Pathway to excellence in cancer care: learning from Qatar's experience

In 2011, Qatar launched the First National Cancer Control Program in the GCC. The National Cancer Strategy, A Path to Excellence (2011‐2016) and the companion document, Qatar National Cancer Research Strategy (2012) transformed cancer care in Qatar. Cancer outcomes are now equivalent to countries with long established National Cancer Strategies (The Lancet, 2018). Critical to the success were robust governance structures, informed and committed leadership, comprehensive involvement of all sectors including public and private providers, charities, private sector employers, academic partners and the judicious use of expert groups and subject matter experts. Major milestones have been reached in the prevention, early detection, treatment and care of cancer throughout the period the National Cancer Strategy has been in place. Achievements have included harmonized multi‐sectoral awareness, education, and myth busting campaigns aligned to a single National Awareness Calendar. A National Breast Cancer Screening Program, a National Bowel Cancer Screening Program and an opportunistically ran Cervical Cancer Screening Program have been established, supported by a dedicated Cancer Screening Call Center and a Mobile Screening Unit for those hard to reach geographical areas in Qatar. Internationally peer reviewed cancer specific teams included new and extended roles, the introduction of forefront diagnostic and treatment modalities and a patient centered approach to the organization of care have improved clinical outcomes, patient experience, and public confidence. Future development will focus on consolidating areas of significant achievement incorporating emerging evidence and new technologies. This will include evidence‐based approaches for public engagement, prevention and early detection, particularly the use of personalized approaches. As with any successful cancer program, survivorship and transition programs need to be enhanced to include chronic illness and palliative care models. Rare cancers, further development of local faculty and maturity of Qatar's high impact Cancer Research portfolio are also a focus. Qatar provides a model that illustrates how the principles of good cancer control are internationally applicable but need to be locally owned and adapted to the country and be culturally specific. It is critical to have clear leadership and governance, as well as the right people in all partner organizations to work collaboratively in achieving a common goal. We make key policy recommendations that are applicable inside and outside of Qatar. Moreover, we share the successful cancer care framework learned from the Qatar experience.

how the principles of good cancer control are internationally applicable but need to be locally owned and adapted to the country and be culturally specific. It is critical to have clear leadership and governance, as well as the right people in all partner organizations to work collaboratively in achieving a common goal. We make key policy recommendations that are applicable inside and outside of Qatar. Moreover, we share the successful cancer care framework learned from the Qatar experience. Qatar is a small country on the Arabian Peninsula that has seen rapid development over the past decades. It has a high per capita GDP and a small, relatively young national population. It also has a large expatriate population.
Cancer is already the nation's second noncommunicable disease, after cardiovascular disease and is projected to triple between 2010 and 2030 as a result of a combination of ageing and population growth. Public Health Care is available free for all residents who have paid a minimum fee for health insurance and this includes cancer care.
There is also access to ad hoc support for treatment on an exceptional or compassionate need basis from other sources such as charities, including the Qatar Cancer Society (QCS).

| Global perspective
Cancer is a global health challenge whose incidence is on the rise and it is also a leading cause of death worldwide. The World Health Organizational (WHO) recommends that all countries develop and implement a Cancer Control Program to prevent cancer, detect it early when it does occur and manage the disease and its impact effectively through treatment into survivorship or palliative care. It was in response to this call that Qatar developed The National Cancer Strategy, A Path to Excellence (2011-2016). 2 According to the WHO estimates in 2015, cancer is the first or second leading cause of death before age 70 years in 91 of 172 countries. It ranks third or fourth in an additional 22 countries of which Qatar is one of them ( Figure 1).

| The cost of cancer
Cancer and its treatment result in the loss of economic resources and opportunities for patients, families, employers, and society overall.
These losses include financial loss, morbidity, reduced quality of life, and premature death. The economic burden of cancer is a growing global issue and the burden on individuals and families is profound.
Research estimates that based on premature death and disability from cancer worldwide the total economic impact of cancer is around 1.5% of the total global GDP, which does not include direct costs of treating cancer. 7

| Qatar perspective
Qatar is a relatively young country, but its cancer incidence is project to almost triple between 2010 and 2030 due to aging and population growth ( Figure 2).
As in other countries, cancer incidence increases with age and life expectancy in Qatar continues to rise for both men (79 years) and women (82 years) ( Table 1). It is the second cause of death from noncommunicable diseases.

| Premature mortality from cancer
Data from Qatar National Cancer Registry in 2016, shows that a total of 1566 new cancer cases were diagnosed in 2016, of which 21% were Qataris; 42% females and 58% males. The most common cancer was breast cancer, constituting 17% of all cancer cases, followed by colorectal at 10%. The crude incidence was found to be 59.8 per 100 000 of the population.
Benchmarking Qatar to the rest of the GCC mortality rate seems similar. Qatar has a 16% mortality rate ( Figure 3).     The interventional radiology suite offers state-of-the-art imaging equipment for diagnosing and treating cancer by undertaking minimally invasive procedures using X-rays, CT imaging, ultrasound and MRI.

| Service developments and advanced treatment technologies
These techniques allow the doctor to insert miniature, highly advanced, medical instruments into the body which are then directed to the required location. Procedures that once required significant surgery can now be undertaken with a minimal incision ensuring effective, highquality medical care that is less stressful and painful for the patients.
A Cyclotron provides radioisotopes used to make radiopharmaceutical that are used in PET/CT. This is a sophisticated technology using nuclear medicine to diagnose and treat certain cancers. Moreover, the cyclotron also supplies radiopharmaceuticals to Cardiology and Neurology as well as other local approved providers. This is likely to increase with the successful uptake of populationbased screening services, which result in cancer being detected earlier where a potentially curative surgery is more likely to be an option. There are plans to upscale the medical and equipment infrastructure to support the development of Cell Therapy and Gene Therapy options, which offer the population access to forefront treatments and early clinical trials while providing a service that will have regional benefits.

| Precision medicine and genetics in cancer
Precision medicines has the potential to change the cancer paradigm regarding cancer prevention, detection, treatment and follow up personalized to the individual.
• Cancer can be prevented by identifying actionable genetic mutations that offer the person choices such as prophylactic surgery to prevent cancer.
• Patients identified as being at high risk of cancer can have additional surveillance and counseled in high-risk clinics. B O X 1 Breast cancer-incidental BRCA1/2 breast cancer findings case Next Generation Sequencing (NGS). Prediction of genetic risk for disease is needed for preventive medicine. Decreasing NGS cost made genome-wide analyses affordable to assess variation in cancer susceptibility genes. The genome sequencing data provided by the Qatar Genome project and Qatar Biobank set the stage for cancer genomics studies in Qatar. Studying the genetic variation of cancer genes in the Qatari population, researchers from WCMQ, Sidra Medicine and HBKU-QCRI analyzed the genomes of 6000 Qatari. They obtained sequence details of more than 786 cancer genes including BRCA1 and BRCA2 that are known to be responsible of Hereditary Breast and Ovarian Cancers. The analyses revealed the presence of pathogenic BRCA1/2 mutations in 20 Qatari subjects. Given the high risk of breast and ovarian cancers in these individuals and/or other members of their families, a task force was formed by QPMI and HMC to setup a work plan for intervention and genetic counseling. There are inequities across the genders with men showing greater uptake of tobacco smoking than women do ( Figure 5).

| Information and support
Information and support for those affected by cancer should cover the entire patient pathway from pre diagnosis, through treatment and into survivorship, palliative care, and bereavement.
The term "affected by cancer," acknowledges that it is not only the patient who requires information and support but that the needs of family members may differ from that of the patients. Children can be affected by cancer as a patient, or as a child or sibling of someone who has cancer. Age appropriate information and support is required.
Some individuals who will never get cancer will also have complex support and information needs such as those attending high-risk clinics and making difficult choices following genetic testing.
Complimentary patient information pathways should be developed, alongside disease specific pathways for each disease group.
These should be approved by the National Clinical Advisory Groups to assure of the quality and provide consistency.

| Transitions programs-living with and beyond cancer
The Cancer Paradigm has changed and increases in survival in both  One example is the Qatar Cardio-Oncology service which cares for patients experiencing cardiac problems associated with cancer treatments.
Other services which require specialist input can be delivered in community-based locations close to the patient such as outreach lymphedema, prosthetics and continence promotion services.
Shared care protocols with Primary Health Services, with devolved monitoring and follow-up models will be developed, coupled with essential rapid re-entry pathways to specialist services. Links with the Qatar Rehabilitation Institute will be strengthened, and cancer specific vocational rehabilitation programs will enable patients return to work and contribute to society.
Charities, faith and community groups can be supported and skilled up to provide community lead wellness, fitness, counseling, and support groups. These must be supported by professionals to ensure evidence-based practices and quality standards are maintained. They should also allow for a wide range to ensure they are age appropriate and respect gender and personal preference. Teenage and Young Adult transitions programs are also required. A multi-sectoral, high-level strategic approach is essential if appropriate Palliative Care is to be equitably available for all who require it, including those with other chronic illness not amenable to cure.

| Extending palliative care nationally
In common with many countries' community-based palliative care, outreach services, and access to community specialist palliative care all need to be further developed. These can be supported by community-based Specialist Palliative Care Nurses, Allied Health Professionals, and Primary Clinicians with a special interest.
All health care professional regardless of sector need to be educated in palliative care, communication, and bereavement skills which should also be included in undergraduate and postgraduate education.
Skilled and sensitive public awareness campaigns are required, and palliative care should be included in all chronic disease strategies.
As in many other countries, National Guidelines need to be developed and changes in legislation and regulation may be required especially regarding palliative medication.
Bereavement services in many countries are run by charities with expert professional leading a team of highly skilled and appropriately qualitied volunteers.

| Further extend precision medicine across the patient pathway
Developments in genomic and genetics can be used to identify those at particular risk of some cancers and high-risk monitoring and prophylactic approaches can be developed.
Building local capability and capacity in a range of other omics to extend the range of diagnostic assessments to inform clinical decision making.
Emerging pre and post diagnostic predictive and prognostic testing will enable more tailored approaches to treatment and care.

| Transition programs
A successful cancer strategy results in many more people living with and beyond cancer. The effects of cancer and its treatment may be prolonged or even permanent. Cancer trajectories for patient may vary between curative, living for decades with cancer as a chronic illness or palliation so traditional binary model of curable/incurable are no longer adequate.
Additionally, some patients will transition from potentially curative to palliative when disease reoccurs or fails to respond to treatment.
Children and adolescents with cancer may also face the transition of becoming an adult living with or beyond childhood cancer. Successful transition programs benefit patient, families, and society by ensuring the maximum health and wellbeing possible for as long as is possible.
Transition programs are a cost effective means of maximizing the health and wellbeing gained from a cancer program, particularly when they embrace the expansion of roles and new innovative models of care, including from nontraditional providers.

| Communicate early detection and preventive values
Core to reducing the cancer burden is prevention and early detection.

| Setting standards and expanding roles
Equity in cancer requires standardization of care. International and national expertise can be merged to ensure cancer services are delivered to the best available evidence, yet are adapted to local need, capacity and capability.
Specialization increases outcomes and this can be used to extend scopes of practice and create innovative roles.
Nursing and Midwifery are the key to rapid and cost-effective expansion of high quality universal health coverage, Doha WISH 2018.5 The effectiveness of a National Cancer Program is ultimately measured by its outcomes in terms of mortality morbidity and the experience of those affected by cancer so appropriate outcomes and evaluation mechanisms need to be agreed.6

| Essential components for a developmental cancer care framework
We believe that the below components are essential to the delivery of a successful cancer framework.
1. Clearly articulated vision tailored to national realities and cancer profile.
2. Committed leadership with robust progress monitoring and governance arrangements. 8. Outcomes are measured through robust data capture and registries, which include the experiences of those affected by cancer.

| CONCLUSIONS
Qatar has developed a high-quality national cancer program in a relatively short strategic time scale. Essential to this was a clearly articulated cancer strategy for which had excellent strategic fit to the wider Qatar policy context, which was tailored to be responsive to local and cultural needs in a young country that is developing rapidly. It was supported by engaged, committed political, and clinical leadership.
Central to success was excellent integration between primary, secondary, and tertiary services, the Ministry of Public Health, and other public, private, and third sector organizations.
Qatar's size offers the possibility to work on a national scale and with a whole population. This also presents some challenges in terms of rarer cancers and disease volumes, which has been addressed by super sub specialization for some conditions and establishing close partnership arrangements with international centers of excellence.
Qatar is fortunate as a developing country to be relatively wealthy with one of the highest per capita incomes in the world.
However, while this has permitted the development of advanced technology treatment, the principal successes of the National Cancer Strategy has been through a clear vision, supportive leadership, judicious use of expertise, expansion of roles, and comprehensive involvement of all the relevant partners across specialisms and sectors working toward a common goal.
Regardless of resource constraints, Qatar's experience would support the belief that a well-conceived and well-managed National Cancer Program helps reduce the cancer burden and improves services, outcomes, and experiences for cancer patients and their families.

ACKNOWLEDGMENTS
The author wants to thank his institution for their continued support.

CONFLICT OF INTEREST
The author declares that there are no conflicts of/or competing interests.

AUTHOR CONTRIBUTIONS
The author conceived, designed, and implemented conceptual work, framework, writing, and critical editing. Author read and approved the final manuscript.

DATA AVAILABILITY STATEMENT
All data generated or analyzed during this study are included in this published article.

ETHICS STATEMENT
Ethics approval and consent to participate: Not applicable.
Consent for publication: Not applicable.