Cancer is a very complex disease associated with mutations in almost 1,000 known cancer-related genes in humans. These mutations are, in the majority of cases, acquired and caused by environmental, occupational or some other factors. In approximately 10 per cent of cancer cases, however, mutations in cancer-related genes are hereditary.

Molecular (or genetic) testing plays an important role in cancer diagnostics. A good example of a molecular genetic test used to diagnose cancer is the DNA analysis of Breast Cancer susceptibility gene 1 (BRCA1) and Breast Cancer susceptibility gene 2 (BRCA2), mutations which can increase the risk of breast, ovarian, and several other cancers. This type of testing came into the limelight following Angeline Jolie’s public disclosure of her BRCA1 pathogenic mutation, which resulted in a spike in breast cancer genetic testing that experts described as the “Angelina Jolie effect”.

Traditionally, identification of genetic cancer risk has been performed through single-gene testing in a stepwise manner using Sanger sequencing. The introduction of next-generation sequencing (NGS) in molecular diagnostics added more layers of complexity to clinical decision-making for clinicians. Presently, clinicians have to choose between single-gene testing, multigene panel (MGP) testing or even whole-exome sequencing (WES) for their first-tier clinical diagnostic test.

A single-gene assay is indicated in cases when the clinical diagnosis is obvious and only confirmation testing is required. Nevertheless, high cost, longer time, and the laboriousness of the approach shifted cancer testing to the MGP. MGP testing refers to the concurrent sequencing of multiple pre-selected genes for the detection of actionable DNA variants.

Changing the clinical landscape

The introduction of MGP testing in cancer diagnostics quickly changed the clinical landscape for cancer patients and their families. Not only did it contribute to the management of the condition in patients, but it also helped with the risk management and reduction of the disease in risk group individuals.

There are many MGPs employed in cancer diagnostics today, some of which are used for the detection of pathogenic alterations in risk individuals or individuals with a history of breast cancer, the most common cancer among women and a high cause of mortality worldwide according to the World Health Organization. With the majority of cases of hereditary breast and ovarian cancers being caused by germline mutations in the BRCA1 and BRCA2 genes, many women at an increased risk of the disease and who had previously tested negative for pathogenic mutations in both genes had finally pathogenic variants of other breast cancer-related genes detected through the MGP approach. In fact, many studies highlight the utility of multigene panels in patients with a history of negative BRCA1/2 genetic testing.

One such study shows that using the MGP approach in patients who had previously tested negative for mutations in BRCA1 and BRCA2 genes improved identification of pathogenic variants in other genes that cause breast or ovarian cancer susceptibility at a detection rate ranging between 2.9 and 9.3 per cent. Another advantage of MGP is the decreasing cost of genetic testing due to NGS technology. Because the price of ordering a genetic test was the same regardless of the number of genes on the panel, test selection is dependent only on patient and provider preferences, rather than price. Despite the many documented advantages of the MGP approach, the technique has still faced certain criticism by the scientific and clinical community.

In MGP testing, genes without strong ties to the corresponding cancer syndrome can be added to the panel, which increases the risk of overestimating the clinical implications of a result. Additionally, this type of testing can increase the detection rate of variants of uncertain clinical significance (VUS) for which management is unclear. This highlights the importance of variant annotation and interpretation pipelines to prioritise the variants properly. Other problems and challenges associated with MGP testing include the identification of secondary findings, whereby unexpected deleterious variants in genes associated with conditions other than the ones originally tested for are detected. This may be useful however if the patient’s family history is unknown or limited. Whole exome sequencing (WES) is another molecular genetic testing approach that is used when MGP does not help. In fact, one important disadvantage of targeted multigene panels is that they may become outdated relatively quickly.

During the time in which a panel is developed and validated for clinical use, new studies identifying newly characterised disease genes are already being published. As such, an advantage of WES is the ability to sequence the entire protein-coding regions of the human genome, at once, allowing for the assessment and analysis interpretation and re-interpretation of alterations in all genes. WES also allows the analysis of a significantly larger number of genes at a reasonable cost, the potential to identify novel genes, and the ability to sequence the exomes of multiple family members simultaneously if needed. As a matter of comparison, MGP provides nearly 100 per cent coverage in targeted genes, WES has a unique advantage of analysing a much broader gene list, including newly reported disease genes.

Results

A recent study demonstrated that WES improved diagnostic rate in 8 per cent of patients who first underwent multigene panel testing. Phenotype-driven WES interpretation also greatly reduced the rates of uncertain results. As such, if high cancer risk is present but the specific syndrome is uncertain, WES can be the method of choice. It is worth to mention that WES shares with MGP increased rate of detection of VUS and incidental (secondary) findings. The choice between the different genetic testing approaches depends on each case.

The MGP approach is ideal for analysing specific mutations or genes that have suspected associations with disease. In addition, focusing on individual genes or gene regions provides a higher depth of sequencing than WES, which then enables the identification of rare variants. WES, on the other hand, allows for a comprehensive analysis of the whole exome, which is especially important if genes of interest are unknown. This method is also highly likely to play an increasingly important and powerful role in cancer diagnostics.

Although the choice of testing approaches for the identification of genomic risks might raise some questions, it is certain that the use of multigene testing in the clinical setting has re-defined both the optimal care of patients with cancer and the management of unaffected individuals. This is made possible because it ultimately allows for surveillance programmes, planning strategies of prevention and early intervention for enhanced patient management. It is very important that any future progress made in the genetic testing space is accompanied by a deep understanding and awareness of the implications of its potential by both physicians and patients. 

References available on request.

The healthcare sector in Dubai is undergoing an evolution on the back of rapid advancements in technology and R&D, reveals a new Colliers report. However, healthcare providers and professionals are grappling with several challenges including patients becoming customers and the patient care changing to “fee for quality” rather than “fee for service”.

The demand profile is also changing from provision of more beds at general hospitals to specialised hospitals, daycare surgical centers and Centers of Excellence, and from curative care to preventive care.

The Dubai healthcare market is very competitive, but still offers ample opportunities for both operators and investors. Sustainable growth of the healthcare sector in Dubai will be dependent on embracing, developing and adopting new technologies and innovations whilst delivering data driven, patient-centric and result oriented healthcare.

Key factors driving Dubai’s healthcare market are:

• High population growth rate. The population of Dubai reached 3.35 million at the end of 2019. Based on Colliers projections, the population of Dubai is expected to reach between 4.96 million to 5.73 million by 2030, increasing demand for healthcare services.
• The population of Dubai is predominantly a young and expatriate-based population. Majority of whom are considered Generation X (born between 1965 and 1980) and Generation Y (born between 1981 and 2000). As the current population of the UAE including Dubai ages, there is likely to be a sharp rise in healthcare demand as approximately 80% of a person’s healthcare requirements typically occurs after the age of 40 – /50 years.
• Introduction of compulsory health insurance in Dubai. Since the introduction of compulsory health insurance, there has been a significant increase in demand for healthcare. At the same time, insurance companies are applying vigilant policies to ensure a balance between insurance premium vs. provision of services and highlighting potential misuse of health insurance.
• High returns on healthcare investments. High quality, efficient private hospitals could still achieve 15% - 20% net profit margins after initial stabilisation years
• Heavy reliance on imported medicine and medical equipment. This increases the cost of establishing healthcare facilities. A number of medical equipment suppliers provide medical equipment on long-term leases and even equity investment in order to facilitate healthcare initiatives
• Continued growth of regional medical tourism. The government of Dubai has recently taken several initiatives to establish and promote Dubai as a medical tourism hub.

The report, the 13th in the Pulse series, provides a brief snapshot on the key factors impacting the Dubai healthcare sector’s outlook. From general hospitals to specialised hospitals and from curative care to preventive care, there are a number of opportunities for operators and investors to establish cost effective surgical centers & Centers of Excellence to meet the growing demand for healthcare services in Dubai.

Mediclinic Middle East, one of the UAE’s leading private healthcare groups, has recently completed its first company-wide Joint Commission International (JCI) accreditation initiative, with all seven hospitals and 21 clinics in Dubai, Abu Dhabi and Al Ain receiving JCI accreditation.

JCI is considered the gold standard in healthcare accreditation and the most rigorous evaluator of international standards in quality and patient safety. In the U.S., Joint Commission (JC) has accredited over 20,000 organisations/ hospitals and its international wing Joint Commission International (JCI), operating outside of the U.S., and has accredited hundreds of facilities in 90 countries worldwide.

The successful accreditation process, which began at Mediclinic Ibn Battuta, Dubai in May 2019 and concluded at Mediclinic City Hospital in Dubai earlier this month, means that patients at every Mediclinic Middle East facility in the UAE can be assured of the highest levels of service, safety and healthcare quality, benchmarked against global best practice.

David Hadley, CEO of Mediclinic Middle East, said: “Mediclinic Middle East’s focus on ethical, high quality, international standard healthcare services has been recognised by JCI in this unprecedented group-wide accreditation. A huge amount of time and effort has been invested in making sure that all our hospitals and clinics can withstand the rigorous assessment carried out by JCI, and underlines our commitment to providing a superior level of service to all our patients, wherever they live and whichever facility they visit.”

Dr. Zaka Ullah Khan, Senior Corporate Medical Director, Mediclinic Middle East, said: “The accreditation is granted for three years with a triannual renewal. It is considered the gold standard of Patient Safety and Quality. JCI accreditation is mandated by DHCRA and is considered as a minimal standard of quality and patient safety for the DHA and the DOH.”

The JCI has 14 chapters in both the hospital and the ambulatory care standards. These are divided into 291 standards for the hospitals and 154 for ambulatory care. The standards are measured by measurable elements, 1,199 for the hospitals and 565 for the ambulatory care. The chapters, standards and the measurable elements cover the entire spectrum of patient safety, quality of care, governance and facility management over a period of five days. Measurable elements are scored as, Met, Partially Met and Non-Met.

Any facility that is accredited by JCI needs to meet the following criteria;

• The organisation demonstrates acceptable compliance with each standard. Acceptable compliance is:
  • A score of at least “5” on each standard.
• The organisation demonstrates acceptable compliance with the standards in each chapter. Acceptable compliance is:
  • An aggregate score of at least “9” for each chapter of standards.
• The organisation demonstrates overall acceptable compliance. Acceptable compliance is:
  • An aggregate score of at least “9.8” on all standards.
• The total number of measurable elements found to be “Not Met” or “Partially Met” is not above the mean (three or more standard deviations) for organisations surveyed under the hospital accreditation
• No measurable element in the International Patient Safety Goals (IPSGs) is scored “Not Met”.

Picture this. A patient comes home to gather with family members for an occasion such as Eid Al Fitr or Eid Al Adha. But before that, a patient is given service in the hospital or any other healthcare facilities directly by the doctor, nurse or health workers. However, before the process starts, the doctor, nurse or health workers need sterile supplies provided by Central Sterile Services Department (CSSD).

CSSD process reusable instrument or medical device from all areas such as the operating theatre, wards, critical care, outpatient, endoscopy, etc. The department also sterilises supply such as gauze or linen. Even though CSSD doesn’t meet the patient directly, the finish products from them are directly used by the patient. Therefore, CSSD must understand the patient safety concept thoroughly, as it supports patient safety by breaking the chain of infection.

The fundamental role of the CSSD is to receive, clean, decontaminated, packaged, and sterilised medical devices that can be distributed. These devices are reprocessed in reprocessing equipment, such as washer-disinfectors and sterilisers that are routinely maintained and validated in order to prevent cross-contamination and infection in patients. This is achieved by well-trained and knowledgeable staff working in the CSSD under the supervision of experienced and trained managers who understand and implement strategies of risk management and quality assurance. 

Culture of patient safety

A culture of patient safety should be built in CSSD. Culture is defined as the deeply rooted assumptions, values, and norms of an organisation that guide the interactions of the member through attitudes, customs, and behaviour.

A culture of patient safety involves leadership, teamwork and collaboration, evidence-based practices, effective communication, learning, measurement, a just culture, systems thinking, human factors, and zero tolerance. Leaders in CSSD are responsible for establishing safety. Leaders set patient safety as a priority and motivate staff to perform. They ensure all the standards are followed, and no short-cuts are taken. Leaders provide tools to ensure all steps are done seamlessly. Leadership is critical to the success of patient safety in CSSD.

Decontamination process in CSSD cannot be done by one person. Teamwork and collaboration combine the talents and skills of each member of a CSSD team and serve as a check and balance method, making sure every process is done the right way. CSSD must encourage thinking, suggestion and action from all staff. Teamwork and collaboration in the department also decrease risk to staff.

Also, communication is a vital aspect. Open communication between leaders and staff or between staff encourage sharing technological and environmental information. Communication is based on mutual trust and setting the best practices in CSSD. Communication includes written, verbal, or electronic, and can be used for sharing data, sharing policies and procedures, literature studies and also reporting systems.

Sterilisation should be used for evidence-based literature. Sterilisation cannot be done only as a habit; a generation-to-generation practice has shown that people don’t use evidence-based standard. Evidence-based practice in CSSD is a basic element of patient safety. Evidence-based guideline for CSSD best practice is available from the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and Asia Pacific Society of Infection Control (APSIC). Adoption of best practices sometimes meets resistance. Leadership together with staff must increase awareness, improve the desire to change to meet the standard, and even ask for incentives.

All members of CSSD should learn. Learning together can improve the ability to create desired results. The department’s staff should encourage participating in learning formulating policies and procedures. They can schedule monthly meetings when a group of staff presents one topic, while others pay attention and ask questions to the presenter group.

To monitor compliance with best practices and to identify gaps in care, CSSD must collect and report reliable data. The staff must collect any problem when reprocessing instrument, particularly in cleaning, disinfection or sterilisation. CSSD can also get information from users. Any report that shows lack of compliance from best practice should be analysed and managed to improve cleaning, disinfection or sterilisation practice.

All processes in healthcare facilities are systems, involving interconnected components, people, supplies and equipment. CSSD practice seems simple, however, it is really complex. It needs trained technicians, facilities, supplies, and water. Systems change or system thinking should be done to achieve and sustain success in CSSD practices.

A CSSD practice is not only done using a machine but needs staff; human factors should be considered. Some principles in human factors include simplifying the process, standardising the process, reducing dependence on memory, using forcing function, and working toward reliability.

To err is human and some will inevitably make errors. CSSD can review the systems and learn from errors. These errors can be addressed by providing feedback and encouraging productive conversation and critical analysis to prevent future errors. The no-blame culture focuses on systems that led to the error rather than on the individual. Blaming personnel only creates anxiety and fear and does little to solve current problems or prevent them.

However, in a condition that shows purposeful disregard of the rules, zero-tolerance culture is used. Leaders must not tolerate non-adherence. When best practices are known, these should be expected of all staff. If staff takes a short-cut in cleaning, disinfection or sterilisation process, these behaviours should be addressed and not ignored.  

The department’s staff should encourage participating in learning the formulating policies and procedures.

Challenges of CSSD

Complex instruments, for example, air-powered endoscopes, instruments with lumens or channels, are difficult to clean. When there is a failure in cleaning, the instrument cannot be sterilised or disinfected. While reprocessing complex instruments, always look for written instructions from device manufacturer and follow completely.

Written instruction from manufacturers known as Instructions for Use (IFU), include how to clean, disinfect or sterilise. Some reckless practice includes never reading the IFU and practicing only using sense or experience. CSSD should have this on paper, share with the whole team, and practice every step in reprocessing the instrument.

Immediate Use Steam Sterilization (IUSS), known before as flash sterilization, should be used only when there is insufficient time to process by the preferred method. IUSS should not be used as a substitute for insufficient instrument inventory. However, in many developing countries IUSS is often used.

Also, reusing Single Use Device (SUD) happens in developing countries. Reusing SUD usually has a high cost, high volume, and high demand criteria. Reusing SUD gives challenges in the cleaning process. Mostly SUD cannot be cleaned, there are a lot of channels or lumens. Healthcare facilities must have policies and procedure to reuse SUD and follow local guidelines. Tracking single-use devices that can be used again should be done correctly.

References available on request.

There are around 54.8 million diabetics in the MENA region in 2019, according to IDF Diabetes Atlas. This condition is present in 12.8 per cent of the MENA population and almost half of the cases remain undetected. Out of these, almost 20-25 per cent suffer from some sort of visual impairment due to diabetes. Hence, there is a need for growing awareness for this health condition in the region.

According to Dr. Raeba Mathew, HOD, Specialist Ophthalmologist, Canadian Specialist Hospital, Dubai: “The main reasons diabetics suffer from visual impairment is poor management of the condition and failure to seek an eye check-up. For diabetic patients, an eye check-up is just as important as checking the blood sugar levels while the patients don’t seem to be aware of that”.

Causes and diagnosis

Diabetic retinopathy is a condition where high blood sugar levels damage the retina, the nerve layer lining the innermost part of the back of the eye. It can lead to vision impairment by leakage of the fluid into the central part of the retina, causing a gradual loss of central vision. It can also lead to a sudden loss of vision due to the bleeding into the cavity of the eyeball, caused by rupture of small new blood vessels that grow in the retina because of diabetes where the patient may notice floating dots or even total loss of vision.

The detection of retinopathy can be done by retinal examinations followed by digital fluorescein angiography and a retinal scan. “Eye check-ups are not the top priority for diabetic patients who end up confusing them for the routine eye check-ups with the optometrist. But in fact, they are entirely different from each other and are covered by most insurance companies,” added Dr. Mathew.

“Early diagnosis of the condition is essential in the treatment of diabetic retinopathy. The first retinal examination should be done at initial diagnosis of Diabetes mellitus and, thereafter, every year. Patients, who have been diagnosed with retinopathy, may need to be seen more frequently. The incidence and severity of diabetic retinopathy depend on the duration and level of control of diabetes. Patients diagnosed with diabetes before the age of 30 years may have a higher chance of developing retinopathy,” added Dr. Mathew.

Treatment

Once detected, the treatment of diabetic retinopathy is first and foremost by informing, educating and promoting better diabetes management in the patient, regularising follow-ups with the doctor and monitoring the other aspects of diabetes including heart and kidneys. All stages of diabetic retinopathy do not require treatment for the eye. Depending on the severity of the retinopathy, the treatments available may be laser, injections or surgery.

“Diabetic patients need to have proper management of other risk factors such as high blood pressure, high cholesterol levels, obesity and anaemia. Smoking is to be avoided as it may further compromise the blood supply to all parts of the body, including the eyes. Mandatory eye check-up for retinopathy is needed at diagnosis and, thereafter, once a year or more frequently depending on the presence and severity of diabetic retinopathy.

“Early detection and timely treatment significantly help in preventing permanent impairment of vision due to diabetes. Regular eye screening is advised thereafter to monitor the effectiveness of treatment and also for further progression of retinopathy. As diabetes is a lifelong condition, retinal evaluation on a regular basis is mandatory along with control of blood sugar. Treatment instituted after the development of advanced diabetic eye disease, when visual symptoms occur, may not help much in restoring vision to functional levels,” concluded Dr. Mathew.

Given that cancer is one of the leading causes of death in the UAE, there is a chance that someone in your organisation is suffering from cancer. Which raises the question — can organisations really play a role in reducing the risk of cancer?

Cancer and the workplace

Before we look at how organisations can help combat cancer, it is important to consider how they can contribute to cancer. Some jobs expose workers to environmental hazards, and even shift patterns can heighten the odds that a worker will develop cancer. But workplace cancer risks are much more widespread because many modern workplaces contribute to lifestyles that increase people’s odds of developing cancer. According to the American Cancer Society, 42 per cent of cancer cases (and 45 per cent of cancer deaths) are linked to modifiable risk factors, chief among them smoking (and second-hand smoke), alcohol, excess body weight, diet, physical inactivity, exposure to ultraviolet radiation and a handful of infections, including the virus that causes cervical cancer.

Modern office work contributes directly to three of those risk factors — excess body weight, diet, and physical inactivity — so much so, in fact, that experts now talk about the “sitting disease.” How widespread is this “disease”? According to the website Very Well Health, “Research has shown that sitting for as little as 30 minutes at a time without standing up or otherwise engaging in physical activity causes the beginning of a cascade of events throughout the body, a chain reaction that includes poor circulation, inflammation, and endothelial dysfunction (dysfunction of the lining of the blood vessels). This translates, in the longer run, into higher rates of cardiovascular disease, overweight and obesity, and possibly even cancer.”

Cancer-fighting strategies to consider

While cancer is too big for any one organisation to defeat, here are seven ideas companies can implement to help in the fight.

Assess your workplace

If your workplace is smoke-free, focus less on lung cancer. If your employees tend to be overweight or if there’s a high instance of pre-diabetes or diabetes, focus more on diet and physical activity. The American Cancer Society recommends a workplace health assessment to gauge how your organisation’s wellness programmes compare with best practices and peer companies.

Encourage regular screenings

Ensure that your health benefits cover key screenings, such as mammography and colonoscopy, but also ensure that company policy makes screenings feasible. For example, a colonoscopy takes two days (one for prep and one for screening); workers are more likely to get screened if they can use sick days or other non-vacation/annual leave/holiday days and don’t have to recruit someone to cover for them at the office.

Alternatively consider hosting a mobile mammography unit or skin-cancer clinic on-site. This increases busy workers’ odds of getting screened while reducing time away from work. This is particularly important here in the UAE, where Aetna International research found that nearly a third (32 per cent) of UAE respondents say they “don’t have time to be ill at work” and a quarter (25 per cent) cite lack of time off from work as the reason behind their health inertia.

Go smoke-free

Smoking is a leading cause of cancer and in most developed countries, smoking accounts for approximately 30 per cent of cancer cases. Clearing the air — and providing workers with smoking-cessation programmes — is an important way to reduce cancer risk in the workplace.

Make healthy eating easy

If you’re encouraging workers to eat right, be sure healthier options are available in the company cafeteria and onsite vending machines. To promote healthy eating, consider posting nutritional information like calorie counts, making healthier foods the default option and subsidising the cost of healthier foods.

Promote physical activity

Use onsite fitness facilities, discounted gym memberships, and incentives like step challenges to encourage workers to engage in regular exercise. One study found that people who get 1.25 to 2.5 hours of vigorous activity per week (or double that amount of moderate-intensity activity) have a 31 per cent lower risk of cancer death compared with people who are physically inactive.

Regularly and consistently share tips and advice

Regularly sharing articles and information with employees can prompt them to make small adjustments to their behaviours, gradually helping to improve their well-being over time.

Support mental health — and total well-being — at work

Chronic stress can feed cancer. Making Employee Assistance Program (EAP) provisions for employees to learn about, adopt and practise stress-reduction techniques and strategies — such as Mindfulness Based Stress Reduction and therapeutic counselling — will have far-reaching benefits.

For decades, organisations around the globe have recognised that they have a moral, and often legal, obligation to promote health and safety among their workers. Now, many are realising that the obligation and opportunity extend beyond simply enforcing safety rules and providing hearing protection and ergonomic chairs. In fact, successfully embedding holistic health and safety policies and programmes can play a role in fighting several diseases that plague modern society, particularly the likes of cancer.

References available on request.

Recent studies have shown how fertility experts are leveraging artificial intelligence (AI) technology to assist infertile couples in their journey of parenthood. A recent development to have come out in this regard is from the United States.

Researchers have claimed that the results of their study could help enhance the success rate of In-vitro Fertilisation (IVF) method, a widely known Assisted Reproductive Technology, by determining early on if an in vitro fertilised human embryo could lead to live birth. According to a report, they used an AI-driven system to examine a large number of time-lapse images of the early-stage embryos to identify “with a great degree of accuracy” which ones would most likely result in healthy babies. The technique is also seen to help lower the risk of multiple pregnancies.

Prof. Dr. Human Fatemi, IVI Middle East Fertility Clinic, explained that the process of selecting the healthiest embryos for implantation in a woman’s uterus involves a careful examination of the embryo's appearance at the blastocyst stage or the early development phase. He highlighted that bringing AI into the picture would help improve and standardise the current critical embryo selection system, which, for many experts, has remained very subjective and inconsistent. The technology utilises mathematical methods to point out a viable embryo.

Changing the landscape

“Generally speaking, the embryo quality is just one factor used by specialists to establish the chances of having a successful pregnancy in the IVF procedure. With that said, however, it should be pointed out that it is highly crucial in the entire process. AI has been changing the landscape of many fields and disciplines and the area of fertility treatment is no different. We should continue to look into the benefits of fully embracing this technology and its impact on our efforts to continuously increase our success rate. This will bring greater hope to many couples who are struggling to conceive,” added Dr. Laura Melado, IVF Specialist, IVI Fertility, Abu Dhabi.

Additionally, recent publications showed that utilising the AI technology is cost-effective and non-invasive apart from accelerating and promoting higher consistency in the embryo selection process.