Radiotherapy is an evolving yet inseparable element in the realm of cancer management. It has a myriad of applications which include being a definitive curative option, in slowing cancer growth or as a palliative modality. Several studies have emphasized this importance of RT, showing that on an average more than half of all cancer patients require RT administration at least once during the course of their treatment (12, 13). In view of this, every patient should be able to have access to this beneficial modality of treatment. However, as we review data from around the world, there is a glaring disparity in the availability of RT services, which contrasts significantly between high-income countries when compared to middle to low-income countries. To further broadly analyze this area of concern, a study done in 2013 demonstrated high income countries such as the United States to have an estimate of 5075 RT departments with a total of 8911 megavoltage machines. This significantly differs from the middle to low income countries which range between having from 590 to as low as 40 RT departments with only 60-1000 machines (14).
Studies focusing on the availability of RT in Europe have demonstrated that almost three out of four cancer patients who have an evidence-based indication for RT have access to it (15, 16). In a stark contrast to this, low income countries in sub-Saharan Africa have an almost-complete absence of RT facilities (17, 18). To specifically focus on the situation of RT in Turkey, in 2012 there were 95 radiotherapy centers with 201 megavoltage equipment treating 160,808 patients with expected 44% unmet need (19). Even though there has been a definite increase in the development in the field of RT in Turkey over the past few decades, these resources are not sufficient to meet the demands of the ever-increasing burden of patients diagnosed with cancer each year who require these facilities (20, 21).
There are a number of possible reasons as to why we observe this disproportionate chasm between the high-income and low-income countries. To establish RT centers equipped with megavoltage machines, the country’s income classification plays a major role. A majority of the lower income countries still to this day struggle to provide RT services as they deal with the crippling issues of poverty and political instability, pushing services like radiation further down the list of things deemed crucial (22, 23). Aside from this, other factors such as the availability of electricity and the presence of highly qualified trained personnel to oversee the particulars of treatment delivery also play a crucial part in contributing to the underservices of RT (14).
Despite these impediments, Turkey has not only provided refuge to those fleeing the Syrian turmoil but has made all aspects of the healthcare system accessible to those in need, free of cost. On further introspection into the situation of Syrian refugees and the utilization of RT, there is another important aspect that should not be overlooked. In this analysis we found that even though only a small proportion of Syrian refugee patients with cancer received RT due to the reasons we discussed above, a significant number of these patients were non-compliant with multiple scheduled RT sessions. Patient noncompliance is a major setback which eventually hinders the possibility of achieving cancer remission, increasing patient morbidity and mortality. Certain studies have shown that the chances of increase of local recurrence with treatment interruption is almost 2% per day (24). Tumor repopulation, which is an accelerated growth in malignant tissue after treatment with radiation has been initiated, has been deemed as an integral factor in causing this cancer remission (25). In a retrospective analysis done to ascertain the survival in patients with head and neck carcinoma, any interruption in treatment for more than two weeks was found to be a strong, statistically significant determinant of tumor persistence (26). Apart from its obvious effects on cancer treatment, non-compliance also leads to other complications. In a study conducted in the United States, a ripple-like effect was observed, in which non-compliant patients, by missing their scheduled treatments, indirectly caused delay in treatments of other patients by occupying slots on linear accelerator machines. It was also noted that non-compliance ultimately led to a failure to adhere to follow-up evaluations and other interventions crucial to cancer management (27).
The noncompliance rates vary globally owing to various factors influencing treatment adherence across different nations. In a New York-based clinical investigation involving 1227 patients with various malignancies, Ohri et al concluded that around 20% of the study patients were non-compliant (28). In another study conducted in a tertiary care center in India, Gupta et al demonstrated a non-compliance rate of almost 13% in 203 cancer patients (29). As per our analysis of the 1010 refugee cancer patients in Turkey that were able to get treated with RT, almost 20% of them were non-compliant.
There are several factors which can eventually result in non-compliance to radiotherapy and these have been extensively researched in various studies. Significant correlations between non-compliance and low socioeconomic status (SES) have been identified by multiple researchers, with patients belonging to a lower SES group having higher rates of non-compliance (30, 31). Another important predictor that has been reviewed is the duration of treatment course. Longer treatment courses have been linked to a greater percentage of patients with non -adherence (32). In rural and suburban populations, the distance required to travel to avail RT services has also been implicated in leading to non-compliance. Patients living farther away from the treatment centers were shown to be more likely to forego RT (33, 34). Older age groups have been associated with increased rates of non-compliance. Sharma et al demonstrated in their study of 47 elderly patients with head and neck cancer, that nearly one-third of the study group were not compliant with treatment (35).
As being refugees in an unfamiliar land places them in dire and blindsiding circumstances, they are posed with an additional set of elements that lead to non-compliance when compared with the general population. We have set out to analyze these factors in further detail. Language and cultural barriers play a major role as this hinders communication between refugees and the native healthcare workers (36). Refugees are also faced with competing priorities that include availing basic accommodation, security, hygiene, nutrition and education which take precedence over their need for cancer treatment (37). Non-compliance factors that were extracted specifically in our study were concurrent chemoradiation and living in refugee camps. Some refugees who are financially capable, seek to find their own homes to rent, but many who do not have this luxury are provided temporary refugee camps to stay in on arrival. Patients who have been living in refugee camps when compared to homes are faced with a harsher living environment, contributing to their non-compliance to RT.
Turkey has stood as a beacon of hope to millions of refugees by aiding them in not only providing a home away from their homeland in times of need, but also in allowing these new immigrants access to the same basic human rights as their native citizens. The Turkish government has taken multiple steps to overcome the challenges faced by the Syrian refugees in making use of its healthcare facilities. Provision of translators to overcome the language barriers and appointment of sufficient qualified medical professionals has helped refugees immensely. Above all, healthcare is also provided free of cost, whether it is at the primary, secondary or tertiary levels, with means to alleviate their medical predicaments and ease their transition into the new society (38). Although Turkey has played a crucial role in aiding those escaping the Syrian war, there is still a disparity between what refugees need and what they are granted. A multidisciplinary plan can be taken to address these affairs but, as the well-being of refugees is an international affair, it needs to have a global amalgamation of efforts to produce visible results. Organizations such as the United Nations (UN), the European Union (EU) and World Health Organization (WHO) can align their efforts with an even greater focus to attempt to alleviate this situation (39). Effective implementation of services should also be ensured with an emphasis on accountability. Measures on a smaller scale can be taken by providing refugees with local working opportunities along with taking the time to teaching them the local dialect, to help them ease integration into the new society. Further studies also need to be done to fathom the finer nuances that refugees deal with on a daily basis as this information can prove invaluable in providing a possible solution to this complex situation. It is imperative that borders do not become barriers in providing optimal radiotherapy for these inconvenienced individuals, regardless of the geopolitical reality.