News www.thelancet.com/oncology Published online August 10, 2023 https://doi.org/10.1016/S1470-2045(23)00398-4 1 Lancet Oncol 2023 Published Online August 10, 2023 https://doi.org/10.1016/ S1470-2045(23)00398-4 For the Globocan 2020 report on cancer incidence in Iraq see https://gco.iarc.fr/today/data/ factsheets/populations/368- iraq-fact-sheets.pdf For the Iraqi National Cancer Control Program Five Year Plan for 2010–14 see https://www. iccp-portal.org/system/files/ plans/IRQ_B5_cancer%20 program.pdf For more on international efforts to improve cancer care in Iraq see Perspectives Lancet Oncol 2018 19: 291–92 For more on cancer diagnosis and cancer care during periods of conflict in Iraq see Front Oncol 2022; 12: 1087476 and Front Oncol 2023; 23: 1151242 For more on the Iraqi–Italian collaboration see Cancer Med 2023; 12: 256–65 For more on efforts in Iraq towards regional cooperation see https://www.iaea.org/ newscenter/news/iaea-review- prompts-regional-cooperation- to-address-cancer-workforce- challenges-in-iraq For more on the latest imPACT report on Iraq see https://www. iaea.org/newscenter/news/iraq- makes-progress-in-improving- cancer-services-implements- impact-review-recommendation For the recent media report on the impact of cancer in Iraq see https://www.thenationalnews. com/health/2023/08/04/ cancers-devastating-toll-in-iraq- families-face-emotional-and- financial-strain/ For more on the possible effects of contaminants from warfare on Iraqi citizens see Confl Health 2011; 5: 15 A legacy of war: cancer care fragmentation in Iraq In his 20 years in service, Layth Mula-Hussein, a consultant radiation oncologist at Sultan Qaboos Comprehensive Cancer Care and Research Centre (Oman) and originally from Iraq, and has seen more than enough patients with cancer whose care could have been improved with an unbattered health-care system in the war-torn Arab nation. “I was raised in Mosul, and my city boasted the second largest hospital in the country”, Mula-Hussein told The Lancet Oncology. “There are still numerous problems in Iraq, but considering our war history, we are making strides of improvement.” According to the world cancer registry Globocan, the estimated cancer incidence in Iraq in 2020 was nearly 34 000 (134·9 per 100 000 population). These estimates might seem lower than other countries, such as the USA, Canada, and countries in western Europe, or even the neighbouring countries of Iraq; however, Mula- Hussein explained, “considering the Iraqi health system, war history, and economic capacity, the recorded cancer burden is still too high for the country to bear”. Of all the types of cancer, the most commonly diagnosed are breast cancers, which tend to present at a relatively late stage. In men of all ages, the most prevalent cancers are leukaemia and lung, colorectal, prostate, and bladder cancer. The challenges in cancer care delivery and management in Iraq date back to the 1950s, and continued even after the fall of Saddam Hussein’s regime in 2003, not changing much until the end of the 2000s. “I remember being both a radiation oncologist and a medical oncologist administrating chemotherapy”, Mula-Hussein told The Lancet Oncology. But during the period 2010–20 he began seeing meaningful strides of improvement in health care in Iraq, including cancer care. Government initiatives such as the Iraqi National Cancer Control Program aimed to enhance cancer care facilities, train medical professionals, and increase access to cancer treatment. International collaborations and partnerships contributed to capacity building in cancer care, such as partnerships with the International Atomic Energy Agency’s (IAEA) Programme of Action for Cancer Therapy (PACT). Even amid the occupancy by the Islamic State of Iraq and the Levant between 2014 and 2017, Iraq reportedly remained resilient in cancer care and diagnosis, participating in international collaborations such as the Iraqi–Italian collaboration in the management and care of more than 1000 paediatric patients with cancer. For regional partnerships, working with IAEA PACT, Iraq has periodically reviewed and assessed its cancer programme in an effort to improve regional cooperation to address cancer workforce challenges. In collaboration with the Iraqi Ministry of Health and UN agencies, IAEA PACT assessed Iraq’s cancer care status quo in 2022—everything from prevention to palliative care, including cancer registration and surveillance, national cancer control, planning, and governance—and helped them with a prioritisation exercise and to look at the implementation of country- specific activities appropriate for Iraq. According to the latest IAEA imPACT report, Iraq is making meaningful progress in improving cancer services, with further plans to develop a national cancer control strategy and cancer plan. However, there are gaps in Iraqi health care. A recent media report highlights issues such as high financial liability on patients for access to advanced care given that, for instance, a new cancer treatment centre in Wasit province, south of Baghdad, has only 30 beds. Such gaps exist and need greater attention, according to Mula-Hussein. “There are gaps across the cancer continuum”, he told The Lancet Oncology. “Iraq could work on cancer prevention initiatives, screening, and early detection to improve diagnosis, access to affordable treatment, and palliative care”. According to Mula-Hussein, Iraq also is long due for a comprehensive cancer centre, but the impact of war has caused delays. “Because hospitals like in Mosul and their cancer services were devastated during the war, we only have fragmented centres, so patients do not have access to facilities such as modern treatments, molecular characterisation of cancers, or access to clinical trials of drugs in development”, he said. Another gaping, but often ignored, burden is linked to war and deployed warfare in Iraq, according to Christopher Busby (Green Audit, Aberystwyth, UK), who studies, and testifies in court about, the harmful health effects of particles and ionising radiation. For instance, contaminants from warfare agents, such as uranium, have been found in citizens in Fallujah, Iraq, and linked with birth defects and cancer. “Wars produce a lot of microscopic airborne particles and if these are depleted uranium, as happened in both Iraq wars, inhalation can pass them into the lymphatic system and then to any organ where they can remain for a long time, causing high local cell doses, chromosome damage, and increased cancer risk”, Busby told The Lancet Oncology. He explained that the cancer burden due to wars is something a country can solve only without war. “You can’t mitigate it—it is not a button you can press and stop.” Nevertheless, the experts The Lancet Oncology spoke with believe that Iraq is evolving its cancer care and management, albeit not at a pace that people in need might hope for. Vijay Shankar Balakrishnan sasacvetkovic33/Getty Images