International Journal of
Radiation Oncology biology
physics
www.redjournal.org
Lebanon: An Evolving Hub for Radiation Therapy in the Arab World Youssef H. Zeidan, MD, PhD,*,y and Fady Geara, MD, PhDy *Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida; and yDepartment of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon Received Nov 3, 2014. Accepted for publication Dec 15, 2014.
Introduction Radiation oncologists are increasingly expressing an interest in and concern about the practice of radiation oncology around the world. The Red Journal is reflecting this by devoting a special edition to global health and a series of articles outlining the practice of radiation therapy in specific nations (1). In this edition we travel to the Middle East, destination Lebanon. Once called the “Switzerland of the Middle East,” Lebanon is among the most scenic countries of the eastern Mediterranean because of its diverse geography and favorable climate (Fig. 1). Historically, Lebanon thrived under the French mandate after World War I. After its independence in 1943, it retained strong ties with France, particularly in the fields of education and medicine. Currently, the population is estimated at 4.8 million, with a unique mosaic composed predominantly of Muslims and Christians but also of 18 religious sects of various smaller sizes. The Lebanese health sector extends its services well beyond its own population, and in spite of the high toll of the civil war, Lebanon remains a hospitalization hub for the Middle East, particularly for neighboring Arab countries. This is driven by the availability of specialized medical care and the relative safety in comparison with neighboring countries such as Syria and Iraq. For a long time, epidemiologic studies describing cancer trends in the region generally, and Lebanon in particular, were lacking. In 2004, the Lebanese Cancer Epidemiology Reprint requests to: Youssef Zeidan, MD, PhD, Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW
Int J Radiation Oncol Biol Phys, Vol. 91, No. 5, pp. 888e891, 2015 0360-3016/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2014.12.036
Group first reported cancer incidence in the country based on a network of hospitals and pathology laboratories (2). In 2014, the largest epidemiologic study to date was published using a database of 45,753 patients from the National Cancer Registry (3). An average annual increase of 4.5% and 5.4% was found among male and female individuals, respectively. The authors anticipated 296 and 339.5 cases per 100,000 in 2018 among male and female individuals, respectively. Cancers of the prostate, lung, bladder, and colon and non-Hodgkin lymphoma were the 5 most common cancers in men, and cancers of the breast, ovaries, lung, and colon and non-Hodgkin lymphoma were the most prevalent among women (3).
Practicing in Times of Peace Lebanon was among the earliest countries to offer radiation therapy in the Middle East. The first 2 centers were established at the Hotel Dieu de France (HDF) Hospital (1930s) and the American University of Beirut (AUB) Medical Center (1950s). Currently, there are 8 medical centers offering mainly teletherapy around the country. The distribution of linear accelerators (LINACS) among the 5 Lebanese governorates is shown in Figure 2. With 14 operational LINACS, the country is estimated to currently have a ratio of 2.9 LINACS per million population, which is low in comparison with 5.6 in Europe (4). Brachytherapy (mainly HDR) services are offered at only 2 centers. Over the past decade, the country has witnessed a major 12th Ave, Suite 1500, Miami, FL 33136. Tel: (305) 243-4916; E-mail: [email protected] Conflict of interest: none.
Volume 91 Number 5 2015
Fig. 1.
Around the Globe
Byblos, Lebanon.
revamping of available technology. Although all centers currently offer 3-dimensional conformal therapy (3DCRT), intensity modulated radiation therapy (IMRT), image guided radiation therapy, stereotactic radiosurgery, and ablative radiation therapy remain restricted to just a few major centers. Intraoperative radiation therapy and prostate brachytherapy services are currently unavailable. The country’s diversity in religion and ethnicity is reflected in the radiation therapy community of physicians, physicists, dosimetrists, and therapists. Indeed, it is amplified by a great variety of international training. There are just 11 radiation oncologists staffing the nation’s centers. Four were trained in France, 3 in the United States, 1 in Canada, and 3 locally. Three of the 11 radiation oncologists hold American Board Certification. Physics support is provided by 9 physicists holding either master’s or doctorate degrees in medical physics, and 3 of these hold American Board Certification. The Lebanese University offers a master’s program in medical physics, which is
889
currently the only medical physics program in the country. Most of the current practicing physicists are Lebanese citizens who obtained their training, at least in part, in French, American, or Canadian centers. Because of the lack of formal dosimetry training programs, most dosimetrists hold bachelor’s degrees in physics and receive training at the employing institution. Although general radiology technology training exists, the country lacks radiation oncology technology training programs; thus, therapists receive additional training at their respective institutions. The current Lebanese health care sector is fragmented and inefficient. The civil war (1975-1991) was largely to blame for stunting development in health care. In the years immediately after the civil war, the government focused on rebuilding the country’s infrastructure (eg, roads, electricity), leaving the health sector uncontrolled and deregulated. Financing is provided by 5 entities: the national social security fund, the ministry of public health, armed and security forces, private insurance, and self payers. Out of the country’s 164 hospitals, only 28 are public. Radiation therapy is offered in just 2 public centers, meaning that the field is mainly controlled by the private sector. Wealthier members of the population seek treatment at private hospitals, although a small minority travel for treatment in Europe or the United States. These local centers offer treatment on the latest radiation platforms, albeit at a higher cost. For instance, in the past 2 years, 2 TrueBeam units were acquired by the HDF hospital. The ministry of public health (MOPH) contributes to coverage of patient treatments and offers up to 85% coverage for patients treated in private hospitals with special contracts. However, because of financial difficulties, the MOPH often delays reimbursement or sometimes defaults, leading several private centers to shy away from MOPH contracts.
Practicing in Time of War
Beirut (6)
Mou n Leba t non (5)
North (1) Bekaa (1)
South (0) Nabatieh (1)
Fig. 2. Distribution of functional linear accelerators in Lebanon by governorate.
In 1975, a brutal and devastating civil war shook the country. Over the subsequent 26 painful years, the war transformed Lebanon from a country of ruins to a country in ruins. The health care sector faced major challenges because the Lebanese infrastructure was being destroyed by the savage war machine. Basic amenities of life such as electricity and water became limited. Oncologists rose to the challenge at times when medical services were needed the most. The capital, Beirut, was divided into an Eastern part, controlled by Christian groups, and a Western part controlled by Muslim troops backed by the Syrian army. Staff often risked their lives, and even the commute to work became perilous because of snipers, militia checkpoints, and roadblocks. Occasionally staff would be trapped indoors because of the heavy shelling outside their medical centers. Patients often took long alternative routes and stopped for interrogation at checkpoints en route to chemotherapy and radiation therapy appointments. At one point the Children Cancer Center of Lebanon partnered
890
Around the Globe
with a nearby hotel to keep children and their families nearby. Militiamen often broke into medical centers and interrupted normal workflow. Oncologists had to carefully select their systemic therapy regimens in an environment with limited medical supplies. Academically, reputable medical schools in the country were unable to maintain requirements for international accreditation. In 1991, when the civil war ended, the health care sector had been left critically wounded. In March 2011, the Lebanese health care sector was faced with yet another challenge, this time coming from the eastern borders with Syria. The Syrian civil war resulted in more than a million refugees entering Lebanon in search of security and shelter (5). This rapidly unfolding humanitarian catastrophe currently overwhelms Lebanon’s limited resources, particularly the medical infrastructure. Refugees have to navigate a different health care system, which contrasts sharply with the government-run public hospitals in Syria. Coverage of medical care for the Syrian refugees is currently provided by private payees, United Nations agencies, international aid, nongovernmental organizations, and philanthropy. With more than 540 refugee housing sites around the country, and the continued turmoil in Syria, there is no end in sight for the refugee problem in Lebanon (6).
Academic Environment There are 2 radiation oncology residency programs in the country. The first program was created at the AUB Medical Center (AUBMC) in 1991. The AUB was established in 1866 by American missionaries led by Daniel Bliss. It functions under a charter from the State of New York and is arguably the region’s premier institution for higher education. Starting in 1991, the radiation oncology program at AUBMC has had on average 1 to 2 residency spots per year. Similar to most American residencies, it consists of 4 years after completion of an internship year. This program benefits from affiliations and close ties with international programs like the MD Anderson Cancer Center through a sister institution agreement, and also with Memorial Sloan Kettering Cancer Center through joint philanthropic grant funds. Several graduates of this program have successfully completed fellowships in the United States. The second program at Saint Joseph University offers a year of training in general medicine, 3 years of local radiation oncology training, and 1 year of training in a partner department in France such as Institute Gustave Roussy, Villejuif. Although there is a Lebanese Society for Radiation Oncology, there is currently no national board regulating licensing or maintenance of certification. In addition to training local physicians, Lebanese programs also offer training workshops for staff from regional centers. For instance, in 2009 the department at AUBMC collaborated with the Iraqi Ministry of Health in a program aimed at the rehabilitation of radiation oncology in Baghdad and other Iraqi regions. The program was given over
International Journal of Radiation Oncology Biology Physics
14 months. It hosted several working groups of physicians, physicists, and radiation therapy technologists from several institutions in Iraq and consisted of a series of didactic lectures and practical hands-on training sessions. Other aspects of academic radiation oncology practice still require considerable development. In particular, research opportunities are limited by the lack of local funds and inadequate infrastructure. In addition, the absence of any national cooperative group and a lack of communication between existing centers hinders the conduction of phase 2/3 trials. Perhaps Lebanon could play a leading regional role in this regard, given that it continues to host important regional oncology conferences such as the annual Middle East Medical Assembly, held by AUBMC and in collaboration with international institutions, and is among the first official sites for the annual Best of American Society of Clinical Oncology conference.
Challenges A shortage of financial resources and understaffing are main challenges currently hindering the practice of radiation oncology in Lebanon. The country’s average monthly disposable income is $1090, with a very wide variation, and the Gross Domestic Product per capita is $15,757 (7). A typical course of 3DCRT (breast, for example) costs $6000, whereas IMRT costs $17,250. Most insurance companies (including the national social security fund) currently cover 3DCRT but not IMRT. Patients often face financial hardships attributable to out-of-pocket expenses. In addition, such insurance policies affect the physician’s choice of treatment modality. The second challenge is a shortage of human resources. With only 11 radiation oncologists and 9 physicists, staff members are often stretched between several centers. The establishment of 2 residency programs in the country has recently helped to address the immediate need in terms of physicians, but long-term planning remains insufficient. Faced by socioeconomic challenges and volatile security conditions, some physicians elect to practice abroad after specialty training. Alarmingly, 96% of Lebanese medical students recently expressed an interest in working abroad in a recent survey (8, 9). As the guardian of the health care sector in the country, the MOPH is expected to assess the current staffing gaps and work with academic institutions to increase training positions.
Conclusion Looking ahead, the practice of radiation therapy in Lebanon is expected to face an increasing patient load. By 2025, Lebanon is projected to have 10% of its population over the age of 65, leading the Arab world in terms of proportion of aging citizens (10). Furthermore, it is estimated that 20% to 30% of current radiation therapy patients are noncitizens (Iraqis and Syrians), and that will likely
Volume 91 Number 5 2015
rise, given the ever-increasing numbers of refugees and immigrants as a result of the regional political unrest and security conditions. Given the limited treatment resources and increasing demands, cancer prevention and screening programs should ideally be implemented. The availability and affordability of radiation therapy should be improved through opening new facilities in underserved areas and revisiting insurance coverage policies. More than anything else, a comprehensive national cancer care program that thinks ahead and designs proactive strategies to deal with these challenges is required.
References 1. Chin F. Inside the Singapore medical system. Int J Radiat Oncol Biol Phys 2013;87:864-866. 2. Shamseddine A, Sibai AM, Gehchan N, et al. Cancer incidence in postwar lebanon: Findings from the first national population-based registry, 1998. Ann Epidemiol 2004;14:663-668.
Around the Globe
891
3. Shamseddine A, Saleh A, Charafeddine M, et al. Cancer trends in Lebanon: A review of incidence rates for the period of 2003-2008 and projections until 2018. Popul Health Metr 2014;12:4. 4. Bentzen SM, Heeren G, Cottier B, et al. Towards evidence-based guidelines for radiotherapy infrastructure and staffing needs in Europe: The ESTRO QUARTS Project. Radiother Oncol 2005;75: 355-365. 5. Saab B. Reflections on the plight of Syrian refugees in Lebanon. Br J Gen Pract 2014;64:94. 6. El-Khatib Z, Scales D, Vearey J, et al. Syrian refugees, between rocky crisis in Syria and hard inaccessibility to health care services in Lebanon and Jordan. Conflict Health 2013;7:18. 7. Saad W. Financial development and economic growth: Evidence from Lebanon. Int J Econ Finance 2014;6:173. 8. Akl EA, Maroun N, Major S, et al. Post-graduation migration intentions of students of Lebanese medical schools: A survey study. BMC Public Health 2008;8:191. 9. Akl EA, Maroun N, Rahbany A, et al. An emigration versus a globalization perspective of the LEBANESE physician workforce: A qualitative study. BMC Health Serv Res 2012;12:135. 10. Sibai AM, Sen K, Baydoun M, et al. Population ageing in Lebanon: Current status, future prospects and implications for policy. Bull World Health Organ 2004;82:219-225.
Radiation Oncology biology
physics
www.redjournal.org
Lebanon: An Evolving Hub for Radiation Therapy in the Arab World Youssef H. Zeidan, MD, PhD,*,y and Fady Geara, MD, PhDy *Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida; and yDepartment of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon Received Nov 3, 2014. Accepted for publication Dec 15, 2014.
Introduction Radiation oncologists are increasingly expressing an interest in and concern about the practice of radiation oncology around the world. The Red Journal is reflecting this by devoting a special edition to global health and a series of articles outlining the practice of radiation therapy in specific nations (1). In this edition we travel to the Middle East, destination Lebanon. Once called the “Switzerland of the Middle East,” Lebanon is among the most scenic countries of the eastern Mediterranean because of its diverse geography and favorable climate (Fig. 1). Historically, Lebanon thrived under the French mandate after World War I. After its independence in 1943, it retained strong ties with France, particularly in the fields of education and medicine. Currently, the population is estimated at 4.8 million, with a unique mosaic composed predominantly of Muslims and Christians but also of 18 religious sects of various smaller sizes. The Lebanese health sector extends its services well beyond its own population, and in spite of the high toll of the civil war, Lebanon remains a hospitalization hub for the Middle East, particularly for neighboring Arab countries. This is driven by the availability of specialized medical care and the relative safety in comparison with neighboring countries such as Syria and Iraq. For a long time, epidemiologic studies describing cancer trends in the region generally, and Lebanon in particular, were lacking. In 2004, the Lebanese Cancer Epidemiology Reprint requests to: Youssef Zeidan, MD, PhD, Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW
Int J Radiation Oncol Biol Phys, Vol. 91, No. 5, pp. 888e891, 2015 0360-3016/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2014.12.036
Group first reported cancer incidence in the country based on a network of hospitals and pathology laboratories (2). In 2014, the largest epidemiologic study to date was published using a database of 45,753 patients from the National Cancer Registry (3). An average annual increase of 4.5% and 5.4% was found among male and female individuals, respectively. The authors anticipated 296 and 339.5 cases per 100,000 in 2018 among male and female individuals, respectively. Cancers of the prostate, lung, bladder, and colon and non-Hodgkin lymphoma were the 5 most common cancers in men, and cancers of the breast, ovaries, lung, and colon and non-Hodgkin lymphoma were the most prevalent among women (3).
Practicing in Times of Peace Lebanon was among the earliest countries to offer radiation therapy in the Middle East. The first 2 centers were established at the Hotel Dieu de France (HDF) Hospital (1930s) and the American University of Beirut (AUB) Medical Center (1950s). Currently, there are 8 medical centers offering mainly teletherapy around the country. The distribution of linear accelerators (LINACS) among the 5 Lebanese governorates is shown in Figure 2. With 14 operational LINACS, the country is estimated to currently have a ratio of 2.9 LINACS per million population, which is low in comparison with 5.6 in Europe (4). Brachytherapy (mainly HDR) services are offered at only 2 centers. Over the past decade, the country has witnessed a major 12th Ave, Suite 1500, Miami, FL 33136. Tel: (305) 243-4916; E-mail: [email protected] Conflict of interest: none.
Volume 91 Number 5 2015
Fig. 1.
Around the Globe
Byblos, Lebanon.
revamping of available technology. Although all centers currently offer 3-dimensional conformal therapy (3DCRT), intensity modulated radiation therapy (IMRT), image guided radiation therapy, stereotactic radiosurgery, and ablative radiation therapy remain restricted to just a few major centers. Intraoperative radiation therapy and prostate brachytherapy services are currently unavailable. The country’s diversity in religion and ethnicity is reflected in the radiation therapy community of physicians, physicists, dosimetrists, and therapists. Indeed, it is amplified by a great variety of international training. There are just 11 radiation oncologists staffing the nation’s centers. Four were trained in France, 3 in the United States, 1 in Canada, and 3 locally. Three of the 11 radiation oncologists hold American Board Certification. Physics support is provided by 9 physicists holding either master’s or doctorate degrees in medical physics, and 3 of these hold American Board Certification. The Lebanese University offers a master’s program in medical physics, which is
889
currently the only medical physics program in the country. Most of the current practicing physicists are Lebanese citizens who obtained their training, at least in part, in French, American, or Canadian centers. Because of the lack of formal dosimetry training programs, most dosimetrists hold bachelor’s degrees in physics and receive training at the employing institution. Although general radiology technology training exists, the country lacks radiation oncology technology training programs; thus, therapists receive additional training at their respective institutions. The current Lebanese health care sector is fragmented and inefficient. The civil war (1975-1991) was largely to blame for stunting development in health care. In the years immediately after the civil war, the government focused on rebuilding the country’s infrastructure (eg, roads, electricity), leaving the health sector uncontrolled and deregulated. Financing is provided by 5 entities: the national social security fund, the ministry of public health, armed and security forces, private insurance, and self payers. Out of the country’s 164 hospitals, only 28 are public. Radiation therapy is offered in just 2 public centers, meaning that the field is mainly controlled by the private sector. Wealthier members of the population seek treatment at private hospitals, although a small minority travel for treatment in Europe or the United States. These local centers offer treatment on the latest radiation platforms, albeit at a higher cost. For instance, in the past 2 years, 2 TrueBeam units were acquired by the HDF hospital. The ministry of public health (MOPH) contributes to coverage of patient treatments and offers up to 85% coverage for patients treated in private hospitals with special contracts. However, because of financial difficulties, the MOPH often delays reimbursement or sometimes defaults, leading several private centers to shy away from MOPH contracts.
Practicing in Time of War
Beirut (6)
Mou n Leba t non (5)
North (1) Bekaa (1)
South (0) Nabatieh (1)
Fig. 2. Distribution of functional linear accelerators in Lebanon by governorate.
In 1975, a brutal and devastating civil war shook the country. Over the subsequent 26 painful years, the war transformed Lebanon from a country of ruins to a country in ruins. The health care sector faced major challenges because the Lebanese infrastructure was being destroyed by the savage war machine. Basic amenities of life such as electricity and water became limited. Oncologists rose to the challenge at times when medical services were needed the most. The capital, Beirut, was divided into an Eastern part, controlled by Christian groups, and a Western part controlled by Muslim troops backed by the Syrian army. Staff often risked their lives, and even the commute to work became perilous because of snipers, militia checkpoints, and roadblocks. Occasionally staff would be trapped indoors because of the heavy shelling outside their medical centers. Patients often took long alternative routes and stopped for interrogation at checkpoints en route to chemotherapy and radiation therapy appointments. At one point the Children Cancer Center of Lebanon partnered
890
Around the Globe
with a nearby hotel to keep children and their families nearby. Militiamen often broke into medical centers and interrupted normal workflow. Oncologists had to carefully select their systemic therapy regimens in an environment with limited medical supplies. Academically, reputable medical schools in the country were unable to maintain requirements for international accreditation. In 1991, when the civil war ended, the health care sector had been left critically wounded. In March 2011, the Lebanese health care sector was faced with yet another challenge, this time coming from the eastern borders with Syria. The Syrian civil war resulted in more than a million refugees entering Lebanon in search of security and shelter (5). This rapidly unfolding humanitarian catastrophe currently overwhelms Lebanon’s limited resources, particularly the medical infrastructure. Refugees have to navigate a different health care system, which contrasts sharply with the government-run public hospitals in Syria. Coverage of medical care for the Syrian refugees is currently provided by private payees, United Nations agencies, international aid, nongovernmental organizations, and philanthropy. With more than 540 refugee housing sites around the country, and the continued turmoil in Syria, there is no end in sight for the refugee problem in Lebanon (6).
Academic Environment There are 2 radiation oncology residency programs in the country. The first program was created at the AUB Medical Center (AUBMC) in 1991. The AUB was established in 1866 by American missionaries led by Daniel Bliss. It functions under a charter from the State of New York and is arguably the region’s premier institution for higher education. Starting in 1991, the radiation oncology program at AUBMC has had on average 1 to 2 residency spots per year. Similar to most American residencies, it consists of 4 years after completion of an internship year. This program benefits from affiliations and close ties with international programs like the MD Anderson Cancer Center through a sister institution agreement, and also with Memorial Sloan Kettering Cancer Center through joint philanthropic grant funds. Several graduates of this program have successfully completed fellowships in the United States. The second program at Saint Joseph University offers a year of training in general medicine, 3 years of local radiation oncology training, and 1 year of training in a partner department in France such as Institute Gustave Roussy, Villejuif. Although there is a Lebanese Society for Radiation Oncology, there is currently no national board regulating licensing or maintenance of certification. In addition to training local physicians, Lebanese programs also offer training workshops for staff from regional centers. For instance, in 2009 the department at AUBMC collaborated with the Iraqi Ministry of Health in a program aimed at the rehabilitation of radiation oncology in Baghdad and other Iraqi regions. The program was given over
International Journal of Radiation Oncology Biology Physics
14 months. It hosted several working groups of physicians, physicists, and radiation therapy technologists from several institutions in Iraq and consisted of a series of didactic lectures and practical hands-on training sessions. Other aspects of academic radiation oncology practice still require considerable development. In particular, research opportunities are limited by the lack of local funds and inadequate infrastructure. In addition, the absence of any national cooperative group and a lack of communication between existing centers hinders the conduction of phase 2/3 trials. Perhaps Lebanon could play a leading regional role in this regard, given that it continues to host important regional oncology conferences such as the annual Middle East Medical Assembly, held by AUBMC and in collaboration with international institutions, and is among the first official sites for the annual Best of American Society of Clinical Oncology conference.
Challenges A shortage of financial resources and understaffing are main challenges currently hindering the practice of radiation oncology in Lebanon. The country’s average monthly disposable income is $1090, with a very wide variation, and the Gross Domestic Product per capita is $15,757 (7). A typical course of 3DCRT (breast, for example) costs $6000, whereas IMRT costs $17,250. Most insurance companies (including the national social security fund) currently cover 3DCRT but not IMRT. Patients often face financial hardships attributable to out-of-pocket expenses. In addition, such insurance policies affect the physician’s choice of treatment modality. The second challenge is a shortage of human resources. With only 11 radiation oncologists and 9 physicists, staff members are often stretched between several centers. The establishment of 2 residency programs in the country has recently helped to address the immediate need in terms of physicians, but long-term planning remains insufficient. Faced by socioeconomic challenges and volatile security conditions, some physicians elect to practice abroad after specialty training. Alarmingly, 96% of Lebanese medical students recently expressed an interest in working abroad in a recent survey (8, 9). As the guardian of the health care sector in the country, the MOPH is expected to assess the current staffing gaps and work with academic institutions to increase training positions.
Conclusion Looking ahead, the practice of radiation therapy in Lebanon is expected to face an increasing patient load. By 2025, Lebanon is projected to have 10% of its population over the age of 65, leading the Arab world in terms of proportion of aging citizens (10). Furthermore, it is estimated that 20% to 30% of current radiation therapy patients are noncitizens (Iraqis and Syrians), and that will likely
Volume 91 Number 5 2015
rise, given the ever-increasing numbers of refugees and immigrants as a result of the regional political unrest and security conditions. Given the limited treatment resources and increasing demands, cancer prevention and screening programs should ideally be implemented. The availability and affordability of radiation therapy should be improved through opening new facilities in underserved areas and revisiting insurance coverage policies. More than anything else, a comprehensive national cancer care program that thinks ahead and designs proactive strategies to deal with these challenges is required.
References 1. Chin F. Inside the Singapore medical system. Int J Radiat Oncol Biol Phys 2013;87:864-866. 2. Shamseddine A, Sibai AM, Gehchan N, et al. Cancer incidence in postwar lebanon: Findings from the first national population-based registry, 1998. Ann Epidemiol 2004;14:663-668.
Around the Globe
891
3. Shamseddine A, Saleh A, Charafeddine M, et al. Cancer trends in Lebanon: A review of incidence rates for the period of 2003-2008 and projections until 2018. Popul Health Metr 2014;12:4. 4. Bentzen SM, Heeren G, Cottier B, et al. Towards evidence-based guidelines for radiotherapy infrastructure and staffing needs in Europe: The ESTRO QUARTS Project. Radiother Oncol 2005;75: 355-365. 5. Saab B. Reflections on the plight of Syrian refugees in Lebanon. Br J Gen Pract 2014;64:94. 6. El-Khatib Z, Scales D, Vearey J, et al. Syrian refugees, between rocky crisis in Syria and hard inaccessibility to health care services in Lebanon and Jordan. Conflict Health 2013;7:18. 7. Saad W. Financial development and economic growth: Evidence from Lebanon. Int J Econ Finance 2014;6:173. 8. Akl EA, Maroun N, Major S, et al. Post-graduation migration intentions of students of Lebanese medical schools: A survey study. BMC Public Health 2008;8:191. 9. Akl EA, Maroun N, Rahbany A, et al. An emigration versus a globalization perspective of the LEBANESE physician workforce: A qualitative study. BMC Health Serv Res 2012;12:135. 10. Sibai AM, Sen K, Baydoun M, et al. Population ageing in Lebanon: Current status, future prospects and implications for policy. Bull World Health Organ 2004;82:219-225.
