It is believed that refugees could have more delays in diagnosis of cancer and also present at later stages of disease than host nation because of being foreign of the health system, financial limitations, fear of persecution because of political or security issues related to their situation(4,11). Breast cancer is most prominent cancer in SR living in Turkey(12). In a study conducted in Jordan(8), median age of SR breast cancer was 47, in our study it was 45 in SR while in Turkish counterpart it was 50. SR breast cancer patients were younger than TC and it was statistically significant. (p:0,003). Like our study, in the western world, a study conducted in Canada breast cancer immigrants were younger than Canada-born women, mean age was 53.5 years and 62.3 years respectively (p < 0.0001).(11) Immigrant women were less likely diagnosed with stage I breast cancers than Canadian-born women (adjusted OR = 0.85; 95% CI: 0.79–0.91; p < 0.0001).(13). This difference could be attributable to poor hygiene, inadequate feeding, physiological and psychological stress that make suspectible person to developed cancer earlier. Abdel-Razeq et al.(8) found that 23% breast cancer diagnosed at metastatic stage, similarly in study by Kotek Sedef et al. (6) 47% SR cancer patients presented at metastatic stage and both studies concluded that SR patients had advanced disease. In our study, we found that 23% of SR and 21.3% of Turkish citizens were denovo metastatic(p>0,05). While ratio of metastatic stage were same in both the study by Abdel-Razeq (8) and in our study , contrary to our study the former study did not contain natives counterpart. A study conducted in Jordan found 20% of Syrian patients with
breast cancer presented with distant metastasis compared with o 16% among Jordanians have been seen during the same period and author suggest that cancers among refugees are diagnosed at a more advanced stage. That study was carried out merely to explore burden of cancer in SR living in Jordan, not to compare breast cancer patients although there was 4% difference, statistical significance was not reported (14) While in one (6) study almost half of patients diagnosed at metastatic stage, they accuralled all Syrian patients with different cancers and breast cancer consist of 35.6% of population and there was no host nation control arm so it is not appropriate to compare it with our study.
One of the main objective of this study is to find out whether there is difference of neoadjuvant approach to Syrian refugees and additionally to find out if Syrian refugeees can reach appropriate treatment compare to Turkish counterpart. Neoadjuvan ChT should be offered to especially HER-2 positive and triple negative patients as well as some luminal subtypes in local or locally advanced breast cancer. In our study we found 33.3% of Syrian patients should have been offered neoadjuvan ChT while in Turkish patients 25.4% should have been offered same treatment modality however they were upfront operated, there was no difference between two groups.(p>0,05) As far as we know this is first study that showed neoadjuvan approach was same in both groups.
Another main topic of our study was time to reach treatment in both group. Median time from first medical encounter to surgery in upfront operated patients found to be 8 weeks in Jordanian study.(5) We searched time in three seperate section. For neoadjuvan setting median time from pathologic diagnosis to first day of ChT was 47 days in SR, in TC it was 37 days although numerically seems different actually no statistically difference exist (p>0,05). For adjuvant setting median time from diagnosis to surgery was 42 days in SR, in TC it was 40 days(p>0,05). For denovo metastatic patients median time from diagnosis to first day of ChT was 38 to 41 in SR and TC respectively( p>0.05) These results shows SR treated like Turkish counterparts at least in field of neoadjuvan treatment as well as they can reach treatment as fast as Turkish counterparts. This is the first study that found there was no treatment delay in SR when compare Turkish counterparts.
Because of high expenses of cancer treatment and lack of funding many cancer patients are not able to reach and mostly they are turned away when they seek care, as an example, only 246 of 511 patients were funded by UNHCR in Jordan between 2010 and 2012 (15). Goverment of Jordan had allowed Syrian refugees to access primary health center and govermental hospital up to 2014, from that time policy had been changed and thus SR were required to pay all expenses when using these facilities.Moreover, in Lebanon, Ministery of Public Health reguested $50 million from the UNHCR but they received only $15 million because of the lack of funding opportunities(16) Secondary and tertiary health centers within Lebanon are completely privatized and they are far expensive for refugees to afford. (17)
In Turkey situation is completely different, almost all registered SR have identification cards and thanks to these cards they can reach public hospitals including secondary and tertiary center as much easily as host nation. This policy enable SR to seek medical assistance, being diagnosed and treated like TC.