Pathway to excellence in cancer care: learning from Qatar's experience

Abstract

In 2011, Qatar launched the First National Cancer Control Program in the GCC. The National Cancer Strategy, A Path to Excellence (2011-2016) and the companion document, Qatar National Cancer Research Strategy (2012) transformed cancer care in Qatar. Cancer outcomes are now equivalent to countries with long established National Cancer Strategies (The Lancet, 2018). Critical to the success were robust governance structures, informed and committed leadership, comprehensive involvement of all sectors including public and private providers, charities, private sector employers, academic partners and the judicious use of expert groups and subject matter experts. Major milestones have been reached in the prevention, early detection, treatment and care of cancer throughout the period the National Cancer Strategy has been in place. Achievements have included harmonized multi-sectoral awareness, education, and myth busting campaigns aligned to a single National Awareness Calendar. A National Breast Cancer Screening Program, a National Bowel Cancer Screening Program and an opportunistically ran Cervical Cancer Screening Program have been established, supported by a dedicated Cancer Screening Call Center and a Mobile Screening Unit for those hard to reach geographical areas in Qatar. Internationally peer reviewed cancer specific teams included new and extended roles, the introduction of forefront diagnostic and treatment modalities and a patient centered approach to the organization of care have improved clinical outcomes, patient experience, and public confidence. Future development will focus on consolidating areas of significant achievement incorporating emerging evidence and new technologies. This will include evidence-based approaches for public engagement, prevention and early detection, particularly the use of personalized approaches. As with any successful cancer program, survivorship and transition programs need to be enhanced to include chronic illness and palliative care models. Rare cancers, further development of local faculty and maturity of Qatar's high impact Cancer Research portfolio are also a focus. Qatar provides a model that illustrates how the principles of good cancer control are internationally applicable but need to be locally owned and adapted to the country and be culturally specific. It is critical to have clear leadership and governance, as well as the right people in all partner organizations to work collaboratively in achieving a common goal. We make key policy recommendations that are applicable inside and outside of Qatar. Moreover, we share the successful cancer care framework learned from the Qatar experience.

Abbreviations
• ASR
• age standardized rate
• CT
• computed tomography
• HBKU
• Hamad Bin Khalifa University
• HMC
• Hamad Medical Corporation
• GCC
• Gulf Cooperation Council
• GDP
• Gross Domestic Product
• MDTs
• multi-disciplinary teams
• MENA
• Middle East and North Africa
• MRI
• magnetic resonance imaging
• MR-IGABT
• magnetic resonance image guided adaptive brachytherapy
• MRgHIFU
• magnetic resonance guided high intensity focused ultrasound
• PHCC
• primary health care corporation
• QBB
• Qatar Biobank
• QCRI
• Qatar Computer Research Institute
• QCRP
• Qatar Cancer Research Partnership
• QCS
• Qatar Cancer Society
• QGP
• Qatar Genome Program
• QPMI
• Qatar Precision Medicine Institute
• SGRT
• radiation therapy surface guided radiotherapy
• TBI
• total body irradiation
• WCMQ
• Weill Cornell Medicine—Qatar
• WHO
• World Health Organizational
• WISH
• World Innovation Summit for Health

INTRODUCTION

In 2011, Qatar launched the First National Cancer Control Program in the Gulf Collaboration Council.¹ The National Cancer Strategy, A Path to Excellence (2011-2016)² was a 5-year plan to transform cancer care in Qatar. It was also the first disease specific strategy in Qatar and formed a key priority within the National Health Strategy 2011-2016.³

Designed around the patient pathway, it also articulated the necessary governance structures including a National Cancer Committee at the Ministry of Public Health, the establishment of National Clinical Advisory Groups for each cancer and a Project Support Team composed of subject matter experts.

A companion document, the Qatar National Cancer Research Strategy, 2012⁴ provided a framework to develop world class basic, clinical, and translational cancer research while developing national capacity and capability utilizing the excellent existing academic infrastructure.

The National Cancer Framework: Next Steps in the Pathway to Excellence (2017-2022)⁵ built on these solid foundations to bring the cancer services and cancer research agenda together to create a single unified plan. It too connected closely with the Better Health dimension of the National Health Strategy 2017-2022⁶: Better Health, Better Care, and Better Value.

Qatar is a small country on the Arabian Peninsula that has seen rapid development over the past decades. It has a high per capita GDP and a small, relatively young national population. It also has a large expatriate population.

Cancer is already the nation's second noncommunicable disease, after cardiovascular disease and is projected to triple between 2010 and 2030 as a result of a combination of ageing and population growth.

Qatar has a unique, understudied population with atypical disease presentations and patterns, which are of international interest and of importance for the people of the Gulf region as well as the growing global Arabian diaspora.

It has an excellent Cancer Research Infrastructure across academic partners in universities and research institutions, which offers the possibility to occupy some niche positions in cancer research. This includes an established infrastructure to support innovation and biotech development.

Public Health Care is available free for all residents who have paid a minimum fee for health insurance and this includes cancer care. There is also access to ad hoc support for treatment on an exceptional or compassionate need basis from other sources such as charities, including the Qatar Cancer Society (QCS).

THE CANCER BURDEN Global perspective

Cancer is a global health challenge whose incidence is on the rise and it is also a leading cause of death worldwide. The World Health Organizational (WHO) recommends that all countries develop and implement a Cancer Control Program to prevent cancer, detect it early when it does occur and manage the disease and its impact effectively through treatment into survivorship or palliative care. It was in response to this call that Qatar developed The National Cancer Strategy, A Path to Excellence (2011-2016).²

According to the WHO estimates in 2015, cancer is the first or second leading cause of death before age 70 years in 91 of 172 countries. It ranks third or fourth in an additional 22 countries of which Qatar is one of them (Figure 1).

FIGURE 1. Cancer Burden. Adapted global map indicating national ranking of cancer as a cause of death at ages below 70 years in 2015.Source: World Health Organization

The cost of cancer

Cancer and its treatment result in the loss of economic resources and opportunities for patients, families, employers, and society overall. These losses include financial loss, morbidity, reduced quality of life, and premature death. The economic burden of cancer is a growing global issue and the burden on individuals and families is profound. Research estimates that based on premature death and disability from cancer worldwide the total economic impact of cancer is around 1.5% of the total global GDP, which does not include direct costs of treating cancer.⁷ For Qatar, this would equate to approximately $2.87 billion. The WHO and global health experts believe that significant costs from cancer could be mitigated by targeted, cost effective interventions that have worked in some nations.

Qatar perspective

Qatar is a relatively young country, but its cancer incidence is project to almost triple between 2010 and 2030 due to aging and population growth (Figure 2).

FIGURE 2. Projected Incidence of Cancer in Qatar.Source: Ministry of Public Health—Qatar

As in other countries, cancer incidence increases with age and life expectancy in Qatar continues to rise for both men (79 years) and women (82 years) (Table 1). It is the second cause of death from noncommunicable diseases.

TABLE 1 WHO reported cancer situation 2018

	2014 (WHO cancer country profiles)	2018 (WHO Globocan)	Approximate annual increase
Incidence	540	1260	33%
Mortality	400	672	17%

Premature mortality from cancer

Data from Qatar National Cancer Registry in 2016, shows that a total of 1566 new cancer cases were diagnosed in 2016, of which 21% were Qataris; 42% females and 58% males. The most common cancer was breast cancer, constituting 17% of all cancer cases, followed by colorectal at 10%. The crude incidence was found to be 59.8 per 100 000 of the population.

Benchmarking Qatar to the rest of the GCC mortality rate seems similar. Qatar has a 16% mortality rate (Figure 3).

FIGURE 3. Cancer Proportional Mortality in GCC Countries.Source: Noncommunicable diseases country profiles 2018. WHO (2018)

Cancer incidence

Amongst Qatari's, breast cancer was the most common cancer with 20.66% of overall cases, followed by colorectal cancer with around 12% of cancer incidence. Cancer survival rates among Qataris has reached 89% for breast cancer, 69% for colorectal cancer, 67% for leukemia, and 90% for thyroid cancer. During the year 2016, there were 165 deaths amongst Qatari cancer patients, the Age Standardized Rate for death was 126 per 100 000. Lung cancer was the first cause of death with almost 14% of the cases followed by liver 11% and colorectal cancer at 8.5%.

In 2018, breast cancer accounted for the biggest burden of disease1 from cancer in Qatar with a cumulative risk of mortality from breast cancer, more than twice as much as from other leading cancer types such as colon, leukemia, Non-Hodgkin Lymphoma and twice as much as lung cancer.

QATAR'S PROGRESS

Qatar has made major progress since the launch of the National Cancer Strategy in 2011. Formally structured and internationally peer reviewed cancer services are delivering outcomes comparable to those in countries with a longer tradition of comprehensive cancer care. This has translated into an increased confidence in cancer services by the population, demonstrated by steady increase in the use of the services especially by Qatari nationals.

Governance, structure, and communication

Governance arrangements to oversee the strategy include a National Cancer Committee with representation from all sectors which monitors progress with the framework and several inclusive subgroups have been established. These include a Communications Group to ensure cancer information and awareness raising messages are consistent. The National Cancer Research Partnership oversees implementation of the research agenda and ensures collaboration across academic partners.

National Cancer Clinical Advisory Groups have been established for each cancer and these are composed of representative stakeholders from the Primary Health Care Corporation, Hamad Medical Corporation, private providers, and not for-profit groups. They act as expert reference groups for the Ministry of Public Health and the State of Qatar on the needs of specific cancer populations.

These groups also oversee the development of National Clinical Management Guidelines including Referral Criteria for the Urgent Suspected Cancer Pathway. They also agree service standards and improvement programs to ensure that cancer services in Qatar stay abreast of evidence-based innovation in treatment and care.

Fourteen formally constituted Specialist Multi-Disciplinary Teams (MDT's) have been established for each cancer type. New roles have been developed such as the Patient Pathway and MDT Coordinators and the introduction of Cancer Clinical Nurse Specialists who hold a Masters in Cancer Nursing delivered locally.

The establishment of the Early Detection of Cancer Program was vitally important to the chance of successful treatment and improves outcomes for most cancers. Nationally mandated Qatar wide cancer screening programs follow clear screening guidelines which make best use of forefront technology and are delivered in convenient locations for the population.

The highly valued Population Based Screening Programs were established to enable eligible Qataris and expatriate residents with services via walk-in, self-referral or a physician's referral.

Primary Health Care Corporation (PHCC) is currently delivering the following three cancer screening programs (Figure 4). In the breast cancer screening program 25 427 women were screened yielding 174 positive outcomes. While for the bowel cancer screening program 20 894 men and women were screened resulting in 42 positive outcomes. Data for the cervical cancer screening program is under analysis.

FIGURE 4. Primary Health Corporation (PHCC) National Cancer Screening Programs and Outcomes

Coverage amongst the Qataris is above 50% for the breast cancer screening program and around 30% for the bowel cancer screening program. Regular marketing and awareness campaigns target the age eligible target populations for the national screening programs.

In the first complete round length for breast cancer screening 25 427 women were screened in total between February 2016 and January 2019 with 174 positive outcomes, whilst during the same period 20 894 men and women have received bowel cancer screening with 42 positive outcomes.

This program includes purpose-built Cancer Screening Suites from three local close to patient PHCC Health Centers to maximize participation. There is a plan to expand the breast and bowel cancer screening services into an additional health center.

A dedicated National Screening Call Center for actively calling and recalling the eligible target populations has been established. In addition to 11 schedulers, the National Call Center includes two Nurse Navigators to support determining the suitability of some people to participate in the screening programs.

For those hard to reach geographical areas within Qatar, the national screening programs are supported by a Mobile Screening Unit, which houses a mammography machine and doubles as an excellent promotional marketing and awareness tool for the screening programs.

Complimentary rapid referral pathways to tertiary services have been developed between the National Screening Programs and other population-based institutions such as Hamad Medical Corporation and the Qatar Genome Project for incidental findings and actionable identified risks. High-risk clinics have been established for those with familial or identified genetic risk.

A National Cancer Registry has been established and there are plans to further develop this into a National Cancer Information Center, which collates all available cancer intelligence to facilitate evidence-based planning and monitoring of cancer policy, services, and outcomes while also being an essential tool for research.

A Single Unique National Patient Identifier Number and an Electronic Patient Record harmonized across all public providers has facilitated service improvements such as Electronic Urgent Suspected Cancer Referral and better public health data collection but can be expanded to improve continuity of care and patient safety across sectors and providers.

Service developments and advanced treatment technologies

Throughout the period of the strategy, the environment in which cancer patients are treated has changed beyond recognition. Investments in infrastructure and new technologies have enabled clinical practice improvement and significantly enhanced the facilities in which care is delivered.

A 10-bedded Specialist Palliative Care unit has been opened on the site of the cancer center and there is an accredited fellowship-training program.

Qatar's health system has invested heavily in the most advanced technology for treating cancer patients and is now comparable to the world's best. The State-of-the-Art Diagnostic and Treatment Modalities in Imaging and Radiotherapy have also improved the patient experience as well as outcomes.

CyberKnife is a Robotic Radiosurgery System for the treatment of both cancerous and noncancerous brain lesions. It delivers noninvasive high-dose radiation therapy with extreme accuracy providing patients with a pain-free, nonsurgical option of treatment and offers new hope for patients with inoperable or surgically challenging conditions.

MRI guided High Intensity Focused Ultrasound (MRgHIFU) for the treatment of cancer that has metastasized (spread) to the bones is the first in the GCC region and one of only 17 centers globally with the capacity to perform these treatments under MRI guidance.

Magnetic Resonance Image Guided Adaptive Brachytherapy (MR-IGABT) treats patients with advanced cervical cancer and can significantly improve the results of treatment in cases of inoperable cervical cancer.

Radiation Therapy Surface Guided Radiotherapy (SGRT) is a new technique for accurate patient positioning which is crucial for hitting the tumoral target. Real-time patient surface detection through video cameras provides a radiation free approach for patient positioning and monitoring during treatment.

Total body irradiation (TBI) supports bone marrow transplant patients and the first TBI patient was successfully treated on January 2018.

The interventional radiology suite offers state-of-the-art imaging equipment for diagnosing and treating cancer by undertaking minimally invasive procedures using X-rays, CT imaging, ultrasound and MRI. These techniques allow the doctor to insert miniature, highly advanced, medical instruments into the body which are then directed to the required location. Procedures that once required significant surgery can now be undertaken with a minimal incision ensuring effective, high-quality medical care that is less stressful and painful for the patients.

A Cyclotron provides radioisotopes used to make radiopharmaceutical that are used in PET/CT. This is a sophisticated technology using nuclear medicine to diagnose and treat certain cancers. Moreover, the cyclotron also supplies radiopharmaceuticals to Cardiology and Neurology as well as other local approved providers.

Surgical oncology

Qatar in common with other countries with small total populations faces the challenge of low volumes in some rarer cancer. Outcomes in cancer, as with many other specialties, are enhanced where each practitioner and department deal with a critical volume of each cancer annually. This has been resolved by limiting operators to designated sub specialization and super specialization for each cancer as well as links with international centers of excellence.

The use of emergent technologies has enabled the provision of a range of sophisticated and minimally invasive techniques in clinical practice. Minimally invasive surgical options should be further developed, studied, evaluated and formally linked into the research and academic agenda. This will be supported by the reporting of 30, 60, and 90-day postoperative outcomes.

This is likely to increase with the successful uptake of population-based screening services, which result in cancer being detected earlier where a potentially curative surgery is more likely to be an option.

Stem cell therapies

Qatar has established a National Stem Cell Transplant Program for adults with excellent patient outcomes. The program is aligned with the World Marrow Donor Agency, European society for Blood and Marrow Transplantation and the Centre for Bone and Marrow Transplant Research. It will be complemented with a pediatric program.

There are plans to upscale the medical and equipment infrastructure to support the development of Cell Therapy and Gene Therapy options, which offer the population access to forefront treatments and early clinical trials while providing a service that will have regional benefits.

Precision medicine and genetics in cancer

Precision medicines has the potential to change the cancer paradigm regarding cancer prevention, detection, treatment and follow up personalized to the individual.

• Cancer can be prevented by identifying actionable genetic mutations that offer the person choices such as prophylactic surgery to prevent cancer.
• Patients identified as being at high risk of cancer can have additional surveillance and counseled in high-risk clinics.
• Precision medicine in cancer treatment can ensure the patients gets the treatment most effective as a result of the analysis of the individual's unique genetic characteristics, the molecular characteristics of their tumor and pharmacogenomic information.
• Advances in technologies pre and post treatment, can also offer predictive and prognostic indicators in which ongoing monitoring and surveillance for recurrence can also be personalized.

Breast cancer is the most frequent malignancy in Middle East and North Africa (MENA) women, accounting for over one third of the cancers. Over the past 10 years, breast cancer incidence has increased progressively in the region, with the highest rates found in the nationals of Qatar and Bahrain. In recent years, several chemotherapy drugs have been introduced that have promoted a significant decrease in breast cancer mortality. We believe that advances in research techniques, particularly genomic and proteomic approaches that focus on the genes and proteins involved in cancer and its growth to enable and implement precision medicine, will contribute to a more significant decrease in breast cancer mortality in the coming years.

Although not cancer specific, the Qatar Biobank (QBB) in Qatar hosts a collection of samples and information on health and lifestyle from the Qatari population. On the other hand, The Qatar Genome Program (QGP) is a national initiative aiming to map the genome of the local population. QGP uses QBB data to identify genotype-phenotype associations relevant to the Qatari population. Moreover, a comprehensive Qatari genotyping array, the Q-Chip has been developed (Box 1).

BOX 1 Breast cancer-incidental BRCA1/2 breast cancer findings case

Next Generation Sequencing (NGS). Prediction of genetic risk for disease is needed for preventive medicine. Decreasing NGS cost made genome-wide analyses affordable to assess variation in cancer susceptibility genes. The genome sequencing data provided by the Qatar Genome project and Qatar Biobank set the stage for cancer genomics studies in Qatar. Studying the genetic variation of cancer genes in the Qatari population, researchers from WCMQ, Sidra Medicine and HBKU-QCRI analyzed the genomes of 6000 Qatari. They obtained sequence details of more than 786 cancer genes including BRCA1 and BRCA2 that are known to be responsible of Hereditary Breast and Ovarian Cancers. The analyses revealed the presence of pathogenic BRCA1/2 mutations in 20 Qatari subjects. Given the high risk of breast and ovarian cancers in these individuals and/or other members of their families, a task force was formed by QPMI and HMC to setup a work plan for intervention and genetic counseling. Gene Chip Development. The microarray chip content (Q-chip) is based on Qatari genetic and genomic data (gene variants and disease associated mutations). The Q-Chip will provide more accurate genetic testing for a wide range of disorders and clinical diagnosis of cancer. The Q-Chip was the result of a collaborative work led by QGP and numerous local stakeholders. The new version will have more refined clinical content and design to suit the local needs delivering on the promise of precision medicine and precision healthcare for the population.

The combined wealth of such QBB and QGP data provides unique insights that enable the development of patient centric precision healthcare, accelerates innovation and breakthrough discoveries as well as informing policy makers involved in future planning.

A newly created entity is the Qatar Precision Medicine Institute (QPMI) which is working closely with local institutes and health care providers to develop first model examples of precision medicine for those with a predisposition or higher risk to cancer. One of these is the formation of a task force between partners to unveil the landscape of the genetic variation of cancer genes in the Qatari population (Box 1).

The adoption of these technologies highlights Qatar's commitment to providing a high-quality service, with a focus on the health and wellbeing of each cancer patient utilizing cutting-edge treatment modalities and state-of-the-art techniques.

QGP and Breast Cancer. The most common cancer among women globally is breast cancer. It is a heterogeneous, highly complex, and multifactorial disease. Several documented risk factors contribute to breast cancer development. Inflammatory breast cancer, a type of cancer that affects only about 1%-2% of patients in the United States and Europe but represents between 12%-15% of cases in MENA populations. Inflammatory breast cancer, which takes over as an inflammation of the entire breast rather than emerging as a lump, is a highly aggressive form of the disease that progresses rapidly and often results in death. If we can identify the genes and proteins underlying this aggressive form of breast cancer, we can begin to identify and understand the mechanisms underlying the transition from local and controlled breast cancer to the more aggressive form.

Principally, genetic factors are instrumental in increasing cancer risk (Box 1). Therefore, breast cancer susceptibility genes identification has meaningfully improved patients care by targeting altered genes involved in carcinogenesis and treatment failure.

It is well known that the characteristics of breast cancer differ among various patients. Indeed, substantial genomic changes often occur in disease progression from primary location to metastasis. Thus, it is the genomic analysis and characterization of several biomarkers that has revolutionized the clinical management of patients. These gene alterations represent novel target to engineer new therapies for breast cancer.

Research and academic activity

The Qatar Cancer Research Partnership (QCRP) was established in 2013, to oversee the implementation of the research and academic elements of the Cancer Strategies.

In addition to the national cancer care providers, it has senior representation from Universities and Research Institutes across Qatar. The Ministry of Health, the Qatar Genome Project, Qatar Bio Bank and Qatar Cancer Society are also core members.

QCRP serves to align cancer research, training and teaching programs across Qatar and encourage joint translational research projects. This correlates with a steadily increasing number of cancer relevant PhD programs across Qatar Universities.

The establishment of the Qatar Genome Project and the associated disease specific genomic platforms have facilitated competitive research projects with local and international collaborations. Breakthroughs in Cancer Immunology have been translated into clinical practice and clinical research activities across the Qatar research community, thus bringing healthcare in Qatar to the forefront with respect to technology and treatment modalities.

The Qatar Cancer Research Partnership works across providers and academic partners to support an annual calendar of cancer related educational and conference activity.

It will work with the QCS and other stakeholders on a cancer research awareness and public engagement initiative, which will align with the overall cancer awareness program.

Multi-sectoral working in educating and understanding cancer program

Collaborative, cross sectoral cancer awareness programs, and initiatives have been actively underway in Qatar since 2012.These involved the public, academic partners, nonprofit and charitable organizations, leaders in the society and various community groups.

These aim to increase education and understanding of cancer through myth-busting campaigns, cancer awareness events supported by a comprehensive Qatar-specific cancer information website. These include awareness of the National Cancer Screening Programs. The awareness campaigns are evaluated post campaign to tailor future activity.

A Common Cancer Awareness Calendar has been established and there is cross-sectorial collaboration on the content of patient and public information regarding cancer. Qatar has a very a diverse population, so evidence informed information and messages are tailored to meet a variety of needs.

To support a healthy future population, cross-sectoral initiates with the Ministry of Education are held with schools and university including a volunteer base amongst university students.

The Qatar Cancer Society (QCS) is the national cancer charity of Qatar. It works with public, private and other third sector organizations nationally and internationally to deliver the national cancer agenda, educate the community, support, empower and advocate for people living with or beyond cancer. In addition to engaging in professional development and research in the field of cancer.

Strategically the QCS is represented on key groups at the Ministry of Public Health such as the National Cancer Committee, Awareness and Communication Groups and the Qatar Cancer Research Partnership where it represents the lay perspective.

It is also a key player in the coordination of private sectors contribution to the cancer control and support program. Examples include Qatar Cancer Society partnered with a Qatari Telecom Company, Ooredoo 2017 to establish a cancer awareness center away from the hospital setting. The first of its kind in the Middle East, it acts as a hub for cancer awareness delivered through inter-sectoral partnership.

It also works closely with patient facing services to support a range of activities such as cross-sectoral educational sessions for urgent suspected cancer referral and specialist training for cancer nurses. QCS also works directly with those living with and beyond cancer by supporting them emotionally, financially, and physically.

It also serves an advocacy function in terms of lobbying for legislative and regulatory issues that affect cancer care and through enabling people living with and beyond cancer, to continue to be effective and productive members of their families and community by advocating for people living with cancer in and beyond Qatar.

NEXT STEPS FOR QATAR Ongoing awareness and prevention

Ongoing evidence based, risk stratified, and tailored public awareness, education, and involvement are required. In Qatar, noncommunicable diseases account for 1 in 2 deaths. One in 3 men aged 18 years and older are physically inactive. One in 3 men 15 years and older use tobacco. One in 2 women aged 18 years and older are physically inactive. Associated risk factors for NCDs in Qatar indicate a need for targeted education and awareness to support the population in adopting a healthier lifestyle.

There are inequities across the genders with men showing greater uptake of tobacco smoking than women do (Figure 5).

FIGURE 5. Trends in Cancer Risk Factors in Qatar. Based on 2016 population of 2 570 000.Source: WHO Country profile 2014 and NCD profile 2018

Information and support

Information and support for those affected by cancer should cover the entire patient pathway from pre diagnosis, through treatment and into survivorship, palliative care, and bereavement.

The term “affected by cancer,” acknowledges that it is not only the patient who requires information and support but that the needs of family members may differ from that of the patients. Children can be affected by cancer as a patient, or as a child or sibling of someone who has cancer. Age appropriate information and support is required.

Some individuals who will never get cancer will also have complex support and information needs such as those attending high-risk clinics and making difficult choices following genetic testing.

Complimentary patient information pathways should be developed, alongside disease specific pathways for each disease group. These should be approved by the National Clinical Advisory Groups to assure of the quality and provide consistency.

Transitions programs—living with and beyond cancer

The Cancer Paradigm has changed and increases in survival in both curable and noncurable cancers by providing life extensions over decades. Transition Programs seek to support patients to maximize health and quality of life and managing the impact of cancer and its treatment. These include long term and late effects or exacerbation of core morbidities. Services that address these issues are required but do not necessarily need to follow a traditional formal provider model.

Risk stratified survivorships programs seek to de-medicalize those aspects of care which might be better undertaken in community-based locations while concentrating specialist follow up for the care of challenging late effects, ongoing treatment and recurrence.

One example is the Qatar Cardio-Oncology service which cares for patients experiencing cardiac problems associated with cancer treatments.

Other services which require specialist input can be delivered in community-based locations close to the patient such as outreach lymphedema, prosthetics and continence promotion services.

Shared care protocols with Primary Health Services, with devolved monitoring and follow-up models will be developed, coupled with essential rapid re-entry pathways to specialist services. Links with the Qatar Rehabilitation Institute will be strengthened, and cancer specific vocational rehabilitation programs will enable patients return to work and contribute to society.

Charities, faith and community groups can be supported and skilled up to provide community lead wellness, fitness, counseling, and support groups. These must be supported by professionals to ensure evidence-based practices and quality standards are maintained. They should also allow for a wide range to ensure they are age appropriate and respect gender and personal preference. Teenage and Young Adult transitions programs are also required.

Extending palliative care nationally

Providing access to appropriate Palliative and End of Life Care for those with life limiting illnesses is a core requirement of responsible societies. The Prague Declaration and the WISH End of Life Care Report, Dying Healed: Transforming End of life Care through Innovation 2013 articulate the policy requirements.

A multi-sectoral, high-level strategic approach is essential if appropriate Palliative Care is to be equitably available for all who require it, including those with other chronic illness not amenable to cure.

In common with many countries' community-based palliative care, outreach services, and access to community specialist palliative care all need to be further developed. These can be supported by community-based Specialist Palliative Care Nurses, Allied Health Professionals, and Primary Clinicians with a special interest.

All health care professional regardless of sector need to be educated in palliative care, communication, and bereavement skills which should also be included in undergraduate and postgraduate education.

Skilled and sensitive public awareness campaigns are required, and palliative care should be included in all chronic disease strategies.

As in many other countries, National Guidelines need to be developed and changes in legislation and regulation may be required especially regarding palliative medication.

Bereavement services in many countries are run by charities with expert professional leading a team of highly skilled and appropriately qualitied volunteers.

Further extend precision medicine across the patient pathway

Developments in genomic and genetics can be used to identify those at particular risk of some cancers and high-risk monitoring and prophylactic approaches can be developed.

Building local capability and capacity in a range of other omics to extend the range of diagnostic assessments to inform clinical decision making.

Emerging pre and post diagnostic predictive and prognostic testing will enable more tailored approaches to treatment and care.

Deploy cancer care technologies

Advancing technologies such as low dose CT for patients at high risk of lung cancer or the use of molecular technology to identify those at high risk of recurrence of their apparently treated cancer in order to risk stratify on, on-going monitoring and care.

Technology and telemedicine approaches can also be used for monitoring of those on treatment; including side effects as well as personalizing follow up.

POLICY RECOMMENDATIONS Key recommendations: learning from Qatar's experience

In 2005, the WHO called on all countries to develop a national cancer program to reduce the number of cancer cases and deaths and improve quality of life of cancer patients'' and their families. This involves implementing systematic, equitable, and evidence-based strategies for prevention, early detection, diagnosis, treatment, and palliation using available resources.

In Qatar, The National Cancer Strategy A Pathway to Excellence lays out a clear, stepwise approach, which could be adopted to accommodate national health, cultural realties and requirements elsewhere. The companion document, the Qatar National Cancer Research Strategy and the subsequent National Cancer Framework: Next Steps on the Path to Excellence were built on this foundation.

Cancer is a complex disease that affects individuals, family communities, and wider society. The cancer programs require broad engagement of all stakeholders. These include providers across all sectors including public, private and not for profit, commissioners, regulators, educational, academic, research establishments and community groups.

Companion strategies Cancer research

Cancer research is integral to comprehensive cancer care. Cancer research ensures that cancer prevention, detection treatment and care are tailored to the population they serve. Basic research provides insight into the unique aspects of the population studied and translational research ensures innovations are readily adopted into practice. Clinical trials offer patient's access to forefront treatments whilst health services research can identify the most effective models of care.

Cancer strategies should consider the research component as part of the aspiration to comprehensive cancer care.

Palliative care

The WISH End of Life Care Report, Dying Healed: Transforming End of life Care through Innovation 20132 calls for the adoption of the Prague Charter 2013 and the development of a National Strategy for Palliative and End of life Care for all regardless of disease.

Countries where palliative care is not yet fully developed and integrated should develop Palliative Care, End of Life Strategies and have Palliative and End of Life Care components are incorporated in all health policies. In Muslim-majority countries, substantial attention should be paid to palliative care from an Islamic bioethics perspective while considering others and remaining culturally sensitive. Palliative care services for Muslim patients will become more ethical and eventually effective.3

Transition programs

A successful cancer strategy results in many more people living with and beyond cancer. The effects of cancer and its treatment may be prolonged or even permanent. Cancer trajectories for patient may vary between curative, living for decades with cancer as a chronic illness or palliation so traditional binary model of curable/incurable are no longer adequate.

Additionally, some patients will transition from potentially curative to palliative when disease reoccurs or fails to respond to treatment. Children and adolescents with cancer may also face the transition of becoming an adult living with or beyond childhood cancer. Successful transition programs benefit patient, families, and society by ensuring the maximum health and wellbeing possible for as long as is possible.

Transition programs are a cost effective means of maximizing the health and wellbeing gained from a cancer program, particularly when they embrace the expansion of roles and new innovative models of care, including from nontraditional providers.

Communicate early detection and preventive values

Core to reducing the cancer burden is prevention and early detection. Preventive and public awareness strategies need to be evidence based and tailored to age, ethnicity, health literacy, cultural, and personal preferences. Campaigns should be multi-sectoral and consistent with wider health messages. Innovative technologies and AI can be harnessed to develop personalized approaches.

Early detection strategies to encourage the uptake of screening programs should also be evidence based. Interventions found more consistently to improve participation in cancer screening, including in underserved populations were prescreening reminders, general practitioner endorsement, more personalized reminders for nonparticipants, and more acceptable screening tests in bowel and cervical screening. (The World Innovation Summit for Health policy report on Behavioral insights 20184).

Setting standards and expanding roles

Equity in cancer requires standardization of care. International and national expertise can be merged to ensure cancer services are delivered to the best available evidence, yet are adapted to local need, capacity and capability.

Specialization increases outcomes and this can be used to extend scopes of practice and create innovative roles.

Nursing and Midwifery are the key to rapid and cost-effective expansion of high quality universal health coverage, Doha WISH 2018.5

The effectiveness of a National Cancer Program is ultimately measured by its outcomes in terms of mortality morbidity and the experience of those affected by cancer so appropriate outcomes and evaluation mechanisms need to be agreed.6

Essential components for a developmental cancer care framework

We believe that the below components are essential to the delivery of a successful cancer framework.

• Clearly articulated vision tailored to national realities and cancer profile.
• Committed leadership with robust progress monitoring and governance arrangements.
• Wide stakeholder involvement from development to implementation and evaluation should include formal and informal providers, societies, and communities.
• Strategies should cover the cancer continuum from prevention and early detection.
• Essential companion elements such as research, education, palliative care, and survivorship are either integrated or have supplementary strategies.
• Service and clinical standard are set through judicious use of internal and external expertise such as international partners and National Clinical Advisory Groups.
• Formalize specialization, innovative role extensions to extend capability with attention to the development of future facility and workforce.
• Outcomes are measured through robust data capture and registries, which include the experiences of those affected by cancer.

CONCLUSIONS

Qatar has developed a high-quality national cancer program in a relatively short strategic time scale. Essential to this was a clearly articulated cancer strategy for which had excellent strategic fit to the wider Qatar policy context, which was tailored to be responsive to local and cultural needs in a young country that is developing rapidly. It was supported by engaged, committed political, and clinical leadership.

Central to success was excellent integration between primary, secondary, and tertiary services, the Ministry of Public Health, and other public, private, and third sector organizations.

Qatar's size offers the possibility to work on a national scale and with a whole population. This also presents some challenges in terms of rarer cancers and disease volumes, which has been addressed by super sub specialization for some conditions and establishing close partnership arrangements with international centers of excellence.

Qatar is fortunate as a developing country to be relatively wealthy with one of the highest per capita incomes in the world. However, while this has permitted the development of advanced technology treatment, the principal successes of the National Cancer Strategy has been through a clear vision, supportive leadership, judicious use of expertise, expansion of roles, and comprehensive involvement of all the relevant partners across specialisms and sectors working toward a common goal.

Regardless of resource constraints, Qatar's experience would support the belief that a well-conceived and well-managed National Cancer Program helps reduce the cancer burden and improves services, outcomes, and experiences for cancer patients and their families.

ACKNOWLEDGMENTS

The author wants to thank his institution for their continued support. The author thanks the following colleagues for their input during the course of this work. Sara McConnell-Campalani, National Center for Cancer Care & Research, Cancer Services, Hamad Medical Corporation, Doha, Qatar. Hadi Mohamad Abu Rasheed, Professional Development and Scientific Research Department, Qatar Cancer Society, Doha, Qatar. Amani Mohamed Elkhatim, Ministry of Public Health, Doha, Qatar. Masood Ali Abdul Khaliq, Primary Health Care Corporation, Doha, Qatar. Shaikha Abu Shaikha, Primary Health Care Corporation, Doha, Qatar. Karl Richard Alexander Knuth, National Center for Cancer Care & Research, Hamad Medical Corporation, Doha, Qatar.

CONFLICT OF INTEREST

The author declares that there are no conflicts of/or competing interests.

AUTHOR CONTRIBUTIONS

The author conceived, designed, and implemented conceptual work, framework, writing, and critical editing. Author read and approved the final manuscript.

DATA AVAILABILITY STATEMENT

All data generated or analyzed during this study are included in this published article.

ETHICS STATEMENT

Ethics approval and consent to participate: Not applicable.

Consent for publication: Not applicable.

Endnotes: 1WHO 2019, Qatar Factsheet. https://gco.iarc.fr/today/data/factsheets/populations/634-qatar-fact-sheets.pdf 2 https://www.wish.org.qa/wp-content/uploads/2018/01/27425_WISH_End_of_Life_web.pdf 3 https://www.wish.org.qa/wp-content/uploads/2018/11/IMPJ6078-WISH-2018-Islamic-Palliative-Care-181026.pdf 4 https://www.wish.org.qa/wp-content/uploads/2019/11/WISH-rep.pdf 5 https://www.wish.org.qa/wp-content/uploads/2018/11/IMPJ6078-WISH-2018-Nursing-181026.pdf 6 https://www.uicc.org/