ARAB JOURNAL OF UROLOGY 2022, VOL. 20, NO. 2, 81–87 https://doi.org/10.1080/2090598X.2021.2024984 ONCOLOGY/RECONSTRUCTION: ORIGINAL ARTICLE Prostate cancer in the Arab world: Bibliometric review and research priority recommendations * * * a a a a b Adel Hajj Ali * , Hussein Awada * , Hasan Nassereldine * , Mohammad Zeineddine , Zahy Abdul Sater , c d Albert El-Hajj and Deborah Mukherji a b Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Global Health Institute, American University of Beirut, Beirut, c d Lebanon; Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon; Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut, Lebanon ABSTRACT ARTICLE HISTORY Received 20 July 2021 Objective: To conduct a scoping review examining the status of prostate cancer research in Accepted 10 October 2021 Arab countries and systematically map publications across the cancer care pathway. Prostate cancer incidence has been rising in the Arab world and tackling its increasing burden will KEYWORDS require evidence-based policies. Prostate cancer; Arab region; Methods: We searched Medline, PubMed and Scopus for peer-reviewed publications related to bibliometrics; screening; both our research topic and countries of interest by using controlled vocabulary and keywords. oncology; urology Search results were limited for the period between 2000 and 2020, screened for duplicates, and then included in our study based on pre-specified eligibility criteria. We used a structured data extraction form to extract information related to the article, its methodology, its cancer care pathway, funding status, and authorship. Results: A total of 4142 publications were retrieved from our search, of which 874 articles remained after applying eligibility criteria. Trends show a steady increase in prostate cancer research in the Arab world. Most studies were focussed on diagnosis and treatment, whereas a lack in studies concerning screening and prevention, as well as epidemiological data, was evident. Most studies were not funded and had no female author. Country gross domestic product and population were positively correlated with its research output. The USA had the highest number of corresponding authors. The majority of Arab-based studies did not involve collaborations with other countries. Most research conducted was basic or clinical studies with a low level of evidence. Conclusion: Our present review identified significant gaps and limitations in prostate cancer research in Arab countries. Priority areas for research investment have also been highlighted as a first step towards context-specific health policies. Abbreviations: ASR: age-standardised rate; COVID-19: coronavirus disease 2019; GDP: gross domestic product; HDI: Human Development Index; KSA: Kingdom of Saudi Arabia; UAE: United Arab Emirates Introduction predicted that the Arab world will see the highest relative increase in cancer incidence globally. Prostate cancer is a leading cause of cancer-related Moreover current data may be inaccurate given defi - morbidity and mortality affecting men worldwide. The ciencies in access to healthcare, limited cancer regis- pathophysiology of prostate cancer in different popula- tries, and low screening rates in Arab countries . The tions remains poorly understood; established risk factors lower incidence of prostate cancer may also be due to include advanced age, family history of malignancies, biological differences that are specific to Arab men. For Black race, and certain genetic polymorphisms . example, several studies have shown that lower rates Countries with a high Human Development Index of prostate cancer persist in populations of Arab immi- (HDI) record higher incidence and mortality rates for grants when compared to the non-Arab populations of prostate cancer compared to those with a low HDI. their host countries . Still, prostate cancer was more Recent trends have revealed a steady increase in pros- common among these Arab immigrants than the Arab tate cancer in Low and Middle Income Countries, which locals of their native countries . These studies may be due to increased diagnostic testing and chan- emphasised how both genetic, environmental, and ging population demographics . diagnostic differences are responsible for the discre- Even though the age-standardised rate (ASR) of pancy in prostate cancer incidence and mortality prostate cancer remains relatively low in the Arab between the Arab countries and the rest of the world. world compared to Europe and North America, it is CONTACT Deborah Mukherji email@example.com Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut, Lebanon *These authors contributed equally to this work. © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 82 A. H. ALI ET AL. The Arab world consists of 22 countries, 12 of which then reviewed articles to select the appropriate are distributed across the Middle East and 10 through match, remove any duplicates, and identify the fund- different parts of Africa. These countries vary greatly in ing status, presence or absence of a female author, terms of population, development, socioeconomic sta- study design, type of publication, number of citations, bility, and healthcare status . The incidence and each author’s country, and the paper’s research ques- mortality of prostate cancer varies in between these tion. Gender-neutral author’s names were hand- countries, partially influenced by the availability and searched for accuracy. quality of cancer data registries. In many cases cancer The following 22 Arab countries were included: incidence and particularly mortality data are derived Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, from modelled estimates rather than verified clinical Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, records . With most countries in the Arab world Oman, Palestine (West Bank and Gaza), Qatar, Kingdom undergoing demographic transition resulting in popu- of Saudi Arabia (KSA), Somalia, Sudan, Syria, Tunisia, lation ageing plus improved access to diagnostic test- United Arab Emirates (UAE), and Yemen. ing, regional prostate cancer incidence is increasing, as For each country, we obtained the gross domestic is the need for context-specific research . product (GDP) and the population size from the World Despite the need for anticipatory policies to tackle Bank. In addition, the ASR of prostate cancer was the expected increase in disease burden, there remains obtained in the selected countries . To minimise a paucity of accurate epidemiological and demo- the bias between Arab countries, we divided the num- graphic data to inform these policies. There remains ber of publications of each country by its correspond- a relative lack of published medical literature originat- ing GDP, population size, and ASR to obtain the ing from the Arab world. In a study performed in 2016, number of publications per billion GDP, per million the average number of medical publications per persons, and per ASR respectively. one million people in the Middle East and North The analysis was conducted on both Statistical Africa was shown to be equal to a quarter of the Package for the Social Sciences (SPSS®; SPSS Inc., IBM world average . Corp., Armonk, NY, USA) and R (R Foundation for To address this relative data poverty and make Statistical Computing, Vienna, Austria) statistical tools. recommendations for regional prostate cancer Numerical data are reported as frequency and percen- research priorities, we aimed to map the landscape of tage. The data were analysed by chi-square analysis prostate cancer research in the Arab world. To estab- and an α < 0.05 was considered significant. Graphical lish the gaps in our knowledge base to be addressed, data are presented by tables, pie charts, bar graphs, we assessed methodology and productivity in different cluster graphs and a heat map. areas, with a special focus in the analysis on collabora- tion, diversity, and the extent of funding for publica- Results tions. We also reviewed the epidemiological and demographic differences between these countries as Mapping the characteristics of the publications we compared trends in research output. From a total of 4142 publications retrieved from the databases, 2128 duplicate articles were excluded; the remaining 2014 articles were assessed by titles and Methods abstracts, of which 874 were eligible for the study A comprehensive search of all prostate cancer publica- and 1129 articles were excluded (Figure 1). Most of tions was carried on PubMed, Medline, and Scopus up the included publications were in English, two articles to January 2021. A Boolean operator (AND, OR, and were in French and one in Italian. NOT) in addition to [ad] was used to conduct the Research output in 18 out of 22 Arab countries was search. The terms used in the search included ‘prostate related to prostate cancer, with Egypt having the high- cancer’, ‘prostate carcinoma’, ‘PSA’, ‘prostate adenocar- est number of publications, followed by KSA and cinoma’, ‘prostate metastasis’, ‘prostate oncology’, Lebanon, while Comoros, Djibouti, Mauritania, and ‘prostate neoplasm’, ‘prostate neoplasm’, ‘prostate Somalia had no published articles (Figure 2). The malignancy’, ‘prostate nodule’, ‘prostatectomy’, trend of publications by country of affiliation across ‘Gleason score’, and ‘prostate biopsy’. The articles the years (2000–2020) showed a general increase in were chosen according to the following eligibility cri- the yearly total output (mean increase of 17 publica- teria: articles published between 2000 and 2020, arti- tions/year) and a notable rise in the outputs of Egypt, cles that include at least one author affiliated to an KSA, Jordan, and Lebanon (Figure 3). The publications academic institute or research facility in the 22 Arab were issued in a wide variety of journals with no jour- countries listed below, and the article should be dis- nal having >20 (2.3%) publications related to prostate cussing any topic pertaining to prostate cancer. We cancer in the Arab countries. ARAB JOURNAL OF UROLOGY 83 Corresponding authors originate mainly from the USA, followed by Egypt, KSA, and Tunisia. In addition, the following countries Egypt, Tunisia, Lebanon, Jordan, Kuwait, and UAE had more single country publications than multiple country publications as opposed to KSA, Algeria, and Bahrain (Figure 4). Publications across the cancer care pathway The articles demonstrated various cancer care pathway topics. In all, 55.8% of the articles covered diagnosis and treatment, followed by 30.8% for risk factors and prognosis, 5.0% for epidemiology, 3.3% for screening and prevention, 1.7% health system studies, 1.7% knowledge and education, 1.3% for palliative care and metastatic diseases, and 0.5% for mental health. Most of the funded articles represented diagnosis and treatment (56.7%) followed by risk factor and prog- nosis (30.0%). Publications and epidemiology When normalised to population size, Arab countries with relatively small population sizes such as Lebanon, Qatar, Jordan, and Kuwait had the largest output of publications. Next, when adjusting to the GDP of the Figure 1. Flow chart of the search results. country, Jordan, Lebanon, and Tunisia had the largest output. Furthermore, a significant positive correlation Only 37.9% of the total number of articles were between the number of publications and the country’s funded. Of the funded articles, 39.9% of the funds GDP was noticed (P = 0.001). Similarly, we adjusted the were from Arab sources, while 60.1% were from non- number of publications to the GDP per capita, which Arab countries; in addition, 41.6% was from public showed a measurable advantage for Egypt. sources and 58.4% from private sources of funding. Our analysis of the studies for the presence of at Multiple collaborations have taken place among the least one female author among the authors shows Arab countries and between the Arab countries and a proportion of only 35.3% (n = 313). Furthermore, the world on the topic of prostate cancer; however, our when dissecting the type of studies with at least one analysis sheds light on a strong collaboration between female author, we found that 66.1% (n = 207) were the KSA and the USA, and between Egypt and the USA. basic science publications while 33.9% (n = 106) were Figure 2. Geographical representation of the articles across the Arab countries. 84 A. H. ALI ET AL. Figure 3. Trends of publications of each Arab country across the years 2000–2020. clinical studies reflecting the fact that women remain 20 years, with the exception of the period between underrepresented in academic and leadership posi- 2010 and 2012. This period coincided with the tions in the region. height of the ‘Arab Spring’, during which political instabilities and conflict took their toll on medical research by exacerbating the brain drain to the Type of studies West and shifting funding away from research [4,7,10]. Indeed, ongoing conflict-affected countries Most of the articles were clinical and biomedical stu- in the Arab world including Syria, Yemen and Libya dies (91.6%), while public health studies represented have contributed the least to prostate cancer 8.4%. In all, 78.4% of the articles were original research research among Arab countries as per our search. papers, while 18.8% were review articles. As for the Similar findings were also found for breast cancer study design of the published articles, 26.6% repre- research conducted in conflict-affected Arab coun- sented basic science research, 18.1% cohort studies, tries in the scoping review by Abdul-Khalek 17.7% descriptive studies, 11.3% quantitative studies, et al. . 9.4% case reports, 6.1% case control, 5.3% cross- Despite the trend of overall yearly increase in pub- sectional studies, 4.4% clinical trials, and 1.2% qualita- lications, the Arab world still falls of other regions of tive studies. Analysis of citations showed only four the world, especially in epidemiological studies, as well articles that had >1000 citations, 13 articles having as research investigating the clinical role and benefits between 100 and 1000 citations, and 127 articles hav- of screening and prevention. Both of these tracks are ing no citations. fundamental in addressing the rising rates of prostate cancer in the Arab world. Interestingly, our present analysis showed that funding was not a factor behind Discussion the discrepancy in research output across the cancer Our present search of the main medical bibliographic care pathways. This suggests that other factors may databases for peer-reviewed publications concerning possibly be behind this variation, such as the lack of prostate cancer yielded a mere 874 contributions from research capacity and research collaboration. The var- the Arab world from the year 2000 to 2020, equivalent iation may also be due to the lack of global consensus to <0.5% of the total prostate cancer research pro- for screening and the relatively high survival rates of duced worldwide since the beginning of the 21st cen- prostate cancer . The deficits in these studies serve tury. These findings were somewhat comparable to the as a warning signal because of the importance of Arab contribution to the study of other types of neo- epidemiological data as the base from which evidence- plasms such as breast cancer (0.8%), suggesting that based public policies are informed, and the role of this scarcity actually pertains to cancer research in clinical screening studies that ‘clinically’ guide these general . policies . Fortunately, our present data indicate that the Funding for medical research remains one of main Arab world has been witnessing a continuous factors hindering its progression in the Arab world, with growth in prostate cancer research over the last the number of Arab-based institutions funding cancer ARAB JOURNAL OF UROLOGY 85 Figure 4. (a) Graphical demonstration of the collaboration among the Arab countries and between the Arab countries and the world. (b) Bar chart showing the country of the corresponding author and its frequency. research, in particular, being a slim minority compared other, were significantly underfunded. While we to the rest of the world [7,14]. Our present data further emphasise the importance of basic research, financing showed the existence of a significant disparity in fund- clinical medical and public health research is equally ing or prostate cancer research among the Arab coun- important as they target the human population and tries. It also revealed how public health research on one health systems in an effort to reduce the burden of hand, and the clinical branch of medical research on the preventable morbidity and mortality . 86 A. H. ALI ET AL. Our present results further showed that the Table 1. Summary of findings and recommendations. Finding Recommendation research output among the Arab countries had Lack of studies focussing on Encouraging these categories of a significantly positive correlation with national GDP, screening and prevention of prostate cancer research among and that the correlation was even stronger when add- prostate cancer others while also allotting Shortage in epidemiological, a specific part of the national ing the population size into the equation. While these public health and clinical research funds for their needs. findings conform well with the literature, most of the studies providing high levels of Arab countries do not rank high when it comes to GDP evidence to inform clinical practice [16–18]. This limits the capabilities of the lower-siding Lack of financial support for Increasing initiatives among Arab countries to allocate funds for research. Unfortunately, prostate cancer research institutes towards establishing Insufficient collaboration with regional and international because of the ongoing regional conflicts, coronavirus regional and international collaborations through which disease 2019 (COVID-19) induced financial constraints institutes they can bypass obstacles and limitations in research and longstanding economic instabilities affecting capacities. some Arab regions, efforts to allocate governmental Low female participation in Breaking down social stigmas by urology related research recruiting female researchers funds towards medical and public health research may and asserting their importance not be worthwhile in some countries [4,7,19]. Instead, in increasing research capacity efforts in these countries must be directed towards and filling the gaps in manpower. bypassing national limitations by establishing regional and international collaborations with other Arab and non-Arab institutions in order to increase the quantity and quality of their research output [20,21]. Mutually To the best of our knowledge, this is the first beneficial collaborations can be set up, in which the bibliometric analysis to study the Arab world pros- concerned parties complement each other’s deficits in tate cancer research output. However, this study has funding, skills, expertise or other resources. Our pre- some additional limitations. First, the study results sent results show that such collaborations do currently might not represent the true scale and intent of exist but only to very limited extents. This is according research of some of the Arab countries because of to our findings that most foreign-based publications the coinciding regional conflicts and publication (according to corresponding authors) from the USA, barriers. Second, bibliometric studies, unlike sys- Canada, France, UK, Italy and Germany involve multiple tematic reviews, focus on the methodologies and country contributions, whereas the majority of Arab- designs of research papers instead of the signifi - based publications utilise contributions from only cance of their results. Analysis of impact factor/cita- a single country. This may suggest that collaborations tions of each paper was not possible due to the are primarily initiated by the non-Arab rather than the volume and time interval of publications reviewed. Arab countries. Furthermore, six countries among the Third, like all the other bibliometric studies, we top 10 contributors are non-Arab. These revelations were reliant on the indexing of the databases further assert the lack of initiatives on behalf of the accessed. Arab countries to both conduct prostate cancer research, as well as establish collaborations with the Conclusion rest of world in an attempt to overcome any research obstacles and bypass capacity limits. Prostate cancer incidence is increasing in the Arab Finally, female investigators remain underrepre- world with expected increases in morbidity, mortality, sented in urology-related research in the Arab world and healthcare costs. Improving impactful research despite the worldwide trend towards increasing activity is a key factor in improving regional health female involvement in the field of urology . policy and cancer control. Although there is a general Cultural and stigmatic effects persist up to this day, increase in research output in the Arab world, we have with our present findings showing that the significant noted significant limitations to be urgently addressed. majority of women scientists contribute to laboratory- Priority areas for investment include epidemiology, based research instead of clinical research. Women screening and prevention, high-quality clinical comprise ~70% of global healthcare workers and research, and initiatives to promote diverse regional improving gender equity and diversity in research and international collaborations. teams can accelerate the growth in prostate research across the Arab world. Techniques to establish the gender of authors are not 100% accurate so this should Disclosure statement be mentioned as a limitation of our analysis. Our main findings and recommendations are summarised in No potential conflict of interest was reported by the author(s). Table 1. 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Arab Journal of Urology
– Taylor & Francis
Published: Apr 3, 2022
Keywords: Prostate cancer; Arab region; bibliometrics; screening; oncology; urology