• Gynecology

In Italy in 2023, Istituto Nazionale di Statistica (ISTAT) identified 5 million foreigners representing 8.6% of the overall Italian population, of which half are women. Due to employment reasons, 60% live in northern Italy. Cancer incidence is increasing, and often individuals from low- and middle-income countries decide to travel to higher-income countries to access treatments that are unavailable locally. The Italian national healthcare system includes a specific regulation that allows foreigners to access healthcare. In our Department of Gynecologic Oncology, in the last 3 years, foreign patients have represented around 16% of women receiving systemic anti-neoplastic treatment, a trend that recently has been progressively increasing.

Herein, we report on the challenges encountered by a tertiary cancer center in northern Italy in providing oncology treatment to a foreign population. The main obstacle is the language barrier. Over 20% of our foreigner patients came to Italy only for health reasons, either alone or to join a relative(s) living in Italy. Indeed, most patients present at medical appointments on their own. We thus evaluate all patients with the assistance of a linguistic mediator and a social worker in order to ensure adequate communication and support throughout the treatment plan. It is essential that women understand and agree with the proposed therapeutic pathway, especially the potential toxicities and their management. We realize that these patients do not spontaneously refer to doctors in the case of adverse events. On the one hand, this is due to the difficulty in reporting: often symptoms are underestimated and there is a lack of awareness in seeking medical attention. On the other hand, there is often the absence of adequate caregivers due to geographical distance (ie, patients live alone in Italy and their families live in their native countries) or the caregivers experience difficulty in taking care of the patients due to employment or social problems. Consequently, we assess these patients clinically on a regular basis. In particular, for those patients being treated with oral therapies (eg, poly (ADP-ribose) polymerase (PARP) inhibitors or tyrosine kinase inhibitors) or triweekly chemotherapy, we perform closer follow-ups in order to address toxicities.

Many foreign patients wish to return to their country of origin. Sometimes this desire can be a temporary one for a short period during active treatment, whereby oncologists and social workers need to orchestrate the appropriate timing for treatment holidays to optimize support systems and resources. The care team has a fundamental role to play in explaining to the patient about their illness severity and prognosis with the support of an unbiased cultural mediator, thus allowing the patient to make informed personal decision(s). Indeed, medical repatriation is usually the final wish of many terminally ill cancer patients and should form a routine part of any end-of-life discussions. This is a fundamental aspect of treatment and must be communicated at an early stage in the patient's oncology therapeutic program. This aspect needs to be planned and coordinated with the patient’s family or sometimes directly with health services in the patient’s native country.

Challenges in caring for international patients can encompass a number of difficulties; however, appropriate management can potentially empower patients, whilst training healthcare professionals and including the linguistic mediator and social worker in daily clinical practice.