, for women age of 30 years and above. Only
FDA HPV approved tests are the accepted test for screening.
Appendix W: Cervical Cancer Screening Program Requirements 731

9.2. Frequency of screening:

The frequency for repeat screening for average risk, symptom free women is as
follows:
9.2.1. Every 3 years for women aged 25–29 years.
9.2.2. Every 5 years for women 30–65 years.
9.2.3. Annually for women who are immune-compromised due to disease or
medication.

10. Cervical Cancer Screening Program Service Specifications

10.1. Eligibility for screening criteria

10.1.1. All sexually active women (past or present), symptom free, aged
25–65 years residing in the Emirate of Abu Dhabi, except where
exclusion criteria for screening apply.
10.1.2. Women are excluded from screening if:
10.1.2.1. They have received a total hysterectomy for benign
indications.
10.1.2.2. They are over 65 years, (if the last three previous smears
were negative).
10.1.3. Women who have had subtotal hysterectomy (preserving the cervix)
or hysterectomy due to cervical cancer or precancerous condition
should continue to have cervical screening.
10.1.4. Screening recommendations remain the same regardless of whether
or not they have received the HPV vaccination.
10.2. Recruitment to screening
Recruitment of eligible women for screening can be made through: Targeted
invitation from the eligible screening facilities.
10.2.1. Opportunistic by:
10.2.1.1. Approaching women who are enrolled in other existing
screening programs; e.g., breast cancer.
10.2.1.2. Physician consultation for related or unrelated reason.
10.2.1.3. As an outcome of a health promotion campaign.
10.3. Risk assessment and physical examination
10.3.1. Women must receive adequate information regarding the screening,
Pap test procedure, and expected outcomes and timeframe to receive
results.
10.3.2. Detailed history must be taken to assess risk and frequency of repeat-
ing screening, including at least:
10.3.3. Menstrual status (last menstrual period, hysterectomy, pregnant,
postpartum, use of contraceptive, or hormone therapy).
10.3.4. Previous screening, results of screening, (negative, abnormal, or pos-
itive), and any previous treatment (biopsy, chemotherapy, radiother-
apy, or surgery).
10.3.5. Immune-compromised status due to diseases (including HIV) or
medication.
732 Appendix W: Cervical Cancer Screening Program Requirements

10.3.6. Full clinical examination must be performed including visual inspec-

tion of the cervix.
10.4. Specimen collection and preparation of adequate Pap test
10.4.1. The following categories of DOH licensed healthcare physicians are
eligible to perform a Pap test:
10.4.1.1. Licensed gynecologists, obstetricians, and family medi-
cine physicians.
10.4.1.2. Physicians already privileged to do so by their institution.
10.4.2. Eligible physicians must:
10.4.2.1. Complete the required form with relevant clinical informa-
tion in accordance with Article 9.1.2.
10.4.2.2. Collect and manage specimens in accordance with the
facility internal policies and procedures and DOH
standards.
10.4.3. Smear taking must be avoided in the following circumstances and
women must be advised when to return for a pap test:
10.4.3.1. Menstruation, blood loss, breakthrough bleeding.
10.4.3.2. Vaginal inflammation/infection.
10.4.3.3. Pregnancy (unless a previous smear was abnormal and in
the interim the woman becomes pregnant, then the follow-
­up smear must not be delayed).
10.5. Cytology smear handling and reporting
Clinical laboratories handling and reporting of cytology specimens and cytology
smears testing must:
10.5.1. Manage cervical cytology smears and perform the cytopathology
testing as indicated and in accordance with the specifications of the
DOH Clinical Laboratory Standards, including without limitation
“Processes for Laboratory Specialties” and “Cytopathology of the
HAAD Clinical Laboratory Standards.”
10.5.2. Make final reports of cervical cytology smear using the Bethesda
System (The Bethesda System for Reporting Cervical Cytology).
10.5.3. The report must be verified by a pathologist for all abnormal and
reactive cases, while negative cases can be verified by licensed cyto-
technologist using standard synoptic reporting format and containing
minimum elements consistent with those of internationally reputable
accrediting bodies.
10.5.4. The report must minimally include the following details:
10.5.4.1. Patient’s name.
10.5.4.2. Age/date of birth.
10.5.4.3. Menstrual status (LMP, hysterectomy, pregnant, postpar-
tum, hormone therapy).
10.5.4.4. Relevant clinical information such as if the patient has pre-
viously had a positive test or had other types of cancer, etc.
10.5.4.5. Specimen description (source).
Appendix W: Cervical Cancer Screening Program Requirements 733

10.5.5. The reporting pathologist is the professional responsible for confirm-

ing the positive cancer results.
10.5.6. Reports for specimen adequacy and cytological findings must be
returned to the referring physician at the screening center within 8
working days of receiving the specimen.
10.5.7. The DOH may, at its discretion, conduct third-party independent
quality assurance testing of laboratories providing cervical smear
laboratory test service. Where it does so, providers must comply with
DOH’s direction and cooperate with the DOH appointed party.
10.6. Screening outcomes and referrals
10.6.1. All women must be notified in writing of the result of their screen-
ing tests.
10.6.2. It is the responsibility of the physician at the screening facility to
notify and provide a written report to a woman regarding her screen-
ing results within 21 days (3 weeks) of the date of specimen taken.
10.6.3. If the test outcome is normal, the woman is discharged to routine
screening as per frequency mentioned in this document.
10.6.4. If the test outcome is unsatisfactory, it must be repeated within 6–12
weeks, treating infection, if present, as indicated.
10.6.5. If the Pap test outcome is abnormal (cytology showed intraepithelial
lesions or malignancy and/or HPV positive), the woman’s test should
be managed according to Appendix Z.
10.6.6. If a suspicious visible abnormality is identified during visualization
of the cervix, the woman must be referred immediately to a gyne-
cologist oncologist without receipt of her test results.
10.6.7. If a woman requires referral for colposcopy or treatment, the physi-
cian must make the referral to an appropriately DOH licensed health-
care professional, privileged to provide the specialty/oncology
service. Timelines for referral should be in compliance with
Appendix AB.
Appendix X: Definitions

Term Definition
The Bethesda system Is a system for reporting cervical or vaginal cytological diagnoses,
(TBS) used for reporting Pap smear results. The name comes from the
location (Bethesda, Maryland) of the conference that established the
system of reporting
HPV Human papilloma virus
HPV co-testing Is a test is done along with the Pap test in women aged 30 years and
above, to screen for a high-risk HPV viral types. Only FDA approved
test is accepted
ASC-US Atypical squamous cells of undetermined significance. It is a finding
of abnormal cells in the tissue that lines the outer part of the cervix
ASC-H Suspicious for high grade dysplasia
LGSIL or LSIL Low-grade squamous intraepithelial lesion
HGSIL or HSIL High-grade squamous intraepithelial lesion
AIS Adenocarcinoma in situ
AGC Atypical glandular cells

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 735
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
 ppendix Y: Eligibility Criteria for a Facility
A
to Participate in DOH’s Cervical Cancer
Screening Program

1. General
In addition to the requirements of this program specification, the healthcare facility
must fulfill the following criteria:
1.1. Plan capacity to match the demand for screening and the facility capacity.
1.2. Allocate appointment slots for cervical cancer screening linked to the DOH
online booking system (when available).
1.3. Have available adequate equipment to provide safe and quality screening:
1.3.1. Send cervical cytology smears only to DOH licensed laboratories
that meet the requirements of this program specification.
1.3.2. Ensure patient privacy, comfort, and confidentiality at all times.
2. Human resources
2.1. The core team must include at least:
2.1.1. A program coordinator.
2.1.2. A licensed physician, family medicine physician, gynecologist or
obstetrician, physician privileged to deliver cervical screening care
and services.
2.1.3. A licensed nurse for each clinic with a minimum of 2 years of expe-
rience in gynecology or obstetric nursing.
2.2. Training of licensed health professionals must be delivered using CME/
CPD courses accredited by DOH CME department at https://www.doh.gov.
ae/en/programs-­initiatives/meed including
2.2.1. For physicians; training for Pap smear taking in accordance with
international evidence-based training standards and guidelines.
3. Registration as DOH screening facilities
Facilities meeting DOH cervical cancer screening requirements should follow DOH
facilities’ registration process:
3.1. Register through DOH facility registration website.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 737
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
 ppendix Z: Cervical Cancer Screening
A
Care-Pathway

30< <

◊
○ ≥25 ≥30
≠
Ω

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 739
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
 ppendix AA: Cervical Cancer Screening
A
Program—Clinical Quality Indicators

Acceptable
Quality indicator level Desirable level
Coverage
Retention rate Percentage of eligible women re-screened 40% 50%
within 3 years after a negative Pap test in
a 12-month period
Cytology performance indicators
Specimen Percentage of Pap tests that are reported 4.7% 1.3
adequacy as unsatisfactory in a 12-month period
unsatisfactory
proportion
Screening test Percentage of women by their most 90% 97%
results Negative severe Pap test result in a 12-month
period
System capacity indicators
Cytology The average time from the date the >80% >90%
turnaround time specimen is taken to the date the finalized
2 weeks report is issued over a 12-month period
Time to Percentage of women with a positive Pap 80% 88%
colposcopy test (HSIL+/ASC-H) who had follow-up
colposcopy within 3, 6, 9 and 12 months
subsequent to the index Pap test
Follow-up
Biopsy rate Percentage of women with a positive To be 11%
screening test result (HSIL+/ASC-H) determined
who received a histological diagnosis in a
12-month period
Cytology- Proportion of positive Pap tests with To be
histology histological work-up found to have a determined
agreement pre-cancerous lesion or invasive cervical
cancer in a 12-month period A
Outcome indicators
Pre-cancer Number of pre-cancerous lesions detected To be 7.1 per 1000
detection rate per 1000 women who had a Pap test in a determined
12-month period

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 ppendix AB: Cervical Cancer Screening
A
Program—Timeframes for Appointments

Cytological pattern Priority Appointment

HSIL or greater Urgent 1–2 weeks
LSIL soon 2–4 weeks
ASC-US/ASC-H Routine 4–8 weeks

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 ppendix AC: Responsibilities of the Facility
A
Cancer Screening Program Coordinator

The healthcare facility cervical cancer screening program coordinator must:

1.1. Be a licensed healthcare professional.
1.2. Have comprehensive and high-quality knowledge in cervical cancer as a dis-
ease and its prevention.
1.3. Be responsible for:
1.3.1. Recruitment of eligible women.
1.3.2. Follow-up and tracking of screening results to ensure the timeliness and
completeness of follow-up.
1.3.3. Assessing relationships between planned care and approved protocols
for care.
1.3.4. Assessing women’s needs for support to remove barriers to screening
and follow-up.
1.3.5. Developing and promoting recall systems that include reminders to
patients as appropriate.
1.3.6. Submitting data on screening visit and outcomes to DOH via the (can-
cer screening e-notification system).

References

1. NHS Cervical Screening Program. https://www.bsccp.org.uk/assets/file/uploads/

resources/NHSCSP_20_Colposcopy_and_Programme_Management_(3rd_
Edition)_(2).pdf.
2. The American Cancer Society guidelines for the prevention and early detection
of cervical cancer. https://www.cancer.org/cancer/cervical-­cancer/prevention-­
and-­early-­detection/cervical-­cancer-­screening-­guidelines.html.
3. Performance monitoring for cervical cancer screening programs in Canada. http://
www.phac-­aspc.gc.ca/cd-­mc/cancer/pmccspc-­srpdccuc/pdf/cervical-­eng.pdf.
4. Ontario cervical screening guidelines. https://www.cancercare.on.ca/common/
pages/UserFile.aspx?fileId=13104.
5. NCCN cervical cancer screening guidelines. https://www.cancercare.on.ca/
common/pages/UserFile.aspx?fileId=13104.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 745
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
746 Appendix AC: Responsibilities of the Facility Cancer Screening Program Coordinator

6. ACOG-cervical cancer screening guidelines. https://www.acog.org/Patients/

FAQs/Cervical-­Cancer-­Screening.
7. Implementation of cancer screening in the European Union. 2017. https://
ec.europa.eu/health/sites/health/files/major_chronic_diseases/docs/2017_cance
rscreening_2ndreportimplementation_en.pdf, https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC2826099/.
8. European guidelines for quality assurance in cervical cancer screening. http://
screening.iarc.fr/doc/ND7007117ENC_002.pdf.
 ppendix AD: DOH Colorectal Cancer
A
Screening Program Specifications

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 747
Springer Nature Singapore Pte Ltd. 2024
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748 Appendix AD: DOH Colorectal Cancer Screening Program Specifications

DOH COLORECTAL CANCER

SCREENING PROGRAM
SPECIFICATIONS

SEPTEMBER 2019

https://doh.gov.ae/-/media/980F1D8087214B6D9E630B457B85E4B9.ashx
Appendix AD: DOH Colorectal Cancer Screening Program Specifications 749

Document Title: DOH Colorectal Cancer Screening Program Specifications

Document Ref. DOH/ADCPH/CRCS/ Version: 1.0
Number: PS/1.0
Approval Date: 04 September 2019 Effective Date: 05 September 2019
Last Reviewed: August 2019 Next Review: October 2020
Revision History: Version 0.9 July, 2012
Document Owner: Public Health and Research Division
Applies to: All DOH Licensed Healthcare Providers
Classification: • Public

1. Purpose

1.1. To set out the minimum service specifications for DOH Colorectal Cancer
Screening Program (CRCSP) through identification of the following:
1.1.1. Duties of the participating healthcare providers.
1.1.2. Clinical and administrative service specifications.
1.1.3. Risk assessment and eligibility criteria.
1.1.4. Data reporting requirements.

2. Scope

2.1. All DOH licensed healthcare providers and professionals who are participating
in DOH’s Comprehensive Screening Program for Adults and providing CRC
screening services including mobile units.

3. Definitions and Abbreviations

3.1. Colorectal Cancer Screening Program (CRCSP) in the Emirate of Abu

Dhabi and for the purpose of this document includes the following services:
3.1.1. Colorectal cancer screening services.
3.1.2. Colorectal cancer assessment and follow-up.
3.1.3. Familial and genetic high-risk assessment.
3.2. Colonoscopy is the endoscopic examination of the large bowel and the distal
part of the small bowel with a Charge Coupled Device (CCD) camera or a fiber
optic camera on a flexible tube passed through the anus. It can provide a visual
sight to detect adenomatous polyps and cancer diagnosis (e.g., ulceration and
polyps). It also gives the opportunity for biopsy or removal of suspected
colorectal cancer lesions.
750 Appendix AD: DOH Colorectal Cancer Screening Program Specifications

3.3. Fecal Immunochemical Test (FIT) is a test that investigates the stool sample
for signs of cancer.
3.4. Case mix includes males and females aged 40–75 years determined eligible
for colorectal cancer screening services, in accordance with the criteria detailed
in these program specifications:
3.4.1. People who are symptomatic and in good health and do not have any
problems.
3.4.2. For adults aged 76–85 years, the decision to screen should be-­
individualized, considering the patient’s overall health prior screening
history. The decision will be based on the healthcare professional judg-
ment and the individual’s preference.
3.4.3. People over 85 should no longer get colorectal cancer screening.
3.5. CT: Computed tomography.
3.6. LFTs: Liver function tests.
3.7. OLT: Orthoptic liver transplant.
3.8. PSC: Primary sclerosing cholangitis.
3.9. CRC: Colorectal cancer.

4. Duties of CRCSP Participating Healthcare Providers

All DOH licensed healthcare providers (facilities and professionals) engaged in

CRCSP must:
4.1.Follow the pathway for CRC Screening as per Appendix AE.
4.2.Adhere to the clinical performance indicators and timelines in accordance with
Appendix AF.
4.3.Include a CRC risk assessment and refer individuals to appropriate screening
test based on risk categories as per Appendix AG.
4.4.Assign a CRCSP coordinator/director who will be accountable to:
4.4.1.Report and submit screening outcome data to DOH specified in Sect. 4.
4.4.2.Maintain records for screening tests and outcomes.
4.4.3.Establish internal audit policies and procedures and conduct regular audits,
monitoring and evaluating to demonstrate compliance with these program spec-
ifications and other associated regulatory policies and standards.
4.5.Has an endoscopy unit that meets the criteria for a competent unit infrastructure,
equipment and personnel, as per Appendix AH.
4.6.Comply with DOH direct or DOH third-party independent quality assurance
testing of laboratories providing CRC screening test service.
4.7.Establish an invitation system to ensure successful participation of eligible pop-
ulation. The system may be manual or electronic.
4.8.Provide clinical services and patient care in accordance with these program
specifications and in accordance with DOH policies and standards including
data submission and cancer E-notification through DOH Data Dictionary
Website.
Appendix AD: DOH Colorectal Cancer Screening Program Specifications 751

4.9. Provide clinical services and patient care in accordance with laws and regula-
tions of the UAE and the Emirate of Abu Dhabi.
Laboratory services requirements:
DOH licensed healthcare providers engaged in CRCSP must provide labora-
tory services that:
4.10. Perform the CRC screening laboratory tests in accordance with the require-
ments and specifications of the CRCSP.
4.11. Use specimen identification and labelling in accordance with DOH Clinical
Laboratory Standards and industry best practices.
4.12. Is accredited by an internationally accrediting body for CRC screening tests.
4.13. Ensure that laboratory performing the FIT test:
4.13.1. Follow the manufacturer’s instructions for use of the FIT testing kit.
4.13.2. Use an explicit definition for cut-off levels for hemoglobin
concentration.
4.13.3. Make provision to record the information concerning the actual
amount of hemoglobin, both for tests classified as negative and for
those classified as positive.
4.13.4. Employ licensed professionals who are privileged and have evi-
denced their ability to undertake different types of fecal occult blood
test and in-depth understanding of the technology required to per-
form the fecal occult blood test.
4.14. Ensure that laboratory performing genetic testing must have a specialist cyto/
histopathological support services.
Healthcare professional requirements:
DOH licensed healthcare providers engaged in CRCSP must:
4.15. Have a multi-disciplinary team that includes a gastroenterologist, colorectal
surgeon, gastrointestinal oncologist, pathologist, radiologist, medical, and a
nurse to review the outcomes of screening for colorectal cancer.
4.16. All healthcare professionals participating in colorectal cancer screening must:
4.16.1. Obtain informed patient consent prior to screening.
4.16.2. Where consent is granted or refused, the treating physician must doc-
ument and retain signed consent forms on patients’ medical records.
4.16.3. Inform all patients of the procedures and expected timeframe to be
screened and to receive results.
Reporting requirements:
In addition to the routine e-Claims data, DOH licensed healthcare providers
(facilities and professionals) engaged in CRCSP must:
4.17. Collect and submit to DOH data on screening visits and outcomes within 2
weeks of the screening date, through the cancer screening form of the cancer
E-notification system on DOH Data Dictionary Website.
4.18. Report all screening-detected cancers to DOH, using cancer case notification
form (Cancer Notification Appendix AR) available on DOH Data Dictionary
Website.
752 Appendix AD: DOH Colorectal Cancer Screening Program Specifications

5. CRCSP Risk Assessment and Eligibility Criteria

5.1. Risk assessment

5.1.1. A detailed medical history of the screening candidate, such as that
described in the cancer screening form available at DOH e-services
website or as per Appendix AU should be taken to determine if the can-
didate’s risk category is average, increased or high as per Appendix AG.
5.1.2. Colorectal Screening Program-Screening individuals at increased risk
for CRC:
5.1.2.1. Individuals with increased risk for CRC should be referred for
assessment and screening to specialized centers or hospitals
that have specialized multidisciplinary teams providing gastro-
enterology, genetic counseling, genetic testing, surgery, oncol-
ogy, and preferably psychosocial support services.
5.1.2.2. All individuals at increased risk must be managed in accor-
dance with Appendices AI, AJ, and international best practices
and guidelines such as NICE Guidelines for colorectal cancer
screening and surveillance in moderate and high-risk groups
and NICE guidelines for colonoscopy surveillance for the pre-
vention of colorectal cancer in people with ulcerative colitis,
Crohn’s disease or adenomas.
5.1.3. Colorectal Screening Program-Familial/Genetic High-Risk Assessment:
5.1.3.1. All individuals with suspected or confirmed genetic/familial
high risk as per Appendices AK and AL should be referred only
to specialized centers or hospitals that have specialized multi-
disciplinary teams providing gastroenterology, genetic coun-
seling, genetic testing, surgery, oncology, and preferably
psychosocial support services for the purpose of assessment,
genetic counselling, and mutation analysis of relevant genes
where appropriate.
5.1.3.2. Individuals with gene mutation must be managed in accor-
dance with international best practices and guidelines.
5.1.3.3. Genetic counseling is highly recommended when genetic test-
ing is offered and after disclosure of results.
5.1.3.4. Genetic counseling can be given by a genetic counselor, medi-
cal geneticist, oncologist, surgeon, oncologist, or other health-
care professional with expertise and experience in genetic
counseling who is privileged by the facility to provide
counseling.
5.1.3.5. A list of recommended genetic tests is available in Appendix AL.
5.2. Screening tests and frequency
5.2.1. For individuals at average risk of colorectal cancer:
5.2.1.1. Eligible population must be offered the two options for colo-
noscopy screening as per Appendix AE or FIT test in case of
colonoscopy refusal.
Appendix AD: DOH Colorectal Cancer Screening Program Specifications 753

5.2.1.2. Frequency of screening should be as follows:

5.2.1.2.1. Colonoscopy screening, every 10 years.
5.2.1.2.2. Fecal Immunochemical Test (FIT) every year
(annually).
5.2.2. For individuals at increased or high risk of colorectal cancer:
5.2.2.1. Colonoscopy screening should be offered.
5.2.2.2. The frequency and age of initiation should be individualized
for each person as described in Appendices AI–AK.
5.2.2.3. Further investigations, genetic testing, and counselling should
be pursued for individuals with suspected familial/genetic high
risk as per Appendices AK and AL.
5.2.2.4. All healthcare providers must utilize evidence based-practice
for CRC screening as per Appendices AG and AM–AU.
5.2.3. For individuals who will go through CRCSP with Fecal Immunochemical
Test (FIT), they must be provided with clear and simple instructions
regarding collection of the sample.
5.3. Recruitment for screening
Individuals eligible for CRC screening may be recruited in healthcare facilities
through one of the following:
5.3.1. Targeted invitation which may be established via an electronic or man-
ual invitation system call and recall initiative with Daman.
5.3.2. Opportunistic:
5.3.2.1. New physician consultation for related or unrelated reason.
5.3.2.2. Engagement in a health promotion campaign.
5.4. Online booking to screening appointment
All DOH Licensed Healthcare Providers (Facilities and Professionals) engaged
in CRCSP:
5.4.1. Are encouraged use optional online booking system for screening
appointments in order to facilitate access to screening services available
at DOH website.
5.4.1.1. Facilities that utilize the provided appointment system must
nominate a person to access the online booking schedule by
which secure access will be provided by DOH.
5.4.2. Are encouraged to provide flexible timeslots to enable this
functionality.
5.4.3. Ensure that they meet the available appointments to receive patients.
5.5. Outcomes and referrals
5.5.1. At the end of the screening procedure, in case of positive outcome, the
screening unit must provide the candidate with a copy of the DOH
e-cancer screening referral form (Appendix AT).
5.5.2. The time between completion of a screening test and receipt of results
by the participant must be less than 15 working days (acceptable stan-
dard >90% within 15 days).
5.5.3. Screening with colonoscopy
754 Appendix AD: DOH Colorectal Cancer Screening Program Specifications

5.5.3.1. In case of normal results, (i.e., negative for polyps) individuals

must be re-invited for screening in accordance with the fre-
quencies specified in point 5.2.
5.5.3.2. In case of the presence of adenoma, colonoscopy must be
repeated in accordance with Appendix AE.
5.5.3.3. Adenoma detection rate must be monitored and audited. It is
limited to screening colonoscopies and surveillance proce-
dures. Repeat endoscopic procedures are excluded.
5.5.3.4. The time interval between a positive colonoscopy (cancer) and
beginning of definitive management must be less than 31 work-
ing days (acceptable standard ≥95% of cases must be no more
than 31 days).
5.5.3.5. Death within 30 days after colorectal cancer screening, attrib-
uted to complications caused by colonoscopy, must be recorded
by e-notification.
5.5.4. Screening with FIT test (not applicable for increased and high-­
risk group)
5.5.4.1. Patients with a negative test result should be re-invited for
screening as per frequencies specified in point 5.2.
5.5.4.2. Patients with a positive test result must be scheduled for fol-
low-­up colonoscopy within 31 days of referral.
5.5.4.3. The FIT test must be repeated if results are unclear or spoilt in
accordance with Appendix AL.

6. Enforcement and Sanctions

6.1. Healthcare providers participating in DOH Comprehensive Screening

Program—Colorectal Screening Program, payers and third-party administra-
tors must comply with the terms and requirements of these program
specifications.
6.2. DOH may impose sanctions in relation to any breach of requirements under
these program specifications in accordance with the Chapter on Inspections,
Complaints, Appeals and Sanction, the Healthcare Regulatory Manual.

7. Payment for Screening and Follow-Up of Colorectal Cancer

7.1. Eligibility for reimbursement under the Health Insurance Scheme must be in
accordance with the Standard Provider Contract and as applicable by the Thiqa
Prevention List, DOH Mandatory Tariff and associated Claims and Adjudication
Rules and the Coding Manual. All documents are available from the DOH
website in Data Dictionary.
 ppendix AE: Colorectal Cancer
A
Screening—Care-Pathway

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 ppendix AF: Colorectal Cancer Clinical
A
Performance Indicators1

Desirable
Indicator Acceptable level level
Screening uptake (participation) rate >55% >70%
Minimum number of screening colonoscopies undertaken >150 per annum >250
annually by each screening colonoscopist
Inadequate FIT rate (proportion of people screened with <3% <1%
one or more FIT returned none of which were adequate)
Maximum time between screening FIT test and receipt of >90% 100%
result should be 7 days from sample’s dispatch
Rate of referral to follow-up colonoscopy after positive 95% >100%
FIT test (detects cancer)
Maximum time between referral after positive screening >90% >95%
FIT test and conducting a follow-up colonoscopy should
be within 31 days
Cecal intubation rate (CIR). Follow-up and screening >90% >95%
colonoscopies to be recorded separately (unadjusted CIR
with video recorded and photographic evidence)
Adenoma detection rate on males 25% Auditable
outcome
Adenoma detection rate on females 15% Auditable
outcome
Cancer detection rate ≥2 per 100 screened Auditable
by FIT ≥11 per 100 outcome
colonoscopies
Withdrawal time in negative colonoscopies (withdrawal ≥6 min Auditable
from cecal pole to anus) outcome
Polyp retrieval rate (retrieval of polypectomy specimens >90% per 100 >95% per
for histological analysis per colonoscopist)b polyps excised 100 polyps
excised
Rate of high-grade neoplasia reported by pathologists in a <10%
FIT screening program

1
NHS Cancer Screening Programs quality assurance guidelines for colonoscopy. European guide-
lines for quality assurance in colorectal cancer screening and diagnosis.

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758 Appendix AF: Colorectal Cancer Clinical Performance Indicators

Desirable
Indicator Acceptable level level
Endoscopic complications of colonoscopy screening Bleeding <1:150
programs Perforation <1:1000
Post polypectomy perforation rate <1:500 Auditable
outcome
Time interval between positive colonoscopy and start of >90% >95%
definitive management within 31 days
Bowel cleansing should be audited
Proposed standard: At least more than 90% of examinations should be rated as “adequate” bowel
cleansing or excellent
a
Excellent: no or minimal solid stool and only clear fluid requiring suctionAdequate: collections
of semi-solid debris that are cleared with washing/suctionInadequate: solid or semi-solid debris
that cannot be cleared effectively
b
Numerator: number of polyps with histological tissue retrieved for analysisDenominator: number
of polyps recorded during lower GI endoscopies
 ppendix AG: Pre-colonoscopy Risk
A
Assessment for Colorectal Cancer

Average risk:
1. Age ≥40
2. No history of adenoma or colorectal cancer
3. No history of inflammatory bowel disease
4. Negative family history
Increased risk:
1. Personal or family history of adenoma, sessile serrated polyp (SAP),1 colorectal
cancer, inflammatory bowel disease.
2. Positive family history of first- or second-degree relative with colorectal cancer
(screening recommendations vary depending on family history).
High risk:
1. Hereditary nonpolyposis colorectal cancer (HNPCC).
2. Family history of polyposis syndromes (Classical Familial Adenomatous
Polyposis (FAP-1), Attenuated Familial Adenomatous Polyposis (AFAP-1),
MYH associated polyposis (MAP-1), Peutz-Jeghers syndrome (PJS-1), Juvenile
Polyposis Syndrome (JPS-1), Hyperplastic Polyposis Syndrome (HPP-1 Cowden
syndrome, Li-Fraumeni syndrome).

1
Increased risk is based on personal history of adenoma(s)/sessile serrated polyp(s) found at
colonoscopy:
(a) Low-risk adenoma: ≤2 polyps, <1 cm, tubular.
(b) Advanced or multiple adenomas: high-grade dysplasia, ≥1 cm, villous (>25% villous), between
3 and 10 polyps (fewer than 10 polyps in the setting of a strong family history or younger age
(<40 years) may sometimes be associated with an inherited polyposis syndrome).
(c) More than 10 cumulative adenomas (fewer than 10 polyps in the setting of a strong family his-
tory or younger age (<40 years) may sometimes be associated with an inherited polyposis
syndrome).
(d) Incomplete or piecemeal polypectomy (ink lesion for later identification) or polypectomy of
large cancer.

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 ppendix AH: Colorectal Cancer Screening
A
Endoscopy Unit Infrastructure, Equipment
and Personnel

Endoscopy unit infrastructure and equipment must:

1. Include facilities for adequate pre-colonoscopy assessment, recovery and be
designed to allow efficient patient flow.
2. Match the demand with respect to unit capacity (e.g., equipment and personnel).
3. Provide video-endoscopes that facilitate focal application of the dye for the
detection and assessment of high-risk colorectal lesions.
4. Provide adequate supply of accessories suited to the endoscopic interventions
undertaken.
5. Provide properly maintained resuscitation equipment in the endoscopy rooms
and recovery areas.
6. Conduct regular reviews of all the functioning and cleansing of the colonosco-
pies. Results of the reviews should be available at all times in the unit.
7. Plan capacity that matches demand for screening. Referral to colonoscopy to be
within 31 days from a positive FIT test (detects the presence of occult blood in
the fecal sample).
Criteria colorectal cancer screening core team to include:
All members in the colorectal cancer core team should participate in regular
multidisciplinary team meetings to discuss each patient with colorectal cancer.
1. At least 2 gastroenterologists: licensed by DOH, colonoscopy volume minimum
150 per colonoscopist per year with a cecal completion rate of >95%.
2. Nurse: Two nurses trained to provide support, assistance, information, and
advice to every patient. An in-depth understanding of colorectal cancer (diagno-
sis, treatment, prognosis, staging, and importance of stage at diagnosis), an in-­
depth understanding of the colorectal screening process (including screening
theory and particularly the potential benefits and harms of screening, and the
prime importance of quality assurance), and advanced communication skills.

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 ppendix AI: DOH Recommendation
A
for Colorectal Cancer Screening
and Surveillance, Increased and High-Risk
Disease Family Group

High-­risk Screening procedure

disease groups Screening procedure Time of initial screen and interval
Colorectal cancer
Consultation, CT, LFTs and Colonoscopy within CT liver scan within
colonoscopy 6 months of resection 2 years post-op.
only if colon Colonoscopy 5
evaluation pre-op is years until
incomplete co-morbidity
outweighs
Colonic adenomas
Low risk 1–2 adenomas, both <1 cm Colonoscopy 5 years or no
surveillance
Intermediate 3–4 adenomas, or at least one Colonoscopy Every 3 years
risk adenoma ≥1 cm
High risk ≥5 adenomas or ≥3 with at Colonoscopy Yearly 3 months
least one ≥1 cm piecemeal Colonoscopy or consider open
polypectomy flexi-si (depending surgical resection if
on polyp location) incomplete healing
of polypectomy scar
Ulcerative colitis and Crohn’s colitis
Low risk Extensive colitis with no Pancolonic dye spray Every 10 years from
inflammation or left-sided with targeted biopsy. onset of symptoms
colitis or Crohn’s colitis of If no dye spray, then
<50% colon 2–4 random biopsies
Intermediate Extensive colitis with mild every 10 cm After surgery by 10
risk active disease or post- years
inflammatory polyps or family
history of colorectal cancer in a
FDR <50 years
Extensive at least moderate
colitis or stricture in past 5
years or dysplasia in past 5
years (declining surgery) or
PSC or OLT for PSC) or
colorectal cancer in a FDR <50
years
Ureterosigmoidostomy

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764 Appendix AI: DOH Recommendation for Colorectal Cancer Screening....

High-­risk Screening procedure

disease groups Screening procedure Time of initial screen and interval
Acromegaly
Acromegaly – Colonoscopy At 40 years
 ppendix AJ: DOH Recommendations
A
for Colorectal Cancer Screening
and Surveillance in Moderate Risk Disease
Family Groups

Initial screening 10 years earlier than the youngest affected FDM

Family history Screening procedure Screening interval
One first-degree Colonoscopy Start at 40 years of age or 10 years younger
relative with CRC or than the earliest diagnosis in the patient’s
advanced adenoma family, whichever comes first; colonoscopy
diagnosed before 60 should be repeated every 5 years
years of age or two
first-degree relatives
diagnosed at any age
One first-degree Colonoscopy Start screening colonoscopy at 40 years of age;
relative with CRC or colonoscopy should be repeated every 10 years
advanced adenoma
diagnosed at 60 years
or older or two
second-degree
relatives with CRC
One second- or Colonoscopy Average-risk screening (e.g., start at 40)
third-degree relative
with CRC
Individuals who have Colonoscopy Colonoscopy screening should begin 8–10
Crohn disease with years after the onset of symptoms
colonic involvement
or ulcerative colitis.
Screening repeated
every 1–3 years
In individuals with Colonoscopy Colonoscopy should begin at 25 years of age
hereditary and be repeated annually
nonpolyposis
colorectal cancer
Individuals with Colonoscopy Colonoscopy between 10 and 20 years of age
adenomatous and be repeated every 1–2 years
polyposis syndromes

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766 Appendix AJ: DOH Recommendations for Colorectal Cancer Screening...

Family history Screening procedure Screening interval

Individuals with Colonoscopy Esophagogastroduodenoscopy, colonoscopy,
Peutz-Jeghers and video capsule endoscopy should begin at 8
syndrome. If results years of age. If results are negative, testing-
are, negative, testing repeated every 3 years
repeated every 3
years.
Individuals with Colonoscopy Colonoscopy should begin as soon as the
sessile serrated diagnosis is established and be repeated
adenomatous annually
polyposis

• Affected relatives who are first-degree relatives of each other AND at least one is
a first-degree relative of the patient.
• Combinations of 3 affected relatives in a first-degree kinship include: parent and
aunt/uncle and/or grandparent OR 2 siblings/1 parent; OR 2 siblings/1 offspring.
Combinations of 2 affected relatives in a first-degree kinship.
• Include a parent and grandparent, or >2 siblings, or >2 children, or child + sib-
ling. Where both parents are affected, these count as being within the first-degree
kinship.
• Clinical genetics referral recommended.
• Centers may vary depending on capacity and referral agreements. Ideally, all
such cases should be flagged systematically for future audit on an emirate level.
 ppendix AK: DOH Summary
A
of Recommendations for Colorectal Cancer
Screening and Surveillance in High-Risk
Disease Family Groups

Screening Age at initial Screening interval and

Family history categoriesa procedure screen procedure
At-risk HNPCC (fulfils MMR gene Colonoscopy from Colonoscopy every
modified Amsterdam testing of age 25 years 18–24 months (OGD
criteria, or untested FDR of affected OGD from age 40 every 2 years from age
proven mutation carrier) relative years or screening 40 years)
colonoscopy 10 years earlier
± OGD than the youngest
affected FDM
MMR gene carrier Colonoscopy
± OGD
At-risk FAP(member of APC gene Puberty Annual colonoscopy or
FAP family with no testing of Flexible approach until aged 30 years
mutation identified) affected Importance of Thereafter 3–5 yearly
relative making allowance until 60 years
colonoscopy for variation in proctocolectomy or
maturity colectomy if positive
Fulfils clinical FAP criteria, Colonoscopy Usually at Recommendation for
or proven APC mutation Colonoscopy/ diagnosis proctocolectomy and
carrier opting for deferred OGD otherwise puberty pouch/colectomy before
surgery Flexible approach age 30 years
Prophylactic surgery Importance of Cancer risk increases
normally strongly making allowance dramatically age >30
recommended for variation in years
maturity
Twice yearly
colonoscopy
FAP post-colectomy and Colonoscopy After surgery Colonoscopy
IRA OGD OGD from age 30 Every 3 years forward
years and side-viewing OGD
FAP post-procto colectomy DRE and After surgery Annual exams
and pouch pouch OGD from age 30 alternating
endoscopy years Flexible/rigid pouch
Forward and Endoscopy every 3
side-viewing years
OGD Forward and side-
viewing OGD

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768 Appendix AK: DOH Summary of Recommendations for Colorectal Cancer Screening...

Screening Age at initial Screening interval and

Family history categoriesa procedure screen procedure
MUTYH-associated Genetic Colonoscopy from Mutation carriers should
polyposis (MAP) testing age 25 years be counselled about the
Colonoscopy OGD from age 30 available limited
± OGD years evidence
Options include
prophylactic colectomy
and ileorectal
anastomosis; or biennial
colonoscopy surveillance
Every 3–5 years
gastro-duodenoscopy
FDR with MSI-H colorectal Colonoscopy Colonoscopy from Colonoscopy every 2
cancer and IHC shows loss ± OGD age 25 years years (with OGD aged
of MSH2, MSH6, or PMS2 OGD from age 40 >40 years).
expression years
MLH1 loss and MSI
specifically excluded
(MLH1 loss in elderly
patient with right-sided
tumor is usually somatic
epigenetic event)
Peutz-Jeghers syndrome Genetic Colonoscopy from Twice yearly
testing of age 25 years. colonoscopy/consider
affected OGD from age 25 colectomy and IRA for
relative years colonic cancer
Colonoscopy Small bowel MRI/ Small bowel VCE or
± OGD enteroclysis MRI/enteroclysis 2–4
yearly
OGD twice yearly.
Juvenile polyposis Genetic Colonoscopy from Every 2 years
testing of age 15 years colonoscopy and
affected OGD from age 25 OGD. Extend interval
relative years >35 years
Colonoscopy
± OGD

1. The Amsterdam criteria for identifying HNPCC are three or more relatives with
colorectal cancer:
• One patient a first-degree relative of another.
• Two generations with cancer.
• One cancer diagnosed under the age of 45 or other HNPCC-related cancers,
e.g., endometrial, ovarian, gastric, upper urothelial, and biliary tree.
2. Clinical genetics referral and family assessment required, if not already in place
or if clinical genetics did not initiate referral.
3. FAP, familial adenomatosis polyposis; FDR, first-degree relative (sibling, par-
ent, or child) with colorectal cancer; HNPCC, hereditary non-polyposis colorec-
tal cancer; IHC, immunohistochemistry of tumor material from affected proband;
MSI-H, micro-satellite instability-high (two or more MSI markers show instabil-
ity); OGD, esophagogastroduodenoscopy endoscopy; VCE, video capsule
endoscopy.
Appendix AL: Genetic Test

Available genetic tests for the patient or his/her affected family member(s) that may
be recommended by the cancer genetics professional based on the assessment.
Disease Reasonable gene
Lynch syndrome/hereditary non-polyposis Genes responsible: MLH1, MSH2, MSH6,
colorectal cancer (HNPCC) PMS2
<OMIM 114500, 120435, 120436, 276300,
609309, 600678, 600259
Familial adenomatous polyposis (FAP) APC
<OMIM 175100
Peutz-Jeghers syndrome LKB1
<OMIM 175200
Juvenile polyposis SMAD4, BMPR1A (Juvenile polyposis)
<OMIM 174900
Rare subtype hereditary mixed juvenile/ Locus on chr15q (GREM1 or SGNE1 may be
adenomatous polyposis responsible)
<OMIM 601228
MUTYH associated polyposis (MAP) MUTYH
<OMIM 608456

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Appendix AM: Pre-colonoscopy Assessment

1. Pre-colonoscopy documentation must include:

2.1. Patient demographics
2.2. Anticoagulant use
2.3. History of diabetes mellitus and use of insulin
2.4. Presence of implantable defibrillators or pacemakers
2.5. Previous gastrointestinal procedures
2. Assessment of patient risk: physical status of the patient must be documented in
accordance with the American Society of Anesthesiology (ASA) (Appendix AN).
3. ASA class 3 or higher is at higher risk for cardiopulmonary events and appropri-
ate measures must be taken in this respect.
4. Colonic cleansing: Type of bowel preparation must be documented including
documentation of careful preparation in accordance with international standards
and guidelines. Written instructions to be given to patient concerning colonic
cleansing.
5. Inadequate bowel preparations must not exceed 10% of examinations.

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 ppendix AN: Pre-colonoscopy
A
Assessment—American Society
of Anesthesiology Classification System

Class Description
1 Patient has no organic, physiologic, biochemical, or psychiatric disturbance (healthy, no
comorbidity)
2 Mild-moderate systemic disturbance caused either by the condition to be treated
surgically
or by other pathophysiologic processes (mild-moderate condition, well controlled with
medical management; examples include diabetes, stable coronary artery disease, stable
chronic pulmonary disease)
3 Severe, systemic disturbance or disease from whatever cause, even though it may not be
possible to define the degree of disability with finality (disease or illness that severely
limits normal activity and may require hospitalization or nursing home care; examples
include severe stroke, poorly controlled congestive heart failure, or renal failure)
4 Severe systemic disorder that is already life threatening, not always correctable by the
operation (examples include, acute myocardial infarction, respiratory failure requiring
ventilator support, renal failure requiring urgent dialysis, bacterial sepsis with
hemodynamic instability)
5 The moribund patient who has little chance of survival

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Appendix AO: Colonoscopy Procedure

1. Facility specific Policies and Procedures must be in place for the following:
1.1. Colonoscopy decontamination including infection control in accordance
with: http://www.healthdesign.com.au/haad.hfg/Full_Index/haad_b_day_
surgery_procedure_unit.pdf
1.2. Sedation of patient, considering patient status and preferences and record-
ing of all sedation methods and outcomes; consider involving anesthesia
service in patients with significant comorbidities such as patients with ASA
3, 4, and 5 (Appendix AM).
1.3. Patient support and comfort, including positioning during the colonoscopy.
2. To achieve high-quality colonoscopic examination, complete intubation of the
colon and careful inspection of the mucosa during withdrawal are necessary.
2.1. If a complete colonoscopy is not achieved, imaging for documentation of
incomplete intubation may be necessary and reasons must be clearly
documented.
2.2. Auditable photo documentation of colonoscopy completion must be avail-
able; including a panoramic image of the appendiceal orifice, ileo-cecal
valve and cecum, or a video clip with a respective image.
2.3. Documentation of completion of rectal retroflexion (retroflexion of the
endoscope during colonoscopy to increase diagnostic yield) must be
recorded.
2.4. Withdrawal times of the colonoscopy from cecum to anus must be docu-
mented and must be not less than 6 min (when no biopsies or polypecto-
mies are performed). The times to be documented include when:
• Endoscope is inserted into the rectum.
• Withdrawal from cecum was started.
• Endoscope is withdrawn completely.
A record of the actual model and instrument number used must be main-
tained by the unit staff to track procedure volume, problems, and infec-
tion transmission and instrument repairs.

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776 Appendix AO: Colonoscopy Procedure

2.5. Any adverse clinical events (fall in blood pressure, unplanned reversal of
sedation medications, oxygen desaturation, etc.) that occur during colonos-
copy as well all serious events (perforation, bleeding requiring blood trans-
fusion, and/or surgery) must be documented and attached to the colonoscopy
report (Appendix AS) and reported in accordance with DOH Standard for
Adverse Events Management and Reporting.
Appendix AP: Post-colonoscopy Procedures

1. Patients must be contacted 24 h post-procedure or on the next working day to

monitor any complications; this contact must be documented.
2. Patients must receive instructions about management of any potential adverse
events following discharge and must be informed that complications may occur
within 1–4 weeks post procedure.
3. A contact number must be provided to the patient for this purpose and docu-
mented in the patient records.
4. Post-procedure complications must be tracked over a 30-day interval after a
colonoscopy.
5. Discharge instruction form should be-given to patient instructing him to call
endoscopy unit or the gastroenterology physician on call or to come to ER in
case, there is any abdominal pain or any complication or concerns after the pro-
cedure. Patient should sign this form acknowledging that he understood the post
colonoscopy and the pre-discharge instructions.

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 ppendix AQ: Colonoscopy Findings
A
Colonoscopy Findings

1. If use of vague terms to describe polyps in the report should be avoided.

2. An estimation of the size and dimension of all polyps must be documented.
Terms such as “large” or “small” must not be used
3. Tattoos must be placed for all lesions ≥10 mm and those with concerning appear-
ance for cancer to mark the location of colon lesions for repeat colonoscopy or
surgery as per international updated recommendations and best practice.
4. Lesions that are too large to be safely-removed must be biopsied and a tattoo
injection performed in the-vicinity of the lesion and not into the lesion.
5. Specimen identification and labelling must be in accordance with DOH Clinical
Laboratory Standards and industry best practices.
6. Procedures and protocols for adequate specimen collection, handling, labelling,
and reporting must be in accordance with DOH Clinical Laboratory Standard
and must be-communicated to clinical staff and other clients who are involved in
the procedures for processing of colorectal specimens.

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Appendix AR: Colonoscopy Report

1. Each facility must develop a patient colonoscopy report form, retained on the
patient’s medical record and made available to DOH auditors.
2. The report must include at least the following information:
2.1. Patient demographics and history.
2.2. Assessment of patient risk and comorbidity.
2.3. Procedure indications.
2.4. Procedure: technical description.
2.5. Colonoscopy findings.
2.6. Interventions/unplanned events.
2.7. Assessment.
2.8. Follow-up plan.
2.9. Pathology.

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782 Appendix AR: Colonoscopy Report
 ppendix AS: Example of—Techniques
A
for Colonoscopic—Tattooing Protocol

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 ppendix AT: E-Notification Cancer Screening
A
Referral Form

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 ppendix AU: Cancer Screening Data
A
Requirement—Screening Visit Outcome

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788 Appendix AU: Cancer Screening Data Requirement—Screening Visit Outcome
Appendix AU: Cancer Screening Data Requirement—Screening Visit Outcome 789
 ppendix AV: JAWDA KPI Quarterly Guidelines
A
for Hematopoietic Stem Cell Transplant (HSCT)
Service Providers

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792 Appendix AV: JAWDA KPI Quarterly Guidelines for Hematopoietic Stem Cell…

Jawda HSCT Quality Performance Indicators

JAWDA KPI Quarterly

Guidelines for
Haematopoietic Stem Cell
Transplant (HSCT) Service
Providers

January 2020

1
https://www.doh.gov.ae/-/media/Feature/Muashir/Jawda/Jawda-Quarterly-Submission-
Guidelines/HSCT-Jawda-KPI-Guidance--2020.ashx
Appendix AV: JAWDA KPI Quarterly Guidelines for Hematopoietic Stem Cell… 793

Executive Summary

The Department of Health—Abu Dhabi (DOH) is the regulatory body of the health-
care sector in the Emirate of Abu Dhabi and ensures excellence in healthcare for the
community by monitoring the health status of its population.
The Emirate of Abu Dhabi is experiencing a substantial growth in the number of
hospitals, centers, and clinics. This is ranging from school clinics and mobile units
to internationally renowned specialist and tertiary academic centers. Although,
access and quality of care have improved dramatically over the last couple of
decades, mirroring the economic upturn and population boom of Emirate of Abu
Dhabi; however, challenges remain in addressing further improvements.
The main challenges that are presented with increasingly dynamic population
include an aging population with increased expectation for treatment, utilization of
technology and diverse workforce leading to increased complexity of healthcare
provision in Abu Dhabi. All of this results in an increased and inherent risk to qual-
ity and patient safety.
DOH has developed dynamic and comprehensive quality framework in order to
bring about improvements across the health sector. This guidance relates to the
quality indicators that DOH is mandating the quarterly reporting against by the
operating general and specialist hospitals in Abu Dhabi.
The guidance sets out the full definition and method of calculation for patient
safety and clinical effectiveness indicators. For enquiries about this guidance, please
contact jawda@DoH.gov.ae
This document is subject for review and therefore it is advisable to utilize online
versions available on the DOH at all times.
Published: January 2020 Version 1

About This Guidance

The guidance sets out the definitions and reporting frequency of JAWDA hemato-
poietic stem cell transplantation (HSCT) facilities performance indicators. The
Department of Health (DoH), with consultation from local and international exper-
tise of hematopoietic stem cell transplantation (HSCT), has developed hematopoi-
etic stem cell transplantation performance indicators that are aimed for assessing
the degree to which a provider competently and safely delivers the appropriate clini-
cal services to the patient within the optimal period of time.
The JAWDA KPI for hematopoietic stem cell transplantation patients in this
guidance includes measures to monitor morbidity and mortality in patients undergo-
ing hematopoietic stem cell transplantation. Healthcare providers are the most qual-
ified professionals to develop and evaluate quality of care for kidney disease
patients; therefore, it is crucial that clinicians retain a leadership position in defining
performance among hematopoietic stem cell transplantation healthcare providers.
Who is this guidance for?
All DoH licensed healthcare facilities providing hematopoietic stem cell trans-
plantation services in the emirate of Abu Dhabi.
794 Appendix AV: JAWDA KPI Quarterly Guidelines for Hematopoietic Stem Cell…

How do I follow this guidance?

Each provider will nominate one member of staff to coordinate, collect, monitor,
and report hematopoietic stem cell transplantation services quality indicators data
as per communicated dates. The nominated healthcare facility lead must in the first
instance e-mail their contact details (if different from previous submission) to
JAWDA@doh.gov.ae and submit the required quarterly quality performance indica-
tors through JAWDA online portal.
What are the regulation related to this guidance?
• Legislation establishing the health sector.
• As per DoH Policy for Quality and Patient Safety issued January 15, 2017, this
guidance applies to all DoH licensed hospital healthcare facilities in the emirate
of Abu Dhabi in accordance with the requirements set out in this standard.
• DOH standard on stem cell therapies and products and regenerative medicine.

 ematopoietic Stem Cell Transplantation Quality

H
Performance Indicators
Type: Hematopoietic stem cell transplantation         Number: BMT001
KPI description (title) Percentage of patients with successful engraftment
Domain Patient centered
Sub-domain Clinical outcome
Definition Percentage of patients with successful engraftment
Calculation Numerator: Number of patients where engraftment was
successful (successful defined as neutrophil count of (>0.5
× 109 L) for 3 consecutive days by day plus 28)
Denominator: Total number of patients transplanted in
the first 6 months of the previous 7 month reporting
period
Reporting frequency Quarterly
Unit measure Percentage
International comparison if Specialized Services Quality Dashboards—Blood and
available infection metric definitions for 2019/20
Desired direction Higher is better
Data source • Centrally collected claim data (KEH)
• Patient medical record

Type: Hematopoietic stem cell transplantation         Number: BMT002

Percentage of patients dying within 100 days of autologous
KPI description (title) transplant
Domain Patient centered
Sub-domain Clinical outcome
Definition Percentage of patients dying within 100 days of autologous
transplant
Calculation Numerator: Number of patients in denominator who died
within 100 days of autologous transplant
Denominator: Total number of autologous transplants in the
first 365 days of the previous 465-day reporting period
Appendix AV: JAWDA KPI Quarterly Guidelines for Hematopoietic Stem Cell… 795

Percentage of patients dying within 100 days of autologous

KPI description (title) transplant
Reporting frequency Quarterly
Unit measure Percentage of BMT died within 100 days of autologous
transplant
International comparison if Specialized Services Quality Dashboards—Blood and
available infection metric definitions for 2019/20
Desired direction Lower is better

Type: Hematopoietic stem cell transplantation         Number: BMT003

Percentage of patients alive at 1 year post autologous
KPI description (title) transplant
Domain Patient centered
Sub-domain Clinical outcome
Definition Percentage of patients alive at 1 year post autologous
transplant
Calculation Numerator: Number of patients in denominator alive
1 year after autologous transplant
Denominator: Total number of autologous
transplants in the first 12 months of the previous
24-month reporting period
Reporting frequency Annual
Unit measure Percentage of survival at 1 year after autologous
transplant
International comparison if available Specialized Services Quality Dashboards—Blood and
Infection metric definitions for 2019/20
Desired direction Higher is better
Data source • Centrally collected claim data (KEH)
• Patient medical record

Type: Hematopoietic stem cell transplantation         Number: BMT004

Percentage of patients dying within 100 days of
KPI description (title) allogenic transplant
Domain Patient centered
Sub-domain Clinical outcome
Definition Percentage of patients dying within 100 days of
allogenic transplant
Calculation Numerator: Number of patients in denominator who
died within 100 days of allogenic transplant
Denominator: Total number of allogenic transplants
in the first 365 days of the previous 465-day reporting
period
Reporting frequency Quarterly
Unit measure Percentage of BMT died within 100 days of allogenic
transplant
International comparison if available Specialized Services Quality Dashboards—Blood and
infection metric definitions for 2019/20
Desired direction Lower is better
Data source • Centrally collected claim data (KEH)
• Patient medical record
796 Appendix AV: JAWDA KPI Quarterly Guidelines for Hematopoietic Stem Cell…

Percentage of patients dying within 100 days of autologous

KPI description (title) transplant
Data source • Centrally collected claim data (KEH)
• Patient medical record

Type: Hematopoietic stem cell transplantation         Number: BMT005

Percentage of patients alive at 1
KPI description (title) year post allogenic transplant
Domain Patient centered
Sub-domain Clinical outcome
Definition Percentage of patients alive at 1
year post allogenic transplant
Calculation Numerator: Number of patients in
denominator alive 1 year after
allogenic transplant
Denominator: Total number of
allogenic transplants in the first 12
months of the previous 24-month
reporting period
Reporting frequency Annual
Unit measure Overall survival at 1 year
Exclusions Percentage of survival at 1 year
after allogenic transplant
International comparison if available Specialized Services Quality
Dashboards—Blood and infection
metric definitions for 2019/20
Desired direction Higher is better
Data source • Centrally collected claim data
(KEH)
• Patient medical record chart
 ppendix AW: DOH Lung Cancer Screening
A
Service Specifications

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798 Appendix AW: DOH Lung Cancer Screening Service Specifications

DOH LUNG CANCER

SCREENING SERVICE
SPECIFICATIONS

December 2018

https://www.doh.gov.ae/-/media/Feature/Resources/Standards/Lung-Cancer-Screening-Service-
Specifications_Publish.ashx
Appendix AW: DOH Lung Cancer Screening Service Specifications 799

Document Title: DOH Lung Cancer Screening Service Specifications

Document Ref. PH/NCD/LCSC/SR/0.9 Version: 0.9
Number:
Approval Date: 20/12/2018 Effective Date: 20/12/2018
Document Owner: Cancer Prevention and Control Section, NCD, Public Health
Division
Applies to: Licensed Healthcare Providers in the Emirate of Abu Dhabi
participating in the DOH’s Lung Cancer Screening Program
Classification: • Public

1. Purpose

1.1. This document sets the service specifications for DOH’s lung cancer screening
program in the emirate of Abu Dhabi.
1.2. It specifies the minimum service specifications to ensure that high-risk candi-
dates screened for lung cancer receive quality and safe care and timely referral
for diagnosis and/or treatment.

2. Scope

These specifications apply to healthcare providers (facilities, professionals, and

laboratories) licensed by DOH in the emirate of Abu Dhabi who are participating in
DOH’s Lung Cancer Screening Program and specify:
2.1. Terms used in DOH Lung Cancer Screening Program.
2.2. Recommended roles, responsibilities, and services offered by healthcare pro-
viders (facilities and professionals) participating in DOH’s Lung Cancer
Screening Program across the emirate of Abu Dhabi.
2.3. Lung cancer screening case mix.

3. Definitions
Category Definition
3.1 Lung cancer screening The process for the early detection of lung cancer. It
includes recruitment of individuals at a high risk of
developing lung cancer, counseling of these individuals
and low-dose computer topography aided screening by
a multidisciplinary team
800 Appendix AW: DOH Lung Cancer Screening Service Specifications

Category Definition
3.2 LDCT scan A procedure that uses low-dose computer topography
(LDCT) radiation to make a series of very detailed
pictures of areas inside the body in a spiral path. The
procedure is also called a low-dose helical CT scan
3.3 Case mix High-risk candidates for lung cancer, except where
exclusion criteria for LDCT apply
3.4 Lung cancer screening An estimate of the likelihood of developing lung cancer
risk assessment in asymptomatic candidate based on age, total
cumulative exposure to tobacco smoke, years since
quitting tobacco and additional risk factor for lung
cancer other than second-hand smoking
3.5 Additional risk factor Include cancer history, lung disease history as chronic
lung cancer other than obstructive pulmonary disease or pulmonary fibrosis,
second-hand smoking family history of lung cancer, radon exposure and
occupational exposure of silica, cadmium, asbestos,
arsenic, beryllium, chromium, diesel fumes, and nickel
3.6 Pack-year A way to measure the amount a candidate has smoked
over a specific period
3.7 Informed and shared A documented process of mutual decision-making
decision-making involving eligible candidate and lung screening
healthcare provider and before any decision is made to
initiate lung cancer screening including the following
elements:
 • Willingness to undergo follow-up diagnostic
testing and treatment
 • The importance of adherence to lung cancer
screening schedule
 • Lung cancer screening potential benefits (reduce
the risk of dying from lung cancer)
 • Lung cancer screening potential limitations and
harms (false-positive and false-negative results,
over diagnosis, incidental findings, and radiation
exposure)
 • Adherence to tobacco cessation counseling and
treatment
3.8 False-positive result Positive screening with a completed negative work-up
or follow-up of at least 12 months with no diagnosis of
lung cancer
3.9 False-negative result Negative screening associated with diagnosis of lung
cancer within 12 months of baseline examination
3.10 Over diagnosis The detection of indolent lung cancer that would not
have become clinically apparent
3.11 Incidental findings Results that arise outside the original purpose of lung
cancer early detection
3.12 Multi-disciplinary team A team responsible for individualized and evidence-
based management of candidates with positive lung
cancer screening results. It consists of radiologists,
pulmonologists, thoracic surgeons, oncologists,
pathologists, family physicians, and nurses
Appendix AW: DOH Lung Cancer Screening Service Specifications 801

Category Definition
3.13 Tobacco cessation Tobacco cessation counseling and treatment for more
intervention than 10 min at PRIMARY CARE CLINCS visit
including brief advice, set up quitting date, offer
pharmacological agents treatment, offer tobacco
cessation specialist appointment, and enforce
maintaining tobacco abstinence if former tobacco user

4. General Duties of the Health Care Providers

All licensed and eligible healthcare providers participating in DOH’s Lung Cancer
Screening Program must:
4.1. Submit data to DOH via e-claims in accordance with the DOH Reporting of
Health Statistics Policy and as set out in the DOH Data Standards and
Procedures (found online at www.haad.ae/datadictionary).
4.2. Comply with relevant DOH policies and standards.
4.3. Comply with DOH’s requests to inspect and audit records and cooperate with
DOH authorized auditors as required by DOH.
4.4. Comply with requirements for information technology (IT) and data manage-
ment including sharing of screening/diagnosis and where applicable, pathol-
ogy results, electronic patient records, and disease management systems.

5. Lung Cancer Screening Program-Facilities Specifications

In order to be designated as DOH lung cancer screening center, the facility should
obtain DOH approval prior to offering the services by completing the service provi-
sion form (refer to Appendix AZ)
5.1. All DOH licensed healthcare providers (facilities and professionals) engaged
in DOH lung cancer screening program must comply with general regulations
governing health care facilities and specific regulations related to these stan-
dards (refer to Appendices AX and AY).
5.2. DOH designated lung cancer screening center should adhere to DoH lung can-
cer screening program performance indicators (refer to Appendix BA).
5.3. A lung cancer screening center should assign a program coordinator/director
who will be accountable to:
5.3.1. Report screening and screening outcome data to DOH.
5.3.2. Notify screened candidates of their screening results within the expected
timeframe.
5.3.3. Ensure the candidate’s enrollment in tobacco cession program.
5.3.4. Assure clear and communicated process for the management of positive
cases either within the same facility or in another facility approved by
DOH to participate in the Lung Cancer Screening Program.
802 Appendix AW: DOH Lung Cancer Screening Service Specifications

5.3.5. Maintain records for screening tests and outcomes.

5.3.6. Ensure that the candidate is provided with the right information regard-
ing the screening, assessment, follow-up care, and ensure that the can-
didate’ informed consent form is obtained and documented.
5.3.7. Ensure program key performance indicators are met and records are
kept for audits purposes.
5.3.8. Coordinate and organize CME training for the healthcare providers
involved in screening program for quality assurance.

6. Case Mix-Eligibility Criteria and Recruitment

6.1. Inclusion/eligibility criteria:

6.1.1. High-risk candidates of lung cancer aged 55–75 years with:
6.1.1.1. 30 Pack-year history of smoking, and/or tobacco cessation <15
years (refer to Appendix BB for calculation of pack-year
tobacco use).
6.1.1.2. 20 Pack-year history of tobacco use, and/or tobacco cessation
<15 years and one additional risk factor.
6.1.1.3. 20 Year history of water pipe (shisha) and/or dokha, medwakh
and/or all other forms of smoked tobacco use.1
6.2. Recruitment-eligible candidates for lung cancer screening might be recruited
through one of the following:
6.2.1. Opportunistic recruitment.
6.2.2. Online subscription: booking a screening appointment is available at
www.haad.ae/simplycheck.ae.
6.3. Exclusion criteria-potential reasons to exclude eligible candidates from screen-
ing may include the following:
6.3.1. Metallic implants or devices in the chest or back, such as pacemakers or
Harrington fixation rods.
6.3.2. Personal history of lung cancer.
6.3.3. Requirement for home oxygen supplementation.
6.3.4. Unexplained weight loss of more than 7 kilograms in the 12 months
prior to eligibility assessment.
6.3.5. Pneumonia or acute respiratory infection treated with antibiotics in the
last 12 weeks.
6.3.6. Chest CT examination in the 12 months prior to eligibility assessment.
6.3.7. Patient is not a good candidate for surgical treatment.

1
This category was not addressed in the international guidelines; it was added to be assessed in the
pilot phase of the program, due to the popularity of this form of tobacco use among smokers in
emirate of Abu Dhabi.
Appendix AW: DOH Lung Cancer Screening Service Specifications 803

7. DOH Lung Cancer Screening Pathway (Refer to Appendix AY)

Lung cancer screening center should follow the DOH Lung Cancer Screening
Pathway:
7.1. Physician in lung cancer screening facility should obtain and document
informed consent from eligible candidate to participate in lung cancer screen-
ing program.
7.2. All eligible candidates enrolled in a screening program should receive smok-
ing cessation interventions.
7.3. Tobacco cessation program physicians liaising with lung cancer screening cen-
ters should:
7.3.1. Collect data and complete the DOH E-cancer screening form jointly
(refer to Appendix BC).
7.3.2. Ensure the candidate was provided proper education and information
regarding the screening benefits and limitation, assessment, follow-up
care, ensure that candidate’ informed consent is obtained and documented.
7.4. Healthcare providers at the Lung Cancer Screening Center should:
7.4.1. Inform the candidate about the date and method of receiving screening
results.
7.4.2. Report screening outcomes to DOH through the e-notification system.
7.5. In case of negative results, the candidate should:
7.5.1. Have the next lung cancer screening appointment scheduled as per the
screening criteria.
7.5.2. Be encouraged to continue following up with the tobacco cessation
clinic/center.
7.6. In case of positive results:
7.6.1. The screening results should be assessed and discussed by a multi-­
disciplinary team prior to referral of the candidate to a treatment facility
(refer to Appendix BD for the roles and responsibilities of the multidis-
ciplinary team).
7.6.2. The candidate must be referred to a treatment facility.
7.6.3. The program coordinator must report confirmed cancer cases to DOH
using the Cancer Case Notification Form of the Cancer Surveillance
e-notification.

8. DOH Lung Cancer Screening Protocol

8.1. Screening centers should develop a documented protocol used for lung cancer
screening to include image production, image reading, screening frequency,
follow-up of scan results, and management of positive cases and communica-
tion of results.
8.2. The protocols may be reviewed and updated based on evidence-based best
practices recommended by the National Comprehensive Cancer Network
(NCCN), the American College of Radiology (ACR), or equivalent.
804 Appendix AW: DOH Lung Cancer Screening Service Specifications

8.3. Double reading of screening LDCT2 is required:

8.3.1. LDCT should be interpreted by two independent radiologists.
8.3.2. In case of discordant opinions between two radiologists, either consen-
sus or preferably arbitration using a third expert screening radiologist
can be carried out.
8.4. Lung cancer imaging report must be-completed by radiologist, containing at
least the following information:
8.4.1. Interpreting physicians’ names.
8.4.2. Date of examination.
8.4.3. Patient identification.
8.4.4. Description of significant imaging lesions.
8.4.5. Final assessment (Lung RADS).
8.4.6. Recommended next steps.
8.5. Final assessment report should be prepared/completed using Lung-RAD
assessment categories or equivalent (refer to Appendix BE).

9. Screening and Tobacco Cessation

Screening should not be viewed as an alternative to tobacco cessation:

9.1. Candidates currently using tobacco should be informed of their continuing risk
of developing lung cancer.
9.2. Candidates currently using tobacco that are willing to participate in lung can-
cer screening program should receive tobacco cessation intervention parallel to
lung cancer screening.
9.3. Healthcare provides should increase attention to all forms of tobacco use
including shisha, medwakh, and others.
9.4. Healthcare providers are encouraged to use their best clinical judgment in
assessing the risk of lung cancer for shisha and medwakh (refer to Appendix
BB, for pack-years approximation regarding other forms of tobacco use).

10. Cessation of Screening for Lung Cancer

Yearly lung cancer screening should cease when the candidate being screened:
10.1. Turns 76 years old.
10.2. Has not smoked in 15 years.
10.3. Develops a health problem that makes him or her unwilling or unable to have
surgery if lung cancer is found.

2
The only approved and recommended screening tool for lung cancer is low dose computed topog-
raphy CT scan (LDCT).
Appendix AW: DOH Lung Cancer Screening Service Specifications 805

11. Data Collection and Submission

Facilities participating in DOH Lung Cancer Screening Program should sub-

mit to DoH:
11.1. Via e-claims in accordance with the DOH Reporting of Health Statistics
Policy and as set out in the DOH Data Standards and Procedures (www.DOH.
ae/datadictionary).
11.2. Data on screening visits, outcomes within 2 weeks of the screening date,
through the cancer screening form of the cancer surveillance e-notification
system found on the DOH website at: http://www.DOH.ae/DOH/tabid/1084/
Default.aspx.
11.3. Report all screen-detected cancers to DOH, through cancer case notification
form, of the cancer surveillance e-notification, available from: https://bpm-
web.DOH.ae/usermanagement/login.aspx.

12. Payment Mechanism

Eligibility for reimbursement under the health insurance scheme is as follows:

12.1. For Thiqa holders, reimbursement must be consistent with the DOH (previ-
ously HAAD) Standard for Thiqa Preventive List of Interventions available at
www.haad.ae.
12.2. For non-Thiqa holders, payment must be consistent with the individual’s
health insurance product/plan.

13. Enforcement and Sanctions

13.1. Healthcare providers and professionals participating in the DOH’s (previ-

ously HAAD) Cancer Screening Program must comply with the:
13.1.1. Terms and requirements of this standard.
13.1.2. DOH (Previously HAAD) standard provider contract.
13.2. DOH may impose sanctions in relation to any breach of requirements under
this standard in accordance with the [DOH (Previously HAAD) Policy on
Inspections, Complaints, Appeals and Sanctions].
Appendix AX: Related Regulations

Written orders for lung cancer LDCT screenings must be appropriately documented
in the beneficiary’s medical record and must contain the following information:
• Date of birth.
• Actual pack-year smoking history (number).
• Current smoking status, and for former smokers, the number of years since quit-
ting smoking.
• A statement that the beneficiary is asymptomatic (no signs or symptoms of lung
cancer).
• The provider identifier (license number) of the ordering practitioner.

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Appendix AY: Care Pathway

Lung cancer screening care-­pathway

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 ppendix AZ: Lung Cancer Screening Centre
A
Application Form

Facility informations
Name of the facility Address/Street:
City/Town: Pod. Box:
Tick if appropriate
Follow screening protocol according to DOH standards or lung cancer screening
specifications
We will submit e-claims
We will submit data on screening visits and outcomes through cancer e-notification,
found at: http://www.DOH.ae/DOH/tabid/871/Default.aspx
We will comply with DOH standards for Lung Cancer Screening and Diagnosis, found
at http://www.DOH.ae/DOH/tabid/820/Default.aspx
Screening specified Time Days of the week
appointment slots Saturday Sunday Monday Tuesday Wednesday Thursday
Lung cancer screening clinic A.M.
P.M.
LDCT scanning A.M.
P.M.
Name Mobile Office E-mail
landline
Designated program
coordinator
Facility medical director
Facility administrator

Filled in by _____________________   Signature: ___________________

Date: __________________
Please fill in and return to Cancer Prevention and Control Section, Public Health
and Research Division DOH, email: ldeen@doh.gov.ae

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 ppendix BA: Lung Cancer Screening
A
Performance Indicators

Performance Acceptable Desirable

indicators Definition Calculation level level
Participation Percentage of subjects who [Number of screened >10% >12%
rate have a screening LDCT as a subjects/Population at
proportion of the population at risk] × 100
risk
Retention Percentage of LDCT negative [Number of annual >50% >70%
rate screened subjects who follow-up screening
follow-up screening examinations/Baseline
screening
examinations] × 100
Abnormal Proportion of screened subjects [Number of clinical <25% <20%
recall rate recalled for further assessment follow-up screening
(clinical follow-up screening examinations/Baseline
examinations) screening
examinations] × 100
False positive Percentage of positive screening [Number of positive <27% <16%
rate without definitive diagnosis screening without definitive
within 1 year diagnosis within 1 year/True
negative results] × 100
True negative results =
initial negative results + of
positive screening without
definitive diagnosis
Lung cancer Number of detected lung cancer [Number of detected lung 0.5% –1%
detection rate cases per 1000 screening cancer cases (per 1-year
examinations period)/Total number of
screening CT] × 1000
Stage 1 lung Percentage of lung cancer [Number of stage 1 lung >65% >80%
cancer rate patients diagnosed with stage 1 cancer detected/Total
number of lung cancer
detected] ×100
Incidental Percentage of findings requiring [Number of detected >5% >7.5%
findings rate follow-up for diseases other non-lung cancer related
than lung cancer abnormality/Total screened
population] × 100
Tobacco quit Percentage screened persons [Number of tobacco quit >12% >20%
rates among who have quit tobacco after rates among participates/
participates participation in lung cancer Total tobacco users] × 100
in the screening program
program

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 813
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814 Appendix BA: Lung Cancer Screening Performance Indicators

Performance Acceptable Desirable

indicators Definition Calculation level level
Diagnostic Maximum time between LDCT screening and receipt of result ≥90% within 7 working days
interval
 ppendix BB: Calculation of Pack-Year Tobacco
A
Use

It is calculated by multiplying the number of packs of cigarettes smoked per day by

the number of years the person has smoked.
• Number of pack-years = (packs smoked per day) × (years as a smoker) or
• Number of pack-years = (number of cigarettes smoked per day × number of
years smoked)/20

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Appendix BC: DOH E-Cancer Screening Form

For information only, web-based “Cancer Screening Form” must be completed,

available on http://www.haad.ae/DOH/tabid/1084/Default.aspx.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 817
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 ppendix BD: Lung Cancer Screening Multi-­
A
disciplinary Team Composition

Lung cancer screening multi-disciplinary team members and their roles

Radiologists • Have documented training in diagnostic radiology and radiation
safety
• Involvement in the supervision and interpretation of at least 300
chest computed tomography acquisitions in the past 3 years
• Direct supervision LDCT screening process
• Reporting the results of LDCT scans for lung cancer screening
• Take full responsibility for the quality of the LDCT report
• Ensure minimum radiation exposure to screening participants
Oncologists (preferred Participate in developing follow-up and treatment plan
thoracic oncologist)
Thoracic surgeons • Experience in minimally invasive techniques, VATS procedures,
and VATS lobectomy with complete staging through lymph,
adenectomy
• Reporting on surgical outcomes
Pathologists • Expertise in cytopathology and pulmonary pathology to report
increased number of cytologies, biopsies, and other procedures
that result from LDCT screening. Expertise includes lung cancer
biomarker testing performed by immunohistochemistry. Double
reporting of all lung cancer diagnosis
• Use current international standards (Royal College of
Pathologists, UK or College of American Pathologists Cancer
Protocols) for pathology reporting of cytology/small biopsy,
resections, and standardized data collection for future
development of the screening program, tumor registries,
research, audit and clinical trials. http://www.cap.org/
ShowProperty?nodePath=/UCMCon/Contribution%20Folders/
WebContent/pdf/cp-­lung-­17protocol-­4000.pdf)
• Tissue triage, conservation and referral to molecular pathology
for lung cancer predictive biomarker testing or other studies
• Timely communication of results at multidisciplinary meetings,
correlation of radiology and pathology results, determining
appropriate and timely management for patients with lung cancer
• Quality assurance—Participation in proficiency testing of lung
cancer predictive biomarker tests, relevant subspecialty schemes,
and audit of reports

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820 Appendix BD: Lung Cancer Screening Multi-­disciplinary Team Composition

Lung cancer screening multi-disciplinary team members and their roles

Pulmonologist s • Evaluate lung nodules
• Perform non-surgical bronchoscopy, image-guided biopsy,
Endobronchial Ultrasound (EBUS) services
Family physicians • Recruiting for the program
• Explain to participants harms and benefits of lung screening
• Collect data
• Reporting to DOH
Nurses and support staff Assist patients with coordination of their care within the continuum
 ppendix BE: Lung Cancer Screening RAD
A
Reporting Lung-RADS™ Version 1.0
Assessment Categories April 28, 2014

Category
descriptor Category descriptor Primary category Management
Incomplete – 0 Additional lung
cancer screening CT
images and/or
comparison to prior
chest CT
examinations are
needed
Negative No nodules and definitely 1 Continue annual
benign nodules screening with
LDCT in 12 months
Benign Nodules with a very low 2
appearance likelihood of becoming a
or behavior clinically active cancer
due to size or lack of
growth
Probably Probably benign 3 6-month LDCT
benign finding(s)—short-term
follow-up suggested;
includes nodules with a
low likelihood of
becoming a clinically
active cancer
4A 3-month LDCT; PET/CT Findings for which Suspicious
may be used when there is additional diagnostic testing
a ≥8 mm solid component and/or tissue sampling is
recommended
4B Chest CT with or without contrast, PET/CT and/or
tissue sampling depending on the probability of
malignancy and comorbidities. PET/CT may be
used when there is a ≥8 mm solid component
Significant—other S
Prior lung cancer C

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822 Appendix BE: Lung Cancer Screening RAD Reporting Lung-RADS™ Version...

References

1. National Comprehensive Cancer Network. Lung cancer screening guideline,

version 1.2015.
2. American College of Radiology. Lung CT screening reporting and data system,
Lung-RADS™. 2014.
3. U.S. Preventive Services Task Force recommendation statement: screening for
lung cancer, USPSTF. 2013.
4. U.S. Preventive Services Task Force recommendation statement: screening for
lung cancer, USPSTF. 2016.
5. National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al.
Reduced lung-cancer mortality with low dose computed tomographic screening.
N Engl J Med. 2011;365:395–409.
6. The American College of Chest Physicians Lung Cancer Standards. 3rd ed.
7. Medicare coverage for cancer prevention and early detection.
8. Dataset for histopathological reporting of lung cancer. Royal College of
Pathologists UK.
9. Protocol for the examination of specimens from patients with primary non-small
cell carcinoma, small cell carcinoma, or carcinoid tumor of the lung, College of
American Pathologists, Cancer Protocol Templates.
Appendix BF: Standards for Oncology
Services: Version (1)

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 823
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824 Appendix BF: Standards for Oncology Services: Version (1)

All rights © reserved by the Dubai Health Authority @ 2024. The contents of this document shall
not be copied or reproduced in any form without prior written permission from the Authority.
Appendix BF: Standards for Oncology Services: Version (1) 825

Introduction

The Health Regulation Sector (HRS) plays a key role in regulating the health sector.
HRS is mandated by the Dubai Health Authority (DHA) Law No. (6) of the year
2018 with its amendments pertaining to DHA, to undertake several functions includ-
ing but not limited to:
• Developing regulation, policy, standards, guidelines to improve quality and
patient safety and promote the growth and development of the health sector.
• Licensure and inspection of health facilities as well as healthcare professionals
in ensuring compliance to best practice.
• Managing patient complaints and assuring patient and physician rights are upheld.
• Governing the use of narcotics, controlled and semi-controlled medications.
• Strengthening health tourism and assuring ongoing growth.
• Assuring management of health informatics, e-health and promoting innovation.

The Standards for Oncology Services aims to fulfil the following overarching
priorities of Dubai Health Sector Strategy 2026:

• Pioneering human-centered health system to promote trust, safety, quality, and

care for patients and their families.
• Make Dubai a lighthouse for healthcare governance, integration, and regulation.
• Pioneering prevention efforts against non-communicable diseases.
• Foster healthcare education, research, and innovation.

Executive Summary

Dubai Health Authority (DHA) is pleased to present the DHA Standards for
Oncology Services, which aims to improve the quality of oncology services in
healthcare facilities.
This regulation places an emphasis on services’ requirements with a focus on
quality of services and safety of patients and healthcare professionals based on the
international standards of best practices in this domain, while taking into consider-
ation the local and federal laws. Therefore, this document provides a base for the
Health Regulation Sector (HRS) to assess the oncology services provided in the
Emirate of Dubai and to ensure a safe and competent delivery of services.
It will also assist oncology service providers in developing their quality manage-
ment systems and in assessing their own competence to ensure compliance with
DHA regulatory requirements and the United Arab Emirates (UAE) federal laws.

Definitions

Antineoplastic: Meaning anti-cancer therapy and cytotoxic (cell-killing) therapy.

Includes immunotherapy, hormonal therapy, targeted therapy, and chemotherapy.
826 Appendix BF: Standards for Oncology Services: Version (1)

Cancer: Defined as a term for diseases in which abnormal cells divide without
control and can invade nearby tissues.
CT simulation: Shall be defined as a CT procedure in which the specific pathol-
ogy is localized within the patient, who is placed in a precise and reproducible posi-
tion, for use in treatment planning for radiation therapies. CT simulation utilizes a
conventional CT scanner outfitted with specific simulation hardware and software.
External radiation therapy: Shall be defined as the use of high-energy pene-
trating wave or particle beams used to damage or destroy cancerous cells. External
radiation therapy may also be used as a form of treatment for some non-cancerous
diseases and is frequently delivered on a recurring outpatient basis. High-energy
beams do not leave the patient “radioactive,” and there are no concerns about expo-
sure of the patient to other persons post-treatment. See Linear Accelerator.
Healthcare professional: Shall be defined as healthcare personal working in
healthcare facilities and required to be licensed as per the applicable laws in United
Arab Emirates.
Hospice: Shall be defined as a facility or program designed to provide a caring
environment for meeting the physical and emotional needs of the terminally ill.
Intensity modulated radiation therapy (IMRT): Shall be defined as an
advanced external beam radiation therapy, which utilizes computer images to match
radiation to the size and shape of a tumor. Using multiple smaller beams from dif-
ferent angles and of varying intensities, IMRT varies the shape of the radiation
delivered to the treatment area, minimizing damage to surrounding healthy tissue.
See Stereotactic Radiosurgery.
Internal radiation therapy: Shall be defined as the use of low-level radioactive
implants or “seeds” to deliver radiation to local tissue structures. Frequently
implanted in tumors, the radioactive decay damages or destroys the immediately
surrounding tissue. Implants are specifically chosen to match the prescribed radia-
tion dose necessary to damage the tumor while protecting the surrounding healthy
tissues. Radioactive implants are placed surgically. Depending upon the implant’s
intensity, patients may be “radioactive” for a period of time post-implantation and
may need to remain in hospital, segregated from others until the radioactive decay
reduces the strength of the implant.
Licensure: Shall be defined as issuing an official permission to operate a health
facility to an individual, government, corporation, partnership, Limited Liability
Company (LLC), or other form of business operation that is legally responsible for
the facility’s operation.
Linear accelerator (Linac): Shall be defined as a device, which produces and
delivers high-energy beams, which, in the hospital setting, is used to damage or
destroy targeted tissues or structures, frequently cancerous tumors, within the
patient’s body. See Stereotactic Radiosurgery.
Multidisciplinary team: MDT in oncology is defined as the cooperation
between different specialized professionals involved in cancer care with the over-
arching goal of improving treatment efficiency and patient care.
Oncology: Shall be defined as a branch of medicine that specializes in the diag-
nosis and treatment of cancer. It includes medical oncology (the use of
Appendix BF: Standards for Oncology Services: Version (1) 827

chemotherapy, hormone therapy, and other drugs to treat cancer), radiation oncol-
ogy (the use of radiation therapy to treat cancer), and surgical oncology (the use of
surgery and other procedures to treat cancer).
Palliative: Shall mean an approach that improves the quality of life of patients
and their families facing the problem associated with life-threatening illness,
through the prevention and relieving of suffering by means of early identification
and impeccable assessment and treatment of pain and other problems, physical,
psychosocial, and spiritual.
Palliative care: Refers to patient- and family-centered care that optimizes qual-
ity of life by anticipating, preventing, and treating suffering.
Patient: Shall be defined as any individual who receives medical attention, care,
or treatment by any healthcare professional or admitted in a health facility.
Picture archiving and communication system (PACS): Shall be defined as the
digital capture, transfer, and storage of diagnostic images. A PACS system consists
of workstations for interpretation, image/data producing modalities, a web server
for distribution, printers for file records, image servers for information transfer and
holding, and an archive of off-line information. A computer network is needed to
support each of these devices.
Precision oncology: Aims to deliver the right cancer treatment to the right
patient at the right dose and the right time.
Radiation therapy: Shall be defined as use of high-energy radiation to shrink
tumors and kill cancer cells. X-rays, gamma rays, and charged particles are types of
radiation used for cancer treatment. The radiation may be delivered by a machine
outside the body (external beam radiation therapy), or it may come from radioactive
material placed in the body near cancer cells (internal radiation therapy, also called
brachytherapy).
Stereotactic radiosurgery: Shall be defined as the process by which radiation
beams are projected to the tumor or target area from multiple points of origin. This
allows relatively high radiation doses to the target area while exposing the surround-
ing tissues to significantly lower levels of radiation energy. Stereotactic radiosur-
gery equipment is available in both frame-based systems for treatment of head and
neck, and frameless systems, which can treat any anatomic area.
Supervised area: Shall be defined as any area not already designated as a con-
trolled area but where occupational exposure conditions need to be kept under
review even although specific protection measures and safety provisions are not
normally needed.
Surgical oncology: Shall be defined as a specialized area of oncology that
engages surgeons in the cure and management of cancer.
Treatment planning: Shall be defined as following precise identification of the
position, size, and shape of a tumor or target area, typically through MR, PET/CT,
SPECT/CT, or CT based simulation, the optimal means of radiation therapy is
planned in which the precise radiation doses are delivered to target areas while
minimizing the radiation exposure to adjacent and surrounding tissues. This plan is
typically mapped out three dimensionally and computer plotted to guide radiation
therapy/radiosurgery.
828 Appendix BF: Standards for Oncology Services: Version (1)

Abbreviations

ACLS Advanced Cardiac Life Support

BLS Basic Life Support
DHA Dubai Health Authority
DM Dubai Municipality
ECG Electrocardiography
EMT Emergency Medical Technician
FANR Federal Authority Nuclear Regulation
HRS Health Regulation Sector
ICU Intensive Care Unit
IPPV Intermittent positive pressure ventilation
MDT Multidisciplinary Team
PALS Pediatric Advanced Life Support
PPE Personal Protection Equipment
QAP Quality Assurance Program
RN Registered Nurse
UAE United Arab Emirates
UPS Uninterrupted Power Supply

1. Background

1.1. Oncology services provide diagnoses, treatment, and follow-up for cancer in
adults using chemotherapy, hormonal therapy, biological therapy, targeted
therapy, and immunotherapy. Those services include but are not limited to
breast cancer screening, bowel cancer screening, upper or lower GI endoscopy
and bronchoscopy, comprehensive tumor board, genomic testing, surgery,
radiotherapy, and second opinion.

2. Scope

2.1. All DHA licensed facilities that provide oncology services.

3. Purpose

3.1. To assure provision of the highest levels of safety and quality for oncology
services in Dubai Health Authority (DHA) licensed health facilities.
Appendix BF: Standards for Oncology Services: Version (1) 829

4. Applicability

4.1. DHA licensed healthcare professionals and health facilities providing oncol-
ogy services.

5. Standard 1: Registration and Licensure Procedures

5.1. All health facilities providing oncology services shall adhere to the United
Arab Emirates (UAE) Laws and Dubai regulations.
5.2. Health facilities aiming to provide oncology services shall comply with the
DHA licensure and administrative procedures available on the DHA website
https://www.dha.gov.ae.
5.3. Licensed health facilities opting to add oncology services shall inform Health
Regulation Sector (HRS) and submit an application to HRS to obtain permis-
sion to provide the required service.
5.4. Oncology services shall only be provided in one of the following facilities:
5.4.1. Hospital/unit attached to a hospital
5.4.2. Day surgical center
5.4.3. Cancer treatment center
5.4.4. Breast unit
5.4.5. Outpatient clinic

6. Standard 2: Health Facility Requirements

6.1. The health facility should meet the health facility requirement as per the DHA
Health Facility Guidelines (HFG).
6.2. A comprehensive oncology service shall consist of the following:
(Note: If the applicant provides a single oncology service, then only the rele-
vant requirements should be considered).
6.2.1. Reception and waiting areas
6.2.2. Consultation and examination rooms
6.2.3. Diagnostic imaging services
6.2.4. Radiotherapy services
6.2.5. Mould room
6.2.6. Treatment planning room
6.2.7. Chemotherapy services
6.2.8. Surgical care
6.2.9. Intensive Care Unit (ICU)
6.2.10. Palliative care
6.2.11. Acute hematology service
6.2.12. Bone marrow transplant
6.2.13. Pediatric oncology hematology service
6.2.14. Nuclear medicine
830 Appendix BF: Standards for Oncology Services: Version (1)

6.2.15.
Interventional radiology
6.2.16.
Oncology pharmacy with aseptic chemotherapy preparation area
6.2.17.
Histopathology
6.2.18.
Fertility preservation service
6.2.19.
Inpatient rooms
6.2.20.
Outpatient holding area
6.2.21.
Clinical laboratory and blood services
6.2.22.
Support areas for oncology care
6.2.23.
Staff areas including staff station, staff change areas, etc.
6.2.24.
Meeting room where the multidisciplinary team gets together to dis-
cuss cases
6.3. The health facility should install and operate equipment required for provision
of the proposed services in accordance to the manufacturer’s specifications.
6.4. The health facility shall ensure easy access to the health facility and treatment
areas for all patient groups.
6.5. The health facility design shall provide assurance of patients and staff safety.
6.6. The health facility shall have appropriate equipment and trained healthcare
professionals to manage critical and emergency cases.
6.7. The health facility should develop the following policies and procedure, but
not limited to:
6.7.1. Patient acceptance criteria
6.7.2. Patient assessment and admission
6.7.3. Patient education and informed consent
6.7.4. Patient health record
6.7.5. Infection control measures and hazardous waste management
6.7.6. Incident reporting
6.7.7. Patient privacy
6.7.8. Medication management
6.7.9. Emergency action plan
6.7.10. Patient discharge/transfer
6.8. The health facility shall provide documented evidence of the following:
6.8.1. Appropriate storage and preparation of chemotherapy, targeted therapy,
and immunotherapy medicine
6.8.2. Transfer of critical/complicated cases when required
6.8.3. Patient discharge
6.8.4. Clinical laboratory services
6.8.5. Equipment maintenance services
6.8.6. Multidisciplinary decision-making and management of patients
6.8.7. Laundry services
6.8.8. Medical waste management as per Dubai Municipality (DM)
requirements
6.8.9. Housekeeping services
6.9. The health facility shall maintain charter of patients’ rights and responsibilities
posted at the entrance of the premise in two languages (Arabic and English).
Appendix BF: Standards for Oncology Services: Version (1) 831

6.10. The health facility shall have in place a written plan for monitoring equip-
ment for electrical and mechanical safety, with monthly visual inspections for
apparent defects.
6.11. The health facility shall ensure it has in place adequate lighting and utilities,
including temperature controls, water taps, medical gases, sinks and drains,
lighting, electrical outlets, and communications.

7. Standard 3: Healthcare Professionals Requirements

7.1. Medical oncologist

7.1.1. A medical oncologist is a highly trained specialist who is responsible
for the diagnosis and treatment of patients with cancer. They must be
assisted by a competent team to provide effective treatment.
7.2. Radiation oncologist
7.3. Radiation therapist
7.4. Surgical oncologist
7.4.1. Including specialization in colorectal, upper GI, hepatobiliary, breast
oncoplastic, urology, GYN oncology, thoracic surgery, head and neck
surgery, and neurosurgery
7.5. Oncology nurses
7.6. Chemotherapy nurses
7.7. Oncology pharmacist
7.8. Oncology social worker
7.9. Radiation technician
7.10. Radiation physicist
7.11. Pathologist
7.12. Hematologist
7.13. Lab technician
7.14. Nutritionist
7.15. Physical therapist
7.16. Palliative care specialist
7.17. Healthcare professionals with sub-specialty or specialty oncology training
from a DHA approved institution
7.18. Nuclear medicine specialists
7.19. Chemotherapy unit includes (but not limited to):
7.19.1. Internal medicine consultant/specialist present at the facility at
all times
7.19.2. Medical oncologist
7.19.3. Clinical pharmacist
7.19.4. Specialty nurse—oncology
7.19.5. Palliative care physician
7.20. Multidisciplinary team:
7.20.1. All Cancer Care Centers must have a multidisciplinary team with a
minimum membership including diagnostic radiologists, patholo-
832 Appendix BF: Standards for Oncology Services: Version (1)

gists, surgical oncologist, radiation oncologists, and medical oncolo-

gists to achieve high levels of quality care to manage the disease.
7.20.2. The multidisciplinary team may include physicians ranging from pri-
mary care providers to specialists in all oncology disciplines. In addi-
tion, care requires input from many other clinical and allied-health
professionals including nursing, social work, genetics, nutrition,
rehabilitation, and others.
7.20.3. Multidisciplinary team must meet on a regular basis to discuss the
management of patients who are diagnosed with cancer.
7.20.4. The multidisciplinary team is responsible for goal setting, planning,
initiating, implementing, evaluating, and improving all cancer-related
activities in the program.
7.21. Diagnostic imaging unit:
7.21.1. Diagnostic radiologist
7.21.2. Radiologist
7.21.3. Radiographer
7.21.4. Magnetic Resonance Imaging (MRI) technologist
7.21.5. Sonographer
7.21.6. Interventional radiology service
7.22. For radiation therapy unit, the clinical use of ionizing radiation is a complex
process involving highly trained personnel in a variety of interrelated activi-
ties that include:
7.22.1. Radiation oncologist
(a) There should be one (1) radiation oncologist for each 35–45
patients under treatment at the facility.
7.22.2. Physicist:
(a) There should be one physicist present for each center
(b) A therapist with specialized training in dosimetry, a “Dosimetrist,”
may render additional support
7.22.3. Radiotherapy technologist
(a) Two technologists are required for the operation of each treat-
ment machine.
(b) An additional technologist will also be present with special train-
ing in simulation techniques.
7.22.4. Mould room technician
7.22.5. Nuclear medicine technologist
7.22.6. Specialty nurse—Oncology
(a) A nurse with special competence and skills required for the man-
agement of oncology patients.
7.22.7. Support personnel
(a) Personnel will be present to attend to the needs of the patients
and the facility in the general categories of administration, com-
piling of documentation, scheduling, etc.
(b) Additional staff may be required for transcription, mold fabrica-
tion, and other tasks as identified by the facility.
Appendix BF: Standards for Oncology Services: Version (1) 833

7.23. Surgical oncology unit includes (but not limited to):

7.23.1. Anaesthesiologist
7.23.2. Surgical oncologist
7.23.3. Specialty nurse—Oncology
7.23.4. Anesthesia technologist
7.23.5. Anesthesia technician
7.24. Pediatric oncology unit
7.24.1. Pediatric oncologist
7.24.2. Pediatric hematologist
7.24.3. Pediatric surgeon/surgical oncologist (as per 7.20.12)
7.24.4. Pediatric transfusion medicine
7.24.5. Registered nurse
7.24.6. Pediatric nurse
7.24.7. The medical staff at such a facility is composed of a multidisciplinary
team of a primary care pediatrician, pediatric medical subspecialists,
and pediatric surgical specialist like hematologists/oncologists, sur-
geons, urologists, neurologists, neurosurgeons, orthopedic surgeons,
radiation oncologists, pathologists, child life specialists, and diag-
nostic radiologists. These physicians and nurse practitioners, pediat-
ric nurses, social workers, pharmacists, nutritionists, and other
allied-health professionals shall care for the child or adolescent
with cancer.
7.24.8. Pediatric hematologist/oncologist is the coordinator for the diagnosis
and treatment of most children and adolescents with cancer. He/she
must be assisted by a competent team to provide effective treatment
that can comprise of:
(a) Pediatric oncology nurses who are certified in chemotherapy,
knowledgeable about pediatric protocols, and experienced in the
management of complications of therapy.
(b) Rehabilitation pediatric physical and mental rehabilitation ser-
vices including pediatric physiatrists.
(c) Social workers and access to support groups.
(d) Pediatric nutrition expert.
7.24.9. Radiologists with specific expertise in the diagnostic imaging of
infants, children, and adolescents.
7.24.10. Radiation oncologist trained and experienced in the treatment of
infants, children, and adolescents.
7.24.11. Pediatric surgeons/urologist, surgical specialists with pediatric
expertise (i.e., training and certification, if available) in neurosurgery,
orthopedics, ophthalmology, otolaryngology, etc.
7.24.12. Pediatric subspecialists available to participate actively in all areas of
the care of the child with cancer, including anaesthesiology, intensive
care, infectious diseases, cardiology, neurology, endocrinology and
metabolism, genetics, gastroenterology, child and adolescent psy-
chiatry, nephrology, and pulmonology.
834 Appendix BF: Standards for Oncology Services: Version (1)

7.24.13. A pathologist experienced in pediatric oncology is an essential mem-

ber of the multidisciplinary team at the pediatric oncology center.
7.25. Clinical laboratory:
7.25.1. Anatomic and clinical pathologist
7.25.2. Cytopathologist
7.25.3. Hematopathology
7.25.4. Pediatric pathologist
7.26. Support staff that the facility may have are as follows:
7.26.1. Nursing staff
7.26.2. Biomedical engineer
7.26.3. Quality assurance officer
7.26.4. IT support staff
7.26.5. Pharmacist
7.26.6. Therapist (Physiotherapist, Occupational Therapist, Speech
Therapist)
7.26.7. Social workers
7.26.8. Clinical psychologist
7.26.9. Dieticians
7.26.10. Wig fitters
7.26.11. Emergency medical technician advances (paramedic)
7.27. Physicians:
7.27.1. A suitably qualified DHA licensed consultant oncologist/physician
shall be nominated as medical director of the oncology center who
shall be responsible for overall management of the facility.
7.27.2. A DHA licensed consultant pediatric oncologist must be associated
with the facility in case pediatric oncology services are provided
(children from birth to eighteen (18) years of age, this age could be
extended to twenty-one (21) years of age as per the American Cancer
Society).
7.27.3. The paediatric oncologist must be present when pediatric oncology
services are provided.
7.27.4. The oncologist must ensure adequate monitoring of patients during
treatment, and subsequent aftercare.
7.27.5. The oncologist shall be contactable at all times to render emer-
gency care.
7.27.6. In the event that the oncologist on duty is unable to fulfil his/her full
responsibility to the patients of the oncology center, he/she must
arrange for a similarly qualified physician to be responsible for the
total care of the patients in the facility.
7.27.7. The medical director is ultimately responsible in ensuring that the
monitoring and safety devices and resuscitation equipment are in
proper working condition at all times.
7.27.8. The need for treatment and choice of modality shall be based on
MDT recommendation, sound clinical principles, internationally rec-
Appendix BF: Standards for Oncology Services: Version (1) 835

ognized guidelines, and thorough clinical evaluation of medical con-

dition and comorbid by the attending oncologist.
7.27.9. The attending oncologist may recommend to the end stage cancer
patient the modality that is best suited to him/her. This shall be based
on the patient’s, other comorbid conditions, ability to comply with
treatment, available family support, and other social factors.
7.27.10. The patient shall be allowed to make a fully-informed choice of
modality, after receiving adequate counseling from his/her oncolo-
gist on the different modalities available and the modality that is most
appropriate for the patient’s need.
7.27.11. There shall be a documented Quality Assurance Program (QAP) to
ensure quality patient care through objective and systematic monitor-
ing, evaluation, identification of problems and action to improve the
level and appropriateness of care. The QAP shall include:
(a) Documented policies and procedures related to the safety while
conducting all patient care activities.
(b) Documented regular biannual reviews of the policies and
procedures.
(c) Documented reviews of deaths, accidents, complications, and
injuries arising from treatment.
7.28. Nursing staff:
7.28.1. Nurses with specialized knowledge and skills shall provide oncology
nursing care.
7.28.2. The nurse in charge must be a qualified DHA licensed Registered
Nurse (RN), with at least two (2) years of experience in oncology.
7.28.3. The ratio of trained RNs/patients shall be 1:3 at a given time.
7.28.4. All the nurses shall have an Oncology Nursing Society (ONS) certi-
fication and maintain Continuous Professional Development (CPD)
by attending ONS programs.
7.28.5. There shall be at least one (1) nurse with a minimum of six (6) months
of training or experience/training to be physically present at the
oncology center at all times to monitor the patients throughout the
treatment/procedure, to be available to deal with any emergencies
that may arise and to alert the oncologist when necessary.
7.28.6. The attending RN is responsible for the general checkup of the
patient including vital statistics and recording the initial assessment
in the medical records.
7.28.7. All RNs shall hold current BLS and ACLS certifications.
7.29. Biomedical engineer:
7.29.1. Employ a biomedical engineer or have contracts with the manufac-
turers of the equipment for regular monitoring and maintaining
equipment.
7.30. Radiation safety officer:
7.30.1. Uses ionizing radiations for medical use may be required to have a
Radiation Protection Program (RPP).
836 Appendix BF: Standards for Oncology Services: Version (1)

7.31. Quality assurance officer:

7.31.1. The quality assurance officer will monitor the quality improvement
program activity and report the findings to the cancer committee at
least annually and recommend corrective action if activity falls below
the annual goal or requirement.
7.32. Pharmacist
7.32.1. A DHA licensed pharmacist shall be in charge of maintaining the
medicines and solutions that will be administered to patients with a
minimum of one (1) year experience in chemotherapy preparation.
7.33. Therapist (Physiotherapist, Occupational Therapist, Speech Therapist):
7.33.1. DHA licenses healthcare professionals to support the cancer treat-
ment offered at the facility.
7.34. Clinical psychologist:
7.34.1. At least one (1) DHA licensed clinical psychologist to help people
who are having difficulty coping with cancer or cancer treatment.
7.35. Dietician:
7.35.1. At least one (1) dietician shall maintain progress notes of all patients
treated in the facility.
7.36. Medical social worker:
7.36.1. There shall be some medical social workers associated with oncol-
ogy center.
7.36.2. The medical social workers shall be involved in psychosocial evalu-
ation, case work counseling of patients and families, group work,
evaluate and facilitate rehabilitation, team care planning, and col-
laboration, facilitate community agency referral, and improve com-
munication with treating team.
7.36.3. The social workers are required to maintain notes of the patients.
7.37. Infection control nurse:
7.37.1. To perform regular audits, conducts surveillance of cultures and
insures best practice for patient access.

8. Standard 4: Diagnostic Imaging Requirements

8.1. The diagnostic imaging services may include the following:

8.1.1. Conventional radiography (X-ray unit)
8.1.2. Ultrasound
8.1.3. MRI
8.1.4. Digital mammography
8.1.5. Sonography
8.1.6. CT: PET CT imaging and SPECT/CT
8.1.7. For detailed information, please refer to Diagnostic Imaging Services
Regulation on the DHA website www.dha.gov.ae.
8.1.8. Diagnostic imaging services must comply with the FANR laws and
regulations regarding the use of ionizing radiation and radioactive
materials. For further information regarding FANR, law and regula-
tions please visit FANR website www.fanr.gov.ae.
Appendix BF: Standards for Oncology Services: Version (1) 837

9. Standard 5: Radiation Requirements

9.1. The facility layout shall be planned in accordance with the local radiation
safety regulations and internationally accepted radiation safety standards and
in consultation with the radiation oncologist, physicist, and equipment
manufacturer.
9.2. The room design, construction, and shielding shall be as per FANR and the
manufacturers.
9.3. The radiation unit may have an inpatient facility for frail patients, patients
traveling long distances and the occasional patient who has severe reactions
to any of the treatments administered in the facility (a bed for every 10
patients).
9.4. The radiation therapy unit shall:
9.4.1. Be located on the ground floor or lower floors of the oncology center
to accommodate the weight of the equipment and ease of installation
and replacement.
9.4.2. Ensure properly designed rigid support structures located above the
finished ceiling for ceiling mounted equipment.
9.4.3. Provide equipment and infrastructure for treatment of patients using
radioactive rays.
9.5. The radiotherapy unit should include the following functional areas, but not
limited to:
9.5.1. CT simulation room with an adjacent control area and changing room
9.5.2. Treatment planning room for physicist/dosimetrists
9.5.3. Film processing and storage area
9.5.4. Physics laboratory/dosimetry equipment area (if thermoluminescent
dosimetry (TLD) and film dosimetry are available, an area shall be
designed for these activities)
9.5.5. Film processing room, storage areas
9.5.6. Radiotherapy room/bunkers to house the equipment to deliver treat-
ment with an adjacent computer control area and changing rooms
9.5.7. Holding area/recovery area
9.5.8. Hypothermia room
9.5.9. Mould room (optional)
9.5.10. Exam room
9.6. If intra-operative therapy is proposed, the radiation oncology unit shall be
only hospital based and located close to the operating unit or with a direct link.
9.7. Areas requiring specific protection measures (controlled areas) include:
9.7.1. Irradiation rooms for external beam
9.7.2. Therapy and remote afterloading brachytherapy
9.7.3. Brachytherapy rooms
9.7.4. Simulator room
9.7.5. Radioactive source storage and handling areas
838 Appendix BF: Standards for Oncology Services: Version (1)

9.8. These areas shall maintain define controlled areas by physical boundaries
such as walls or other physical barriers marked or identified with “radiation
area” signs.
9.9. The area of the control panel shall be considered as a controlled area, to pre-
vent accidental exposure of patients by restriction of access to non-related
persons, and distraction to the operator of a radiotherapy machine.
9.10. Supervised areas may involve areas surrounding brachytherapy patients’
rooms or around radioactive source storage and handling areas.
9.11. Certain staff members need to be monitored with individual dosimeters.
Individual external doses can be assessed by using individual monitoring
devices such as thermoluminescent dosimeters or film badges, which are usu-
ally worn on the front of the upper torso. These shall include:
9.11.1. Radiation oncologists
9.11.2. Radiotherapy physicists
9.11.3. Radiation protection officer
9.11.4. Radiotherapy technologists
9.11.5. Source handlers
9.11.6. Maintenance staff
9.11.7. Nursing or other staff who must spend time with patients under treat-
ment with brachytherapy
9.12. Indications for radiation must undergo quality control and auditing
9.13. Healthcare professional requirements for a radiation therapy unit shall be
according to the table in Appendix BG.

10. Standard 6: Chemotherapy Requirements

10.1. The chemotherapy unit can be:

10.1.1. A part of a hospital
10.1.2. A satellite unit—on a hospital campus, but not in the hospital.
10.1.3. Integrated cancer care—a part of an oncology center that provides
diagnostic services, radiation therapy, and/or surgical facility.
10.1.4. Freestanding unit—in case a chemotherapy unit is a freestanding
facility it shall:
(a) Maintain a contract with the closest hospital with inpatient ser-
vices to manage emergencies or complications.
(b) Provide an in-house ambulance service.
10.2. The chemotherapy unit shall be designed to provide designated, discreet,
and easy access for patients who may arrive by public transport or vehicles,
with families and children or those who arrive on a wheel chair, ambulance
stretcher, or patient trolley.
10.3. Chemotherapy can be provided in an outpatient service except in the case of
acute leukemia patients where the patients shall be treated in a multispe-
cialty health facility with inpatient, outpatient, and ICU services.
Appendix BF: Standards for Oncology Services: Version (1) 839

10.4. The chemotherapy unit can have inpatient services only with an Internal
Medicine Consultant/Specialist present at the facility at all times and pro-
vide a minimum of 5–6 inpatient beds.
10.5. The chemotherapy unit shall have the following functional areas:
10.5.1. Reception/waiting area
10.5.2. Consultation room
10.5.3. Sterile preparation room/buffer area
10.5.4. Anteroom/pharmacy
10.5.5. Aseptic chemotherapy preparation area
10.5.6. Patient treatment areas/procedure room with treatment chairs or beds
10.5.7. Isolation room(s)
10.5.8. Clean utility/dirty utility
10.5.9. Medication preparation room with a 100% exhaust Class II B2
safety cabinet
10.5.10. Staff areas
10.5.11. Support areas
10.5.12. Storage areas for clinical, non-clinical and bulk items storage, e.g.,
fluids, equipment including infusion/syringe pump storage
10.5.13. Waste disposal room
10.6. Patient treatment areas shall consist of treatment bays to provide chemo-
therapy to patients.
10.7. Patient privacy shall be considered in the design.
10.8. Special consideration given to patients with special needs.
10.9. Nurse call and emergency call facilities shall be provided in all patient areas
(e.g., bed/chair spaces, toilets, etc.) and clinical areas in order for patients
and staff to request for urgent assistance. The alert to staff members shall be
done in a discreet manner.
10.10. Provision of duress alarm system shall be provided for the safety of staff
members who may at times face threats imposed by clients/visitors. Call
buttons shall be placed at all reception/staff station areas and consultation/
treatment areas where a staff may have to spend time with a client in isola-
tion or alone. The combination of fixed and mobile duress units shall be
considered as part of the safety review during planning for the unit.
10.11. Inclusion of medical gases (oxygen and suction) units of one (1) per two (2)
chairs shall be provided.
10.12. Hand washing facilities with liquid soap dispenser, disposable paper towels,
and personal protection equipment (PPE) shall be readily available for staff
within the unit.
10.13. The chemotherapy unit shall maintain an easily accessible chemotherapy
work flowchart for high quality and standardized care.
10.14. The chemotherapy unit shall maintain a crash cart to deal with emergencies.
10.15. Services that support and are linked with chemotherapy may include:
10.15.1. Physiotherapy (lymph oedema management)
10.15.2. Occupational therapy
10.15.3. Dietetic/nutrition services
840 Appendix BF: Standards for Oncology Services: Version (1)

10.15.4. Clinical psychology

10.15.5. Social work services
10.15.6. Community and outreach cancer services
10.15.7. Palliative care and hospice
10.15.8. Complementary therapies (e.g., relaxation, stress management,
and massage)
10.15.9. Wig and prosthesis services
10.16. All cytotoxic drug waste shall be separated from general waste.
10.17. Cytotoxic waste shall be destroyed in an incinerator approved for the
destruction of cytotoxic drugs.
10.18. Breakable contaminated needles, syringes, ampoules, broken glass, vials,
intravenous sets and tubing, intravenous and intravesical catheters, etc. shall
be placed into designated leak-proof; puncture proof sharps containers that
clearly and visibly display the cytotoxic hazard symbol.
10.19. Non-breakable contaminated materials including disposable gowns, gloves,
gauzes, masks, intravenous bags, etc. shall be placed in thick sealed plastic
bags, hard plastic or cytotoxic containers that clearly and visibly display the
cytotoxic hazard symbol. When full, the bags and containers shall be placed
in the oncology waste container.
10.20. Clearly marked chemotherapy waste receptacles shall be kept in all areas
where cytotoxic drugs are prepared or administered.
10.21. If access to an appropriately licensed incinerator is not available, the accept-
able alternative shall be transportation to and burial in a licensed hazardous
waste dump.
10.22. Special written protocol shall be maintained for:
10.22.1. Management of an incident in case a patient/family member is
contaminated with a cytotoxic agent.
10.22.2. Management of cytotoxic spill in or outside the BSC.
10.22.3. Safe transportation of cytotoxic agents.
10.23. All chemotherapy protocols and deliveries must be audited by oncologists
and oncology pharmacists. A flag system should be in place for excessive
use of chemotherapy in the last 2 week before death.

11. Standard 7: Surgical Oncology

11.1. All oncology/suspected cancer surgeries must be approved by MDT except

emergency surgeries and this must be audited regularly.
11.2. Surgical oncology procedures must be done by surgeons with specialized
training in oncology.
11.3. Rectal surgeries must be done by colorectal surgeons.
11.4. Sarcoma surgeries must be done by orthopedic surgeons with special train-
ing in oncology.
Appendix BF: Standards for Oncology Services: Version (1) 841

11.5. For detailed information on operating theater, critical care, airborne infec-
tion isolation, emergency area, and inpatient services refer to the “Hospital
Regulation” on www.dha.gov.ae.

12. Standard 8: Pediatric Oncology

12.1. The pediatric facility shall:

12.1.1. Be a part of a multidisciplinary hospital.
12.1.2. Have accessible and fully staffed, on-site pediatric intensive care
unit (PICU).
12.1.3. Have access to an up-to-date diagnostic imaging facilities to per-
form radiography, computed tomography, magnetic resonance
imaging, ultrasonography, radionuclide imaging, and angiography;
positron-emission tomography (PET CT) scanning and other emerg-
ing technologies are desirable.
12.1.4. Have an up-to-date radiation therapy equipment with facilities for
treating pediatric patients shall be available.
12.1.5. Have an access to hematopathology laboratory capable of perform-
ing cell-phenotype analysis using flow cytometry, immunohisto-
chemistry, molecular diagnosis, and cytogenetic and access to blast
colony assays and polymerase chain reaction-based methodology
shall be available.
12.1.6. Have access to hemodialysis and/or hemofiltration and apheresis for
collection and storage of hematopoietic progenitor cells.
12.1.7. Have a clinical chemistry laboratory with the capability to monitor
antibiotic and antineoplastic drug levels.
12.1.8. Have an access to blood bank capable of providing a full range of
products including irradiated, cytomegalovirus negative, and leuco-
depleted blood components.
12.1.9. The facility shall have a pharmacy capable of accurate, well-moni-
tored preparation and dispensing of antineoplastic agents and inves-
tigational agents.
12.1.10. Have the capability of providing sufficient isolation of patients from
airborne pathogens, which can include high-efficiency particulate
air (HEPA) filtration, or laminar flow and positive/negative pres-
sure rooms.

13. Standard 9: Patient Care

13.1. All clinical trials should have all regulatory approvals and a designated prin-
cipal investigator with experience in conducting clinical oncology trials.
Patients should be fully aware and consented to unlicensed treatments.
842 Appendix BF: Standards for Oncology Services: Version (1)

13.2. Palliative care:

13.2.1. The availability of palliative care services is an essential component
of cancer care, beginning at the time of diagnosis and being “con-
tinuously available” throughout treatment, surveillance, and when
applicable.
13.2.2. Palliative care must be available in all cancer centers.
13.2.3. Palliative care services shall be available to patients either on-site or
by referral.
13.2.4. An interdisciplinary team of medical and mental health profession-
als, social workers, and spiritual counselors shall be available or
accessible to provide palliative care services.
13.2.5. Palliative care services on-site will vary depending on the scope of
the program, staff expertise, and patients treated.
13.2.6. The palliative service team consists of:
(a) Physician: Hospice and palliative medicine physician is
strongly encouraged
(b) Nurse: Trained in hospice and palliative care is strongly
encouraged
(c) Pharmacist
(d) Social worker
(e) Chaplain or spiritual care counselor
(f) Trained volunteer
13.2.7. Palliative care services include, but are not limited to, the following:
(a) Team-based care planning that involves the patient and family
(b) Pain and symptoms management
(c) Communication among patients, families, and healthcare team
(d) Continuity of care across a range of clinical settings and
services
(e) Attention to spiritual comfort
(f) Psychosocial support for patients and families
(g) Bereavement support for families of patients who die and team
members who provided care to the person who died
(h) Hospice care: Hospice care is one aspect of palliative care and
is a service delivery system that provides palliative care for
patients who have a limited life expectancy
(i) Hospice is presented as an option to patients and families when
the prognosis is limited and death will not be surprising
13.3. Psychological support.
13.4. Psychosocial services:
13.4.1. Ensure patient access to psychosocial services either on-site or by
referral.
13.4.2. These services address physical, psychological, social, spiritual,
and financial support needs that result from a cancer diagnosis and
help ensure the best possible outcome.
Appendix BF: Standards for Oncology Services: Version (1) 843

13.4.3. A policy or procedure is in place to ensure patient access to psycho-

social services.
13.5. Rehabilitation services:
13.5.1. Ensures access to rehabilitation services and identifies the rehabili-
tative services that are provided either on-site or by referral.
13.5.2. Rehabilitation services help patients cope with activities of daily
living affected by the cancer experience and enable them to resume
normal activities.
13.5.3. A policy or procedure is followed to access rehabilitation services.
13.6. Nutrition services:
13.6.1. Nutrition services are essential components of comprehensive can-
cer care and patient rehabilitation. These services provide safe and
effective nutrition care across the cancer continuum (prevention,
treatment, and survivorship) and are essential to promote quality
of life.
13.6.2. An adequate spectrum of services shall be available (screening and
referral for nutrition-related problems, comprehensive nutrition
assessment, nutrition counseling, and education) either on-site or by
referral, with a procedure in place to ensure patient awareness of
and access to services.
13.6.3. A policy or procedure in place to access nutrition services.
13.7. Critical care services:
13.7.1. Every freestanding oncology center must have a contract/agreement
with a hospital with an Intensive Care Unit (ICU), which must be
accessible (less than 10 min response time) to receive patients in
case of emergency.
13.7.2. There must be a competent and DHA licensed RN with suitable
training and experience in critical care on duty to provide the criti-
cal care services if required. The evidence of competency and train-
ing shall include, but not limited to the following:
(a) Recognizing arrhythmias
(b) Infection control principles
(c) Training in using defibrillator
(d) Life support
(e) Airway management
13.7.3. Critical care equipment must be immediately available at the oncol-
ogy center for immediate and safe provision of care if required.
13.8. Emergency services:
13.8.1. It is the responsibility of the healthcare facility management in
addition to the oncologist in charge to ensure that there are facilities
for emergency resuscitation, as well as documented protocols/pro-
cedures to deal with cardiopulmonary collapse and urgent medical
treatment as patients may develop hypotension, fits, or collapse dur-
ing treatment.
844 Appendix BF: Standards for Oncology Services: Version (1)

13.8.2. In addition, the healthcare facility management under the supervi-

sion of the oncologist in charge must:
(a) Ensure that there are prior arrangements made for patients
receiving treatment to be admitted in a nearby hospital in case
of a freestanding facility, shall the need arise, within 10 min
driving time.
(b) Ensure oncology group practice by having standing arrange-
ments with other healthcare professionals to provide immediate
medical care in the event that the physician in charge is not
available.
(c) Ensure there is an ambulance available at any given time to
transfer the patient to a hospital in case of any medical
emergency.
(d) Ensure that the ambulance service is accessible and at close
proximity.
(e) In case the oncology center has its own ambulance service, the
ambulance services shall be ready with licensed, trained, and
qualified Emergency Medical Technicians (EMT) for patient
transportation if required, this service can be outsourced with a
written contract with an emergency service provider licensed in
Dubai. Clear patient transport protocol shall be maintained.
13.8.3. The ambulance shall maintain the following, but not limited to:
(a) Sets of instruments, which shall include suturing set, dressing
set, foreign body removal set or minor set and cut down set.
(b) Disposable supplies which shall include suction tubes (all
sizes), tracheostomy tube (all sizes), intravenous cannula (dif-
ferent sizes), IV sets, syringes (different sizes), dressings
(gauze, sofratulle, etc.), crepe bandages (all sizes), and splints
(Thomas splints, cervical collars, finger splints).
(c) Portable vital signs monitor (ECG, pulse oximetry, tempera-
ture, NIBP, and EtCO2).
(d) Portable transport ventilator with different ventilation mode
(IPPV, SIMV, spontaneous, and PS).
(e) Suction apparatus.
13.8.4. Emergency drugs, devices, equipment, and supplies must be avail-
able for immediate use in the emergency area for treating life-
threatening conditions. Minimum emergency medication
requirements shall be available as per the DHA Emergency
Medication Policy, available on this link: https://www.dha.gov.ae/
uploads/112021/3f5565de-9eb7-46c9-9480-17190a531903.pdf.
13.8.5. Storage areas for general medical or surgical emergency supplies,
medication, and equipment shall be under staff control and out of
path of normal traffic.
13.8.6. A record must be kept for each patient receiving emergency ser-
vices and must be integrated into the patient’s health records, the
Appendix BF: Standards for Oncology Services: Version (1) 845

record shall patient name, date, time and method of arrival, physical
findings, care and treatment provided, name of treating doctor, and
discharging/transferring time.
13.9. Transfer planning:
13.9.1. The oncology center shall maintain policies and procedures con-
cerning patient transfer which reflect acceptable standards of prac-
tice and compliance with applicable regulations in Dubai.
13.9.2. If patient is transferred to another health facility and in order to
ensure continuity of patient care, the other facility shall be informed
about the case and approval for transfer shall be documented in the
patient file.
13.9.3. The duty manager present at the oncology center is responsible for
the coordination of the timely transfer of appropriate information
and discharge notice from the oncology center to a hospital or
another health facility.
13.9.4. A transfer sheet shall be prepared for all patients being transferred
requiring further treatment.
13.9.5. A referral letter shall be given to the patient or family/patient repre-
sentative. Patient shall not be sent under any circumstances to
another facility without prior approval.
13.9.6. Mode of transport shall be decided based on the condition of the
patient, the treating physician and the ambulance team shall decide
who shall accompany the patient, e.g., physician present or
trained nurse.
13.10. Patient assessment:
13.10.1. An effective patient assessment process aims to be comprehensive,
includes multidisciplinary teams, and is based on clinical and pri-
ority needs of each individual patient. Such assessment shall result
in identification and decisions regarding the patient’s condition
and continuation of treatment as the need arise. The oncology cen-
ter shall have policies and procedures on patient assessment:
(a) On admission
(b) Following a change of health status
(c) After a fall
(d) When patient is transferred from one level of care to another
13.10.2. The patient assessment shall include, but not limited to, medical
history, physical, social, and psychological assessment and identi-
fication of patients at risk.
13.10.3. Patients conveying personal health information during any assess-
ment shall be accommodated in an area where privacy is assured.
13.10.4. Discharge preparation starts at admission and includes various
persons, information, and resources like:
(a) The pickup person after treatment.
(b) Travel distance to the patient’s house.
(c) Post discharge transport.
846 Appendix BF: Standards for Oncology Services: Version (1)

(d) The carer’s contact details and their awareness of possible

issues and requirements following discharge.
(e) Contact numbers after discharge in case of an emergency.
(f) Discharge arrangements regarding home care where it is
identified.
13.10.5. Healthcare professionals shall use a formal risk assessment pro-
cess to assess skin integrity and risk of falls of patients.
13.10.6. A comfortable care environment shall be provided in the facility
with focus on patient privacy.
13.10.7. The plan of care must be determined and delivered in partnership
with the patient and when relevant, patient’s family/patient repre-
sentative/legal guardian, to achieve the best possible outcomes.
13.10.8. The patient has the right to refuse the plan of care but this has to be
documented and signed by the patient.
13.10.9. Patient’s participation may include:
(a) Procedure date and admission/discharge time
(b) Physician selection
(c) Treatment preparation
13.10.10. Care shall be delivered by DHA licensed and competent healthcare
professionals and competent multidisciplinary teams and based on
the best available evidence.
13.10.11. A comfortable treatment environment is provided in the facility
with focus on patient privacy.

14. Standard 10: Pharmacy and Medication Requirements

14.1. Pharmacy services should ensure adequate stocking, storage, and dispensing
mechanisms for medications in a proper storage unit adhering to local laws,
DHA pharmacy guidelines and DHA emergency medication policy.
14.2. The facility shall have a pharmacy capable of accurate, well-monitored
preparation and dispensing of antineoplastic agents and investiga-
tional agents.
14.3. Pharmacy must have an oncology pharmacist available/a pharmacist with an
oncology background.

15. Standard 11: Pathology Requirements

15.1. Only an accredited oncology designated lab can diagnose cancer. All speci-
mens suspected of malignancy must be examined and reported indepen-
dently by two pathologists.
15.2. The oncology healthcare facility must have a designated pathology labora-
tory for cancer diagnosis.
15.3. Pathology department must be in-house or an accredited outsourced lab.
Appendix BF: Standards for Oncology Services: Version (1) 847

16. Standard 12: Multidisciplinary Team

16.1. A multidisciplinary team (MDT) recommendation is mandatory for man-

agement of all newly diagnosed cancer cases, and prior to initiating
treatment.
16.2. The major challenge is that many cancer cases are being misdiagnosed or
inaccurately treated leading to poor outcome. MDT must be officially recog-
nized by DHA and must consist of consultant (not specialist) medical oncol-
ogist, consultant radiation oncologist, consultant general surgeon, and
consultant pathologist with training in oncology and preferred surgical
oncologist.
16.3. All hospitals that do not have a full oncology service and do not have a DHA
approved MDT must have an agreement with a DHA approved oncology
MDT in order to treat cancer patients.
16.4. It is the responsibility of the Chief Medical Officer of each healthcare facil-
ity to ensure strict adherence to the protocol: No cancer surgery or cases of
suspected cancer shall be scheduled in the operating room without prior
recommendation and approval by the Multidisciplinary Team (MDT). This
rule is mandatory in all health facilities that provide cancer treatment.

Acknowledgment

HRS developed this document in collaboration with subject matter experts whose
contributions have been invaluable. HRS would like to gratefully acknowledge
these professionals especially mentioning Emirates Oncology Society and thank
them for their dedication toward improving quality and safety of healthcare services
in the Emirate of Dubai.
Health Regulation Sector
Dubai Health Authority

References

1. DHA Regulation for Oncology Services. 2016. Available at: https://www.dha.

gov.ae/uploads/112021/3e270bc1-7e7e-468d-80da-6a5c4bc3ac73.pdf.
Accessed Oct 2023.
2. MOHAP Oncology Center Regulations. 2018. Available at: https://mohap.gov.
ae/assets/download/d1451/Oncology%20Services%20Regulations.pdf.aspx.
Accessed Oct 2023.
3. A guide to chemotherapy day unit, redesign measures for improvement.
Department of Health, State Government Victoria; 2014. p. 1–15. Available at:
https://www.healthfacilityguidelines.com/ViewPDF/ViewIndexPDF/iHFG_
part_b_oncology_medical_chemotherapy. Accessed 10 Oct 2023.
848 Appendix BF: Standards for Oncology Services: Version (1)

4. Abdul Khader MA. Planning a clinical pet centre, vol 11. International Atomic
Energy Agency; 2010. p. 1–146. Available at: https://www-pub.iaea.org/
MTCD/Publications/PDF/Pub1457_web.pdf. Accessed 10 Oct 2023.
5. American Cancer Society. Chemotherapy drugs. Available at: https://www.can-
cer.org/cancer/managing-cancer/treatment-types/chemotherapy/how-chemo-
therapy-drugs-work.html. Accessed 10 Nov 2023.
6. Cancer Center of Excellence. Performance measures, rating system, and rating
standard. Florida Health; 2015. p. 1–20. Available at: https://www.floridahealth.
gov/provider-and-partner-resources/research/_documents/final-cancer-center-
of-excellence-manual.pdf. Accessed Oct 2023.
7. Carey J. Radiation safety officer qualifications for medical facilities. Report of
AAPM Task Group 160; 2010. p. 1–33. Available at: https://www.aapm.org/
pubs/reports/RPT_160.PDF. Accessed Oct 2023.
8. Center for Disease Control and Prevention. Basic infection control and preven-
tion plan for and prevention plan for oncology settings. 2011. Available at:
http://www.cdc.gov/hai/pdfs/guidelines/basic-infection-control-prevention-
plan-2011.pdf. Accessed Oct 2023.
9. Cruz A. Standard treatment guidelines oncology. Ministry of Health & Family
Welfare, Government of India; 2015. p. 1–137. Available at: http://clinical-
establishments.nic.in/WriteReadData/329.pdf. Accessed Oct 2023.
10. Healthcare Quality International LLC. Cancer Diagnosis and Treatment Center.
Sultan Qaboos Cancer Diagnosis and Treatment Center. 2014. Available at:
https://cccrc.gov.om/. Accessed Oct 2023.
11. https://hemonc.medicine.ufl.edu/files/2013/07/ChemoPrinciples.pdf.
12. Multi-Disciplinary Team. https://www.frontiersin.org/journals/oncology/arti-
cles/10.3389/fonc.2020.00085/full.
13. AlShamsi H. The state of cancer care in the United Arab Emirates in 2022.
https://www.mdpi.com/2039-7283/12/6/101.
14. The Comprehensive Cancer Center. 2022. https://link.springer.com/
book/10.1007/978-3-030-82052-7.
15. Interventional radiology and the care of the oncology patient. 2011. https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3196980/.
16. Kash B, Tan D. Physician group practice trends. 2016. https://hospital-medical-
management.imedpub.com/physician-group-practice-trends-a-comprehensive-
review.php?aid=9343.
17. Second opinion in breast pathology: policy, practice and perception. 2014.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521120/.
Appendix BG: Healthcare Professionals
Requirements for Clinical Radiation Therapy

Consultant radiation oncologist-in-chief 1 consultant and 1 specialist as a minimum per

radiation therapy unit
Staff radiation oncologist/physician 1:200/250 patients treated annually
No more than 25–30 patients under treatment by
a single physician at any one time
Radiation physicist 1:400 patients annually
Treatment planning staff: 1:300 patients treated annually
Dosimetrists or physics assistant
RTT (Radio Therapy Technologist) 2:25 patients treated daily
RTT-Simulator 2:500 patients simulated annually
RTT-Brachytherapy As needed
Registered nurses 1:300 patients treated annually
Social worker As needed to provide service
Dietician As needed to provide service
Physiotherapist As needed to provide service
Biomedical engineer If equipment serviced “in-house”
Note: If advanced or special techniques are to be undertaken, staff additional to the above will be
required

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 849
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
Appendix BH: Standards for Autologous
Haematopoietic Stem Cell Transplantation:
Version 1

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 851
Springer Nature Singapore Pte Ltd. 2024
H. O. Al-Shamsi (ed.), Cancer Care in the United Arab Emirates,
https://doi.org/10.1007/978-981-99-6794-0
852 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

Introduction

Health Regulation Sector (HRS) plays an essential role in regulating the health sec-
tor and is mandated by the Dubai Health Authority Law No. (6) of 2018 to under-
take several functions:
• Developing regulation and standards to improve patient safety and quality and
also support the growth and development of the Dubai health sector.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 853

• Licensure and inspection of health facilities and healthcare professionals.

• Managing patient complaints and upholding patient rights.
• Regulating the use of narcotics, controlled and semi-controlled medications.
• Strengthening health tourism and assuring ongoing growth.
• Assuring the management of e-health and innovation.

The Standard for Autologous Haematopoietic Stem Cell Transplantation Stem

Cells aims to fulfil several overarching Strategic Objectives and Programs within
the Dubai Health Strategy (2016–2021):

• Objective 1: Position Dubai as a central medical tourism destination through a

comprehensive, integrated, value-based, and high-quality service delivery system.
• Objective 2: Direct resources to assure a happy, healthy, and safe environment
for Dubai population.
• Objective 4: Foster innovation throughout the continuum of patient care.
• Strategic Program 1: Care model innovation, care model innovation program.
The ambition is to promote innovation and efficiency and ensure residents and
visitors in Dubai to have access to high-quality services.
• Strategic Program 10: Excellence and quality. The ambition is to promote excel-
lence in healthcare service delivery and enhance patient experience and satisfaction.

Acknowledgement

The Health Policy and Standards Department (HPSD) would like to acknowledge
experts in the field for their continued dedication and support to develop the stan-
dard and improve patient safety and quality of care in the Emirate of Dubai.
Health Regulation Sector
Dubai Health Authority

Executive Summary

Haematopoietic Stem Cell Transplant (HSCT) or Bone Marrow Transplant (BMT) is a

life-saving intervention that has been practiced for over five decades and was histori-
cally used to treat bone malignancies. Due to technological advances in medicine,
treatment has become possible across many blood cancers (hematologic malignancies)
and age groups. HSCT has also expanded into the treatment of solid tumour malig-
nancy, hereditary disorders, and immune deficiency syndromes. Future indications for
HSCT therapy include Stroke, CHD, diabetes, neurological and auto-immune diseases.
The purpose of the Standards for Autologous Haematopoietic Stem Cell
Transplantation is to maximise quality and patient safety within DHA licensed health
facilities. The standard is confined to autologous (same person) treatment with pre-
determined inclusion and exclusion criteria. The first part of the standard set out the
health facility and professional requirements to operationalise an effective AHSCT
transplantation unit. The transplant unit shall be led by a Clinical Program Director
who has the necessary experience and competencies to supervise the day-to-day
854 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

operations of the service. The second part of the standard sets out the indications,
requirements for the service, stem cell collection, processing, storage, and transpor-
tation. The final part of the standard provides the service quality and safety require-
ments, and the expectations for stem cell preparation, infusion, and post-follow-up
care and the requirements for documentation to demonstrate improvement.

Definitions

Adverse event: Any unintended or unfavourable symptom or condition that is tem-

porary and associated with an intervention may have a causal relationship with the
intervention, medical treatment, or procedure.
Adverse reaction: An unintended response directly or indirectly caused by the
administration of cellular therapy.
Allogeneic: The biological relationship between genetically distinct individuals
of the same species.
Apheresis: A medical technology in which blood is separated into parts. The required
component is removed, and the remaining components are returned to the donor.
Autologous haematopoietic stem cell transplant: A clinical procedure where
one’s healthy stem cells are collected from mobilised peripheral blood, cord blood,
or bone marrow then processed and stored. The patient then undergoes chemother-
apy and/or radiation followed by infusion of the stem cells to treat an array of blood
cancers or diseases that affect the bone marrow.
Autologous: Derived from an individual and intended for the same individual.
Clinical program: An integrated medical team housed in a defined location. The
program includes a Clinical Program Director who can demonstrate sufficient staff
training, adoption of protocols, written Standard Operating Procedures, implemen-
tation of quality management systems, clinical outcome analysis, and regular inter-
action among clinical sites.
Engraftment: Is the process when the transplanted stem cells begin to grow to
produce new healthy cells (The reconstitution of recipient haematopoiesis with
blood cells and platelets from a donor). It is typical for engraftment to occur between
10 and 15 days, but there are instances where this may take longer. Engraftment is
identified through blood analysis of the white blood cells, neutrophil count, haemo-
globin, and platelets.
Graft versus host disease: The condition occurs when donated bone marrow
stem cells (the graft) identify the host with healthy tissues as alien and leads to an
immune response. Graft versus host disease can also occur after an organ transplant
or within the first few months of a transplant (acute) or, much later (chronic), dam-
aging human tissue and organs. The signs and symptoms may be severe and
life-threatening.
Haematopoietic progenitor cells (HPC): A cellular therapy product that con-
tains self-renewing and/or multipotent stem cells. The cells can mature into haema-
topoietic lineages, lineage-restricted pluripotent progenitor cells, and committed
progenitor cells, regardless of tissue source (bone marrow, umbilical cord blood,
peripheral blood, or another tissue source).
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 855

ISBT 128: A global standard for identifying, labelling, and transferring human
blood, cell, tissue, and organ products.
Peripheral blood stem transplant: Also known as peripheral stem cell support,
in which a procedure is undertaken to replace blood stem cells. Medication is used
to move cells out of the bone marrow, followed by centrifugation and collection of
cells for use or storage. It is the most common of two main types of haematopoietic
stem cell transplantation.
Preparative (conditioning) regimen: A treatment used to prepare a patient for
stem cell transplantation (e.g. chemotherapy, monoclonal antibody therapy, radia-
tion therapy).
Standard operating procedure (SOP): A written document that describes the
process or steps taken to accomplish a specific task.
Stem cell mobilisation: A process whereby certain drugs are used to initiate the
movement of bone marrow stem cells into the blood.
Transplantation: The administration of cells to provide transient or permanent
engraftment in support of therapy of disease.

Abbreviations

AHSCT Autologous haematopoietic stem cell transplant

ASTCT American Society for Transplantation and Cellular Therapy
BMT Bone marrow transplantation
CIBMTR The Center for International Blood and Marrow Transplant
Research
CMV Cytomegalovirus
EBMT European Society for Blood and Marrow Transplantation
FACT-JACIE The Foundation for the Accreditation of Cellular Therapy and the
Joint Accreditation Committee of ISCT-EBMT
GCSF Granulocyte colony stimulating factor
GvHD Graft-versus-host disease
HPC Haematopoietic progenitor cells
HSV-1 or 2 Herpes simplex 1 or 2
ICU Intensive care unit
ISCT International Society for Cellular and Gene Therapy
PBSCT Peripheral blood stem transplant
PCP Pneumocystis carinii pneumonia
PPE Personal protective equipment
PTLD Post-transplant lymphoproliferative disease
QMS Quality management system

Background

Haematopoietic stem cell transplant is a therapeutic intervention used to treat sev-

eral malignant and non-malignant disorders. There are two categories of stem cells,
allogeneic stem cells and autologous stem cells. Allogeneic stem cells involve cells
856 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

from a matching donor, which typically involves a member of the family. Autologous
stem cells are extracted from the individual, purified and then administered back to
the same individual. Autologous stem cell transplantation accounts for the majority
of global stem cell transplantation. Autologous Haematopoietic Stem Cell
Transplantation (AHSCT)/Bone Marrow Transplantation (BMT) offers life-saving
treatment for many haematological malignancies. Haematopoietic stem cells are
capable of destroying tumour cells and forming new cells. Haematopoietic stem cell
extraction is achieved from two sources: the bone marrow to produce functional
cells (after engraftment) to replace diseased cells, or by priming the blood with
granulocyte colony-stimulating factor generate new stem cells known as Peripheral
Blood Stem Transplant (PBSCT). Once priming is completed, the extraction of
stem cells is performed, followed by chemotherapy and/or radiotherapy to destroy
blood-forming cells. New cells are infused back into the body intravenously. There
are several advantages for Peripheral Blood Stem Cell Transplant (PBSCTs), includ-
ing rapid engraftment rate, lower infection rate, and lower haemorrhagic morbidity
and mortality. Due to the possible indications for stem cells, practice is based on the
published case series and clinical consensus.

1. Purpose

1.1. To maximise the quality and patient safety for autologous haematopoietic stem
cell transplantation services in DHA licensed health facilities.

2. Scope

2.1. Autologous Haematopoietic Stem Cell Transplantation (AHSCT) services.

2.2. Autologous Haematopoietic Stem Cell Transplantation (AHSCT) cell banking
facilities.

3. Applicability

3.1. DHA licensed health facilities and professionals providing Autologous

Haematopoietic Stem Cell Transplantation (AHSCT) services.

4. Standard 1: Health Facility Requirements

4.1. All hospitals opting to provide AHSCT services shall apply to the Health
Regulation Sector (HRS) https://www.dha.gov.ae for inspection and licensure.
4.1.1. AHSCT services shall only be performed in a hospital setting that fulfils
the requirements set out in the standard.
(a) Institutions providing AHSCT treatment should be affiliated with a
clinical trial approved by the Dubai Health Authority Ethics
Committee 12–18 months from service commencement.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 857

4.1.2. Comply with DHA facility design and administrative provisions for
inspection and licensure of clinical labs.
(a) Ensure designated inpatient unit with adequate space that mini-
mises airborne microbial contamination (isolated-positive pres-
sure room).
(i) A high-efficiency HEPA filter is required for procedures involv-
ing immune-compromised patients.
(b) There is a written plan for monitoring electrical and mechanical
equipment for safety, with monthly visual inspections for apparent
defects.
(c) The lighting and utilities are adequate, including temperature con-
trols, water taps, medical gases, sinks and drains, lighting, electrical
outlets, and communications.
4.1.3. The unit should only use the equipment required to provide the AHSCT
services following the manufacturer’s specifications.
4.1.4. The health facility should ensure easy access to the health facility and
treatment areas for all patient groups.
4.1.5. The health facility design should provide assurance of patient and staff
health and safety.
4.1.6. The health facility should have the appropriate equipment and trained
healthcare professionals to manage critical and emergency cases.
4.1.7. To establish an autologous stem cell transplant service, the health facil-
ity should have a clear and defined clinical program that includes proto-
cols for stem cell collection, processing, storage, and transportation
before the commencement of AHSCT services.
4.2. Scope of services
4.2.1. Written AHSCT scope of services shall be in place, including but not
limited to:
(a) Donor identification, evaluation, selection, eligibility determina-
tion, and management.
(b) Stem cell collection and apheresis.
(c) Stem cell mobilisation.
(d) Administration of the preparative regimen.
(e) Administration of blood products.
(f) Central venous access insertion and device care.
(g) Administration of HPC as well as other cellular therapy products,
such as products under exceptional release.
(h) Management of cytokine release syndrome and toxicities of the
central nervous system.
(i) Transfusion blood products and monitoring of blood counts.
(j) Infection control and sterilisation for AHSCT.
(k) Communicable disease testing and management.
(l) Monitoring infections and use of antimicrobials.
(m) Disposal of medical and biohazard waste.
(n) Cellular therapy product storage.
858 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

(o) Safe administration of cellular therapy products.

(p) Monitoring organ dysfunction or failure and institution of treatment.
(q) Monitoring graft failure and institution of treatment.
(r) Management of side effects such as vomiting, nausea, pain, and
other discomforts.
(s) Post-transplant clinic follow-ups.
(t) Patient education (pre- and post-op procedure and graft failure).
(u) Medication management.
(v) Clinical laboratory services.
(w) Nutrition management.
(x) Medical equipment management and maintenance.
(y) Patient safety for radiology and chemotherapy.
(z) Long-term follow-up, treatment, and plans of care.
(aa) Palliative care.
(bb) Rehabilitation.
(cc) Patient transportation and emergency management.
(dd) Morbidity and mortality management.
4.3. Laws and regulations
4.3.1. Compliance with laws and regulations including but limited to:
4.3.2. Comply with DHA requirements (Regulations, Policy, Standards and
Guidelines) and Federal Laws:
4.3.3. Federal Law No. (14) of 2014—Concerning the prevention of commu-
nicable diseases.
4.3.4. Federal Decree-Law No. (5) of 2016—On the regulation of human
organs and tissues transplantation.
4.3.5. Cabinet Resolution No. (33) of 2016—The Executive Regulations of
The UAE Federal Law No. 14/2014—On combating communicable
diseases.
4.3.6. Cabinet Resolution No. (67) of 2020—On concerning the implementing
regulation of Federal Law No. (5) of 2019—On the practice of human
medicine profession.
4.3.7. Council of Ministers’ Decision No. (6) of the Year 2020—On the
endorsement of the regulations for cord blood and stem cells storage
centres.
4.3.8. Cabinet Resolution No. (25) 2020—On regulation for human organs
and tissue transplantation.
4.3.9. Cabinet Resolution No. (28) 2020—On the National Cancer Registry.
4.3.10. Data and the register must not be held outside the UAE as per IC Law
No. 2 of 2019, except in cases mentioned in Article no. (2) of the
Ministerial Decision no. (51) of 2021.
4.3.11. Compliance with the Ministry of Health and Prevention for medical
devices, consumables, medication, and medical advertisements.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 859

4.4. Accreditation
4.4.1. The hospital must be accredited as per DHA Policy for Hospital accred-
itation before the commencement of the service.
4.4.2. The hospital lab must be accredited as per DHA Policy for Clinical Lab
before the commencement of service.
4.4.3. The health facility should have a Quality Management System (QMS)
as ‘an organization’s comprehensive quality assessment, assurance,
control, and improvement system’.
(a) An action plan for improvement shall be submitted to DHA for
review before the commencement of service.
4.4.4. The service shall achieve and comply with FACT-JACIE International
Standards for cellular therapy, product collection, processing and
administration, storage and collection accreditation 24 months from
licensure activation.
(a) Center for International Blood and Marrow Transplant Research
(CIBMTR), FACT clinical inspectors should audit the clinical
programs.
(b) Adhere to FACT-JACIE for personnel, quality management, poli-
cies and SoPs, equipment supplier, reagents, coding, and labelling
of cellular therapy, process controls, cellular therapy product stor-
age, transportation, shipping, distribution and recipient, disposal.
4.5. In house lab setup and diagnostics
4.5.1. Equipment and supplies for a stem cell processing lab are set out in
Appendices BI and BJ.
(a) Storage of cells in sealed vials, cryobags, or cryopreserved contain-
ers for haematopoietic progenitor cells shall meet UAE Ministry of
Health and Prevention (MoHaP) requirements.
(b) Backup equipment shall be identified where there is only one device
is in use.
(c) All essential equipment shall be connected with an uninterruptible
emergency power supply.
(d) All product contact reagents should be sterile and infusion-grade,
and disposable.
(e) Reagents should be dispensed into single-use containers before use
to minimise waste.
(f) All reagents and supplies must be inspected, and lot numbers
recorded before use and stored in a controlled environment, sepa-
rate from non-clinical, potentially harmful research reagents.
4.5.2. Tests, diagnostics, and procedures required for AHSCT include but are
not limited to:
(a) Tissues culture.
(b) Immunophenotyping.
(c) Special stains to evaluate iron storage in the marrow for abnormal
erythroid (RBC) precursor with iron particles surrounding the
nucleus, chromosomal analysis, and fluorescence in situ hybridisa-
tion analysis.
860 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

(d) Necessary molecular and cytogenetic tests as per international

guidelines such as T-cell receptor gene rearrangement, B-cell
immunoglobulin gene rearrangement, JAK2 mutation, BCR-ABL,
PML-RARA.
(e) Routine blood tests.
(f) Bone marrow aspirate and biopsy.
(g) Blood transfusion.
(h) Apheresis.
(i) Bronchoscopy.
(j) CT scan, MRI scan, X-ray, and ultrasound.
(k) Electrocardiogram (ECG) and echocardiogram
(l) Endoscopy.
(m) Hickman® Line Insertion.
(n) Liver biopsy.
(o) Lumbar puncture.
(p) Pulmonary function test.
(q) Urine test.
(r) Positron emission tomography scan.
(s) Sperm and ova banking (if not done previously).
4.6. There should be a mechanical freezer capable of storing a liquid nitrogen tank
equipped with an audible alarm.
4.6.1. Self-pressurising dewars should be in place for a regular supply of liq-
uid nitrogen from the main storage tank.
4.6.2. The space containing the liquid nitrogen storage tanks and supply dew-
ars should be separated from the processing laboratory needs.
4.6.3. The tanks should have sufficient air handling capacity to maintain safe
oxygen levels when the liquid nitrogen (N2) tanks are filled.
4.6.4. An oxygen sensor alarm to indicate when oxygen levels are danger-
ously low.
4.6.5. A temperature sensor should be fitted to track and temperature at least
twice a day.
4.6.6. Adequate backup liquid (or vapour) nitrogen storage capacity should be
in place.

5. Standard 2: Healthcare Professional Requirements

5.1. The Privileging Committee and Medical Director of the health facility shall
privilege clinical staff in line with his/her education, experience, training, and
competencies.
5.1.1. The privileges shall be granted or removed as per DHA policy for clini-
cal privileging.
5.2. Only a DHA licensed consultant trained to provide AHSCT shall lead the
AHSCT service as the Clinical Program Director.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 861

5.2.1. The Consultant shall be in trained in haematology, immunology, or

medical oncology with specialty training in Autologous Haematopoietic
Stem Cell Transplant (AHSCT):
(a) The training program should include a minimum of ten (10) suc-
cessfully completed cases during training.
5.2.2. A consultant with specialty training shall have documented evidence
and experience in the field of Haematopoietic Stem Cell Transplantation
(HPC) transplantation for a minimum of (5) years post-training.
(a) The Clinical Program Director must submit evidence of a minimum
of ten (10) successful completed cases per year.
5.2.3. The Clinical Program Director must submit evidence of forty (40) CME
credits for Autologous Haematopoietic Stem Cell Transplant (AHSCT)
per year as per UAE PQR requirements for consultants.
5.3. The Clinical Program Director shall take responsibility for the direct clinical
management of HPC transplant patients in inpatient and outpatient settings.
5.4. The Clinical Program Director shall take responsibility for the design, service,
and elements of the clinical program. This includes quality management, the
selection and care of recipients and donors, and cell collection and processing,
whether internal or contracted services including:
5.4.1. All technical procedures.
5.4.2. Performance of the marrow collection procedure.
5.4.3. Supervision of staff.
5.4.4. Administrative operations.
5.4.5. The medical care of autologous donors undergoing marrow collection.
5.4.6. Pre-collection evaluation of autologous donors at the time of donation.
5.4.7. Care of complications resulting from the collection procedure.
5.4.8. The Quality Management Program, including compliance with federal
and local regulations.
5.4.9. Evaluations of competence shall be performed before the independent
performance of assigned activities and at specified intervals.
5.5. The Clinical Program Director will be responsible for the clinical supervision
of physicians and nursing staff and ensure they have a valid and up-to-date
certification and training to fulfil the service, including the minimum CME
requirements as per UAE prequalification requirement in the past 12 months.
5.6. The Clinical Program Director will ensure all attending physicians:
5.6.1. Have a minimum, 1 year of supervised training. The training shall
include the management of transplant patients in both inpatient and out-
patient settings.
5.6.2. Clinical training and competency should include the management of
autologous transplant recipients.
5.6.3. Evaluations of competence shall be performed for independent perfor-
mance of assigned activities and at specified intervals.
862 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

5.7. The Clinical Program Director shall ensure all AHSCT staff hold written evi-
dence that they have met the service’s expected training and competency
requirements (Appendix BK).
5.8. Nurses shall be trained on:
5.8.1. Haematology/oncology patient care and cellular therapy process.
5.8.2. Administration of preparative regimens.
5.8.3. Administration of growth factors, blood products, cellular therapy
products, and other supportive therapies.
5.8.4. Care interventions to manage cellular therapy complications. This
includes and may not be limited to respiratory distress, cardiac dys-
function, tumour lysis syndrome, cytokine release syndrome, neuro-
logic toxicity, macrophage activation syndrome, hepatic and renal
failure, disseminated intravascular coagulation, anaphylaxis, neutrope-
nic fever, infectious and non-infectious processes, mucositis, pain
management, and nausea and vomiting.
5.8.5. Recognition of emergencies and cellular therapy complications requir-
ing rapid notification of the transplant team.
5.8.6. Palliative and end of life care.
5.9. There shall be written standard operating nursing procedure, including but
not limited to:
5.9.1. Care of immunocompromised recipients.
5.9.2. Age-specific considerations.
5.9.3. Administration of preparative regimens.
5.9.4. Administration of cellular therapy products.
5.9.5. Administration of blood products.
5.9.6. Central venous access device care.
5.9.7. Detection and management of immune effect or cellular therapy
complications.
5.9.8. Trained to operate the apheresis machine and collection of stem cells
and storage.
5.10. Pharmacists shall be trained on:
5.10.1. Haematology and oncology patient care, including the process of cel-
lular therapy.
5.10.2. Adverse events including neurological toxicities and cytokine release
syndrome.
5.10.3. Therapeutic drug monitoring shall include but not be limited to anti-
infective agents, immunosuppressive agents, anti-seizure medica-
tions, and anticoagulants.
5.10.4. Monitoring and recognition of drug/drug and drug and food interac-
tions and necessary dose modifications.
5.10.5. Recognition of medications that require amendment for organ
dysfunction.
5.10.6. Conditioning regimens (chemotherapy, monoclonal antibody ther-
apy, and radiation to the entire body.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 863

5.11. AHSCT services shall have the minimum number of healthcare professionals
for set up of the service detailed below:
5.11.1. A Clinical Program Director.
5.11.2. Facility Medical Director.
5.11.3. Attending physician (Consultant and specialists in haematology,
immunology, oncology, or genetics).
5.11.4. Multidisciplinary support team.
5.11.5. A case manager.
5.11.6. An administrator.
5.11.7. Two registered nurses.
5.11.8. Two lab technicians/technologists.
5.11.9. A clinical pharmacist.
5.11.10. A ward manager.
5.11.11. Nurse patient care coordinator.
5.11.12. Health educator.
5.11.13. A quality assurance manager.
5.11.14. Infection control lead.
5.12. Other medical consultants and specialists for a multidisciplinary team shall
be available as per patient need: Critical Care, Surgery, Haematology,
Oncology, Radiology, Gastroenterology and Histopathology, Pathology,
Transfusion Medicine, Dermatology, Dentistry, Internal Medicine,
Endocrinology, Nephrology, Cardiology, Pulmonology, Reproductive
Medicine, Infectious Diseases, Dietetics, Occupational Therapy, Psychology,
Psychiatry and Palliative Care.

6. Standard 3: Permitted Indications for Autologous HSCT

6.1. Inclusions
6.1.1. Autologous transplant patients for indications within the ‘Standard of
Care’ and ‘Clinical Option’ as per established clinical practice such as
American Society for Transplantation and Cellular Therapy (ASTCT)
guidelines on Indications for Haematopoietic Cell Transplantation and
Immune Effector Cell Therapy, The European Group for Blood and
Marrow Transplantation (EBMT), and the British Society of Blood and
Marrow Transplantation (BSBMT).
6.1.2. Patient health status and overall benefit versus harm should be consid-
ered for:
(a) Repeat transplant patients for failure to engraft.
(b) Repeat autologous transplants for relapsed disease.
6.1.3. Non-urgent cases.
6.1.4. Patients aged 18 years or above.
6.1.5. Planned tandem transplants (sequential or double transplant) following
patient risk score assessment, functional status, and prognosis on using
864 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

chemotherapies such as bortezomib, lenalidomide, and thalidomide and

approval by the Clinical Program Director.
6.2. Exclusions
6.2.1. Allogeneic transplants.
6.2.2. Transplants for indications within the category of ‘Developmental’ and
‘Generally Not Recommended’.
6.2.3. Patients under the age of 18 years.
6.2.4. Emergency cases.
6.3. Use of non-Autologous Haematopoietic Stem Cells.
6.4. Use of double or multiple umbilical cord cells that are not from the same
individual.
6.5. Sale, storage, or use of autologous stem cells for any other person(s) who is not
the same patient/individual is not permitted.
6.6. Transfer of autologous haematopoietic stem cell in or out of the health facility
or Dubai is not permitted. Written approval shall be sought by the competent
regulator (DHA or MoHaP).

7. Standard 4: Autologous HSCT Service Requirements

7.1. The service shall adhere to the following:

7.1.1. Written scope of service that is kept up to date.
7.1.2. Documented roles and responsibilities of all staff.
7.1.3. Adherence to ISBT128 standards terminology, identification, coding
and labelling (https://www.iccbba.org/home) or Eurocode.
7.1.4. Ensure there is a register for autologous haematopoietic stem cell trans-
plantation that is maintained.
7.1.5. Commencement of a clinical trial within 12–24 months.
7.1.6. Minimum expected number of procedures per year for the quality and
safety of the AHSCT Clinical Program:
(a) Five (5) procedures in year one (1).
(b) Five (5) procedures in year two (2).
(c) Ten (10) procedures in year three (3) and thereon.
7.2. Data management and record keeping.
7.2.1. There shall be policies and procedures for all critical electronic record
systems to assure the accuracy, integrity, security, and confidentiality of
all records.
7.2.2. The Clinical Program shall collect all the data necessary to complete the
transplant essential data forms as per the standards set by the Center for
International Blood and Marrow Transplant Research (CIBMTR) or the
Minimum Essential Data-A requirements of the European Society for
Blood and Marrow Transplantation (EBMT).
7.2.3. The Clinical Program shall have in place records for facility mainte-
nance, facility management, complaints, or other general facility issues,
quality control, personnel training, and competency.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 865

7.2.4. Patient records, including, but not limited to consent and records of
care, should be maintained confidentially as per UAE Law.
7.3. The service should have policy and procedures supported by documentation
for the following:
7.3.1. Patient acceptance criteria.
7.3.2. Investigational treatment protocols.
7.3.3. Patient assessment and admission.
7.3.4. Pregnancy testing.
7.3.5. Patient education and informed consent (Appendix BL).
7.3.6. Patient health record.
7.3.7. Pre and post collection care.
7.3.8. Cell collection, processing storage, transportation, and banking.
7.3.9. Conditions and duration of cellular therapy product storage as well as
the indications for disposal.
7.3.10. Good tissue manufacturing practice and cell processing.
7.3.11. Use of equipment, supplies and reagents.
7.3.12. Coding, labelling, verification, and tracing of cellular therapy products.
7.3.13. Available therapies and treatment protocols.
7.3.14. Medication management.
7.3.15. Incident reporting.
7.3.16. Patient privacy.
7.3.17. Post-transplant vaccination schedules and indications.
7.3.18. Emergency action plan.
7.3.19. Patient discharge/post-op care/transfer.
7.3.20. Transfer of critical/complicated cases when required.
7.3.21. Quality improvement and control (including outcome at 100 days, 1
year and 5 years).
7.3.22. Cellular therapy emergency and disaster plan, and the clinical program
response.
7.3.23. Patient complaint management.
7.3.24. Sentinel, adverse events, and adverse reaction reporting.
7.3.25. Disposal of biological and medical waste as per Dubai Municipality
(DM) requirements.
7.4. Infection control program for monitoring and managing infectious processes,
including immune-deficiencies and opportunistic infections, central venous
catheter infection, and potential patient infections. The program shall assure:
7.4.1. Monitoring of infections and use of antimicrobials.
7.4.2. Blood samples for testing for evidence of clinically relevant infection
shall be drawn, tested and reported within timeframes required by local
and federal regulations.
7.4.3. Implement post-procedure infection control measures.
7.4.4. Document infection control measures and hazardous waste management.
7.4.5. Compliance with hygiene and use of attire for personal protective
equipment.
866 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

7.5. The service should maintain the Charter of Patient Rights and Responsibilities
at the facility entrances in two languages (Arabic and English).
7.5.1. Patients have the right to know the percentage of viable cells in the col-
lected samples and estimated success rate over the short- and long-
term basis.

8. Standard 5: Stem Cell Collection, Processing, Storage,

Transportation, and Banking

8.1. Stem cells shall be collected in a sterile environment.

8.1.1. Infection control measures should include but not be limited to:
(a) Processing in clean areas and thorough microbiologic monitoring
of all stages of the stem cell preservation procedure as per best
practice.
(b) Screening for microbiologic contamination before cell collection
and infusion.
(c) There should be separate or protected cellular storage to avoid
cross-contamination where an infectious graft has been detected.
8.2. Processing of cells should be undertaken within 48 h at a controlled tempera-
ture as per the latest evidence-based practice.
8.2.1. Centrifugation shall be used to achieve the minimum number of cells
required for the patient.
8.2.2. Cells shall be counted (CD34+ cell count), assessed for viability and
sterility, and preliminary stored continuously in the recommended con-
trolled temperature (initially −4 °C).
8.3. The sample can be frozen in a controlled manner down to the target tempera-
ture of −156 °C (vapour phase) to −196 °C (liquid phase) for longer term
storage.
8.3.1. Cells should be cryopreserved by methods and reagents detailed in
FACT-JACIE International using reagents approved for human use in
the UAE.
8.3.2. Assessment of the frozen cells should be performed after 72 h.
8.3.3. The sample can be thawed in a 37 °C water bath.
8.3.4. After thawing, cryopreservatives should be washed using a two-step
approach through centrifugation to reduce the toxicity of reagents.
8.3.5. Reassessment of cell viability should be performed to ensure its integ-
rity before stem cell infusion.
8.4. Cell collection, processing, and administration should fulfil the FACT-JACIE
International Standards for haematopoietic cellular therapy product collection,
processing, and administration requirements.
8.5. Cells that require transportation shall:
8.5.1. Have an agreement and clear process between the sender and receiver.
(a) A person (courier) shall be available to accompany the stem cells
between the sender and receiver.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 867

(b) The courier shall be trained for stem cells transportation and veri-
fied by the sender or receiver.
(i) The cell must not be placed in cargo for transportation and
should be transported as hand luggage.
(c) Stem cells must not be exposed to X-ray machines or metal
detectors.
(d) Cells must be placed in the best practice optimal medium to main-
tain cell viability and ensure cell characteristics are not altered.
8.5.2. Have in place a courier tracking mechanism to determine the status of
the cells being transported.
8.5.3. Ensure cells are placed in a credo box that is prepared to 4 °C.
(a) The credo box should be checked prior for integrity to maintain a
controlled temperature of 2–8 °C for 100 h.
(b) There should be two temperature loggers, and temperature readings
should be taken every 15 min.
(c) The credo box shall be sealed to prevent tampering during
transportation.
(d) Have in place a tracking mechanism to determine the status and
position of the cells being transported.
(e) The credo box shall include labels identifying the product being
transported.
8.5.4. Cell transportation should not exceed 72-h to prevent an adverse event.
8.5.5. Transported cells must be documented and coded at both the sending
and receiving sites and confirmed by both sites before infusion.
8.6. For stem cell banking, the health facility shall adhere to best practices such as
the FACT-JACIE international standards for haematopoietic cellular therapy
product collection, processing and administration, and NetCord-FACT
International Standards for Cord Blood Collection, Banking, and Release for
Administration.
8.6.1. The cell banking system should have written documentation for:
(a) Cell banking procedures to include reagents, temperature controls,
and maintenance of medical equipment and devices.
(b) Cell types and sizes are being managed.
(c) Containers, vessels, and closure system used.
(d) Methods of cell preparation, cryopreservation technique.
(e) Safe use of reagents and protectants.
(f) Cell storage and thawing technique.
(g) Transportation and disposal of medical waste.
(h) Procedures used to prevent microbiological contamination and
cross-contamination and tracing.
(i) Documentation and labelling procedures.
(j) Back up and business continuity and recovery from cata-
strophic events.
(k) Cell testing technique.
868 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

(l) Testing for mycoplasma and sterility before the transfer of cells into
the facility.
(i) Bacteriostasis and fungistasis testing should be performed
before sterility testing to assess the sample matrix for inhibition.
(m) Testing program and the schedule should include but not be limited
to testing for:
(i) Species-specific virus (2 weeks).
(ii) Sterility (2.5 weeks).
(iii) Mycoplasma testing (3.5 weeks).
(iv) Retroviruses and animal viruses (5 weeks).
(v) Adventitious virus (6 weeks).
(vi) Antibody production (7 weeks).
8.7. The cell banking facility shall ensure:
8.7.1. Patient consent is obtained, and patients are informed of all costs and
timelines to reaffirm consent.
8.7.2. Patients are informed of the cell quality controls, validation, viability,
sterility, count, and cell typing when cells are needed.
8.7.3. Patients are informed of the site for storing stem cells and any third
party agreements.
8.7.4. Patients are informed of protocols to ensure data confidentiality and
privacy.

9. Standard 6: Safety and Quality Requirements

To assure quality and patient safety, the service shall ensure the following:

9.1. A multidisciplinary team is available to manage the patient needs.

9.2. Patient escort and access to emergency services.
9.3. Supply of immunosuppressants is available for the duration of planned
therapy.
9.4. Intensive Care Unit (ICU) beds and isolation room are available for patients
undergoing AHSCT transplantation.
9.5. Written agreements with suppliers, blood banks, and tertiary hospitals to
ensure patient safety and quality of care are not compromised.
9.5.1. Twenty-four-hour availability of appropriate and irradiated blood
products needed to care for cellular therapy recipients.
9.5.2. Irradiated blood products for patients should be given (if needed) 7
days before transplant and up to 3 months after (unless there are other
reasons to continue).
9.5.3. Patients should be given written information and alert card (if avail-
able), and the Dubai Blood Bank should be informed.
9.6. Chemotherapy and radiation are managed in line with the minimum interna-
tional thresholds to assure reduced-intensity transplantation.
9.7. Infection control measures are robust and monitored regularly.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 869

9.8. Patients and their close family members should take the PCR test 72 h before
admission.
9.9. Patients and their close family members should take the Covid-19 vaccine (or
booster) post auto graft.
9.10. Patients undergoing autologous transplant should be vaccinated but live vac-
cines should not be given. Vaccination schedule (doses and months between
doses) should be followed as per the latest international guidance:
(CDC/WHO):
9.10.1. Influenza A and B inactivated seasonal vaccine.
(a) Recipients aged 65 years and over should receive the adjuvanted
trivalent influenza vaccine (aTIV).
(b) The live-attenuated influenza vaccine (Fluenz Tetra®) must NOT
be given to transplant recipients. Household members should
also receive an inactivated influenza vaccine as there is theoreti-
cal potential for transmission of live-attenuated influenza virus
in Fluenz Tetra® to immunocompromised contacts for 1–2 weeks
following the vaccination 2.
9.10.2. Diphtheria/tetanus/pertussis/inactivated polio/Haemophilus influen-
zae type b/Hepatitis B (DTaP/IPV/Hib/HepB) hexavalent vaccine.
9.10.3. Meningococcal Group B (Men B) multicomponent protein vaccine.
9.10.4. Meningococcal Groups A, C, W & Y (Men ACWY) quadrivalent
conjugate vaccine.
9.10.5. Pneumococcal (Streptococcus pneumoniae) Prevenar 13®, 13 valent
conjugate vaccine (PCV13) and for the subsequent dose Pneumovax
II®, 23-valent, polysaccharide vaccine (PPSV23).
9.10.6. Measles/Mumps/Rubella (MMR) live-attenuated vaccine should not
be given to autologous transplant recipients.
9.11. Appropriate sedation is provided for iliac crest bone marrow harvest and to
manage post-transplant complications.
9.12. Medications to manage symptoms subject to patient profile and risk.
9.13. Growth factors for neutrophils should be used to prevent infection and fungus
during the low count and engraftment phase and early and late
convalescence.
9.14. Adequate anticoagulants should be in place to avoid cell aggregation for stor-
age and transportation for long periods (24–72 h).
9.15. Cellular processing and storage/cryopreservation are controlled in the labora-
tory does not compromise the quality, quantity, and efficacy of AHSCT.
9.15.1. Cryopreservation initial temperature −4 °C.
9.15.2. −156 °C when stored in the vapour phase.
9.15.3. −196 °C when stored in the liquid phase, depending on where the
specimen is stored in the container.
9.16. Cell typing is confirmed before infusion.
9.17. Pre-care, treatment, and aftercare program is comprehensively aligned to best
practice to meet patient needs.
870 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

10. Standard 7: Pre-transplant Period

The pre-transplant period forms an essential part of identifying suitability for

patients to benefit from ASHCT. Pre-transplant workup will include assessing eligi-
bility for transplantation, tissue investigations, and assessing the patient’s fitness
(Appendices BM and BN).

10.1. A detailed medical history of the patient and testing should be taken for all
patients indicated for AHSCT, and the European Medical Blood and Marrow
Transplant (EMBT) scoring system should be adopted to inform clinical
decisions and protocol for treatment. The findings from EBMT should be
discussed with the transplant team and recorded in the patient’s medical file.
10.2. The test should include but not be limited to:
10.2.1. The patient’s age, fitness status, previous and current disease status,
therapies, relapse, drug intake, and prior surgical procedures should
be taken.
10.2.2. Patient profile and suitability for AHSCT should be considered as
per the available evidence base and consensus.
10.2.3. Disease criteria for bone marrow transplant should be met as per
clinical best practice.
(a) Screening for infectious disease shall be undertaken as per the
health facility infectious disease protocols.
10.2.4. The intensity of treatment required and stem cell source.
10.2.5. Contraindication and their absence should be considered.
10.3. The patient should undergo several pre-diagnostic tests before admission,
including but not limited to a dental exam, cardio pulmonary exam, thyroid,
and dietary changes. Computed Tomography (CT) scan and gynaecological
exam should be done where indicated.
10.4. Blood work and urine tests should be performed to assess the blood cells’
status, infectious disease status, and liver and kidney function.
10.5. Referral to reproductive medicine (for storage of ova or sperm) should be
done as chemotherapy and radiation may affect family planning.
10.6. Counselling and psychological services should be offered to the patient to
prepare the patient and manage emotional stress.
10.7. Treatment options and duration should be discussed with the patient (and
next of kin where available), including risks and recorded in the patient’s
medical file.
10.8. Care coordination and the medical care plan should be discussed and agreed
upon with the transplant team and approved by the Clinical Program
Director.
10.9. Preparation for stem cell collection should be undertaken once CD34 levels
have been achieved.
10.10. Use of a central line or Hickman line insertion for peripheral blood stem cell
collection/harvesting should be done before chemotherapy and/or irradiation.
10.10.1. Patients should be managed for toxicities, symptoms, and side
effects.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 871

10.11. The conditioning regimen should be done for 4 days with Grannis Colony
Stimulating Factor (GICSF).
10.11.1. Apheresis machine should be utilised for stem cell collection only,
and the volume should align with the patients’ weight calculation
(750–1000 mL). The buffy coat with white cells (haematopoietic
stem cells) should be separated and placed into a collection bag.
(a) The plasma and red blood cells should be counted (CD34+ cell
count) for a viable transplant and returned to the patient to
minimise blood loss.
10.12. Peripheral blood stem cells in the collection bag shall be labelled, processed
(typing, nucleic sub count, culture), weighed, processed, and cryopreserved.
10.13. If bone marrow harvest is pursued, it should be prepared and conditioned for
transplantation as per best practice protocols (immunosuppression, growth
factors, and myeloablation).
10.13.1. Sedation and aseptic techniques must be met for bone marrow
harvest.
10.13.2. Use of anticoagulation should be administered to prevent clotting.
10.13.3. Bone marrow harvest (iliac crest aspiration) should align to weight
calculations and required stem cell volume (10–20 mL/kg).
10.13.4. Disposable needles should be used for the punch biopsy.
10.13.5. Imaging should be used to guide the biopsy needle.
10.14. All bone marrow stem cells that are collected from the patient shall be main-
tained in a collection bag, labelled, weighed, processed (typing, nucleic sub
count, culture), and labelled in a laboratory according to clinical need within
five (5) to ten (10) day turnaround for all patients.
10.15. Media such as Normasal-R (electrolytes and glucose) should be used to
maintain cell metabolism.

11. Standard 8: Transplant Period (Infusion)

11.1. Stem cells should be thawed at the bedside in a water bath and intravenously
infused to transplant and engraft the stem cells.
11.1.1. Stem cell infusion should be done slowly to minimise reactions.
(a) Side effects such as vomiting, abdominal cramp, nausea, chills,
chest pain, and passing red urine should be managed and
documented.
11.1.2. Patients should be monitored during the recovery period to ensure
sufficient neutrophils are in place to minimise the risk of infection.
11.1.3. An aftercare program should be developed with the patient and their
primary care practitioner should be updated on the treatment and
aftercare plan.
11.1.4. Patients and/or next of kin should be updated regularly and provided
with the required aftercare information.
872 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

12. Standard 9: Post-transplant Period

Engraftment is expected 10–15 days post-transplant and may vary according to the
transplant, patient, complications, and late effects. The transplant team should ensure:

12.1. The timeframes for anticipated engraftment and follow-up are documented.
12.2. There is a dedicated registered nurse in the transplant inpatient and outpatient
areas trained (knowledgeable and skilled) to monitor vital signs, fluid, and
electrolyte balance and implement the treating physicians’ instructions to
manage potential complications. Moreover, side effects related to infection,
drugs, or stem cell transplantation.
12.2.1. The nurse should monitor the patients’ health status and follow emer-
gency procedures issued by the treating physician.
12.3. Blood tests are undertaken to verify engraftment and graft-versus-host dis-
ease status.
12.4. Patient discharge is done once written approval is issued by the treating phy-
sician and clinical director.
12.4.1. Patients who have been approved for discharge should be issued with
a discharge plan in a non-technical manner, supported by verbal
explanation to assist the patient and their nominated caregiver in
understanding the care plan, and the availability of outpatient ser-
vices to meet the patients’ needs.
12.4.2. The discharge plan should include:
(a) Drug management to manage potential complications.
(b) Key contact numbers to seek advice on symptoms or side effects.
(c) Precautionary measures and advice to prevent community infec-
tions should be issued by the treating physician and infection
control lead for common infections:
(i) Month 1—Herpes Simplex (HSV1/2), bacterial and fungal
infections.
(ii) Months 2–3—Cytomegalovirus (CMV), fungal infection,
pneumocystis and carinii pneumonia (PCP).
(iii) Months 0–12—Varicella-Zoster Virus (VZV) infection.
(iv) Months 3–6—Home infection control measures, e.g. replac-
ing air condition filters, removing plants, hand hygiene,
dental hygiene, healthy lifestyles, Personal Protective
Equipment (PPE), and avoidance of public places.
(d) Advice on vaccines and use of over the counter medications.
(e) Follow-up appointments at regular intervals to assess:
(i) The efficacy of the treatment and relapse.
(ii) Potential second malignancies such as organ dysfunction or
myelodysplastic syndrome.
(iii) Post-AHSCT vaccination protocol (including close family
vaccination).
(iv) Long-term post-AHSCT complication follow-up.
Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 873

13. Standard 10: Key Performance Indicators

13.1. The health facility should capture performance measures for each patient and
for the AHSCT program (Tables BH.1, BH.2, and BH.3).
13.2. Performance measures should be readily available upon request
13.2.1. The provider is required to report on any additional performance
requirements or measures issued by DHA.
13.3. Reports should reflect outcomes achieved in the previous quarter.
13.4. The Clinical Director should ensure that all treating physicians maintain an
up-to-date log of treatment and patient outcomes using validated tools.
13.4.1. The service should follow up with patients at frequent intervals to
determine patient outcomes and success rates, and remission status
(1 and 5 years).
13.4.2. Follow up of patient outcomes and reporting should be done as soon
as patient complications have been resolved.
13.4.3. Adverse and sentinel events should be logged and reported to the
Medical Director.

Table BH.1 Baseline assessment

874 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

Table BH.2 Post-intervention assessment

Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation... 875

Table BH.3 Service performance measures for AHSCT program (adopted from Aljurf et al. 2021
and NHS 2017. Specialised services quality dashboards—blood and infection metric definitions
for 2017/18)
• Clinical program:
– Clinical indicator collection indicator processing indicator
– Number of SCT-certified physicians
– Number of SCT-certified nurses
– Number of oncology certified nurses
– Number of publications
– Cancellations
– Incidents reports
– Number of medication errors
– Patient volume
– Bed capacity
– Outpatient clinic capacity
– The average length of hospital stay for inpatient transplants
– Indication of AHSCT
– Overall survival and mortality
   • Survival rate at day 100
   • Survival rate at 1 year
   • Survival rate at 5 years
   • Treatment-related (non-relapse mortality)
– Engraftment outcome
   • Engraftment by type of HCT and source of stem cells, ANC, and platelet count
   • Median time to engraftment
  • Graft failure outcome
– Infections
   • Central venous catheter site infections
   • Percentage of microbial contaminations
– Outcome readmission rate
– Number of HCT patient ED visits
– Staff satisfaction
– Patient satisfaction
• Stem cell collection program
– Number of trained stem cell collection and apheresis staff
– Number of autologous products
– Number of stem cell infusion
– HCT complications during the collection procedure
• Processing laboratory program
– Number of trained cell processing staff
– Quality of collected product (CD34 quantitation)
– SC processing turnaround time
– Number of acceptable HPC viability cells post-cryopreservation
– Number of available SC processing reagents
876 Appendix BH: Standards for Autologous Haematopoietic Stem Cell Transplantation...

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Appendix BI: Equipment Needed to Start a Cell
Processing Lab (Adopted from Leemhuis et al.,
2014. Essential requirements for setting-up a
stem cell processing laboratory. Bone Marrow
Transplant 49, 1098–1105)

Required equipment
Biosafety cabinet (or Refrigerator Balance (scale)
equivalent)
Water bath Centrifuge (with carriers to Freezer (≤−70 °C)
hold 600 mL blood bags)
Plasma extractor Tubing sealer Tubing stripper
Cryo-transporter (−80 °C) or Micropipettes Reference thermometer
liquid nitrogen dry shipper (100 and 1000 μL)
Pipette aid Hemostats
Desired equipment
Sterile connecting device Controlled rate freezer LN2 storage freezer
Label printer CO2 incubator Haemocytometer
Microscope Personal computer
Shared equipment
Flow cytometer Automated instrument for Microbiology lab for bacterial
cell processing and fungal culture
Haematology analyser
Abbreviation: LN2 liquid nitrogen

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Appendix BJ: Essential Requirements for
Setting-Up a Stem Cell Processing Laboratory
(Adopted from Leemhuis et al., 2014. Essential
requirements for setting-up a stem cell
processing laboratory. Bone Marrow
Transplant 49, 1098–1105)

Miscellaneous laboratory supplies

Cryobags (for example: 50; Transfer packs (300; 600 mL) Syringes (1, 3, 10, 30, 60 mL)
250; 500 mL)
Safety needles; couplers Spike to needle, spike to Alcohol swabs, iodine swabs,
spike adapters; stopcocks syringe caps, sterile swabs
Labels, laminating tags; zip 15, 50, 175 mL conical tubes Pipettes (1–50 mL)
ties
Biohazard sample bags Tube racks Pipette tips
Cryovials, microtubes Biohazard bags; sharp Dry ice
containers; garbage bags;
trash can
Sterile overwrap bags
Sample reagent list (will vary depending on products and services offered)
DMSO Plasmalyte (or equivalent) ACD-A
Human serum albumin Hetastarch Heparin
70% IPA; bleach; bactericidal Flow cytometry reagents Trypan blue
and fungicidal detergent
Abbreviations: ACD-A acid citrate dextrose solution A, DMSO dimethyl sulfoxide, IPA isopro-
pyl alcohol

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Appendix BK: Training for Clinical Program
Directors and Attending Physicians (Adopted
from BSBMT 2012)

Knowledge Skills
Indications for • Understands the use of indication tables (S,
• Autologous transplant CO, D, GNR)
• Allogeneic transplant • Understand the outcome of alternative
treatment strategies
Patient selection and pre-transplant • Understands how to assess co-morbidities
assessment and how they affect TRM and overall
• Co-morbidity outcome
• Choice of conditioning regimens • Understands the factors implicated in
deciding between FI/RIC
• Knowledge of organ assessment methods
and interpretation of results
Conditioning regimens • Understands the side effects of specific
• Full intensity chemo/radiotherapy
• Reduced-intensity • Understands the long-term effects of
specific chemo/radiotherapy
• Competent at prescribing conditioning
chemo/radiotherapy
Administration of high-dose therapy • Knowledgeable about the principles of TBI
• Radiotherapy • Recognises acute toxicities
• Knowledge of long-term toxicities
(screening and treatment)
Administration of high-dose therapy • Understands the mechanism of action of
• Chemotherapy chemotherapy conditioning
• Understands the use of prophylactic agents
(e.g. mesna)

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886 Appendix BK: Training for Clinical Program Directors and Attending...

Knowledge Skills
Stem cell mobilisation (PBSC-autologous) • Understand the indications, benefits and
• Cytokine alone side effects of different harvesting
• Chemo/cytokine regimens
• Target cell doses • Knowledgeable about the principles and
practice of apheresis procedures
• Competent at prescribing GCSF (or
another mobilising agent) and understands
side effects
• Knowledge of cell dose targets and
pre-collection CD34 counts
• Competent at prescribing chemotherapy for
stem cell mobilisation
Stem cell harvest (BM-autologous) • Competent at bone marrow harvesting
Identification and selection of HPC source • Understands selection algorithms and is
•  Sibling knowledgeable of risks and benefits
•  Haploidentical/another relative associated with different sources
•  UD/cord
Identification and selection of UD/cord • Competence in requesting an unrelated
donor/cord blood search, including
understands of donor registries
• Competence in donor selection and
suitability
• Understands the methodology and
implications of HLA typing
Donor issues • Competence in taking informed consent
from donors, including the safety of GCSF
• Understands the implications of different
donation methods (BM/PBSC)
• Knowledgeable about infectious diseases
testing
Stem cell processing/lab Knowledgeable about the principles and
practice of:
• Stem cell processing, including cell
counts and cryopreservation
• Basic knowledge of techniques to
determine CD34+ cell counts
• Positive and negative selection of CD34
positive cells, red cell depletion, and
plasma depletion
Stem cell infusion • Competent at requesting/prescribing cells
(stem cells or DLI) from donor registries
• Competent at prescribing cells (and
pre-medication) for infusion
• Proficient in HPCP infusion (including
cryopreserved products)
Post transfusion, non-haemolytic
complications like TRALI, TACO, GvHD
Use of post-transplant growth factors
Appendix BK: Training for Clinical Program Directors and Attending... 887

Knowledge Skills
Management of early transplant-related Able to recognise and treat:
toxicity •  Neutropenic sepsis
• Nausea and vomiting
• Pain and mucositis
• Veno-occlusive disease (SOS)
• TTP
•  Haemorrhagic cystitis
•  Bleeding
•  Pulmonary toxicity
•  Multi-organ failure
•  Renal impairment
Blood product support • Knowledge on the safe and appropriate use
of blood products, including granulocytes
• Understands the implications of ABO
incompatibility (patient/donor) and group
switching
Graft failure • Understand the risk, cause, and outcome of
graft failure
• Knowledge of strategies to manage graft
failure
• Understands of methods and interpretation
of chimerism analysis
Infections in the transplant setting Competent in:
• Prophylaxis • Diagnosis, prevention, and management
• Treatment of fungal disease
• Diagnosis and management of viral
disease
• Diagnosis and management of viral
reactivations, including CMV and EBV
• Diagnosis and management of PTLD
Graft-versus-host disease (GvHD) • Competent in the diagnosis and
• Acute and chronic management of acute and chronic GvHD,
including novel therapies (e.g.
mesenchyma cells, Tregs, ECP)
Disease relapse post-transplant • Understands the risks, management, and
outcomes of relapse post-transplant
• Knowledgeable about the utility of second
transplants of donor leukocyte infusions
• Knowledgeable about methods to monitor
patients at risk of relapse (e.g. MRD
monitoring)
888 Appendix BK: Training for Clinical Program Directors and Attending...

Knowledge Skills
Late effects of transplant • Understands the long-term effects of
chemo/radiotherapy, including screening
for secondary malignancies
• Knowledge of the diagnosis and
management of post-transplant immuno-
deficiencies and organ toxicity
• Knowledge about the long-term anti-
infective prophylaxis and vaccination
• Recognises the need for a multidisciplinary
approach, especially in patients with
chronic GvHD
Psychological issues • Competence in breaking bad news
• Understands the management of terminal
care patients and referral to palliative care
professionals
Ethical issues • Understands the importance of ethics in all
aspects of patient care, including
• Donor rights and care
• Cord blood donation and banking
• Advanced directives
• Research
• Minority group issues
Quality/governance • Knowledge of the regulatory bodies
pertinent to transplantation and legal
requirements
• Knowledge of the national and
international societies and their roles
• Understands the importance of a quality
management plan
• Understands the function and importance
of the MDT
Funding/commissioning • Understands the funding streams within the
NHS, including tariffs
Data collection • Knowledgeable about data submission (e.g.
Med-A and Med-B)
• Understands the principles and use of the
promise database
• Knowledgeable about data protection
Research • Understands the importance of research in
the transplant environment
• Understands GCP
• Understands documentation and reporting
for patients on investigational protocols
Appendix BL: Minimum Requirements for
Consent

Patient Declaration: The approval of the treatment does not mean it has been eval-
uated by DHA. I voluntarily request (insert physician names) as my physician(s),
and such associated deemed necessary, to diagnose and treat my condition, which
has been explained to my satisfaction in a non-technical language. I (insert patient
name) know the potential benefits and risks of this (insert procedure name) and
have talked to my treating physician(s) before participating. I understand clearly
that the evidence for Autologous Haematopoietic Stem Cell Transplant (AHSCT) is
limited. There is no guarantee that the procedure will be successful. I understand
that a positive infectious disease status may render the possibility for AHSCT trans-
plantation. I have also consented to the appropriate treatment to be administered to
carry out the procedure. The specific risks for this (insert procedure name) treat-
ment have been explained to me and include (list all risks):
Patient Name and Signature:         Date:    Time:
The legal guardian of the patient
If unable of consent (name and signature):    Date:     Time:
Treating Physician(s) Declaration: I (insert names) have explained the diag-
nosis, prognosis, alternative options, and the stem cell procedure (insert name of
procedure and site) to be performed and the pertinent contents to the patient. I have
answered all the questions from the patient to the best of my knowledge, and the
patient has been adequately informed of the potential benefits and risks, complica-
tions, and the patient has consented to the (insert name of procedure and site). I
have explained to the patient that the success of the treatment can vary from case to
case. I have explained how anaesthesia/sedation will be administered and the asso-
ciated risks. I will adhere to best practices and have ensured compliance with the
health facilities written protocols for this treatment and agree to assess the treat-
ment’s progress and advise the patient accordingly.
Physician(s) name (s) and Signature:    Date:   Time:
Witness Name and Signature:      Date:   Time:
Relationship and/or Designation:

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Appendix BM: Patient Pathway for
Haematopoietic Stem Cell Transplantation
(Adopted from Welsh Health Specialised
Services Committee 2019)

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Appendix BN: Steps for Haematopoietic Stem
Cell Transplantation (AHSCT) (Adopted from
Research Australia 2021)

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