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A report on the Marrakech International Women’s Cancer Days: dialogs and implications
  1. Sara Nasser1,
  2. Jonathan Berek2,
  3. Andreas Ullrich3,
  4. Livia Giordano4 and
  5. Jalid Sehouli1
  1. 1 Department of Gynecologic Oncology, Charite Comprehensive Cancer Center, Berlin, Germany
  2. 2 Stanford Women's Cancer Center, Stanford, California, USA
  3. 3 World Health Organization (WHO), Geneva, Switzerland
  4. 4 Department of Epidemiology, Center for Cancer Prevention of Piemonte, Turin, Italy
  1. Correspondence to Sara Nasser, Department of Gynecologic Oncology, Charite Comprehensive Cancer Center, Berlin 13353, Germany; sara.nasser{at}charite.de

Abstract

The MarrakechInternational Women’s Cancer Days showcased a first-time international meeting of healthcare professionals worldwide to discuss, over the course of 3 days, aspects of public health, prevention, and treatment of gynecological cancers in the Arabic region. The focus was particularly on promoting globally sustainable research initiatives. The event was a joint initiative organized by the Gynecological Cancer Intergroup and the Pan-Arabian Research Society of Gynecological Oncology. The first conference day focused on the early diagnosis and screening of cervical cancer and the required action to establish equity within screening programs and improve cancer control strategies in the Euro-Mediterranean region. The second day highlighted current screening, diagnosis, and treatment strategies for ovarian cancer in the Arabic region, with particular discussion on the incidence of germline mutations in Arabic women with ovarian cancer. Centers from the Arabic region such as Jordan, Tunesia, Sudan, and Morocco presented their own data on ovarian cancer patients and local clinical practice, and barriers to treatment. It was highlighted that more support is required in surgical training and medical therapies. On the third day , the focus was on cervical cancer therapies and treatment. Interesting surveys on patient awareness of screening programs and cervical cancer were presented from various centers including Lebanon, Sudan, and the UAE. The conference ended with emphasis on patient education, and quality of life. The meeting provided a first-time platform for sustainable worldwide dialog and exchange on all aspects of gynecological cancers focusing on the Arabic woman and the particular barriers, unchartered territories, and challenges this patient population presents to the global healthcare community.

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In April 2018, for the very first time, healthcare professionals from around the world gathered in Marrakech, Morocco to comprehensively discuss best practices and research in screening and clinical management of gynecological cancers in the Arab and Mediterranean world. The 3-day international symposium within the Marrakech International Women's Cancer Days 2018, focused on creating a multidisciplinary dialog between experts from all over Europe, Canada, the USA, and from more than 19 different countries in the Middle East, Arab Gulf, the Mediterranean, and North Africa. The event was a joint venture organized by the Gynecological Cancer Intergroup, a collaborative network of international and national research groups performing clinical trials in gynecologic cancers, and the Pan-Arabian Research Society of Gynecological Oncology.

The Pan-Arabian Research Society of Gynecologic Oncology was established in October 2016 as a charity organization and an advocate for Arabic women with gynecological cancers worldwide. The Pan-Arabian Research Society of Gynecologic Oncology centers are based in 19 different Arabic countries and also include delegates and supporters from several countries in Europe and the USA. These centers collaborate regionally and internationally to form a tumor bank network and to establish international research and educational projects.

This event was the first of its kind, bringing together more than 100 professionals from the fields of gynecology, medical oncology, radiology, pathology, general surgery, primary care, healthcare politics, epidemiology, and psychology with the aim of driving forward research and educational initiatives in gynecological oncology for women in the Arab and Mediterranean region.

The scientific program of the Marrakech International Women’s Cancer Days was uniquely structured to cover the full spectrum of early detection, screening, and patient care over 3 days, with the focus on cervical and ovarian cancer. This is one of the first events to take place in the Arabic region, combining public health aspects of population-based screening with treatment and follow-up. This opened an international platform to discuss aspects of current practice, existing barriers, and, most importantly, joint strategies to overcome them.

The congress

Foremost, the congress promoted the exchange of scientific practice and sharing of current national and regional projects. A total of 11 abstracts were accepted. A recurring theme within the presented abstracts was screening and public health awareness in Arabic countries. For instance, a survey performed on 1000 Saudi Arabian women living in a major city explored public awareness, knowledge, and attitudes toward Pap smear as a screening test for cervical cancer.1 With a response rate of 50%, from mainly married (94%) women, 45% having completed a university degree, the survey showed that more than half (54%) had not heard of the Pap-smear test: 84.6% of women never requested their physician to do a Pap smear. Concerningly, 75.5% reported that their physicians had never advised them to do a Pap smear. Almost all women (95.3%) expressed an interest in knowing more information about the screening test. The authors identified an urgent necessity to educate and foster awareness concerning cervical cancer and screening programs.

This was further reflected in projects presented from Rabat and Kenitra from the Moroccan Pan-Arabian Research Society of Gynecologic Oncology centers.2 The descriptive retrospective study in Kenitra province was conducted on 360 women at 31 primary healthcare and oncology centers. The majority of women (88.4%) were married, and 72.2% had medical insurance. More than 73% of them lived at a distance of 1–5 km from the health center. The highest proportion of loss to follow-up was among women referred to confirm the diagnosis after visual inspection with acetic-acid (27%). The authors emphasized the need for active follow-up during the screening program and the need to improve the communication skills of primary healthcare workers at the time of visual inspection with acetic acid to educate women on the importance of diagnosis confirmation.

Interestingly, a new partner pilot study was also presented between the Center Mohammed VI pour le Traitement des Cancers, Casablanca/Morocco and the Clinic for Gynecology and Gynecological Oncology Charite-Universitaetsmedizin, Berlin/Germany. Within this partnership a pilot prospective cross-sectional study has started comparing human papillomavirus Oncoprotein E6 expression testing vs the time of visual inspection with acetic acid in Morocco. The primary objective of this study was to test the feasibility of OncoE6TM Cervical Test (OncoE6; Arbor Vita, Fremont, CA, USA), including patients’ acceptance, compliance, and quality of the test results in comparison to visual inspection with acetic acid. Recruitment occurred from eight health posts (four rural, four urban) in the Tangier area. All participants were tested by OncoE6 and by visual inspection with acetic acid, and for OncoE6, a physician and a self-collected specimen were obtained from all participants. All participants underwent colposcopy, and, if indicated, a biopsy and histology in a local pathology laboratory. The acceptability of sample self-collection was assessed via a semi-structured questionnaire to evaluate knowledge on cervical cancer, socio-demographic characteristics, medical history, and acceptability of the Evalyn brush-based self-collection. Two hundred and sixteen women from rural (100) or urban (116) settings were recruited: 15.5% (n=31) women had a positive/suspicious result on visual inspection with acetic acid, and 2.3% women tested positive on OncoE6 (self-collected or physician-collected). Multiplex human papillomavirus genotyping done at the Charite-Universitätsmedizin revealed high-risk human papillomavirus + at 11.8% (n=21), with human papillomavirus16 + at 5.7% (n=12). Other HR-human papillomavirus types detected were 51 (n=2), 66 (n=3), 68 (n=1), 73 (=1), and 82 (n=1) with three participants showing multiple infections: 3.1% were diagnosed at CIN1, while no cases of CIN2 or worse were observed. Eighty-two percent of women provided a self-collected specimen, and 68% felt self-collection was straightforward. A control cohort of 20 patients with histologically confirmed invasive cervical cancers recruited at the Cancer Center in Casablanca also underwent OncoE6 testing.

This pilot study demonstrated a high degree of acceptability among the participating Moroccan women for cervical cancer screening and for self-sampling. The time of visual inspection with acetic acid resulted in a substantial number of false positive test outcomes, which could cause costly overtreatment. The existing infrastructure in the target areas may allow for wider implementation of the OncoE6TM cervical test. A validation study in a multicenter and multiregional setting is currently planned within the partnership, and in collaboration with, the Pan-Arabian Research Society of Gynecologic Oncology.

The first day of the conference addressed these topics in a 1-day regional seminar on ‘Cervical Cancer Early Diagnosis and Screening in the Euro-Mediterranean region’. This seminar was organized in collaboration with the Union for the Mediterranean, whose mission is to enhance regional cooperation, dialog, and the implementation of projects and initiatives in all 28 countries of the European Union and 15 countries of the southern and eastern Mediterranean. As part of the women empowerment approach within global healthcare, the event highlighted the need to encourage action to establish equity within screening programs and improve cancer control strategies. Indeed, the Pan-Arabian Research Society of Gynecologic Oncology joined the ongoing Women’s Right to Health, to reduce the incidence and mortality of cervical malignancies in the Euro-Mediterranean region through the design and implementation of a comprehensive cervical control strategy in coherence with national policies, and in close coordination with national health authorities and local healthcare practitioners.

The project was designed within the Euromed Cancer Network and was coordinated by the Italian Center for Cancer Prevention of Piedmont. The first phase of the project, aimed at identifying and testing the most suitable recruitment strategies for cancer screening, is currently under implementation with the support of the Institut National du Cancer.

Effective interventions to improve cancer screening participation have been tested mainly in developed countries and their relevance to developing areas is still unclear. The aim of the Institut National du Cancer project is to shed light onto this still obscure subject, conducting a project in three countries with a different approach toward cervical early diagnosis/screening. While Montenegro invites women aged 30–34 years to perform a DNA Human papillomavirus (DNA human papillomavirus) test within an organized screening program, Morocco offers women aged 30–49 years to perform time of visual inspection with acetic acid opportunistically in primary healthcare facilities. In Albania the cervical cancer screening test is not yet offered to the population, but, for the purposes of the project,women aged 30–50 years were offered a DNA human papillomavirus test.

Different invitation strategies are tested in each country: face-to-face vs phone call in Albania, phone call vs letter in Montenegro, and face-to-face vs phone call/home visit in Morocco, within an overall population of 6000 women. While in Morocco and Montenegro the project is about to start, in Albania it has been concluded and some preliminary results have been presented. As far as analyzed data shows, the usual care has been confirmed as more effective: 95.1% of women accepted to perform an human papillomavirus test with the usual care vs 80.3% with the phone call.

The experience of Women’s Right to Health, a project designed with a multidisciplinary approach, is a good example of global dialog that aims to identify and promote evidence-based, effective, and sustainable strategies to prevent cervical cancer and reduce its mortality and morbidity. This first joint seminar with the Pan-Arabian Research Society of Gynecologic Oncology represented a fruitful opportunity to strengthen this network of expertise, in a joint effort to overcome the cancer burden of disease.

The second day focused on ovarian cancer in three different sessions: screening and prevention, surgical management, and medical therapies. Research initiatives on therapies for ovarian cancer in women of Arabic origin are scarce in the current literature. The themes of the sessions focused on ongoing trials in western countries and the corresponding Arabic perspective.

The Algerian Pan-Arabian Research Society of Gynecologic Oncology Center presented the first Algerian tumor bank in ovarian cancer which is collaborating with the tumor bank in Berlin, Germany.3 Currently, the Algerian tumor bank in ovarian cancer is investigating the anti-cancer effect of the leaves of Pistacia lentiscus and Fraxinus angustifolia, two medicinal plants used in Algerian traditional medicine since the 15th to 16th centuries, on primary ovarian cancer cells in vitro. Using four newly established primary cell lines derived from ascites from patients with high-grade serous and clear cell ovarian cancer, an experimental study to test the therapeutic effects of the substances in patient-derived models was performed. The anti-proliferative activity of plant extracts was measured using WST-1 cell proliferation assay kitand the apoptotic effect assessed using flow cytometry analysis. The impact on constitutive active oncogenic pathways and cytokine release in cell culture supernatant were monitored by Western blotting and enzyme-linked immunosorbent assay (ELISA), respectively. The results showed a cytotoxic effect of the methanolic extract of P. lentiscus on primary cell line cultures, inhibiting intracellular signalling pathways (PI3K/AKT and MAPK/ERK signaling pathways), and decreasing the release of Interleukin-6 (IL6) and Vascular-endothelial-growth-factor (VEGF) by the malignant cells. Moreover, treatment with P. lentiscus increased the sensitivity to platinum-based chemotherapy in the primary cell lines of high-grade serous ovarian cancer patients. The authors concluded that P. lentiscus might be a promising candidate for novel therapeutic approaches in combination with classic chemotherapy for patients with high-grade serous ovarian cancer.

The Pan-Arabian Research Society of Gynecologic Oncology Center in Sudan presented the first descriptive data of patients with ovarian cancer in Sudan, as neither the mortality rate nor survival rate had previously been described in that area.4 This was mainly due to a lack of the availability of death certificates, and the fact that the majority of patients presenting with advanced stage disease were not thoroughly investigated or treated. An interesting discussion point was that pelvic tuberculosis, mimicking ovarian cancer, was the main differential diagnosis in that region.

Breast cancer gene mutation (BRCA) testing in ovarian cancer patients in the Arab world was also an important topic with presentations from Morocco, Germany, and the USA. Within this session the panel discussion focused on the consequences of BRCA mutations for families and therapies with Poly ADP ribose polymerase (PARP)-inhibitors, and current clinical practice in the Arabic region. Genetic disorders are not equally distributed over the geography of the Arabic region, and nearly one-third of the genetic disorders in the Arabic region result from congenital malformations and chromosomal abnormalities.5 Consequently, the proportion of BRCA1 and BRCA2 mutations could be higher in Arab women as compared with the Caucasian population. In Morocco, a large number of distinct polymorphisms and unclassified variants in BRCA1/2 have already been described. In Lebanon 38 BRCA1 sequence variants, many of which are novel, have also been revealed. This raises the issue of a general lack of data in the literature on the prevalence of these mutations in Arab women with ovarian cancer. Furthermore, delegates also raised the issue of lack of resources to provide genetic testing and counseling in some Arabic countries. There is a potential pool of patients that could benefit from targeted therapies, who currently remain unknown. Consequently, the Pan-Arabian Research Society of Gynecologic Oncology launched a prospective comparative study on the prevalence of BRCA1/2 mutations and other biomarkers in Arabic women with ovarian cancer. This will be a joint collaboration between several Pan-Arabian Research Society of Gynecologic Oncology centers.

Currently, there is major resource-dependent variation in the treatment of ovarian cancer within the pan-Arabian region. The congress emphasized the need to drive national adaptation of international guidelines, through showcasing data on the surgical and medical therapies in ovarian cancer and borderline tumors in the primary and relapsed settings. Patients with primary ovarian cancer in Cairo6 receive upfront cytoreductive surgery in 90% of cases and adjuvant chemotherapy in 78% of cases, with a response rate of 55% and a 5-year progression-free survival rate of 57%. The Pan-Arabian Research Society of Gynecologic Oncology Center in Egypt emphasized the need for a national cancer registry, outreach programs for better awareness and transcultural studies on epidemiology, and treatment response for disease site differences. In Morocco,7 a retrospective study highlighted the main issues with the treatment of ovarian cancer patients including diagnostic delays through inaccessible care for patients from rural areas, erroneous diagnosis (tuberculosis being the main differential), and lack of strategy when it comes to developing an oncological treatment plan. These issues were also echoed in presentations from Pan-Arabian Research Society of Gynecologic Oncology centers in Egypt, Sudan, and other Arabic countries.

As for targeted medical therapies, following presentations on current and standard-changing Gynecological Cancer Intergroup Trials, the delegates noticed extreme inter-regional variations. For instance, patients with ovarian cancer in Tunis8 receive standard adjuvant chemotherapy with carboplatin and paclitaxel. Both agents are approved and available in the country with out-of-stock events being very rare. Bevacizumab is not approved for ovarian cancer in many of the Arabic countries. Pegylated liposomal doxorubicin, trabectidin, albumin-bound paclitaxel, and PARP-inhibitors are not approved and not available at all within most Arabic countries. The speakers concluded that within the Tunisian healthcare system, all patients receive standard adjuvant chemotherapy, but access to innovative drugs and second- or third-line chemotherapy regimes in concordance with international standards of care is limited simply due to lack of resources. Consequently, the Gynecological Cancer Intergroup offers a yearly observership to a Pan-Arabian Research Society of Gynecologic Oncology delegate from an Arabic country. The observership is given, following an application process, to a selected delegate to attend a Gynecological Cancer Intergroup Educational Symposium in Europe or the USA, and present current and ongoing research projects, for discussion of possible collaborations. This consolidates standards of research and aids in building a productive research collaboration with the pan-Arabian region.

Due to lack of data, the Pan-Arabian Research Society of Gynecologic Oncology has initiated a multicenter study to characterize molecular biological features, such as BRCA mutations in ovarian cancer samples. On the third day, experts discussed treatment and trials in cervical cancer including the current American Society of Clinical Oncology (ASCO) clinical practice guidelines on human papillomavirus vaccination and testing. This was followed by presentations from Pan-Arabian Research Society of Gynecologic Oncology centers across the Arabic region, which showed a clear variation in available resources and population uptake of vaccination and screening. For instance, a survey on the knowledge of Lebanese women about cervical cancer screening and human papillomavirus from the Pan-Arabian Research Society of Gynecologic Oncology Center in Lebanon9 concluded that vaccination uptake, although significantly associated with religion, profession, and regular visits to a gynecologist, is currently still suboptimal and women are generally not well informed about human papillomavirus and cervical cancer. The Pan-Arabian Research Society of Gynecologic Oncology Center in Sudan presented a similar issue, quoting lack of resources in health education.10 In Abu Dhabi the human papillomavirus vaccination programwas initiated in March 2008 (quadrivalent vaccine), using the existing school vaccination program with a target population of all female students in Grade 11 in government and private schools (mean age 16–17 years). The vaccine is free of charge for nationals, with a small fee for non-nationals (approximately $15). Prior to initiating the vaccine program, the UAE launched a public health awareness campaign with more than 300 engaged healthcare professionals. A UAE-wide survey in 2006 revealed that 45% of UAE respondent mothers were highly willing to vaccinate their daughters and 60% of UAE respondent mothers were highly willing to take the vaccine themselves . Eighty percent of young adult UAE females were willing to take the vaccine and the major documented reason for wanting vaccination was for prevention of cervical cancer and human papillomavirus infection (50%–70%). Accordingly, the uptake for the vaccine in the UAE over the years 2008 to 2011 has been satisfactory and comparable to that in other countries that have implemented the program. The authors showed that the uptake is generally higher in government schools (63%) than in private schools (21%) , and that the uptake in national girls (74%) exceeds that of non- national girls (29%) in governmental schools, but the difference is much smaller in private schools (23% and 21% respectively). The colleagues from the UAE presented an organized national vaccination program with good uptake.11 In view of these highly specific and varying needs of each Arabic country within the area of screening and primary prevention, the Pan-Arabian Research Society of Gynecologic Oncology is currently collaborating with the Union for the Mediterranean, and the World Health Organization to lobby for more support to set up adequate screening programs across Pan-Arabian Research Society of Gynecologic Oncology centers. Moreover, to further strengthen interaction between centers of the Arabic region and western countries, the Pan-Arabian Research Society of Gynecologic Oncology is collaborating to build hospital partnerships. Within this context, the Charite University Hospital in Germany and the Hassan II University in Morocco have received a grant to establish a 2-year program for collaborative research and clinical exchange. This opportunity will be offered to a different Pan-Arabian Research Society of Gynecologic Oncology center every 2 years.

The conference ended on the important topics of communication, quality of life, and sexuality in patients with gynecological cancers. This highlighted a culturally sensitive aspect of the holistic approach to the care of women with gynecological cancers in the Arab world. Currently the Pan-Arabian Research Society of Gynecologic Oncology is collaborating with the North-East Germany Society for Gynecological Oncology to complete a patient survey: EXPRESSION VI, on quality of life including sexuality in long-term survivors of ovarian cancer. EXPRESSION VI has been translated into Arabic and is currently recruiting in three Pan-Arabian Research Society of Gynecologic Oncology centers in the Arabic region, as well as all over Europe. It is expected to show cultural and interregional variations in patients’ perception of their quality of life when living with ovarian cancer, thus aiding healthcare systems and physicians in addressing patients’ needs and expectations more adequately.

As part of building a successful global network of research and education, the Pan-Arabian Research Society of Gynecologic Oncology also announced its strategic alliance partnership with the International Gynecological Cancer Society, an international organization established in 1987 to enhance the care of women with gynecologic cancer worldwide through education, training, and public awareness.

As part of this truly global cooperation, regular tumor board meetings and webinars are held. This provides a global platform for Pan-Arabian Research Society of Gynecologic Oncology centers to discuss cases with experts from the International Gynecological Cancer Society and worldwide, and participate in educational sessions. This alliance has provided members of all Pan-Arabian Research Society of Gynecologic Oncology centers in Arabic countries with the opportunity to participate in trials, access fellowship programs, and a wealth of online educational material.

Conclusion

Overall, this unique event provided an excellent arena for cultural exchange, reaching out to global policy makers, scientists, and world-renowned experts. The conference allowed direct communication on current topics and cultural, medical, and political barriers in the pan-Arabian region and the western countries. Building on from this event, the Pan-Arabian Research Society of Gynecologic Oncology is planning educational sessions, live podcasts, and round-table sessions at the upcoming Charite-Mayo Congress in Berlin in April 2019, and the next International Gynecological Cancer Society Annual Meetings in Rio in 2019, and Rome in 2020. Hands-on workshops and meetings will be organized at various Pan-Arabian Research Society of Gynecologic Oncology centers throughout the year. Delegates are encouraged to check the website (www.parsgo.org) for the latest updates and to join the Pan-Arabian Research Society of Gynecologic Oncology as a member or apply to become a Pan-Arabian Research Society of Gynecologic Oncology center. This is the Pan-Arabian Research Society of Gynecologic Oncology vision: to drive forward research initiatives and training programs to ultimately standardize care for Arabic women with gynecological cancers worldwide.

References

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Footnotes

  • Funding The congress was sponsored by TESARO and AstraZeneca.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned, externally peer reviewed.