22.1 Introduction

Breast cancer is the most common malignancy diagnosed in females worldwide [1, 2], and despite enormous efforts at early detection and the presence of many new and evolving treatments, it remains the leading cause of cancer-related mortality in females as well [3, 4]. The estimated incidence of new breast cancer cases was around 2.26 million in 2020, with a cumulative of 685,000 breast cancer-related deaths worldwide in that year [2]. Cancer in general, and breast cancer in particular, is a growing health issue in the Arab World.

The Arab world comprises 22 countries with memberships in the Arab League, spanning across the Middle East and North Africa. Unfortunately, many of these countries are troubled with financial and political instabilities, some being active war zones. Although there are significant linguistic and cultural ties and similarities, there are also many significant social and economic differences in addition to some ethnic and genetic variations. According to the World Bank ranking, some Arab countries are ranked as high income (i.e., Gulf countries) while others are ranked as low income (i.e., Syria, Sudan, and Somalia), with many in between [5]. These differences have many implications on education, social perspectives, and health care system development and organization in their respective countries, in addition to direct effects on the policies prioritizing health care resources’ allocations.

In the following review, we attempt to discuss the unique features of breast cancer and breast cancer care within Arab Countries. Although the Arab World is viewed as a single region, it is important, as mentioned above, to understand data in the context of the vast variations in political stability and social and economic development variations between the different countries.

22.2 Epidemiology of Breast Cancer in Arab Countries

The exact prevalence and incidence of breast cancer cases in the Arab world are not known due to the lack of well-structured cancer registries in most of these countries. In addition, mortality registries and disease-specific mortality records are lacking and largely unknown. Data on breast cancer in the Arab World mostly stem from literature reviews of published data from individual countries in the forms of retrospective data reports and published individual institution records, many of which are high-quality reports published in peer-reviewed journals.

From available data from the years 2010, 2013, and most recently 2020, breast cancer is thought to be the most common malignancy diagnosed in Arab women, estimating somewhere between 14–42% of all tumors [6, 7] in some reports, and between 17.7–19% of all new cancers in others [8], depending on individual countries and type of reports reviewed. Age-standardized incidence also varies between countries and ranges between 9.5 and 50 cases per 100,000 women per year [7]. Although the incidence of new cases and burden of the disease seem to be lower than that in the more developed Western World and the global averages in general, the incidence has been rising over the past few decades [7, 9, 10], and the rate of increase seems to be similar to the global trend [9]. This increase can be partly attributed to advances in medical care and diagnosis, implementation of limited screening programs leading to better diagnosis of previously unidentified cases, in addition to better reporting. However, this can also be partially attributed to an actual increase in disease burden due to demographic and lifestyle changes. More Arab societies and women are being influenced by Westernized lifestyles such as dietary habits, delayed age at marriage and first pregnancies, lower reproductive rates, in addition to more smoking and more use of oral contraceptives and Hormonal Replacement Therapies (HRTs) [9,10,11].

The median age at the time of diagnosis of women with breast cancer in the Arab world is almost a decade younger than in industrialized countries such as Europe and the USA. It is estimated in different reports to be around 48–52 years compared to around 63 years, with somewhat between one-half and two-thirds of diagnosed individuals below the age of 50 [7, 10, 12, 13], compared to only about 23% below the age of 50 in the United States [14]. This can largely be attributed however to the young population structure. In addition to the younger median population age, elderly Arab women are also likely to be under-represented and more frequently underdiagnosed in relevant analyses, as they are less likely to obtain a mammogram or seek medical care for breast disease [15, 16].

22.3 Breast Cancer Screening and Early Detection

Unfortunately, most Arab countries lack a structured universal screening program. Several awareness campaigns take place on different occasions, especially in the month of October, Breast Cancer Awareness Month. These kinds of campaigns take place in the form of media interventions, advertisements, public physician interviews, and awareness lectures/speeches. Although some promising screening program initiatives have been recently raised in some countries, most women who undergo screening mammograms are either self-motivated, advised by afflicted family members, or by motivated physicians. These screening procedures are, however, not consistently covered by medical insurances. In addition, there is a lack in the number and distribution of mammography centers, and trained personnel, and the existing units are not universally monitored for quality, results, and reporting by any overseeing agency [10, 17].

Although some researchers and experts have suggested that the younger median age at the time of initial breast cancer diagnosis in the Arab World should trigger a younger age for breast cancer screening advice and target population [7, 10], others have challenged this suggestion since the median age of diagnosis in a population is thought to be less relevant than age-specific incidence when forming policies and recommendations [9, 18, 19].

22.4 Diagnosis and Stage

More women in the Arab World present with more advanced diseases compared to Western countries. More patients are diagnosed with larger tumors, positive lymph nodes, and inflammatory breast cancer, and metastatic diseases [17, 20,21,22,23,24]. Reports assessing tumor size at the time of initial presentation have estimated that as high as 70–80% of tumors were more than 2 cm in diameter [20, 21]. Similarly, lymph node involvement at the time of initial diagnosis has also been reported at high percentages of 50–80% [22,23,24].

Inflammatory breast cancer, being the most aggressive form of non-metastatic breast cancer, is associated with the highest mortality. It is considered rare and reported in only 1–2% of new breast cancer diagnoses in the United States [25, 26]. In the Arab world, reported rates are as high as 11% of newly diagnosed cases [27, 28]. Unfortunately, the same applies to a higher incidence of de novo metastatic disease with rates as high as 13.4% compared to 6% [17, 29, 30].

There are many proposed reasons for the late diagnosis and advanced initial stage. Although genetic, adverse molecular variations and racial factors have been proposed; delayed presentation and late seeking of medical advice are likely to play a major role, as well. In addition to impaired access to adequate care, several psycho-social aspects also influence women’s decisions to delay diagnosis and treatment. This is discussed in an upcoming section.

22.5 Obstacles to High-Quality Standardized Management

One major obstacle to optimal cancer care in general and breast cancer care in particular in the Arab region is the social, financial, and political instability of many countries in this region. Some countries are directly inflicted by wars, leading to the routing of health care resources away from many Non-Communicable Diseases (NCDs) such as cancer. With these wars and conflicted areas, there is a growing refugee crisis, as many people move from politically unstable areas to financially unstable countries. There has been an increasing awareness about this issue in recent years [31]. The repercussions of the Syrian crisis and refugee cancer care status have been comprehensively reviewed in several recent articles, for example [32,33,34,35]. Cancer care results in a significant strain on health care systems in hosting countries, both financially and ethically. Although there continue to be international medical relief efforts, both through non-governmental and governmental agencies, the costly nature of cancer care, and the need to prioritize already limited resources, leads in many instances to suboptimal care or even neglect. The need for an increase in funding, in addition to multidisciplinary care teams and evidence-based standard operating procedures in these areas, is highly needed to coordinate and prioritize care and resources, but this is yet to be established [32, 33].

Although the role of multidisciplinary care is well established in cancer care to ensure the best available management approach and treatment outcomes [36], this is seldom available or practiced in the majority of healthcare systems in the Arab region. With few exceptions, many, even though not all, Arab countries lack universal access to comprehensive cancer care centers or patient care by specialized cancer care teams with the adequate advanced oncologic training and expertise needed to provide required complicated treatment plans, leading to suboptimal cancer care. As an example, the rate of modified radical mastectomies in Arab countries is much higher than that in internationally reported literature, reaching up to about two-thirds of cases [10, 20, 37,38,39,40,41], and is as high as 88% in some reports from Syria [42]. Around 21% of patients undergoing modified radical mastectomy will develop clinically significant lymphedema [43], a complication that could potentially be avoided in a subset of patients.

One important reason for a high rate of radical procedures in breast cancer is the advanced stage at the time of disease presentation. However, many of these procedures could otherwise be potentially avoidable, and some reasons for this unexpected high rate have been explored in published reports. Lack of enough radiation therapy centers and accelerator machines in some countries are additional contributing factors [44]. Professional experience in breast-conserving surgery, sentinel lymph node sampling, skin-sparing and nipple-sparing mastectomies is not available in most of the low-income Arab countries and contributes to a higher rate of more radical procedures. Similarly, reconstructive surgeries are not always available, and when they are, not consistently covered by insurance [17].

Cost of cancer treatment in general, and new targeted and immunotherapy in breast cancer, in particular, is a major issue in The Arab World. There has been an approval of several expensive novel agents for breast cancer in recent years. Although these treatments might be readily available in some high-income Arab countries, access to these medications and financial coverage by governmental and non-governmental insurance plans and agencies is limited in many others.

Cost and financial burden also play a role in the limitation of many other aspects of breast cancer care in the Arab world. One major example is genetic testing and counseling. Almost 10–15% of breast cancers worldwide are thought to be inherited [45], and genetic testing for the most prevalent cancer genes such as BRCA1 and BRCA2 has become standard in many countries and is recommended by international guidelines [46]. However, this is not widely practiced or standardized in most Arab countries, reports from these areas are limited, and little is known about the role of these and other genetic mutations in Arab patients, although some reports suggest a higher prevalence in Arab women [47]. One report from Jordan, from a single institution’s experience, showed that about 14% of screened high-risk breast cancer patients had a deleterious mutation [48]. Two different studies in Tunisia showed contrasting variable results for BRCA1 testing in selected populations with a reported prevalence of 16% and 38% [49, 50]. Reports from Lebanon, Morocco, Egypt, and a few other countries have also shown variable results [51,52,53,54,55,56,57], likely reflecting variations in selection criteria for testing referrals, different testing techniques, and small numbers of patients enrolled [48]. This lack of standardized and universal testing contributes to limitations of proper screening and follow-up in patients and their family members, further leading to late diagnoses and advanced disease stage at presentation. Cost and financial burden are not the only factors contributing to inconsistent genetic testing and counseling in the Arab populations, however, with psycho-social aspects also playing a significant role in patient acceptance of testing, and sharing of results.

22.6 Unique Psycho-Social Aspects of Breast Cancer in the Arab World

Unfortunately, even in this time and age, cancer in general and breast cancer, in particular, is associated with significant social stigmatization in many countries and societies in the Arab world, regardless of socio-economic and educational development in these countries. Women diagnosed with breast cancer often describe a feeling of shame or guilt, and fear of being blamed for having cancer, as at times, it is regarded as a sign of punishment for undisclosed sins [8]. In addition, there is added stress of fearing they can pass their illness to their daughters, or that the females in the family are considered potentially diseased, and thus decreasing their chances of future marriage. This is more pronounced in less urban parts of the Arab world where arranged marriages and consanguinity are still a significant part of these societies. Light has been shed on these issues in several different reports from the area [58,59,60,61,62,63,64]. The importance of this particular aspect stems from the fact that this leads many women to conceal their illness, delay seeking medical advice, and delay treatment despite active symptoms and this results in late presentations and more advanced disease stages at the time of diagnosis. In addition, this is an important factor hampering the progress of national efforts for the promotion and implementation of screening programs. Much progress has been made over the past few years in awareness campaigns in many parts of the Arab world, and much more is still needed.

22.7 Conclusion and Future Directions

Breast cancer is the most common cancer diagnosed among women worldwide as well as in Arab countries. More advanced-stage and younger age at presentations are common features in the region. Resources and staff availability are quite variable. Opportunities exist to up-scale the quality of care provided and that should reflect positively on treatment outcomes.