Syrian refugees are diagnosed with breast cancer younger and with more advanced tumors, study finds

Brigham researchers and international collaborators identified the association with younger age and advanced stage at diagnosis, coupled with the trauma associated with displacement, as likely contributors to the disparities.

War and other conflicts impact health in ways that extend far beyond an active combat zone. In a study led by investigators from Brigham and Women's Hospital, a founding member of the Mass General Brigham health care system, in collaboration with international colleagues, researchers found that Syrian migrants, including refugees, with breast cancer were more likely to be younger and diagnosed with late-stage cancers when compared to Jordanian women.

The paper, published today in JAMA Network Open, could help scientists and policymakers identify treatment gaps for refugees and improve their cancer outcomes.

"We know that there is stigma, a delay to accessing care, and competing interests for funding in regard to treating breast cancer in Syrian refugees," said lead author Aditi Hazra, Ph.D., MPH, a genomic epidemiologist and assistant professor in the Brigham's Division of Preventive Medicine. "What this paper adds is a quantitative description of the tumor characteristics of refugee patients."

Prior to the start of the Syrian Civil War, the country was burdened by a severe drought that devastated local agriculture and the economy, and more recently, several large earthquakes have destroyed infrastructure. Researchers have spent over a decade documenting widespread cancer cases among refugees fleeing the crises, but until recently, little was known about the types of disparities displaced patients faced when searching for care.

When researchers began looking at cancer outcomes for Syrian refugees in 2014, they noted that breast cancer was the most common malignancy in women. They also discovered that in order to receive care for their cancers, patients had to apply for treatment funds from the United Nations High Commission for Refugees (UNHCR). Many patients with advanced cancers were considered to have poor odds for survival, and, therefore, denied care.

"Many of these refugees did not have access to early cancer detection. They were diagnosed late, and they were not going to receive care because of it," Hazra said. "That seemed at odds with the idea of health as a human right."

Early studies struggled to collect quantitative data to describe the characteristics of patients' tumors. To address this, Hazra collaborated with officials at the Jordan Cancer Registry (JCR) to analyze data from 7,891 case reports from breast cancer patients, 375 of whom were Syrian refugees.

In the new study, the investigators discovered that women with breast cancer who were refugees tended to be younger than patients who were Jordanian natives. Jordan is considered a middle-income country, and the team noted that both groups developed breast cancer at younger ages than women in high-income countries, such as the United States.

Breast cancers in Syrian refugees also appeared to be further developed than those reported in Jordanian women. Nearly a quarter of refugees with breast cancer had late-stage cancers that had metastasized to faraway locations. Less than 12 percent of Jordanian women had similarly widespread tumors.

Delays in care, coupled with the trauma associated with displacement, were hypothesized to likely be associated with the disparities. Refugees' breast cancers had likely evaded detection that would have been routine prior to the intersecting crises in Syria, causing them to advance to late stages.

The researchers pointed out that gaps in the data limited some of their findings. For example, 23 percent of the cases they reviewed did not include data on the stage of the patient's cancer, potentially clouding results. Data on the treatment patients received after being diagnosed with breast cancer was also incomplete. To combat this, Hazra suggested digitizing records to scale data collection and facilitate the continuity of cancer care.

The study's authors hope that their work will draw attention to the specific health care gaps of Syrian refugees with breast cancer. They say multistakeholder support, drawing in refugee and local perspectives, integrating refugees in national cancer plans, and resources for scaling early cancer detection with the Jordan Breast Cancer Program for Jordanians and refugees will allow scientists to improve health systems and survival rates.

"Only one to two percent of global health funding goes to non-communicable diseases (NCDs) including heart disease, diabetes, and cancer," Hazra said. "Those are the major killers. We need multistakeholder support to reduce delays in care, provide trauma-informed cancer care, and improve NCD outcomes."