In recent years, because they’ve been unable to access the full range of treatments, Palestinian women with breast cancer have organised protests to highlight poor current care standards. The battle to get breast cancer treatment is compounded by movement restrictions due to living in a conflict zone as well as the faltering infrastructure for access to basic needs such as electricity and water.
The evidence shows that early diagnosis and treatment of breast cancer is key to improving survival rates. However, instead of promoting earlier diagnosis and proper access to treatment, the Palestinian Ministry of Health and many non-governmental health organisations are purchasing very expensive digital mammographic machines. There are already about 40 such machines in the Occupied Palestinian Territory (oPt), but most are either not functioning or are underused. Their purchase continues even though there is an enduring lack of essential and necessary follow-up treatment and care needed when women are diagnosed with breast cancer. This creates a basic imbalance between what the government regards as a priority and what women need.
Some would say that the purchase of such machines was not a particularly sensible allocation of scarce resources, especially in a conflict zone such as the oPt where access to health is dependent on the availability of funds and donations. These gestures by the Palestinian government are probably well-intentioned, but it is not a particularly evidence-based decision. In fact in a recently published article analysing how information about mammographic screening has been presented and reported, authors from Palestine and the UK show how Palestinian health research is based on one-sided statistics and selective information to promote mammographic screening for women in the occupied Palestinian territory (oPT).
The debate about the benefits and harms of mammographic screening is not new. However, an increasingly accepted body of evidence shows that many low-income countries emulate high-income countries by purchasing mammographic screening machines when they lack the necessary infrastructure to provide and maintain high-quality screening programmes, and the necessary follow-up treatment and care.
To assess whether Palestinian researchers have done a better job in presenting balanced evidence about the benefits and harms of mammographic screening, the authors reviewed in depth the evidence and opinions expressed about breast cancer screening in Palestinian research reports.
The article makes clear that Palestinian health researchers see it as their duty to promote mammographic screening regardless of the evidence or logic. All 14 research reports included in the article mentioned that mammographic screening would improve survival rates in the occupied Palestinian territory. Many Palestinian researchers significantly overestimated the reduction in breast cancer deaths plausibly attributable to mammographic screening, even in high-functioning healthcare systems.
The established harmful effects of mammographic screening, which are overdiagnosis and subsequent overtreatment, was mentioned by only three reports. The Palestinian Ministry of Health does not contact women by phone, write to them, invite them to attend screening sessions, or remind them about undergoing mammographic screening. There seems to be an expectation that women will hear through social media or by word of mouth that they are eligible for and should have a breast screening examination when they reach a certain age. However, there was also no consistency in these research reports about how often women of different age groups should undergo mammographic screening. Divergence in published advice thus inevitably causes confusion and is a waste of health and research resources.
The authors of the article also highlight the much larger problem of how women are misled with selective reporting of information about the benefits and harms of mammographic screening. Established evidence on the harms of breast cancer screening, including psychological distress and overtreatment related to false positive results, are often left unmentioned in Palestinian health information leaflets. This provides an inadequate basis for women to make informed decisions about undergoing mammographic screening. The prominent advertisement on the Palestinian Ministry of Health’s website simply tells women to attend for mammographic screening, exaggerating its benefits, and neglecting harms altogether.
The authors conclude that “Since sound policies rest on good information, benefits and harms in mammographic screening need to be assessed and presented in a balanced way. Information on this intervention should also reflect the level of scientific uncertainty, allowing women to understand the possible benefits and harms of screening and reach a decision for themselves.”
There is no clear answer to why the Palestinian Health Government and Palestinian health researchers tend to overpromote mammographic screening. The over-reliance on mammographic screening may be due to the dependence on international charitable donations which offer additional machines instead of offering more sustainable training opportunities, self-sufficiency, and basic healthcare facilities that women in the oPt need.
Palestinian researchers also appear not to have access to the evidence necessary to make balanced and informed judgments. Of the 14 research reports reviewed in the article, only five cited evidence from systematic reviews of mammographic screening while others based their recommendations on individual studies. This led to a less balanced perspective in their conclusions.
The research community has an ethical and a professional obligation to report evidence-based information in a transparent and balanced way, regardless of their stance on mammographic screening. Women in a conflict zone such as the occupied Palestinian territory already endure poor access to adequate health services, and do not need the added burden of unclear or unbalanced health advice. It is paramount that research on the benefits and costs of different healthcare treatments and approaches is rigorous and balanced, given the scarcity of funds available, money needs to be well spent on interventions that make the most different, according to the evidence.
Shaymaa AlWaheidi is PhD student at the department of Cancer Epidemiology, Population and Global Health, in the School of Cancer and Pharmaceutical Sciences, King's College London. She is part of the Research for Health and Conflict Middle East and North Africa Group, of which the War Studies Conflict and Health research group is a part. Her PhD aims to identify which policies and interventions can be expected to improve survival rates for women with breast cancer in Gaza.