A Proposal for a National Cancer Control Plan for the UAE: 2022–2026

The United Arab Emirates (UAE) is one of the fastest growing economies with consequent increase in non-communicable diseases including cancer. The number of reported cases and mortality have been increasing in the UAE over the years, despite screening and early detection efforts which appear to be far from target coverage of the intended population. In this work, we highlight key elements of a proposed national cancer control plan for the UAE. The plan is still a work in progress and has not yet been officially adopted. A comprehensive and effective control plan requires accurate data, a reliable cancer registry, and periodic monitoring and evaluation. The UAE cancer control plan is being prepared in line with the WHO and EMRO framework, with defined objectives and goals. The objectives are to combat cancer, reduce incidence, control mortality, and improve outcomes and quality of life for cancer patients. There is also a focus on improving public health education, prevention, early detection, prompt diagnosis, treatment facilitation, continuity of care, performance evaluation, training of workforce, and research.


Introduction
Cancer is a major health problem globally, and the second leading cause of death in the world, with a mortality rate of 8.8 million people in 2015, accounting for approximately 1 out of 6 deaths [1]. Cancer is the fourth leading cause of death in the Eastern Mediterranean region, after cardiovascular diseases, infectious diseases, and trauma [2]. The rate of cancer appears to be increasing in the Middle East, mostly related to rapid population growth, increasing life expectancy, and urbanization with progressively westernized lifestyles [3]. The incidence of cancer is predicted to double in the next two decades, the highest expected increase among all WHO regions. It is expected that by 2030, cancer related deaths will reach 652,097 from 367,441 reported in 2012 [4]. These projections are based on the impact of population growth and aging, the additive effect of increased exposure to cancer risk factors, such as smoking, diet, physical inactivity, and environmental pollution, which would lead to a greater rise in cancer burden. This employs an enormous burden on healthcare services.
Cancer is the third leading cause of death in the United Arab Emirates (UAE) after cardiovascular diseases and trauma. In the UAE, the mortality-to-incidence ratio is 0.39, which is comparable to most developed countries (approximately 0.38). The crude cancer death rate is 10.26/100,000 people, with breast cancer ranking first (110 deaths), while colon cancer ranking second (98 deaths), and lung cancer ranking third (80 deaths) [5][6][7].
Cancer is a preventable disease in a significant number of cases. A substantial number of cancers can be detected in early stages and treated successfully. Even if diagnosed in late stages, cancer pain can be decreased, the disease progression slowed down, quality of life improved, and patients and their families facilitated to cope. Effective cancer control plans are, therefore, indispensable everywhere. In most countries, irrespective of economic status, some level of cancer control activity is ongoing. In many countries, there is no effective cancer control plan, the plan is out of date, or is not effectively implemented. There is thus a need for a comprehensive plan, its effective implementation, regular monitoring, quality assurance, and updating as per local needs and requirement [1,2,4].
Cancer, today, is managed by a multidisciplinary integrated approach with equity and uniform accessibility. The UAE aims to reduce the burden of cancer in the UAE and to make all possible efforts to deliver optimal cancer care for cancer patients and their families. It also aims to expand cancer care services in the UAE in line with international guidelines and the best global practices, adjusted to suit the needs of the country [3,6,7].
In this work we highlight key elements of a proposed national cancer control plan for the UAE. The plan is still work in progress and has not been yet officially adopted.

Cancer Burden in the UAE
During the mid-twentieth century, the UAE rose to become one of the fastest growing economies globally [8,9]. This growth leads to economic, sociodemographic, and lifestyle changes of the population, paralleled by an epidemiological increase in the rates of noncommunicable diseases (NCD) and cancer. Subsequent studies in the UAE linked this increase in cancer with an exposure to several risk factors, including physical inactivity and sedentary lifestyles [10][11][12], the consumption of high-caloric and poorly nutritive meals [13], an increase in obesity [12,13], an increase in smoking [14], and elevated air pollutant levels [15]. There is an impact of improved cancer diagnostics. The reported deaths due to NCD in 2016 were 77.3% of all deaths. The main causes of deaths are cardiovascular diseases (40%) and cancer (12%). Communicable, maternal, perinatal, and nutritional conditions cause around 6% of all deaths, while chronic respiratory diseases and diabetes represent about 5% each [9,11].

Cancer Incidence Rate
A total of 4299 cases were diagnosed in 2017 in the UAE, including 4123 (95.91%) invasive cancer cases and 176 (4.09%) in situ cases. There were 2370 (55.1%) females and 1929 (44.9%) male. The cancer cases reported in 2016 were 4210 indicating a rise in 2017 from 2016, as per data of the annual reports of the National Cancer Registry in the United Arab Emirates. Invasive cancer cases are distributed according to the nationality in 2017, with 680 (62%) female cases and 425 (38%) male cases among UAE citizens, and 1570 (52%) female cases and 1448 (48%) male cases in non-UAE citizens [3,5,6].

The Most Common Cancer Types
The frequency of cancers in males and females as reported from the UAE in 2017 are summarized in Table 1. Breast is the most common site of cancer among the population of the UAE, accounting for 20.23% of all cancer cases in the year 2017. After breast cancer, colorectal cancer (10.24%), thyroid cancer (9.99%), leukemia (7.62%), skin (5.04%), non-Hodgkin's lymphoma (4.17%), and prostate cancer (3.76%) are the most common types of cancers in UAE [3,6].  Table 2 shows the most common pediatric cancers in the UAE. Leukemia was the most common cancer among children in the UAE in 2017, accounting for 41.8% of all cancer cases in children [3,5,6].

Cancer Mortality
In 2017, cancer-related deaths in the UAE reached 955, about 10.82% of total deaths. The crude cancer death rate was 10.26/100,000 people, with breast cancer ranked first (110 deaths), while colon cancer ranked second (98 deaths), lung cancer ranked third (80 deaths), and leukemia ranked fourth (52 cases). The number of cancer deaths shows that the percentage of cancer deaths increased during the year per one thousand of the population in 2018 compared to 2017, which was adopted as a baseline for the index targets [3,6,7].

Cancer Prevention, Screening, and Early Detection
Around one third of cancers can be preventable by changes in lifestyle, genetic testing of high-risk groups, and vaccination. Even though cancer incidence is relatively low in the UAE, we must focus on improving the outcome of patients being treated for cancer. Nothing impacts cancer survival rates more than screening and early detection. Early detection of cancer is known to increase the chance of a successful treatment and improved outcome. Results for 2017 show a lower rate of population coverage for early cancer screening among the target age groups [<70%] than the targets set nationally or by the World Health Organization (Table 3) [1,2,4,5,16].  Table 2 shows the most common pediatric cancers in the UAE. Leukemia was the most common cancer among children in the UAE in 2017, accounting for 41.8% of all cancer cases in children [3,5,6].

Cancer Mortality
In 2017, cancer-related deaths in the UAE reached 955, about 10.82% of total deaths. The crude cancer death rate was 10.26/100,000 people, with breast cancer ranked first (110 deaths), while colon cancer ranked second (98 deaths), lung cancer ranked third (80 deaths), and leukemia ranked fourth (52 cases). The number of cancer deaths shows that the percentage of cancer deaths increased during the year per one thousand of the population in 2018 compared to 2017, which was adopted as a baseline for the index targets [3,6,7].

Cancer Prevention, Screening, and Early Detection
Around one third of cancers can be preventable by changes in lifestyle, genetic testing of high-risk groups, and vaccination. Even though cancer incidence is relatively low in the UAE, we must focus on improving the outcome of patients being treated for cancer. Nothing impacts cancer survival rates more than screening and early detection. Early detection of cancer is known to increase the chance of a successful treatment and improved outcome. Results for 2017 show a lower rate of population coverage for early cancer screening among the target age groups [<70%] than the targets set nationally or by the World Health Organization (Table 3) Table 2 shows the most common pediatric cancers in the UAE. Leukemia was the most common cancer among children in the UAE in 2017, accounting for 41.8% of all cancer cases in children [3,5,6].

Cancer Mortality
In 2017, cancer-related deaths in the UAE reached 955, about 10.82% of total deaths. The crude cancer death rate was 10.26/100,000 people, with breast cancer ranked first (110 deaths), while colon cancer ranked second (98 deaths), lung cancer ranked third (80 deaths), and leukemia ranked fourth (52 cases). The number of cancer deaths shows that the percentage of cancer deaths increased during the year per one thousand of the population in 2018 compared to 2017, which was adopted as a baseline for the index targets [3,6,7].

Cancer Prevention, Screening, and Early Detection
Around one third of cancers can be preventable by changes in lifestyle, genetic testing of high-risk groups, and vaccination. Even though cancer incidence is relatively low in the UAE, we must focus on improving the outcome of patients being treated for cancer. Nothing impacts cancer survival rates more than screening and early detection. Early detection of cancer is known to increase the chance of a successful treatment and improved outcome. Results for 2017 show a lower rate of population coverage for early cancer screening among the target age groups [<70%] than the targets set nationally or by the World Health Organization (Table 3) [1,2,4,5,16]. The causes of low screening rates in the UAE population and some actions recommended/proposed to improve these rates are described in Table 4 [5,6].

Diagnostic Services
A swift and definitive diagnosis is the key to prompt and definite treatment. We lack efficient and well-developed pathways to ensure that patients are referred to an appropriate physician and centers in time to be diagnosed within a minimum possible time. During this timeframe, patients are expected to complete a clinical physical assessment, radiologic imaging, and tissue diagnosis by biopsy and pathology. The plan for further assessment or management must be discussed and approved at multi-disciplinary team (MDT) tumor board meetings. All diagnostic services are not available universally and with the desired equity. We need tumor site-specific diagnostic clinics with a facility to support genetic testing. We will have to ensure quality assurance with international standards and quality control regulations, often requiring accreditation with recognized international organizations. This should come with regulation, development, and implementation of established diagnostic standards [5,[17][18][19][20][21].

Cancer Management
It is a must to establish, improve, sustain, and monitor all-inclusive cancer services, including surgical oncology, medical oncology, radiation oncology, pediatric oncology, and palliative care services. There are newer sub-specialties evolving as gynecologic oncology, uro-oncology, osteo-oncology, neuro-oncology, among others. There is forthcoming necessity and demand to develop these specialized cancer care services with excellence, which are not up to the mark at present, nor in a true construct. We lack well-organized supportive services available to each and every patient such as clinical psychologist, clinical dietitians, social workers, and community nursing services at all levels of care provision. We are still far-away from perfection to develop and implement practice guidelines for referring physicians, radiologists, and pathologists for each cancer. These need to be formulated as per our local data, our set objectives and settings, local disease biology, and access to resources. It is essential to strengthen the role of the MDT tumor boards in cancer institutes and all new cases as well as complex cases must be reviewed and discussed by a MDT, to arrive at a well-documented plan of care for each individual [17][18][19][20][21]. Palliative care services are only available in comprehensive care centers.

Cancer Research
Overall, cancer research productivity is evolving over time, although several evidence gaps continue to persist. The scope for basic and translational research is generally expanding within the country with the continued rise in the number academic institutions and research programs dedicated to molecular and cellular research. Observational studies have been mostly focused on screening and basic parameters of epidemiology. Future directions should focus on expansion of national registries and longitudinal collection of clinically relevant variables that can better inform the clinical and molecular profiles of breast cancer in the country, and, more importantly, survival metrics that can help inform management strategies. Lastly, there is an evident paucity of therapeutic clinical trials, which is a challenge shared by the wider region. Several efforts are currently ongoing to solidify partnerships with clinical trial sponsors to host interventional studies in the country, considering the regulatory and resource infrastructures are well advanced and adaptable to international standards and requirements. There has to also be an equal effort placed on understanding modifiable lifestyle risk factors for cancer, such as smoking, obesity, diet, and physical inactivity, which are perceived to be in 'bad shape' in the UAE although true prevalence rates in Emiratis vs. expats and associations with cancer incidence remain unclear.

The UAE Cancer Control Plan
In 2011 [11,22,23], the WHO proclaimed the crucial demand to create a baseline for monitoring trends and to assess the progress of countries to contest the global epidemic of cancer in confronting this scourge. A cancer control plan needs accurate data assimilation, a consistent and progressive cancer registry, and monitoring and appraisal initiatives to ensure appropriate priority settings and to ensure quality [24]. The WHO advised governments to consolidate their health information systems with reliable and evidencebased research indicators.
The Ministry of Health and Prevention with its partners in the UAE started developing a national cancer control plan to be implemented in accordance with specific objectives. The plan, presented herein, is still a work in progress and has not been officially adopted. The proposed plan covers the years 2022-2026 and was prepared focused on the global action plan for prevention and control of cancer by the WHO and the regional executive framework for prevention and control of cancer for the Eastern Mediterranean Region (EMRO). The outline of this plan reflects the directions and strategy to reduce the cancer incidence and facilitate journey of cancer patients through their disease course, decrease mortality by at least 25%, and improve the quality of life through an integrated approach based on comprehensive activities and cancer care services. The plan is based on nine strategic axes centered across the healthcare system, services, prevention, sustainability, and innovation. It includes areas of governance, prevention, early examination, treatment, palliative care, surveillance, and research [2,6,16].
Development of the plan was made through a committee of local oncology practitioners and policy makers in co-operation with various stakeholders including both public and private sectors involved in clinical care and public health and education; to enrich commitment to global and regional initiatives to fight and control cancer. The plan is a strategic and general framework for the determinants and controls used in formulating policies, developing legislation, and assessing material resources to support the prevention, care, and management programs in the UAE. It further proposed appropriate measures for implementing the plan, continuous monitoring, and a follow-up system. Measurement indicators to evaluate the efficacy of suggested and adopted activities were also established. It represents the roadmap for the implementation of specifics of the plan for the prevention and control of cancer. This plan is aligned with the National Agenda of the UAE for 2021 and aims to reduce cancer death rates which will help achieve the objectives of the agenda [11,21,23,24]. The vision, objectives and strategy of the proposed UAE cancer control plan are summarized in Table 5.

The Guiding Principles and Strategic Directions of the UAE Cancer Control Plan as per WHO and EMRO Guidelines
The national cancer control plan is based on the strategic directions set by the executive framework of the action plan as pronounced by the World Health Organization for the Eastern Mediterranean Region. The recommendations of WHO and EMRO are summarized in Table 6 [4,11,16,24]. Table 6. Recommendations of WHO and EMRO for cancer control plans.

1.
Governance: Focus on developing a strategy and a multi-sectoral committee for the prevention and control of cancer; while ensuring the availability of a sustained budget, adequate national cancer rates, setting costs for care and treatment packages, and determining a mechanism to cover treatment expenses with equity 2.
Prevention: Focus on adopting healthy life by combating smoking, encouraging physical activity, and healthy food in line with the Non-Communicable Disease control framework/plan. The focus should include vaccinations against hepatitis and HPV 3.
Early detection: The strategic directions in this area are based on four axes: Awareness of the population about early warning signs and symptoms of cancer, education, continuing education for health staff on the early signs and symptoms of the common cancers, prompt diagnosis and referral for patients, screening programs, and a continuous evaluation of the effectiveness of these programs. The focus should also be employed on accessibility and the affordability of diagnostic tests for suspected cases.

4.
Treatment: Focus on developing and implementing protocols and best clinical practices based on evidence-based guidelines. Assess human resource needs and focus on accessibility and affordability of cancer care services and extend affordable treatment packages. This must also include the development of integrated, coordinated and prompt referral systems to avoid delays in diagnosis and treatment.

5.
Palliative care: There is a need to develop integrated multidisciplinary palliative care services including pain care and psychological support, available in hospitals and primary healthcare centers. Developing and implementing protocols for best evidence based clinical practice and integrated care, and a swift and early transition. Palliative care should be included in medical academic programs.

6.
Research and Surveillance: Develop a population based national cancer registry, hospital registries, and monitor these with an accredited quality assurance program. The area includes focusing on developing and implementing an integrated plan for research according to the priorities of the country.

Definitions of the Strategic Axes and Executive Framework of the UAE Cancer Control Plan
The UAE cancer control plan should include 3 pivotal focus areas concentrated around nine strategic axes (Table 7). Table 7. Strategic axes of the UAE cancer control plan.

Education and understanding
Enhancing health awareness about the knowledge of cancer, risk factors leading to cancer and correction of misconceptions about the disease

Prevention
Launching awareness campaigns and prevention programs against cancer and known causes

Early detection
Detecting cancer in the early stages to increase the patients' survival and outcome. It involves periodic clinical assessments and reduces the delays in appropriate treatment referrals to receive treatment promptly

Rapid diagnosis
A healthcare center should assess condition of the patient promptly in a systematic integrated way and take appropriate medical decisions based on a developed pathway

Treatment
Provide appropriately validated clinical practices in line with international guidelines for treating cancer according to disease stage to improve outcomes 6. Ongoing care Provide timely transition to post-treatment and palliative care services for cancer patients and educating them about the appropriate ways to live with the disease and directions to avoid disease recurrence

Performance measurements
Establishing national records including all data sources in a central place and assemble comprehensive data of high quality, accuracy, and to record information about a disease 8. Workforce capacity building Providing a qualified and appropriately trained team to deliver prevention, treatment, continuity of care for patients; and provision of suitable training facilities for the workforce

Research
Cancer research improves the diagnosis, treatment, outcome, and enhance quality of life by translating quality research and clinical trials for improvements in personalized care The first is prevention, which revolves around the axes of education, understanding, prevention and detection, early and rapid diagnosis. The second focused area is that of healthcare and services which includes the axes of treatment and continuous care. The third area is that of sustainability and innovation and revolves around the axes of performance measurement, workforce, and research. These are further detailed and explained in depth in Table 8.

Expected Cancer Burden
The reported age-standardized cancer incidence in the UAE is low compared to the United States and other developed countries. There is, however, a real expectation to have an increment of cancer cases by 10-15% annually, keeping in sight existing cancer trends [2,3,[5][6][7][8]11].

Cancer Control Program
An all-inclusive Cancer Control Program is mandatory to formulate strategy, implement prevention, and enforce a comprehensive cancer management through a collaborative process between government organizations, community, and non-government organizations (NGO). An effective and well-balanced plan should steer to risk reduction, early detection, and improved management to enhance survivorship and efficiently reduce the cancer burden.
The Cancer Control Program should be aimed at keeping the incidence rate at its current level or reducing it. A comprehensive national cancer program assesses various ways to control disease and implements most cost-effective and beneficial means for the population. It places emphasis on preventing cancers or detecting cases early at a curable stage and providing maximum possible relief to patients with advanced disease. A well-developed and implemented cancer control program should result in significant risk reduction, increasing early detection, improved treatment, and enhanced survivorship.
We must strengthen the National Cancer Control Committee, with members of the committee representing all stakeholders. We should adhere to the WHO Cancer Control Strategy to have a standard, reproducible, equitable and uniform approach. It is highly desirable to have increased collaboration with other ministries, such as the Ministry of Religious Affairs, Ministry of Education, and media outlets both private and public. We must draw a road map for the steps of adaptation of the WHO strategy based on a local database [8,11,[22][23][24].

Cancer Registry
A cancer registry is the key instrument for any cancer control plan. It can define cancer burden, identify risk factors of cancer, and evaluate the cancer control program itself. A cancer registry can help in cancer control planning and organization through understanding cancer patterns and time trends by gathering epidemiological indicators, such as cancer incidence, mortality, prevalence, stage at diagnosis, and patient survival.
Recently, registry managers from 19 MENA countries reported the presence of 97 population-based, 48 hospital-based, and 24 pathology-based registries. Most populationbased registries were well or partially developed. Lack of accurate death records, complete medical records, and communication between stakeholders and deficiencies in trained personnel were critical challenges that were more severe in active conflict zones and neighboring conflict-affected regions. Cancer registration challenges included weak health infrastructure, absence of legislation mandating cancer registration, and disruption of cancer registration because of active conflict and loss of funding [25].
A well-established national cancer registry regularly documents a yearly report on cancer incidence. Cancer registry should collect comprehensive information, such as stage of disease, mortality, and risk factor data. The registry often operates with an insufficient workforce, unavailability of data on patients diagnosed and treated abroad, and noncompliance from non-governmental institutes and medical personnel, and mobility of population [5,6,[25][26][27]. To have precise, consistent, dependable, comprehensive, and beneficial cancer registry data, we need to 1.
Establish the Cancer Registry Advisory Committee to participate in the planning of cancer registry activities, provide feedback on the data and reports, and contribute to data dissemination and advocacy for the registry; 2.
Establishing and implementing data quality indicators;

3.
To complete data on cancer stage, mortality, risk factors, and cancer prevalence; 4.
Increase the trained human resources; work on retention of current staff through training more registry staff and to give them technical and financial support to ensure completeness of cancer registration and sustainability of the cancer registry; 5.
Collect more inclusive data on cancers as well as non-morphologically; 6.
Mandatory reporting, by working on legal obligation to notify cancer; 7.
Adjustments of cancer notification form and electronic notification forms; 8.
Seek more collaboration from healthcare providers.

Indicators for Monitoring
There are many known global Indicators of attainment employed for monitoring and progress of any national cancer control plan. There can be KPIs, with some being well known and some can be developed according to local situations. Examples of improvement include: education, measured by the cancer awareness measure; reduction in the numbers of smokers; increased proportion of stage 1 and 2 breast and colon cancer; increased proportion of patients diagnosed by screening or urgent referral pathways; publication and comparison of 1-and 5-year cancer survival rates; increase in patients with complete care plans in place across the care pathway; decreasing number of patients travelling abroad for treatment; and more patients accessing ongoing care in primary care/community care services [3][4][5]10,11,16,21,24].

Continuing the Path to Progress and Excellence
Certain progress has been made, but a lot more is needed as the vision for the future of cancer care remains unchanged as an enormous challenge. The UAE will continue to pursue excellence in cancer care by developing complex specialty services and innovative treatments. New, evidence-based approved treatment modalities and technologies, with proven impacts on patient care, will be accessed and incorporated in management strategies. Improvements in the patient experience will be achieved with a focus on the whole pathway of care, which is based upon the WHO Cancer Care Continuum [22,24,25,27].

Public Education and Understanding
It is an implacable requisite to invest in educating people to understand the importance of prevention, enhance prevention and early detection initiatives, and swift definite diagnosis of cancer. There is a need to improve refutation programs and alleviate myths about cancer. There are myths, such as that cancer appears at specific sites, appears only in late stages, is more common in low-income countries, is always fatal, and that surgery makes it spread quickly. There are multiple stigmas about cancer; people feel uncomfortable discussing cancer, avoid using the word cancer, diagnosis indicates weakness, fear of loss of job, and loss of sexual activity [2,4,26,27].

Partnership within the Cancer Community
There is a need to develop close associations within the cancer patient's community with the objectives for enhancing awareness and prevention of cancer, understanding of cancer, sharing experiences, financial support for eligible cancer patients, to coordinate with various stakeholders to organize meetings, seminars, courses, and conferences; and to support research and raising awareness of the disease and its prevention [25,27].

Conclusions
The UAE is a growing economy with a substantial burden of cancer, which is expected to increase with consequent morbidity and mortality. There are screening and early detection efforts which are far from target coverage of the intended population. A comprehensive and effective national cancer control plan is always needed to effectively combat cancer. It needs accurate data collection, an efficient and organized cancer registry, and regular monitoring and evaluation of related activities. A UAE cancer control plan was herein proposed, in line with the WHO and EMRO cancer control initiatives and framework, with well-defined objectives and targets. The objectives are to combat cancer, decrease cancer incidence, restrict morbidity and mortality, improve outcomes, and augment the quality of life for cancer patients. In particular, there is a need to continue on the path of progress and excellence. The cancer registry needs to be broadened and given necessary legislative cover. We must introduce our efforts and commitment more in preventive oncology. We have to also incorporate the ever-growing knowledge, ongoing technological development, and newly approved medications as per international data and guidelines based on clinical trials. We should also endeavor to develop clinical pathways and guidelines, employ these, and continuously monitor our cancer services. We need to expand cancer care initiatives with participation of all stakeholders and deliver cancer services with equity and affordability, keeping in mind the issue of cost-effectiveness. There is a need to induct a qualified workforce, improve their skills and expertise by training and continuing education, and monitor their performance. It is essential to prepare and get international accreditations by known world organizations to be continuously on the path of progress.
The cancer care services must also be accessible with equity, reproducibility, and affordability. Appropriate distribution of resources can enhance delivery of cancer care, often at the patient's doorstep. We need to integrate and link primary healthcare, secondary care hospitals, tertiary care, and private cancer care centers. The focus should be on development and investing in preventive oncology by boosting education, screening and early detection. The pathways of the patient journey from symptoms to definite treatment need to be thoroughly worked in line with local realities and international guidelines and protocols.

Funding:
The publication fees of the manuscript was funded by Amgen without any influence on manuscript contents. The manuscript was developed solely by the authors.
Institutional Review Board Statement: Ethical review and approval were waived for this study, due to review type of the study.