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Abstract Introduction Attacks on healthcare have been committed throughout the Syrian conflict in violation of International Humanitarian Law (IHL), contributing to the devastation of the country’s healthcare system. The conflict has also forcibly displaced over half of Syria’s pre-conflict population, 7.2 million of whom are internally displaced. In this retrospective analysis, we aim to assess the relationships between (1) healthcare attacks and general conflict and (2) healthcare attacks and forced displacement between 2016 and 2022. Methods Data on healthcare attacks, conflict events, and displacement were extracted from the Syrian American Medical Society (SAMS), Uppsala Conflict Data Project, and OCHA Türkiye, respectively. The analysis addresses three research questions: the associations between (1) healthcare attacks and conflict events, (2) healthcare attacks and conflict events in the week after an attack on a healthcare facility, and (3) healthcare attacks and forced displacement. For each, we used generalized additive models with a negative binomial distribution that also accounted for spatial and temporal factors. Results SAMS recorded a total of 541 attack events, comprising 650 attack rounds over 235 facilities between 2016 and 2022. Conflict events were significantly associated with healthcare attacks in the same week (IRR: 1.14, 95% CI 1.12–1.17), and healthcare attacks in one week were associated with a maximum of 1.44 greater risk (95% CI 1.08–1.91) of conflict events in the following week, even when accounting for general conflict levels in the previous weeks. Healthcare attacks were also significantly associated with increased displacement up to three months following the attacks. Discussion We find that healthcare facilities are not avoided during conflict (as obliged under IHL), and that healthcare attacks significantly precede an escalation of general conflict in the same area. Healthcare attacks are also significantly associated with displacement for months following the attacks, even when accounting for conflict levels. Based on these findings, we present a framework outlining one pathway through which healthcare attacks may contribute to larger conflict tactics. Our findings highlight the critical role of healthcare infrastructure in conflict and reaffirm calls to hold perpetrators of these attacks accountable.

ABSTRACT Background Centralising prostate cancer surgical and radiotherapy services, requires some patients to travel longer to access treatment, but its impact on actual treatment utilisation and outcomes is unknown. Methods Using national cancer registry records linked to administrative hospital data, we identified all patients with high risk and locally advanced prostate cancer diagnosed between 1 April 2019 and 31 March 2020 in the English National Health Service (n = 15,971). Estimated travel times from the patient residential areas to the nearest hospital providing surgery or radiotherapy were estimated for journeys by car and by public transport. Multivariable logistic regression was used to model relationships between travel time and receipt of care with adjustment for patient characteristics. Results 10,693 (67%) men received radical surgery or radiotherapy (RT) within 12 months of diagnosis. Average travel time to the nearest hospital providing prostatectomy or RT was 23.2 min by private car and 58.2 min by public transport. We found no association between travel time, either by car or public transport and the likelihood of receiving curative treatment. Patients living in the most socially deprived areas, those aged over 70, those with two or more comorbidities, and those of black ethnic origin, were less likely to receive curative treatment (p& =& 0.001 for all associations). Conclusions The current configuration of national prostate cancer services is not associated with the likelihood of receiving curative treatment. Further increases in capacity will unlikely improve utilisation rates beyond addressing sociodemographic barriers.

ABSTRACT blaNDM, the most prevalent carbapenemase among carbapenem-resistant Enterobacteriaceae, is thought to have emerged in India, as its initial detection in 2008 was linked to this country, and subsequent retrospective surveys had so far established the earliest blaNDM-positive strains to be isolated in India in 2005. Molecular dating and analyses suggest blaNDM emerged within Acinetobacter species decades prior to 2005 on a Tn125 transposon. Despite early reports of elevated rates of carbapenem-resistant Acinetobacter species in Israel starting in the 1990s, limited molecular data are available from this location. We searched for blaNDM among Acinetobacter species isolated in Israel between 2001 and 2006. One A. junii strain, Ajun-H1-3, isolated in January 2004, carried blaNDM-1 within a Tn125-like transposon on a 49-kb plasmid, pNDM-Ajun-H1-3, making Ajun-H1-3 the earliest NDM-positive isolate observed to date. The pNDM-Ajun-H1-3 plasmid matched numerous BJ01-like NDM-positive plasmids identified from 2005 onward in Acinetobacter species as well as Enterobacterales. These results indicate the need for further retrospective work on global strain archives to shed light on the conditions favoring the emergence as well as subsequent evolution and spread of blaNDM.IMPORTANCEThis study presents the earliest observation of blaNDM-1, isolated in a geographical region distant from where it is believed to have originated. In doing so, this study provides novel insights into the emergence and spread of blaNDM, the most prevalent carbapenemase among carbapenem-resistant Enterobacteriaceae, and its associated mobile genetic elements. It also sheds light on the conditions that foster the evolution of antimicrobial resistance, one of the greatest public health challenges we face.

Summary: Background: The COVID-19 global pandemic placed unprecedented pressure on cancer services, requiring new interim Systemic Anti-Cancer Treatments (SACT) options to mitigate risks to patients and maintain cancer services. In this study we analyse interim COVID-19 SACT therapy options recommended in England, evaluating the evidence supporting inclusion and delineating how these have been integrated into routine cancer care. Methods: We performed a retrospective analysis of interim Systemic Anti-Cancer Treatments endorsed by NHS England during the COVID-19 pandemic. Interim therapy options were compared to baseline (replacement) therapies by comparing data from the key pivotal trial(s) in terms of clinical efficacy and potential benefits (e.g., reduced immunosuppression or improved adverse effect profile) within the context of the pandemic. Furthermore, we evaluated the evolution of these interim SACT options, exploring if these have been integrated into current treatment pathways or are no longer accessible at the pandemic end. Findings: 31 interim oncology treatment options, across 36 indications, for solid cancers were endorsed by NHS England between March 2020 and August 2021. Interim therapies focused on the metastatic setting (83%; 30/36), allowing greater utilisation of immune checkpoint inhibitors (45%; 14/31) and targeted therapies (26%; 8/31), in place of cytotoxic chemotherapy. Overall, 36% (13/36) of therapies could not have efficacy compared with baseline treatments due to a paucity of evidence. For those which could, 39% (9/23) had superior efficacy (e.g., overall survival), 26% (6/23) had equivocal efficacy and 35% (8/23) lower efficacy. 53% (19/36) of interim therapies had better or equivocal toxicity profiles (when assessable), and/or were associated with reduced immunosuppression. Almost half (47%; 17/36) of interim therapies did not have UK market authorisation, being classified as ‘off label’ use. Analysing access to interim options at the end of the pandemic (May 2023) identified 19 (53% 19/36) interim options were fully available, and a further four (11% 4/36) therapies were partially available. Interpretation: Interim SACT options, introduced in England, across a range of solid cancers supported delivery of cancer services during the pandemic. Most interim therapies did not demonstrate superior efficacy, but provided other important benefits (e.g., reduced immunosuppression) in the context of the pandemic. Funding: None.

Summary: Background: It is uncertain which biological features underpin the response of rectal cancer (RC) to radiotherapy. No biomarker is currently in clinical use to select patients for treatment modifications. Methods: We identified two cohorts of patients (total N = 249) with RC treated with neoadjuvant radiotherapy (45Gy/25) plus fluoropyrimidine. This discovery set included 57 cases with pathological complete response (pCR) to chemoradiotherapy (23%). Pre-treatment cancer biopsies were assessed using transcriptome-wide mRNA expression and targeted DNA sequencing for copy number and driver mutations. Biological candidate and machine learning (ML) approaches were used to identify predictors of pCR to radiotherapy independent of tumour stage. Findings were assessed in 107 cases from an independent validation set (GSE87211). Findings: Three gene expression sets showed significant independent associations with pCR: Fibroblast-TGFβ Response Signature (F-TBRS) with radioresistance; and cytotoxic lymphocyte (CL) expression signature and consensus molecular subtype CMS1 with radiosensitivity. These associations were replicated in the validation cohort. In parallel, a gradient boosting machine model comprising the expression of 33 genes generated in the discovery cohort showed high performance in GSE87211 with 90% sensitivity, 86% specificity. Biological and ML signatures indicated similar mechanisms underlying radiation response, and showed better AUC and p-values than published transcriptomic signatures of radiation response in RC. Interpretation: RCs responding completely to chemoradiotherapy (CRT) have biological characteristics of immune response and absence of immune inhibitory TGFβ signalling. These tumours may be identified with a potential biomarker based on a 33 gene expression signature. This could help select patients likely to respond to treatment with a primary radiotherapy approach as for anal cancer. Conversely, those with predicted radioresistance may be candidates for clinical trials evaluating addition of immune-oncology agents and stromal TGFβ signalling inhibition. Funding: The Stratification in Colorectal Cancer Consortium (S:CORT) was funded by the Medical Research Council and Cancer Research UK (MR/M016587/1).

Abstract Background Cancer burden in India is rapidly growing, with oral, breast, and uterine cervix being the three most commonly affected sites. It has a catastrophic epidemiological and financial impact on rural communities, the vast majority of whom are socio‐economically disadvantaged. Strengthening the health system is necessary to address challenges in the access and provision of cancer services, thus improving outcomes among vulnerable populations. Objective To develop, test, and validate a health system capacity assessment (HSCA) tool that evaluates the capacity and readiness for cancer services provision in rural India. Methods A multi‐method process was pursued to develop a cancer‐specific HSCA tool. Firstly, item generation entailed both a nominal group technique (to identify the health system dimensions to capture) and a rapid review of published and gray literature (to generate items within each of the selected dimensions). Secondly, tool development included the pre‐testing of questionnaires through healthcare facility visits, and item reduction through a series of in‐depth interviews (IDIs) with key local stakeholders. Thirdly, tool validation was performed through expert consensus. Results A three‐step HSCA multi‐method tool was developed comprising: (a) desk review template, investigating policies and protocols at the state level, (b) facility assessment protocol and checklist, catering to the Indian public healthcare system, and (c) IDI topic guide, targeting policymakers, healthcare workforce, and other relevant stakeholders. Conclusions The resulting HSCA tool assesses health system capacity, thus contributing to the planning and implementation of context‐appropriate, sustainable, equity‐focused, and integrated early detection interventions for cancer control, especially toward vulnerable populations in rural India and other low‐resource settings.

PURPOSETo understand how breast cancer is diagnosed in Gaza, and disease stage distribution, treatment, and survival.MATERIALS AND METHODSA clinical record case series study of women diagnosed in 2017 and 2018 was conducted with follow-up until December 31, 2020. Breast cancer crude incidence rates and age-specific incidence rates were calculated. Clinical characteristics, including investigation, diagnosis, and treatment methods by year of diagnosis, were compared using the chi-square test. The 2-year cumulative risk of death from any cause was estimated using the Kaplan-Meier method, and univariate and multivariate Cox proportional hazard regressions estimated hazard ratios and their 95% CIs.RESULTSFive hundred twenty-four new diagnoses (mean age, 53 years; range, 23-100) were recorded, giving a crude annual incidence rate of 27 per 100,000 population. Six percent (32/524) were diagnosed at stage I, 35% (185/524) at stage II, 33% (171/524) at stage III, and 19% (99/524) at stage IV. More than one half (52%, 271/524) underwent modified radical mastectomy. Seventy-seven percent (405/524) received chemotherapy, 70% (368/524) hormone therapy, and 39% (204/524) radiotherapy. Data on key prognostic factors were mostly available—stage (93%), estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2; 82%), tumor grade (77%), and tumor size (70%). The overall survival was 95.4% at 1 year and 86.6% at 2 years.CONCLUSIONWomen with breast cancer in Gaza have a high short-term survival after diagnosis. However, one half were diagnosed with advanced disease, and their investigations were incomplete. Better reporting on family history, tumor grade, size, and ER, PR, and HER2 receptor status is needed for future studies.

Sudan has been under an armed conflict between the Sudanese Armed Forces and the Rapid Support Forces (RSF) militia since April 15, 2023. The conflict has turned the country into the largest internal displacement humanitarian crisis with 9.05 million internally displaced persons including 2.2 million children younger than 5 years and caused 1.47 million Sudanese to flee the country as refugees. The conflict has had a major destructive impact on the health system, which has incurred targeting with air raids, ground invasion, vandalization, looting of assets and supplies, and killing of doctors, nurses, and other health personnel. Khartoum Oncology Hospital, Sudan's main cancer hub for treatment, diagnostics, and research has become nonfunctional as a result of the conflict. The National Cancer Institute in Wad Medani, the second largest hub, faced a similar fate as the conflict spread to Al-Gezira State. Patients with cancer have been displaced multiple times in Sudan with grave consequences on the continuity of care, worsening of their disease outcomes and palpable negative impacts on children. The oncology workforce in Sudan have themselves been displaced yet are working hard to provide services and care for patients under impossible circumstances. Sudan's doctors in diaspora have rallied to provide support but they face multiple obstacles. As the conflict continues to spread, we call upon the WHO, the United Nations Children's Fund, St Jude Hospital, and all relevant partners to implement an immediate evacuation operation with urgent air lifts of the affected children to continue their cancer care in neighboring countries as was done in Ukraine and Gaza.

Introduction Research is an essential pillar of cancer control and key in shaping regional cancer control agendas. Imbalances in science and technology in terms of lack of female participation have been well documented. However, there is little evidence about country-level female participation in cancer research.Methodology Through a complex filter, cancer research papers were identified and grouped by countries and sex of the first and last authors of each paper and analysed by the percentage of females in these positions alongside other parameters.Results Our analysis of 56 countries’ outputs, in 2009, revealed that females were the first authors in 37.2% and last authors in 23.3% of papers. In 2019, females were the first author in 41.6% and last author in 29.4% of papers. Females increased as first authors by 26%, and as last authors by 12% between these two time periods. The top performing countries in terms female/male parity for first or last authorship were in Eastern and Southern Europe as well as Latin American countries.From 2009 to 2019, the highest proportion of females as first and last authors were from low-income and middle-income countries in Latin America and Eastern Europe.Females were more likely to publish in lower impact journals and were less likely to be cited compared to males.Conclusions Globally, progress in female’s authorship in oncology research has been uneven. More research is needed to understand the reasons behind this. Advancing diversity and equity in research leadership and authorship will be essential to address the complex challenges of cancer globally.

PURPOSEThere is an urgent need to improve access to cancer therapy globally. Several independent initiatives have been undertaken to improve access to cancer medicines, and additional new initiatives are in development. Improved sharing of experiences and increased collaboration are needed to achieve substantial improvements in global access to essential oncology medicines.METHODSThe inaugural Access to Essential Cancer Medicines Stakeholder Meeting was organized by ASCO and convened at the June 2022 ASCO Annual Meeting in Chicago, IL, with two subsequent meetings, Union for International Cancer Control World Cancer Congress held in Geneva, Switzerland, in October 2022 and at the ASCO Annual Meeting in June of 2023. Invited stakeholders included representatives from cancer institutes, physicians, researchers, professional societies, the pharmaceutical industry, patient advocacy organizations, funders, cancer organizations and foundations, policy makers, and regulatory bodies. The session was moderated by ASCO. Past efforts and current and upcoming initiatives were initially discussed (2022), updates on progress were provided (2023), and broad agreement on resulting action steps was achieved with participants.RESULTSSummit participants recognized that while much work was ongoing to enhance access to cancer therapeutics globally, communication and synergy across projects and organizations could be enhanced by providing a platform for collaboration and shared expertise.CONCLUSIONThe summit resulted in new cross-stakeholder insights and planned collaboration addressing barriers to accessing cancer medications. Specific actions and timelines for implementation and reporting were established.

Abstract The United Nations estimate a quarter of the global population currently lives in violent conflict zones. Radiology is an integral part of any healthcare system, providing vital information to aid diagnosis and treatment of a range of disease and injury. However, its delivery in conflict-affected settings remains unclear. This study aims to understand how radiology services are currently delivered in conflict settings, the challenges of doing so, and potential solutions. A hermeneutic narrative review of multiple databases, including grey literature sources, was undertaken. Key themes were identified, and articles grouped accordingly. Various conflict zones including Gaza, Ukraine, Iraq, Yemen, Afghanistan, and Somalia were identified in literature relating to radiology services. Three key themes were identified: underserving of local medical imaging services, strong presence of military hospitals, and the importance of teleradiology. A severe shortage of radiologists, technicians, and equipment in conflict affected settings are a significant cause of the underserving by local services. Teleradiology has been used to blunt the acuity of the these struggling services, alongside military hospitals which often serve local populations. Radiology faces unique challenges compared to other healthcare services owing to its expensive equipment which is difficult to fund and can be less effective due to international sanctions placed on contrast medium to enhance image quality. Further the equipment is reliant on local infrastructure, e.g., power supply, which can be affected in conflict. Key recommendations to improve radiology services include retention of radiologists within conflict zones, careful allocation of funds to supply necessary imaging machinery, international cooperation to ensure sanctions do not affect sourcing of radiology equipment, special training for military medical teams to help preparedness for the unique demands of the local population, and investment in communication devices, like smartphones, to allow international teleradiology efforts.

Abstract Background Healthcare is a basic human right extending across all humanitarian contexts, including conflict. Globally, two billion people are living under conditions of insecurity and violent armed conflict with a consequent impact on public health. Health research in conflict-affected regions has been recognised as important to gain more understanding of the actual needs of such populations, to optimise healthcare delivery, as well as to inform advocacy and policy change. International collaborative research maximises the resources and skills available for dealing with global health issues, builds capacity and endeavours to ensure the research reflects real needs of the populations. Under the UK’s Global Challenge Research Fund in 2017 a number of such international programs were created including the Research for Health in Conflict-Middle East and North Africa (R4HC-MENA) partnership to build capacity in conflict and health research as well as study specific areas, namely noncommunicable diseases in conflict (cancer & mental health) and the political economy of health in conflict. Methods A qualitative study using semi-structured online interviews was conducted to explore researchers’ and stakeholders’ perspectives on the R4HC-MENA programme over its lifetime from 2017 to 2021. It aimed to understand the factors that influenced and accelerated international collaboration within the R4HC-MENA programme on conflict and health research, and to provide deeper insights into the implementation of the programme. Data collection was conducted from March 2022 to June 2022. Purposive and snowball sampling techniques were used for participant recruitment. Thematic analysis was applied for data analysis. Results Twelve researchers/stakeholders participated in this study: four men and eight women. Four main themes were generated: Theme 1: Network building (personal and institutional levels); Theme 2: Hierarchies and power dynamics (power imbalance between different academic status, genders and institutions); Theme 3: Communication challenges; Theme 4: Career development (management, leadership, research, and teaching skills). Conclusions This study provided preliminary insights into perspectives on international collaboration in a major international programme of research on conflict and health. Several key challenges and outputs were generated by the researchers in this study. The findings are important for further developing effective strategies to tackle the challenge of power imbalance and ineffective communication in international research collaborations.

BackgroundChronic hepatitis B (CHB) is endemic in the Aboriginal and Torres Strait Islander population of Australia's Northern Territory. Progression to liver disease can be prevented if holistic care is provided. Low health literacy amongst health professionals is a known barrier to caring for people living with CHB. We co-designed and delivered a culturally safe "Managing hepatitis B" training course for the Aboriginal health workforce. Here, we present an evaluation of the course.Objectives1. To improve course participants CHB-related knowledge, attitudes, and clinical practice. 2. To evaluate the "Managing hepatitis B" training course. 3. To enable participants to have the skills and confidence to be part of the care team.MethodsWe used participatory action research and culturally safe principles. We used purpose-built quantitative and qualitative evaluation tools to evaluate our "Managing hepatitis B" training course. We integrated the two forms of data, deductively analysing codes, grouped into categories, and assessed pedagogical outcomes against Kirkpatrick's training evaluation framework.ResultsEight courses were delivered between 2019 and 2023, with 130 participants from 32 communities. Pre- and post-course questionnaires demonstrated statistically significant improvements in all domains, pConclusionsThe "Managing hepatitis B" training course led to a sustained improvement in the knowledge and attitudes of the Aboriginal health workforce, resulting in improved care and treatment uptake for people living with CHB. Important non-clinical outcomes included strengthening teaching and leadership skills, and empowerment.

BackgroundThe coronavirus pandemic has potential implications for stress levels and resilience among oncology healthcare professionals (HCPs). This study aims to assess perceived stress, resilience, and moral distress levels among oncology HCPs in Jordan during the pandemic and identify associated risk factors.MethodsAn online cross-sectional survey was conducted among oncology HCPs in Jordan using three validated tools: Perceived Stress Scale (PSS), Connor-Davidson Resilience Scale (CD-RSIC), and Moral Distress Thermometer (MDT). Seven items were used to assess sources of stress.ResultsA total of 965 participants enrolled with a 74% response rate. The participants’ ages ranged from 20 to 74 (mean = 32.74, SD = 5.197), with 79.1% males, 45.1% were physicians, 32.6% were public hospital workers, 57.1% were married, and 56.6% had children below 18 years. Findings indicated moderate perceived stress (Mean = 15.87, SD = 5.861), low resilience (Mean = 29.18, SD = 5.197), and high moral distress (Mean = 4.72, SD = 2.564). Females, unmarried individuals, and younger age groups exhibited higher PSS (p = 0.009, p

The need to reconcile food production, the safeguarding of nature, and the protection of public health is imperative in a world of continuing global change, particularly in the context of risks of emerging zoonotic disease (EZD). In this paper, we explored potential land use strategies to reduce EZD risks using a landscape approach. We focused on strategies for cases where the dynamics of pathogen transmission among species were poorly known and the ideas of “land-use induced spillover” and “landscape immunity” could be used very broadly. We first modeled three different land-use change scenarios in a region of transition between the Cerrado and the Atlantic Forest biodiversity hotspots. The land-use strategies used to build our scenarios reflected different proportions of native vegetation cover, as a proxy of habitat availability. We then evaluated the effects of the proportion of native vegetation cover on the occupancy probability of a group of mammal species and analyzed how the different land-use scenarios might affect the distribution of species in the landscape and thus the risk of EZD. We demonstrate that these approaches can help identify potential future EZD risks, and can thus be used as decision-making tools by stakeholders, with direct implications for improving both environmental and socio-economic outcomes.

Background Despite theoretical support for including mental health and psychosocial support (MHPSS) with peacebuilding, few programmes in conflict-affected regions fully integrate these approaches. Aims To describe and assess preliminary outcomes of the Counselling on Wheels programme delivered by the NEEM Foundation in the Borno State of North-East Nigeria. Method We first describe the components of the Counselling on Wheels programme, including education and advocacy for peace and social cohesion through community peacebuilding partnerships and activities, and an MHPSS intervention open to all adults, delivered in groups of eight to ten people. We then conducted secondary analysis of data from 1550 adults who took part in the MHPSS intervention, who provided data at baseline and 1–2 weeks after the final group session. Vulnerability to violent extremism was assessed with a locally developed 80-item scale. Symptoms of common mental disorders were assessed with the Depression, Anxiety and Stress Scale (DASS-21) and Post-Traumatic Stress Disorder Scale (PTSD-8). Data were analysed through a mixed-effect linear regression model, accounting for clustering by community and adjusted for age and gender. Results After taking part in group MHPSS, scores fell for depression (−5.8, 95% CI −6.7 to −5.0), stress (−5.5, 95% CI −6.3 to −4.6), post-traumatic stress disorder (−2.9, 95% CI −3.4 to −2.4) and vulnerability to violent extremism (−44.6, 95% CI −50.6 to −38.6). Conclusions The Counselling on Wheels programme shows promise as a model for integrating MHPSS with community peacebuilding activities in this conflict-affected region of Africa.

PURPOSECancer is a major burden across Middle East, North Africa, Türkiye (MENAT). Many MENAT countries experience multiple conflicts that compound vulnerabilities, but little research investigates the linkages between vulnerability and cancer research. This study examines the current level and the potential for cancer research among vulnerable populations in the MENAT region, aiming to provide direction toward developing a research agenda on the region's vulnerable populations.METHODSExpert-driven meetings were arranged among the 10 authors. After obtaining institutional review board approval, a self-administered online survey questionnaire was circulated to more than 500 cancer practitioners working in 22 MENAT countries.RESULTSTwo hundred sixteen cancer practitioners across the MENAT region responded. Fifty percent of the respondents identified clinical research in vulnerable patients with cancer as a significant issue; 21.8% reported previous research experience that included vulnerable populations, and 60% reported encountering vulnerable populations in their daily clinical practice. The main barriers to conducting research were lack of funding (60%), protected time (42%), and research training (35%). More than half of the respondents believed that wars/conflicts constituted an important source of vulnerability. The most vulnerable cancer populations were the elderly, palliative/terminally ill, those with concomitant mental health-related issues, those with other chronic illnesses, and socioeconomically deprived patients.CONCLUSIONResults support that a major effort is needed to improve cancer research among vulnerable cancer populations in the MENAT region. We call for interdisciplinary research that accounts for the region's unique, compounding, and cumulative forms of vulnerability. This cancer research agenda on different vulnerable populations must balance sociobehavioral studies that explore sociopolitical barriers to quality care and clinical studies that gauge and refine treatment protocols. Building a research agenda through collaboration and solidarity with international partners is prime time.

Rapidly expanding systemic treatment options, combined with improved screening, diagnostic, surgical, and radiotherapy techniques, have led to improved survival outcomes for many cancers over time. However, these overall survival gains have disproportionately benefited patients in high-income countries, whereas patients in low- and middle-income countries (LMICs) continue to experience challenges in accessing timely and guideline concordant care. In September 2022, the Accelerating Anticancer Agent Development and Validation workshop was held, focusing on global cancer drug development. Panelists discussed key barriers such as the lack of diagnostic services and human resources, drug accessibility and affordability, lack of research infrastructure, and regulatory and authorization challenges, with a particular focus on Africa and Latin America. Potential opportunities to improve access and affordability were reviewed, such as the importance of prioritizing investments in diagnostics, investing health infrastructure and work force planning, coordinated drug procurement efforts and streamlined regulatory processing, incentivized pricing through regulatory change, and the importance of developing and promoting clinical trials that can answer relevant clinical questions for patients in LMICs. As a cancer community, we must continue to advocate for and work toward equitable access to high-quality interventions for patients, regardless of their geographical location.

Abstract Background In Syria, disruption to water and sanitation systems, together with poor access to vaccination, forced displacement and overcrowding contribute to increases in waterborne diseases (WBDs). The aim of this study is to perform a spatiotemporal analysis to investigate potential associations between interruptions to water, sanitation, and hygiene (WASH) and WBDs in northeast Syria using data collected by the Early Warning Alert and Response Network (EWARN) from Deir-ez-Zor, Raqqa, Hassakeh and parts of Aleppo governorates. Methods We reviewed the literature databases of MEDLINE and Google Scholar and the updates of ReliefWeb to obtain information on acute disruptions and attacks against water infrastructure in northeast Syria between January 2015 and June 2021. The EWARN weekly trends of five syndromes representing waterborne diseases were plotted and analysed to identify time trends and the influence of these disruptions. To investigate a potential relationship, the Wilcoxon rank sum test was used to compare districts with and without disruptions. Time series analyses were carried out on major disruptions to analyse their effect on WBD incidence. Results The literature review found several instances where water infrastructure was attacked or disrupted, suggesting that water has been deliberately targeted by both state and non-state actors in northeast Syria throughout the conflict. Over time, there was an overall upwards trend of other acute diarrhoea (OAD, p

PURPOSEThe post–COVID-19 funding landscape for cancer research globally has become increasingly challenging, particularly in resource-challenged regions (RCRs) lacking strong research ecosystems. We aimed to produce a list of priority areas for cancer research in countries with limited resources, informed by researchers and patients.METHODSCancer experts in lower-resource health care systems (as defined by the World Bank as low- and middle-income countries; N = 151) were contacted to participate in a modified consensus-seeking Delphi survey, comprising two rounds. In round 1, participants (n = 69) rated predetermined areas of potential research priority (ARPs) for importance and suggested missing ARPs. In round 2, the same participants (n = 49) rated an integrated list of predetermined and suggested ARPs from round 1, then undertook a forced choice priority ranking exercise. Composite voting scores (T-scores) were used to rank the ARPs. Importance ratings were summarized descriptively. Findings were discussed with international patient advocacy organization representatives.RESULTSThe top ARP was research into strategies adapting guidelines or treatment strategies in line with available resources (particularly systemic therapy) (T = 83). Others included cancer registries (T = 62); prevention (T = 52); end-of-life care (T = 53); and value-based and affordable care (T = 51). The top COVID-19/cancer ARP was strategies to incorporate what has been learned during the pandemic that can be maintained posteriorly (T = 36). Others included treatment schedule interruption (T = 24); cost-effective reduction of COVID-19 morbidity/mortality (T = 19); and pandemic preparedness (T = 18).CONCLUSIONAreas of strategic priority favored by cancer researchers in RCRs are related to adaptive treatment guidelines; sustainable implementation of cancer registries; prevention strategies; value-based and affordable cancer care; investments in research capacity building; epidemiologic work on local risk factors for cancer; and combatting inequities of prevention and care access.

IntroductionUniversal health coverage highlights palliative care as an essential component of health services. However, it is unclear what constitutes person-centered care in populations affected by conflict, as they may have specific concerns in the dimensions of physical, emotional, social, and spiritual wellbeing. This study aimed to identify what matters to patients with advanced cancer and family caregivers in Jordan including refugees, to inform appropriate person-centered assessment and palliative care in conflict-affected populations.MethodsCross-sectional face-to-face, semi-structured interviews were conducted at two sites in Amman. Adult patients with advanced cancer and family caregivers were purposively sampled to maximize diversity and representation. Interviews were digitally audio recorded, anonymized, and transcribed verbatim for thematic analysis.FindingsFour themes were generated from 50 patients (22 refugees; 28 Jordanians) and 20 caregivers (7 refugees; 13 Jordanians) (1). Information, communication, and decision-making. Truth-telling and full disclosure from clinicians was valued, and participants expressed concerns that information was not shared in case patients would disengage with treatment. (2) Priorities and concerns for care and support. Participants’ top priority remained cure and recovery (which was viewed as possible). Other priorities included returning to their “normal” life and their “own” country, and to continue contributing to their family. (3) Role of spirituality and Islam. Most participants had strong faith in God and felt that having faith could comfort them. For refugees whose social network was fractured due to being away from home country, prayer and Quran reading became particularly important. (4) Unmet support needs of family caregivers. Family caregivers were affected physically and emotionally by worrying about and caring for the patients. They needed support and training, but often could not access this.DiscussionTruth-telling is highly valued and essential to achieving person-centered care and informed decision-making. This study also reveals specific concerns in conflict-affected populations, reflecting the experience of prior losses and fracturing of existing social networks and support. The role of religion is crucial in supporting refugee communities, and consideration should be paid to the needs of patients and caregivers when caring for a patient at home without access to their communities of origin and the support they accessed.

Background: In this study, we compared and contrasted design characteristics, results, and publications of randomized controlled trials (RCTs) in gastrointestinal (GI), lung, and breast cancer. Methods: A PUBMED search identified phase III RCTs of anticancer therapy in GI, lung, and breast cancer published globally during the period 2014–2017. Descriptive statistics, chi-square tests, and the Kruskal–Wallis test were used to compare RCT design, results, and output across the cancer sites. Results: A total of 352 RCTs were conducted on GI (36%), lung (29%), and breast (35%) cancer. Surrogate endpoints were used in 55% of trials; this was most common in breast trials (72%) compared to GI (47%) and lung trials (43%, p < 0.001). Breast trials more often met their primary endpoint (54%) than GI (41%) and lung trials (41%) (p = 0.024). When graded with the ESMO-MCBS, lung cancer trials (50%, 15/30) were more likely to meet the threshold for substantial benefit. GI trials were published in journals with a substantially lower impact factor (IF; median IF 13) than lung (median IF 21) and breast cancer trials (median IF 21) (p = 0.038). Conclusions: Important differences in RCT design and output exist between the three major cancer sites. Use of surrogate endpoints and the magnitude of benefit associated with new treatments vary substantially across cancer sites.

Confusion over what constitutes appropriate childrearing practices in culturally diverse settings may result in the stigmatization of ethnic minority families and over-reporting to child welfare services. This study explored stakeholders’ views on (in)adequate supervision across cultural and socioeconomic groups and how they assess the risk of harm in cases of lack of supervision. Focus group discussions were held with (a) adult caregivers (n = 39) and adolescents (n = 63) in family-based care from French-speaking Quebecers and migrants from Latin America, the Caribbean, and South Asia; and (b) professionals (n = 67) in the education, health, child welfare, and security sectors in Quebec. The main criteria used to assess the appropriateness of supervision were the maturity, level of ability, age, and sex of the child, as well as contextual factors, such as proximity of other people, location, and type and duration of the activity. Mobility and immobility notions are used to explore the developmental considerations of competence and readiness within the home and in other social environments where adults’ and children’s perceptions of safety and maturity may differ, as well as the need to move away from rigid policy implementation. This paper advocates for careful consideration of the capacity and agency of children affected by migration in the provision of childcare support and their meaningful participation in research and decision making in matters that affect them.

Abstract Background With more than 3.6 million Syrian refugees Turkey hosts the world's largest number of Syrians. Considering the morbidity, mortality, and healthcare spending, cancer is one of the leading health and economic burden for patients and healthcare systems. However, very limited information available in the scientific literature to understand the burden and characteristics of cancer in countries hosting Syrian refugees. The aim of the present study is to evaluate the demographic and clinical characteristics, treatment outcome of Syrian cancer patients living in Konya, Turkey. Methods We retrospectively reviewed medical records of Syrian cancer patients at three major institutions from 2005 to 2020. The information regarding demographic and clinical characteristics of patients were identified. The number of days between the first symptom and diagnosis was considered as the “diagnostic interval”. Patients who failed to attend clinics within four weeks of appointment were assumed abandoned treatment. Survival curves were estimated using the Kaplan–Meier method. Results We identified 230 adult and 38 children refugee diagnosed with cancer during the study period. With regards to adult patients, there were 114 (49.6%) male and 116 (50.4%) female. The median age at diagnosis was 52.4, 47.3 years for male, female respectively. The five most common cancer by site among all were; breast (24.8%), colorectal (10.9%), lung (7.4%), central nervous system (CNS) (7.0%), and stomach (5.2%). 93 (40.4%) had metastatic disease at diagnosis. The overall survival probability was 37.5% at five years for the adult population. Data were extracted for 20 boys and 18 girls with childhood cancer. Their median age at diagnosis was 5.8 and 6.0 years respectively. The three most common childhood cancer were; leukemias (21.1%), lymphomas (21.1%), and CNS (13.2%). Excluding leukemia, 13 (43.3%) of childhood cancer cases had the advanced disease at diagnosis. Three year survival probality was 69.5%. The median diagnostic interval for adult and childhood cancer was 96.5 (IQR = 53–165) and 23 (IQR = 13.5–59) days respectively. Twenty-one adults and four children had treatment abandonment. Conclusion This study contributes to understanding the burden of cancer among Syrian refugees living in Konya, growing health issue for refugees. Larger and prospective studies will help to measure the real burden and compare the difference in cancer risk factors, care, and outcomes among the refugee and host populations.

PURPOSELimited access to adequate cancer surgery training is one of the driving forces behind global inequities in surgical cancer care. Affordable virtual reality (VR) surgical training could enhance surgical skills in low- and middle-income settings, but most VR and augmented reality systems are too expensive and do not teach open surgical techniques commonly practiced in these contexts. New low-cost VR can offer skill development simulations relevant to these settings, but little is known about how knowledge is gained and applied by surgeons training and working in specific resource-constrained settings. This study addresses this gap, exploring gynecologic oncology trainee learning and user experience using a low-cost VR simulator to learn to perform an open radical abdominal hysterectomy in Lusaka, Zambia.METHODSEleven surgical trainees rotating through the gynecologic oncology service were sequentially recruited from the University Teaching Hospital in Lusaka to participate in a study evaluating a VR radical abdominal hysterectomy training designed to replicate the experience in a Zambian hospital. Six participated in semi-structured interviews following the training. Interviews were analyzed using open and axial coding, informed by grounded theory.RESULTSSimulator participation increased participants' perception of their surgical knowledge, confidence, and skills. Participants believed their skills transferred to other related surgical procedures. Having clear goals and motivation to improve were described as factors that influenced success.CONCLUSIONFor cancer surgery trainees in lower-resourced settings learning medical and surgical skills, even for those with limited VR experience, low-cost VR simulators may enhance anatomical knowledge and confidence. The VR simulator reinforced anatomical and clinical knowledge acquired through other modalities. VR-enhanced learning may be particularly valuable when mentored learning opportunities are limited.

PURPOSENational cancer control strategies have been identified as essential tools for reducing and managing the growing burden of cancer in low- and middle-income countries. Cancer registration is an instrumental component of any cancer control strategy, providing the data to inform effective cancer policy. In the Middle East, North Africa, and Turkey (MENAT) region, cancer registration varies immensely and faces multifaceted challenges including protracted conflict. This study investigates and maps out the present capacities and outputs of cancer registration in the MENAT region and identifies thematic barriers facing implementation and utilization of cancer registry data.MATERIALS AND METHODSWe used a self-administered online survey with open and close-ended questions targeting national and institutional cancer registry managers in the MENAT countries.RESULTSRegistry managers from 19 MENAT countries reported the presence of 97 population-based, 48 hospital-based, and 24 pathology-based registries. Most population-based registries were well- or partially developed. Lack of accurate death records, complete medical records, and communication between stakeholders and deficiencies in trained personnel were critical challenges that were more severe in active conflict zones and neighboring conflict-affected regions. Cancer registration challenges included weak health infrastructure, absence of legislation mandating cancer registration, and disruption of cancer registration because of active conflict and loss of funding. Refugee host countries, such as Lebanon, Turkey, and Jordan, also reported conflict-related challenges including refugee mobility and lack of accurate data on forced migrants.CONCLUSIONThis study provides a much-needed understanding of the current landscape and contextual challenges affecting cancer registration in the MENAT. These data are important for identifying areas on which to focus regional capacity-strengthening initiatives.

ABSTRACT: Coxiella burnetti is the causative organism of the zoonotic infection Q fever, of which endocarditis is one of the most common manifestations of the chronic form. Polymicrobial endocarditis with Q fever is extremely rare and is yet to be described among an Australasian cohort. Summary: We present the case of a 32-year-old gardener with culture-negative chronic Q fever prosthetic valve endocarditis concomitant with another bacterial pathogen, leading to aortic root abscess formation, requiring a Bentall procedure, extracorporeal membrane oxygenation, and prolonged antimicrobial therapy, with a fatal outcome. Unique to our case, Q fever was identified early, and the second pathogen was only detected on 16S ribosomal RNA (rRNA) polymerase chain reaction of explanted valvular tissue.Given the high risk for morbidity, we recommend that screening for Q fever in endemic areas among patients with infective endocarditis from other etiologies be considered. In addition, this case highlights the role for Q fever vaccination of the at-risk population with underlying valvulopathy. Furthermore, clinicians should be aware of polymicrobial infective endocarditis and suspicious in case of patients with atypical clinical features.

Abstract Background Chronic and frequently recurring infectious diseases, such as malaria, are associated with expanded populations of atypical memory B cells (MBCs). These cells are different from classical MBCs by the lack of surface markers CD21 and CD27 and increased expression of inhibitory receptors, such as FcRL5. While the phenotype and conditions leading to neogenesis of atypical MBCs in malaria-experienced individuals have been studied extensively, the origin of these cells remains equivocal. Functional similarities between FcRL5+ atypical MBCs and FcRL5+ classical MBCs have been reported, suggesting that these cells may be developmentally related. Methods Here, a longitudinal analysis of FcRL5 expression in various B cell subsets was performed in two children from a high transmission region in Uganda over a 6-month period in which both children experienced a malaria episode. Using B-cell receptor (BCR)-sequencing to track clonally related cells, the connections between IgM+ and IgG+ atypical MBCs and other B cell subsets were studied. Results The highest expression of FcRL5 was found among IgG+ atypical MBCs, but FcRL5+ cells were present in all MBC subsets. Following malaria, FcRL5 expression increased in all IgM+ MBC subsets analysed here: classical, activated, and atypical MBCs, while results for IgG+ MBC subsets were inconclusive. IgM+ atypical MBCs showed few connections with other B cell subsets, higher turnover than IgG+ atypical MBCs, and were predominantly derived from naïve B cells and FcRL5− IgM+ classical MBCs. In contrast, IgG+ atypical MBCs were clonally expanded and connected with classical MBCs. IgG+ atypical MBCs present after a malaria episode mainly originated from FcRL5+ IgG+ classical MBCs. Conclusions Collectively, these results suggest fundamental differences between unswitched and class-switched B cell populations and provide clues about the primary developmental pathways of atypical MBCs in malaria-experienced individuals.

Precision diagnostic testing (PDT) employs appropriate biomarkers to identify cancer patients that may optimally respond to precision medicine (PM) approaches, such as treatments with targeted agents and immuno‐oncology drugs. To date, there are no published systematic appraisals evaluating the cost‐effectiveness of PDT in non‐small‐cell lung cancer (NSCLC). To address this gap, we conducted Preferred Reporting Items for Systematic Reviews and Meta‐Analyses searches for the years 2009–2019. Consolidated Health Economic Evaluation Reporting Standards were employed to screen, assess and extract data. Employing base costs, life years gained or quality‐adjusted life years, as well as willingness‐to‐pay (WTP) threshold for each country, net monetary benefit was calculated to determine cost‐effectiveness of each intervention. Thirty‐seven studies (50%) were included for analysis; a further 37 (50%) were excluded, having failed population‐, intervention‐, comparator‐, outcomes‐ and study‐design criteria. Within the 37 studies included, we defined 64 scenarios. Eleven scenarios compared PDT‐guided PM with non‐guided therapy [epidermal growth factor receptor (EGFR), n = 5; programmed death‐ligand 1 (PD‐L1), n = 6]. Twenty‐eight scenarios compared PDT‐guided PM with chemotherapy alone (anaplastic lymphoma kinase, n = 3; EGFR, n = 17; PD‐L1, n = 8). Twenty‐five scenarios compared PDT‐guided PM with chemotherapy alone, while varying the PDT approach. Thirty‐four scenarios (53%) were cost‐effective, 28 (44%) were not cost‐effective, and two were marginal, dependent on their country’s WTP threshold. When PDT‐guided therapy was compared with a therapy‐for‐all patients approach, all scenarios (100%) proved cost‐effective. Seven of 37 studies had been structured appropriately to assess PDT‐PM cost‐effectiveness. Within these seven studies, all evaluated scenarios were cost‐effective. However, 81% of studies had been poorly designed. Our systematic analysis implies that more robust health economic evaluation could help identify additional approaches towards PDT cost‐effectiveness, underpinning value‐based care and enhanced outcomes for patients with NSCLC.

Cancer registration is a core component of national and regional cancer control strategies. In the Middle East, North-Africa and Turkey (MENAT) region, capacity and resources for cancer registration is variable and shaped by multiple contextual challenges. This viewpoint maps out practical recommendations around cancer registration, in an attempt to inform cancer control planning, policy, and implementation. The recommendations laid out in this viewpoint are informed by the discussions held at the Initiative for Cancer Registration in the MENAT (ICRIM) virtual workshop, which convened registry managers, policy makers, and international agencies from 19 countries in the MENAT region. The discussions were distilled in four categories of recommendations, revolving around cancer registration procedures, collaborative governance, putting cancer registration on the map, and capacity building. This viewpoint provides a much-needed mapping of practical recommendations around cancer registration, informed by direct key stakeholders in the region. These practical recommendations offer a road map for policy making, cancer control planning, and future regional capacity strengthening initiatives.

Introduction Research is a critical pillar in national cancer control planning. However, there is a dearth of evidence for countries to implement affordable strategies. The WHO and various Commissions have recommended developing stakeholder-based needs assessments based on objective data to generate evidence to inform national and regional prioritisation of cancer research needs and goals.Methodology Bibliometric algorithms (macros) were developed and validated to assess cancer research outputs of all 54 African countries over a 12-year period (2009–2020). Subanalysis included collaboration patterns, site and domain-specific focus of research and understanding authorship dynamics by both position and sex. Detailed subanalysis was performed to understand multiple impact metrics and context relative outputs in comparison with the disease burden as well as the application of a funding thesaurus to determine funding resources.Results African countries in total published 23 679 cancer research papers over the 12-year period (2009–2020) with the fractional African contribution totalling 16 201 papers and the remaining 7478 from authors from out with the continent. The total number of papers increased rapidly with time, with an annual growth rate of 15%. The 49 sub-Saharan African (SSA) countries together published just 5281 papers, of which South Africa’s contribution was 2206 (42% of the SSA total, 14% of all Africa) and Nigeria’s contribution was 997 (19% of the SSA total, 4% of all Africa). Cancer research accounted for 7.9% of all African biomedical research outputs (African research in infectious diseases was 5.1 times than that of cancer research). Research outputs that are proportionally low relative to their burden across Africa are paediatric, cervical, oesophageal and prostate cancer. African research mirrored that of Western countries in terms of its focus on discovery science and pharmaceutical research. The percentages of female researchers in Africa were comparable with those elsewhere, but only in North African and some Anglophone countries.Conclusions There is an imbalance in relevant local research generation on the continent and cancer control efforts. The recommendations articulated in our five-point plan arising from these data are broadly focused on structural changes, for example, overt inclusion of research into national cancer control planning and financial, for example, for countries to spend 10% of a notional 1% gross domestic expenditure on research and development on cancer.

Objectives: Investigate the weaponization of water during the Syrian conflict and the correlation of attacks on water, sanitation, and hygiene (WASH) infrastructure in Idlib and Aleppo governorates with trends in waterborne diseases reported by Early Warning and Response surveillance systems. Methods: We reviewed literature and databases to obtain information on attacks on WASH in Aleppo and Idlib governorates between 2011 and 2019. We plotted weekly trends in waterborne diseases from two surveillance systems operational in Aleppo and Idlib governorates between 2015 and early 2020. Results: The literature review noted several attacks on water and related infrastructure in both governorates, suggesting that WASH infrastructure was weaponized by state and non-state actors. Most interference with WASH in the Aleppo governorate occurred before 2019 and in the Idlib governorate in the summer of 2020. Other acute diarrhea represented >90% of cases of diarrhea; children under 5 years contributed 50% of cases. There was substantial evidence (p < 0.001) of an overall upward trend in cases of diarrheal disease. Conclusions: Though no direct correlation can be drawn between the weaponization of WASH and the burden of waterborne infections due to multiple confounders, this research introduces important concepts on attacks on WASH and their potential impacts on waterborne diseases.

PURPOSEThe WHO essential medicines list (EML) guides selection of drugs for national formularies. Here, we evaluate which medicines are considered highest priority by Indian oncologists and the extent to which they are available in routine practice.METHODSThis is a secondary analysis of an electronic survey developed by the WHO EML Cancer Medicine Working Group. The survey was distributed globally using a hierarchical snowball method to physicians who prescribe systemic anticancer therapy. The survey captured the 10 medicines oncologists considered highest priority for population health and their availability in routine practice.RESULTSThe global study cohort included 948 respondents from 82 countries; 98 were from India and 67 were from other low- and middle-income countries. Compared with other low- and middle-income countries, the Indian cohort was more likely to be medical oncologist (70% v 31%, P < .001) and work exclusively in the private health system (52% v 17%, P < .001). 14/20 most commonly selected medicines were conventional cytotoxic drugs. Universal access to these medicines was reported by a minority of oncologists; risks of significant out-of-pocket expenditures for each medicine were reported by 19%-58% of oncologists. Risk of catastrophic expenditure was reported by 58%-67% of oncologists for rituximab and trastuzumab. Risks of financial toxicity were substantially higher within the private health system compared with the public system.CONCLUSIONMost high-priority cancer medicines identified by Indian oncologists are generic chemotherapy agents that provide substantial improvements in survival and are already included in WHO EML. Access to these treatments remains limited by major financial burdens experienced by patients. This is particularly acute within the private health system. Strategies are urgently needed to ensure that high-quality cancer care is affordable and accessible to all patients in India.

PURPOSEAccess to essential cancer medicines is a major determinant of childhood cancer outcomes globally. The degree to which pediatric oncologists deem medicines listed on WHO's Model List of Essential Medicines for Children (EMLc) essential is unknown, as is the extent to which such medicines are accessible on the front lines of clinical care.METHODSAn electronic survey developed was distributed through the International Society of Pediatric Oncology mailing list to members from 87 countries. Respondents were asked to select 10 cancer medicines that would provide the greatest benefit to patients in their context; subsequent questions explored medicine availability and cost. Descriptive and bivariate statistics compared access to medicines between low- and lower-middle–income countries (LMICs), upper-middle–income countries (UMICs), and high-income countries (HICs).RESULTSAmong 159 respondents from 44 countries, 43 (27%) were from LMICs, 79 (50%) from UMICs, and 37 (23%) from HICs. The top five medicines were methotrexate (75%), vincristine (74%), doxorubicin (74%), cyclophosphamide (69%), and cytarabine (65%). Of the priority medicines identified, 87% (27 of 31) are represented on the 2021 EMLc and 77% (24 of 31) were common to the lists generated by LMIC, UMIC, and HIC respondents. The proportion of respondents indicating universal availability for each of the top medicines ranged from 9% to 46% for LMIC, 25% to 89% for UMIC, and 67% to 100% for HIC. Risk of catastrophic expenditure was more common in LMIC (8%-20%), compared with UMIC (0%-28%) and HIC (0%).CONCLUSIONMost medicines that oncologists deem essential for childhood cancer treatment are currently included on the EMLc. Barriers remain in access to these medicines, characterized by gaps in availability and risks of catastrophic expenditure for families that are most pronounced in low-income settings but evident across all income contexts.

Abstract Background It is estimated that over 40% of the half a million humanitarian workers who provide frontline care during emergencies, wars and disasters, are women. Women are at the forefront of improving health for conflict-affected populations through service delivery, education and capacity strengthening, advocacy and research. Women are also disproportionately affected by conflict and humanitarian emergencies. The growing evidence base demonstrating excess female morbidity and mortality reflects the necessity of evaluating the role of women in leadership driving health research, policy and programmatic interventions in conflict-related humanitarian contexts. Despite global commitments to improving gender equality, the issue of women leaders in conflict and humanitarian health has been given little or no attention. The aim of this paper focuses on three domains: importance, barriers and opportunities for women leaders in conflict and humanitarian health. Following thematic analysis of the material collected, we discuss the following themes: barriers of women’s leadership domain at societal level, and organisational level, which is subcategorized into culture and strategy. Building on the available opportunities and initiatives and on inspirational experiences of the limited number of women leaders in this field, recommendations for empowering and supporting women’s leadership in conflict health are presented. Methods A desk-based literature review of academic and grey sources was conducted followed by thematic analysis. Results There is very limited evidence on women leaders in conflict and humanitarian health. Some data shows that women have leadership skills that help to support more inclusive solutions which are incredibly important in this sector. However, deeply imbedded discrimination against women at the organisational, cultural, social, financial and political levels is exacerbated in conflict which makes it more challenging for women to progress in such settings. Conclusion Advocating for women leaders in conflict and health in the humanitarian sector, governmental bodies, academia and the global health community is crucial to increasing effective interventions that adequately address the complexity and diversity of humanitarian crises.

Objectives We explore the routes to cancer diagnosis to further undertanding of the inequality in the reduction in detection of new cancers since the start of the pandemic. We use different data sets to assess stages in the cancer pathway: primary care data for primary care consultations, routine and urgent referrals and published analysis of cancer registry data for appointments and first treatments.Setting Primary and cancer care.Participants In this study we combine multiple data sets to perform a population-based cohort study on different areas of the cancer pathway. For primary care analysis, we use a random sample of 5 00 000 patients from the Clinical Practice Research Datalink. Postreferral we perform a secondary data analysis on the Cancer Wait Times data and the National Cancer Registry Analysis Service COVID-19 data equity pack.Outcome measures Primary care: consultation, urgent cancer referral and routine referral rates, then appointments following an urgent cancer referral, and first treatments for new cancer, for all and by quintile of patient’s local area index of multiple deprivation.Results Primary care contacts and urgent cancer referrals in England fell by 11.6% (95% CI 11.4% to 11.7%) and 20.2% (95% CI 18.1% to 22.3%) respectively between the start of the first non-pharmaceutical intervention in March 2020 and the end of January 2021, while routine referrals had not recovered to prepandemic levels. Reductions in first treatments for newly diagnosed cancers are down 16.3% (95% CI 15.9% to 16.6%). The reduction in the number of 2-week wait referrals and first treatments for all cancer has been largest for those living in poorer areas, despite having a smaller reduction in primary care contact.Conclusions Our results further evidence the strain on primary care and the presence of the inverse care law, and the dire need to address the inequalities so sharply brought into focus by the pandemic. We need to address the disconnect between the importance we place on the role of primary care and the resources we devote to it.

PURPOSETo critically review the evidence and opinions expressed about mammographic screening (MS) in research reports on breast cancer in the occupied Palestinian territory (oPt) and to assess whether benefits and harms in MS are presented in a balanced way.METHODSSearches of PubMed, Cochrane, MEDLINE, EMBASE, CINAHL, and gray literature identified 14 eligible research reports relating to the oPt. We reviewed these documents and then used a thematic analysis to describe and analyze the evidence and the opinions about MS expressed in them.RESULTSAll 14 research reports mentioned that MS would improve survival rates in the oPt. Only three gave information on major harmful effects, and only two emphasized that MS must be accompanied by effective treatment to have any beneficial effects on population mortality. There was no consistency in the recommended frequency of MS.CONCLUSIONMost information presented by Palestinian health researchers was selective and failed to address the important established harms of MS. Thus, calls to support MS in the oPt are not based on a measured discussion of the risks and benefits for women or grounded in the systemic readiness of health care necessary for its effectiveness. As long as diagnostic and treatment facilities remain deficient, screening cannot lead to reduced mortality from breast cancer.

This study sought to investigate the amount of global research activity and investment in pediatric cancer research, using publications as a proxy measure, and to understand geographical differences in research activity. To do this, we used a quantitative method—bibliometrics—to analyze Web of Science publications in the 10 years from 2007 to 2016. We found that global pediatric cancer research outputs have increased from 2,937 in 2007 to 4,513 in 2016, at an annual growth rate of 4.3%. This rate is slower than for both cancer research as a whole and general pediatric research. The increase in output was due almost entirely to China. International collaboration was similar to that in cancer research overall, with the highest levels among countries in close geographical proximity. Hematological and CNS childhood cancers are the main areas for research. Genetics and prognosis were the main research domains, and there was little work on radiotherapy or palliative care. In terms of citations, the best-performing countries were the Netherlands, the United States, and the United Kingdom. On the basis of estimates of the cost of research papers in different countries, the total world pediatric cancer research expenditure is estimated to have been 1.54 billion US dollars (USD) in 2013, and 1.79 billion USD in 2016. Our data suggest that current global policy toward pediatric cancer needs significant review and change to increase investments, balance research portfolios, and improve research that is relevant to low- and middle-income countries.

PURPOSE Cancer is a leading cause of death among children in the Eastern Mediterranean region, where conflict and economic downturn place additional burden on the health sector. In this context, using economic evidence to inform policy decisions is crucial for maximizing health outcomes from available resources. We summarized the available evidence on the economics of pediatric cancer in Jordan, Lebanon, the occupied Palestinian territory, and Turkey. METHODS A scoping review was performed of seven academic databases and gray literature pertaining to pediatric cancer in the four jurisdictions, published between January 1, 2010, and July 17, 2019. Information was extracted and organized using an analytical framework that synthesizes economic information on four dimensions: the context of the health system, the economics of health care inputs, the economics of service provision, and the economic consequences of disease. RESULTS Most of the economic evidence available across the four jurisdictions pertains to the availability of health care inputs (ie, drugs, human resources, cancer registration data, and treatment protocols) and individual-level outcomes (either clinical or health-related quality of life). We identified little evidence on the efficiency or quality of health care inputs and of pediatric cancer services. Moreover, we identified no studies examining the cost-effectiveness of any intervention, program, or treatment protocol. Evidence on the economic consequences of pediatric cancer on families and the society at large was predominantly qualitative. CONCLUSION The available economic evidence on pediatric cancer care in the four countries is limited to resource availability and, to an extent, patient outcomes, with a substantial gap in information on drug quality, service provision efficiency, and cost-effectiveness. Links between researchers and policymakers must be strengthened if pediatric cancer spending decisions, and, ultimately, treatment outcomes, are to improve.

Abstract Background Armed conflict can indirectly affect population health through detrimental impacts on political and social institutions and destruction of infrastructure. This study aimed to quantify indirect mortality impacts of armed conflict in civilian populations globally and explore differential effects by armed conflict characteristics and population groups. Methods We included 193 countries between 1990 and 2017 and constructed fixed effects panel regression models using data from the Uppsala Conflict Data Program and Global Burden of Disease study. Mortality rates were corrected to exclude battle-related deaths. We assessed separately four different armed conflict variables (capturing binary, continuous, categorical, and quintile exposures) and ran models by cause-specific mortality stratified by age groups and sex. Post-estimation analyses calculated the number of civilian deaths. Results We identified 1118 unique armed conflicts. Armed conflict was associated with increases in civilian mortality—driven by conflicts categorised as wars. Wars were associated with an increase in age-standardised all-cause mortality of 81.5 per 100,000 population (β 81.5, 95% CI 14.3–148.8) in adjusted models contributing 29.4 million civilian deaths (95% CI 22.1–36.6) globally over the study period. Mortality rates from communicable, maternal, neonatal, and nutritional diseases (β 51.3, 95% CI 2.6–99.9); non-communicable diseases (β 22.7, 95% CI 0.2–45.2); and injuries (β 7.6, 95% CI 3.4–11.7) associated with war increased, contributing 21.0 million (95% CI 16.3–25.6), 6.0 million (95% CI 4.1–8.0), and 2.4 million deaths (95% CI 1.7–3.1) respectively. War-associated increases in all-cause and cause-specific mortality were found across all age groups and both genders, but children aged 0–5 years had the largest relative increases in mortality. Conclusions Armed conflict, particularly war, is associated with a substantial indirect mortality impact among civilians globally with children most severely burdened.

Abstract Refugees and internally displaced persons in humanitarian settings are particularly susceptible to the spread of infectious illnesses such as COVID-19 due to overcrowding and inadequate access to clean water, sanitation, and hygiene facilities. Countries facing conflict or humanitarian emergencies often have damaged or fragmented health systems and little to no capacity to test, isolate, and treat COVID-19 cases. Without a plan to address COVID-19 in humanitarian settings, host governments, aid agencies, and international organizations risk prolonging the spread of the virus across borders, threatening global health security, and devastating vulnerable populations. Stakeholders must coordinate a multifaceted response to address COVID-19 in humanitarian settings that incorporates appropriate communication of risks, sets forth resource-stratified guidelines for the use of limited testing, provides resources to treat affected patients, and engages displaced populations.

Cyber-attacks against hospitals, medical devices, and healthcare entities are becoming increasingly common; simultaneously, physical attacks against hospitals and healthcare entities are increasing. The purpose of this article is to explore the threat to healthcare from cyber-attacks. We undertake qualitative analysis of current and past cyber-attacks on healthcare system and look at these in the context of the increase in non-traditional threats. We conclude that there is a current and systemic threat to the healthcare sector from cyber-attacks by nation state and criminal groups, which is not currently being addressed in a systematic manner. Finally, we conclude that further discussion on key issues such as legislation and regulatory frameworks needs to take place at both a policy and practitioner level.

Introduction: Syria has the largest number of internally displaced people (IDPs) globally with 6.7 million forced from their homes since the uprising erupted in 2011. Most face multiple intersecting vulnerabilities with adverse health impacts. We explore the key health concerns among IDPs, how the various health systems in Syria have responded to the dynamic health needs of IDPs and what modalities have been used by humanitarian actors to address these needs. Methods: We undertook a scoping review of academic and grey literature for available evidence regarding the health of IDPs in Syria. We then organised an online workshop in November 2021 with around 30 participants who represent local, regional, and international organisations and who have relevant expertise. The discussion focused on how the health systems in Syria's various territories have responded to the health needs of IDPs, what this means to the structure and dynamics of these health systems and their intended outcomes and responsiveness. Findings: These emphasised the weak evidence base around IDP health in Syria, particularly in certain geographical areas. Workshop participants explored the applicability of the term IDP in the Syrian context given the fragmented health system and its impact on IDPs, the importance of considering co-determinants (beyond forced displacement) on the health of IDPs and taking a transectoral, community led approach to identify and respond to needs. Conclusion: This manuscript presents some of the current issues with regards to IDP health in Syria, however, there remain numerous unknowns, both for the health of IDP as well as non-IDP populations. We hope that it will be the foundation for further discussions on practical steps relating to research, analysis and interventions which can support health system responses for IDPs in Syria.

Introduction: The COVID-19 pandemic has had an unprecedented impact on global health systems and economies. With ongoing and future challenges posed to the field due to the pandemic, re-examining research priorities has emerged as a concern. As part of a wider project aiming to examine research priorities, here we aimed to qualitatively examine the documented impacts of the COVID-19 pandemic on cancer researchers.Materials and Methods: We conducted a literature review with the aim of identifying non-peer-reviewed journalistic sources and institutional blog posts which qualitatively documented the effects of the COVID-19 pandemic on cancer researchers. We searched on 12th January 2021 using the LexisNexis database and Google, using terms and filters to identify English-language media reports and blogs, containing references to both COVID-19 and cancer research. The targeted search returned 751 results, of which 215 articles met the inclusion criteria. These 215 articles were subjected to a conventional qualitative content analysis, to document the impacts of the pandemic on the field of cancer research.Results: Our analysis yielded a high plurality of qualitatively documented impacts, from which seven categories of direct impacts emerged: (1) COVID measures halting cancer research activity entirely; (2) COVID measures limiting cancer research activity; (3) forced adaptation of research protocols; (4) impacts on cancer diagnosis, cases, and services; (5) availability of resources for cancer research; (6) disruption to the private sector; and (7) disruption to supply chains. Three categories of consequences from these impacts also emerged: (1) potential changes to future research practice; (2) delays to the progression of the field; and (3) potential new areas of research interest.Discussion: The COVID-19 pandemic had extensive practical and economic effects on the field of cancer research in 2020 that were highly plural in nature. Appraisal of cancer research strategies in a post-COVID world should acknowledge the potential for substantial limitations (such as on financial resources, limited access to patients for research, decreased patient access to cancer care, staffing issues, administrative delays, or supply chain issues), exacerbated cancer disparities, advances in digital health, and new areas of research related to the intersection of cancer and COVID-19.

Background: Causes of variations in outcomes from cancer care in developed countries are often unclear. Australia has developed health system pathways describing consensus standards of optimal cancer care across the phases of prevention through to follow-up or end-of-life. These Optimal Care Pathways (OCP) were introduced from 2013 to 14. We investigated whether care consistent with the OCP improved outcomes for colon cancer patients. Methods: Colon patients diagnosed from 2008 to 2014 were identified from the Australian State of Victoria Cancer Registry (VCR) and cases linked with State and Federal health datasets. Surrogate variables describe OCP alignment in our cohort, across three phases of the pathway; prevention, diagnosis and initial treatment and end-of-life. We assessed the impact of alignment on (1) stage of disease at diagnosis and (2) overall survival. Findings: Alignment with the prevention phase of the OCP occurred for 88% of 13,539 individuals and was associated with lower disease stage at diagnosis (OR = 0.33, 95% confidence interval 0.24 to 0.42), improved crude three-year survival (69.2% versus 62.2%; p