12.1 Oman Demographics

The Sultanate of Oman is an Arab country, bordering Saudi Arabia, UAE, and Yemen. The total area of Oman is about 309,500 km2. Oman is more densely populated in its cities, where 80% of the population lives. The current population of Oman is 5,462,006 as of December 2020, males 3,222,910 (59%) and females 2,239,097 (41%), and rank 120 in the Global list [1,2,3]. The population density in Oman is 16 per km2. The median age in Oman is 30.6 years (Fig. 12.1). Life Expectancy is 77.4 years, while the Population growth rate is 3.4% annually. The country has a fertility rate of 2.92 births per woman, as one of the fastest-growing populations [1, 2, 4]. Current projections believe that the growth rate will peak in 2020. After 2025 the growth rate will continue to slow, getting down to 0.62% by 2050 [4, 5].

Fig. 12.1
figure 1

Population pyramid Oman 2017 (Used With Permission from MoH Oman) [3]

Oman is an ethnically diverse country. There are 38.7% foreigners, mostly expatriate workers from Bangladesh, India, Pakistan, Philippines, and Egypt. Oman has a mortality rate of 3.3 deaths per 1000 populations. It is a relatively young population with 65% less than 30 years of age (Fig. 12.1). The literacy rate in Oman is 93%. The economy is based on agriculture, fishing, and overseas trading. Petroleum revenues account for 40% of GDP. The per capita income is 41,680 dollars [4, 6, 7].

12.2 Cancer Statistics in Oman

Cancer is the leading cause of death with 6% of disease-related mortality [8]. The age-adjusted annual incidence of cancer ranges from 70 to 110 per 100,000 population, which is lower than other regional countries [9, 10]. The leading male cancers in order of prevalence are prostate, colorectal, liver, hematologic, gastric, and lung (Fig. 12.2). The leading female cancers in order of prevalence are breast, thyroid, colo-rectum, hematologic, and uterine (Table 12.3 and Fig. 12.3) [3, 5, 6, 11]. The already known and established risk factors for any cancer are diet, smoked and charcoal prepared food (Gastric Cancer and Colon Cancer), higher life expectancy, obesity, smoking, and diabetes [12].

Fig. 12.2
figure 2

Cancer trends 1996–2017 (used with permission from MoH Oman) [3]

Fig. 12.3
figure 3

Ten most common cancers in Oman 2017 [6]

An increasing number of patients are diagnosed with cancer every successive year (Fig. 12.2, Tables 12.1 and 12.2) [6]. The number of cancer cases registered in 2017 was 2101. Of these, 1892 (90.05%) were among Omanis (1005 females, 887 males), and 188 (8.95%) were among Non-Omanis (123 females, 65 males). One hundred and twenty-seven cases (6.7%) were reported in people aged below 14 years. The median age at cancer diagnosis was 53 years. The crude incidence rates for cancer in Oman were 70.2 per 100,000 for males and 80.9 per 100,000 for females. The Age Standardized Rate (ASR) was 113.3 per 100,000 for males and 114.2 per 100,000 for females. A total reported 193 males and 173 females died of cancer in 2017 [3]. According to GLOBOCAN, the projected new cancer cases expected in 2030 and 2040 are 5761 and 8549 in Oman [5]. Over time, changing trends of incidence have been observed, as colorectal cancer has surpassed stomach cancer, lung cancer is being diagnosed 2–3 times more frequently, thyroid cancer in females has increased five times [6] (Table 12.3).

Table 12.1 Male cancers Oman 1996–2017 [3, 6]
Table 12.2 Frequency of female cancers 1996–2017 [3, 6]
Table 12.3 Frequency of cancers 2017 [6]

12.3 Healthcare System in Oman

Oman spent around 2.6% of its GDP (11% of the budget) on health care, rising by 12.9% annually. It is not possible to specifically tell about the amount spent in oncology. Firstly, the MoH and Ministry of Education are involved in cancer care services. Secondly, the diagnostic, screening, and treatment facilities are done by different sections of MoH. Oman has 69 hospitals (as in 2016), with a total of over 6400 beds, which are expected to grow at an annual rate of 3.1%. Only two hospitals have a cancer care services unit. The government operates 80% of hospitals [13,14,15,16]. The Omani government is inclined to increase the role of the private health sector, to cope with the increasing demand. New hospitals like Sultan Qaboos Medical City in Muscat, along with International Medical City in Salalah will contribute to meeting the increasing demand. The population growth is putting additional pressure on the health care system. An estimated 95% of the population now live within five miles of a medical center. Cancer care services visited in Oman are high, as the public healthcare system is free. This is saturating the system and increases healthcare costs. Omani nationals have free access to healthcare, though expatriates seek medical care in private hospitals. The insurance-financed healthcare and private hospitals are still far from comprehensive and do not cover all cancer treatment like expensive targeted therapy, and immunotherapy. There are NGOs and private charities which do help a number of patients [17].

In 2014, the government commenced a long-term plan for the healthcare sector entitled Health Vision 2050; including extension of existing cancer care services, establishment of two comprehensive care hospitals, and satellite oncology units [13, 14, 17]. The plan, which according to the World Health Organisation (WHO) serves “as a model for strategic planning in health,” envisions large-scale investment in the healthcare sector to create a well-organized, equitable, efficient, and responsive health system. The Health Vision 2050 has pointed out the need to move part of cancer care out of the hospitals and closer to communities and homes, for better service and reduced burden. Oman requires an additional 7000 doctors by 2050. The country now has an accredited medical university and many Omani doctors have obtained their postgraduate medical training overseas in Australia, Canada, the United Kingdom, and the United States.

12.4 Oncology Care in Oman

12.4.1 Access to Cancer Care services

There is an integrated system of primary, secondary, and tertiary medical facilities with a reasonably well-organized referral system by e-referral portal of MoH. All hospitals are interlinked, and the patient’s electronic medical records can be accessed by the treating team from anywhere. The MoH through treatment abroad committee sends patients abroad or to GCC for a treatment modality if it is not locally available. A small number of patients travel abroad on their own expenses, often treated at more than one center and in more than one country.

12.4.2 Multi-sectoral Efforts to Prevent and Control Cancer

The Ministry of Education, social welfare, environmental health, PDO all support a coordinated effort for prevention and control of cancer. Cancer prevention strategies include health education, vaccinations (HPV, Hepatitis), and regular primary health care follow-ups. There is an integrated referral pathway from primary to tertiary care. The treatment facility including oncology surgery, radiation oncology, stereotactic radiotherapy, systemic therapy, bone marrow transplant, and liver transplant is available. There are specialized sub-specialty hospitals for ENT, neurosurgery, dermatology, and orthopedics. There are oncology outreach clinics in Salalah. The prime pathology is Royal hospital for the main focal and referral point. The patients who are cured of cancer follow in an outpatient clinic as per protocol and long-term survivors are followed in survivorship clinics or shifted to tertiary/primary care. A dedicated palliative care team is there for pain management, palliative symptom care, and end-of-life care once the patient is transited to palliative symptomatic care [18, 19].

12.4.3 National Oncology Center: The Royal Hospital

The National Oncology Center (NOC) is the oldest center established in December 2004 by MoH, as an extension of the Royal Hospital in Muscat. The NOC comprises medical oncology, radiation oncology, hemato-oncology and BMT, pediatric hematology, and oncology. The center treats around 70% of all cancer cases in Oman. There are sub-specialty clinics for breast and gastrointestinal tumors. Combined clinics for breast, ear-nose-and-throat, gynae-oncology, pain clinics, and outreach clinics are routinely held. There is a multidisciplinary tumor board. Psycho-social support is available by social workers, counseling nurses, occupational therapists, speech therapists, and dieticians. The patients are given free accommodation during their treatment. The treatment facility for treatment, which is free of charge, is available to Omani nationals only. The NOC is a designated and approved center for Integrated Palliative care by ESMO (European Society for Medical Oncology) and is an approved center with UICC (Union Internationale Cancer Control).

12.4.4 Other Cancer Centers

As infectious diseases have been effectively abridged, Oman is now contending with the rise in Non-communicable diseases like diabetes, obesity, hypertension, and cancer. The hospitals in Oman provide high-quality healthcare. There are two cancer care hospitals in Muscat, The Royal Hospital, and the Sultan Qaboos University Hospital. The healthcare system is primarily in the public sector; the Ministry of Health (MoH), is the main health care provider especially the oncology services [14, 17, 20]. The MoH provides healthcare in a 3-tiered system: primary health care centers, secondary hospitals, and tertiary referral hospitals. Private hospitals and clinics, licensed by the MoH, are playing an increasingly important role in cancer care like Burjeel hospital, NMC, Al Hayat, and Muscat private hospital [7, 13]. The two cancer centers are supported by ancillary diagnostic facilities like radiology, pathology, gastroenterology, urology, respiratory medicine, genetics center, nuclear and molecular imaging centers [21].

12.4.5 National Cancer Registry

The Oman National Cancer Registry, established in 1985 as a hospital registry, helps guide policymakers in setting priorities for cancer control activities. The registry began functioning as a population-based registry in 1996 and publishes an annual report on cancer incidence. Cancer diagnosis notification was made mandatory in 2001. The registry also collects data from treatment abroad committees and Omani patients diagnosed in Qatar [3, 6]. In 2002 and 2007, the International Agency for Research on Cancer (IARC) published Oman’s data in its publication “Cancer incidence in five continents volume VIII and IX,” Oman being the second Arab nation to contribute. In October 2019, on the 20-year anniversary cancer registry released a comprehensive 20 years compilation of cancer data on the trends of cancers and the lists of the most common cancers, and the regional distribution of cancer cases [3, 6, 10, 16].

12.4.6 Community Obligations

NOC along with Oman Cancer Association (OCA) helps to provide professional guidance by advocating community wellness. NOC liaises between different hospitals, polyclinics, community nursing, and social welfare in the care of oncology patients by providing only logistic and financial support. It works in association with MoH and cancer center for conferences and is not doing any research work. There is a patient awareness group at NOC and is actively involved in community awareness programs for different cancers, through print and electronic media. There is a need to develop patient support groups with the participation of educated and willing patients to help patients in coping with a cancer diagnosis, treatment, and treatment-related side effects. Patients with cancers are liable to develop psychological issues especially depression, with a need to incorporate psychologist’s advice and support in managing cancer patients [19].

12.4.7 The Cancer Care Plan

A cancer care plan is based on need assessment of population for convenient and high-quality care focusing patients. It emphasizes the need for prevention, easy access to services, and a road map for future improvements in services. There is a need to streamline existing cancer care services, focusing on patient needs to ensure a continuum of care. The major focus of efforts should be on providing state-of-the-art services and searching for new partners in the public and private sectors to facilitate prompt diagnosis and treatment. It also aims to increase the public understanding of a healthy lifestyle and risk factors, screening, early diagnosis, and prompt treatment. This should translate into improved survival and outcome, decreasing the burden on the health care system. There is a need to bridge the gap in research and clinical practice. There are many taboos and false beliefs in society due to cultural influences, which need to be addressed. The Individual Cancer Care Plan, made for patients by treating physicians at NOC, should facilitate communication between caregivers and families/patients, at every step of management to enhance confidence in the health system and help them cope with the disease. We monitor it by setting targets of performance indicators every year, with a vision to improve it. Efforts should be directed to facilitate the establishment of hospice and home care services. The patients need to be educated about hospice care, and enrolment in trials [6].

12.5 Cancer Risk Factors

In Oman, chronic Non-Communicable Diseases related to lifestyle like coronary artery diseases, hypertension, diabetes mellitus, and cancer; are now emerging as significant potential health challenges [21]. The aging population along with factors like obesity (53%), lack of physical activity, smoking (15%), Westernized lifestyle, change in diet, and other environmental factors contribute to an increased cancer incidence [6, 11]. The International Agency for Research on Cancer (IARC) predicted the doubling of cancer cases in the period 2008–2020 from 1400 to 2500 [22].

12.6 Cancer Screening Programs

A pre-emptive screening for common cancers is integral to improve diagnosis at an early stage, decrease disease burden, improve outcome, and is cost-effective. The MoH and OCA (Oman Cancer Association) run breast cancer screening by mobile mammography services, and a vast number of female patients benefit from it. An analysis of the impact of screening on early-stage detection was submitted for publication, which showed that T1 increased from 28.70% to 71.30%, while T4 decreased from 61.48% to 38.52%. The N0 increased from 32.75% to 67.25%. A comprehensive guideline for breast screening is developed available at www.mog.gov.om. A cancer colon and Hepatocellular screening in susceptible population groups is evolving. A comprehensive Genetic center is recently established under MoH where tests and genetic counseling services are available for hereditary and familial cancers [18].

12.7 Cancer Prevention Programs

In 2018, Oman launched its national policy and action plan for the prevention and control of Non-Communicable Diseases including Cancer. This multisector plan was developed to reduce mortality of NCDs by 25% in 2025 through reinforcing the cooperation between stakeholders from industry, education, information, Sports affairs, Regional municipalities, Council for planning, civil society, and international organizations [13, 17, 21, 23]. These include Oman anti-smoking society, Oman Medical Association, Oman Cancer Association, World Health Organization (WHO), and UNICEF [7, 13]. In addition, several departments in the MoH help in planning, implementation, and monitoring of cancer control and prevention activities like the National Oncology Centre, the directorate general of primary healthcare, and the directorate general of specialized services. This helps to ensure a coordinated and integrated approach between primary, secondary, and tertiary services. HPV vaccination is available but not mandatory at present for everyone.

12.8 Cancer Diagnosis

The cancer care services are supported by sophisticated pathology services including molecular, Fluorescent in situ hybridization (FISH), Immunohistochemistry (IHC), and cytogenetic testing facility. Some genetic tests are sent abroad as well like RAS, BRAF, Oncotype DX, PIK3C, etc. Nuclear imaging centers provide PET scan, bone scan, densitometry, MIBG, PSMA PET, and other scans. A genetic center is established for specialized genetic tests and genetic counseling [24]. The challenges in diagnosis are access, coping up with demand, and limited availability.

12.9 Treatment

The oncology services in Oman started in 1990, the Medical Oncology department was established in 1996 at the Royal hospital, and subsequently, National Oncology center was established in 2004 at the Royal Hospital under MoH. It has expanded to meet the ever-growing needs of the community. Omani nationals have free access to cancer care services. This includes sophisticated diagnostic services up to PET Scans and most recently incorporated therapeutic modalities like targeted therapy, bone marrow transplant, and immunotherapy. Enrolment in Clinical trials is a legitimate treatment option for many diseases and patients. Unfortunately, in Oman, we do not have access to clinical trials as would be desired.

12.9.1 Medical Oncology

Two centers in Oman have a medical oncology and chemotherapy facility, the Royal hospital National Oncology Centre under MoH and Sultan Qaboos University hospital (Ministry of Higher Education). In addition, there are satellite units in Salalah and Sohar. These provide outpatient clinics, diagnostic services, daycare treatment, and inpatient facilities. The chemotherapies are prepared within the NOC Pharmacy. Most state-of-art treatment options are available locally in Oman. Several patients are sent abroad for specialized management at high-volume specialized institutes if the required services are not available locally [6, 9, 11].

12.9.2 Radiation Therapy

National Oncology Centre—The Royal Hospital is the only center with a radiation oncology facility at present, while Sultan Qaboos University Hospital (SQUH) is likely to start radiation therapy in the near future. The two facilities are concentrated in Muscat and patients travel from all over Oman for treatment. The NOC has facilities for IMRT (Intensity Modulated Radiotherapy), Brachytherapy, and SBRT (Stereotactic Body Radiation Therapy). There are two Linear accelerators in NOC and two more are planned to be installed in SQUH [6].

12.9.3 Surgery

Oncologic surgery is still an evolving specialty in Oman, with countable oncology surgeons. They are in breast, colo-rectal, osteo-oncology, hepatobiliary, faciomaxillary, gynecologic-oncology, and uro-oncology. There are multi-modality and multi-specialty combined clinics like breast, ENT, and neuro-oncology. There is a multidisciplinary forum like the tumor board for discussion and consensus decision-making as per current guidelines [11].

12.9.4 Pediatric Oncology

There are two pediatric oncology units, one in NOC Royal Hospital and the other in SQUH dealing with hematologic and solid tumors. They also have inpatient services, outpatient specialty clinics, and daycare facilities. Adolescent oncology is evolving as a further subspecialty with a dedicated trained consultant and team [11].

12.9.5 Survivorship Track

The outcome and survival in malignant diseases have improved, thus increasing the number of long-term cancer survivors. These patients need to follow up due to the risk of relapse, chances of subsequent tumors, long-term sequel of cancer treatment, and their affiliation to a primary cancer care team. A survivorship clinic is run by NOC on a regular basis to cater services to these patients [6].

12.9.6 Palliative Care Track

Cancer patients often present with advanced-stage disease in the developing world, shifting the aim of management from curative to a palliative intent. Oman lacks the required palliative and hospice care, resulting in an increased burden on existing cancer care facilities and compromising the desirable care of potentially treatable cancers. The idea of hospice care is still not morally, socially, or religiously very acceptable in society, probably due to closed integrated families [6, 9]. There is a policy of DNR approved by MoH, ethical experts, and religious factions.

12.10 Research and Education

MoH has set guidelines and priorities for research [25, 26]. NOC is actively involved in undergraduate and postgraduate teaching. NOC has organized one to two international oncology conferences every year since 2009. NOC made several presentations in international conferences and meetings and has published over 150 articles in international journals [27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55]. The research areas of interest at present are Microsatellite Instability, Mismatch Repairs, Colorectal Tumour Bank, Stomach cancer, Breast cancer molecular subtypes, Bevacizumab in Ovarian Cancer, anti-EGFR (epidermal growth factor receptor) in mCRC, utilization of palliative chemotherapy near the end of life, Changing Trends, Management outcomes and survival of Common Cancers, Castration-Resistant Prostate Cancer, the Effect of Diet and Obesity On Colonic Cancer, Impact of Body Mass Index, diet and diabetes on incidence, RAS mutation and clinical outcome of colorectal cancer, Synchronous and metachronous tumors, Chemotherapy induced Neutropenic necrotic Enterocolitis, Rapid Rituximab infusion, Young age Breast Cancer in Oman, Prognostic determinants of gastric cancer, Renal cell carcinoma metastasizing to larynx, Does Traditional WASAM (Cautery Burn) Therapy Facilitate an Early and Extensive Loco regional Metastasis of Breast Cancer?, Primary Gastric Choriocarcinoma, Lean philosophy within cancer-care service in Oman, Breast cancer in Kindlers syndrome, Non-traumatic avascular necrosis of femoral head, Lobbying for regulatory reforms of narcotic analgesics in Middle East, Epidemiology of Lung Cancer in Oman, Cancer Incidence in Oman (1996–2015), and 20-year trends of cancer incidence in Omanis. A lot of presentations, both oral and abstract, were done in local, regional, and international meetings in the Gulf region, Europe, and the USA. The important ones were Outpatient Cisplatin Administration, stress and fatigue in Breast cancer, Brain metastasis in Her-2 (human epidermal growth factor receptor 2) positive Breast cancer, and RAS mutations and ethnicity [27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55].

12.11 Cost-Effective Cancer Care

Effective and prompt management of cancer is increasingly challenged with the escalating cost of diagnosis and treatment with the incorporation of new modalities of diagnosis and integration of more effective drugs. The management has to be balanced with resource allocation and cost-effectiveness due to increasing economic pressures. The paradigm is shifting to cancer prevention, screening, and genetic screening to reduce the economic burden. A comprehensive genetic center was established recently for genetic testing and counseling. The early-stage diagnosis cut down the management cost and was observed with breast screening programs. We are seeing a higher proportion of early-stage curable, treatable breast cancer with less frequency of a relapse. Oman is therefore allocating resources to health education, genetic testing, prevention, and screening with the objective of early detection and cost-effectiveness. These potential programs include familial and genetically determined tumors like colon, sero-positive hepatocellular carcinoma, gastric cancer, endometrial cancer, ovarian cancer, pancreatic cancer, and prostate cancer [54].

Oman is also introducing health economics principles in cancer care for expensive tests and medications in collaboration with the pharmaceutical industry. The country is expanding the use of approved generics and biosimilar. The authorities have developed and approved local institutional guidelines for management and follow-up with the objective of judicious and cost-effective use of laboratory, radiology, and healthcare services.

12.12 Challenges and Advantages

Oman has certain advantages and specific challenges in cancer care plans and services. Oman has a young population, with almost everyone being vaccinated for hepatitis. Local population has free access to comprehensive primary and specialized healthcare services. There is a facility to send patients abroad by MoH, if any needed treatment is not locally available.

The challenges are multi-dimensional and include a high population growth rate, traditional tribal system, social taboos, beliefs, herbal and traditional medications, and a tendency of health tourism. The literacy rate is half in the population over 65 years of age, who influence public opinion. There is a need to invest in health education, prevention and screening programs, diagnostic services, and therapeutic interventions. There is a need for capacity building by training the workforce and investing in cancer care. Increasing economic pressure globally is a challenge with resource allocation, better planning, setting priorities, and implementing cost-effectiveness. There is a need for continuing political will and support and commitment to achieve the set objectives [19, 25, 26].

12.13 The Future of Cancer Care in Oman

Cancer-related mortality is often predestined, but with the execution of the comprehensive Cancer Care Plan, there will be expectantly less mortality in the future. To accomplish these objectives all the partners (public and private, physicians, nurses, patients, and families) must operate concurrently to meet the challenges and realize the targets. There is a need to focus on strengthening the Cancer Control Program, improve Cancer Registry, focus on early detection and prevention, improve integrated cancer management, accessibility, establish integrated palliative care services, engage civil society, capacity building, human resource development, and improve public awareness.

Infrastructure development, lobby for funding, emphasis on research, need to develop clinical pathways and guidelines. There is a continued need for quality assurance, implementing Key Performance Indicators, performance monitoring, and improving patient experience. We need to make a prompt and swift access to cancer services individually or by an integrated referral pathway, decrease referral abroad, make new drugs available for treatment, empower more patients in decision-making, implement patient safety protocols, maintain, and get new certifications, and ensure effective capacity building [56, 57].

12.14 Conclusion

Cancer management is a very dynamic discipline due to a rapid pace of research and development. It is a challenge to offer state-of-the-art cancer care due to increasing cost and access to treatment. Each country has to balance its objectives and resources to have an optimal strategy. There is a necessity for capacity building, reinforcement of cancer control, concentrating on early detection and prevention, developing integrated management, developing local management guidelines, and authenticating palliative care services. Civil society and Non-Governmental Organizations should be involved to the optimum. There is a need for infrastructure improvement, lobby for funding, stress on research, need to develop clinical pathways, demand for quality assurance, implement performance indicators and monitoring, and improve patient experience. It is mandatory to make prompt and swift access to cancer services by everyone through an integrated referral pathway. All the new effective drugs should be made available for treatment, empower patients in decision-making, execute patient safety protocols, maintain and acquire new accreditations, and ensure capacity building.