Cancer diagnoses in Iraqi refugees

There are few reports on the burden of cancer among the more than 43 million displaced persons worldwide [1], especially in countries of first asylum. Active monitoring of the cancer burden could provide a scientific basis for the rational use of limited humanitarian aid resources and help determine cost-effective measures for prevention and screening for cancer. We have previously reported the methods used to collect health data from the Refugee Assistance Information System (RAIS) by the United Nations High Commissioner for Refugees (UNHCR) in Jordan [2]. All diagnoses for the 7642 Iraqi refugees registered in RAIS in 2010 and funded by UNHCR were searched for the keywords “malignancy,” “tumor,” “cancer,” and “dysplasia” and the disease category “cancer.”

There were 164 refugees with primary cancer diagnoses (95 men, median age 48 years, 1^st quartile 38, 3^rd quartile 61, range 1−82), representing 2.15% (95% CI 1.84−2.50%) of all Iraqi refugees seeking health and humanitarian assistance in Jordan (Table I). The majority of cases were in middle-aged adults (Table II). There were 106 individuals with vulnerability status, including serious medical condition (n = 98), disability (n = 10), woman at risk (n = 10), specific legal and physical protection needs (n = 7), older person at risk (n = 6), history of torture (n = 4), and child at risk (n = 1). Many refugees with cancer (n = 79, 48%) submitted applications for third country resettlement.

Table I. Most frequent locations of malignancy among Iraqi refugees seeking health and humanitarian assistance, by sex.*

Men	No. of cases	Mean age of refugees seeking health assistance (y)	Women	No. of cases	Mean age of refugees seeking health assistance (y)
Polycythemia vera	10	40	Malignant neoplasm of the breast	45	54
Malignant neoplasm of the brain	7	43	Malignant neoplasm of the brain	8	46
Malignant neoplasm of the prostate	6	69	Malignant neoplasm of the articular cartilage	5	38
Leukemia of unspecified cell type	4	47	Malignant neoplasm of the ovary	3	47
Malignant neoplasm of colon	4	53	Multiple myeloma and malignant plasma cell neoplasms	3	60
Malignant neoplasm of bone and articular cartilage	4	43
Malignant neoplasm of the testis	4	38

*Includes only those cancer types in which there are 3 or more cases present.

Table II. Most frequent malignancies among Iraqi refugees seeking humanitarian assistance, by age group.

Age group (y)	No. of individuals	Most common cancer types	No. of cases of cancer type
0–18	12	Malignant neoplasm of the brain	2
		Malignant neoplasm of bone and articular cartilage	2
19–39	33	Malignant neoplasm of the breast	6
		Polycythemia vera	5
		Malignant neoplasm of brain	3
		Neoplasm of uncertain or unknown behaviour of endocrine glands	3
40–59	69	Malignant neoplasm of breast	20
		Malignant neoplasm of brain	7
		Malignant neoplasm of bone and articular cartilage	6
		Polycythaemia vera	5
		Malignant neoplasm of colon	3
		Malignant neoplasm of testis	3
60–79	47	Malignant neoplasm of the breast	17
		Malignant neoplasm of the prostate	5
		Malignant neoplasm of the brain	3
≥ 80	3^†

^†Given the few patients in this age group, specific cancer types are not reported here.

Public health services, drug availability, and access to medical care remain major contributing factors to cancer outcomes in developing countries in times of warfare [3,4]. Reports of cancer among Iraqis in Iraq in recent years are exceptional [3−6]. In spite of an available and effective treatment schedule for some cancers in Iraq, death rates can be high due to infections, metabolic complications, and treatment abandonment [3]. A lack of supportive care and, in some cases, distance of the patient from the hospital during political insecurity and armed conflict contributes to poor outcomes [3]. An absolute shortage of medication for cancer due to embargos may also lead to higher than expected numbers of cancer deaths [4], potentially prompting forced migration, either permanently as refugees or temporarily as so-called “medical tourists.”

Our analysis provides foundational data for the reporting of cancer among refugees. We lack specific information on disease stage, disease duration, and current cancer treatment in this registry. More detailed cancer reporting, surveillance, and awareness of treatment needs are necessary in refugees globally. Cancer registry information can be crucial in minimizing delays in cancer treatment, continuing uninterrupted cancer care, and confirming diagnosis. Where possible, incorporation of cancer screening methods in health centers serving refugees in countries of first asylum should include Papanicolaou smears, mammograms, and risk factor reduction programs such as smoking cessation initiatives. This includes “diagonal” approaches that take advantage of existing programs for maternal/child health and other chronic care in refugees.

Acknowledgements

This work was supported by the 2010 Practice Research Fellowship Grant of the American Academy of Neurology (to FJM). The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.