- Email: [email protected]
The Status of Cancer Publications in the Kurdistan Region of Iraq
Journal Pre-proof The Status of Cancer Publications in the Kurdistan Region of Iraq Govand Qadir, Mukhlis Aali, Karwan M. Amen, Kazhan Mahmood, Bestoon Hasan, Mudhir Shekha, Dara K. Mohammad, Hastyar H. Najmuldeen, Dler Mahmood, Farhang Awla, Karzan Mohammed, Abbas Salihi
PII:
S2213-5383(20)30013-8
DOI:
https://doi.org/10.1016/j.jcpo.2020.100221
Reference:
JCPO 100221
To appear in:
Journal of Cancer Policy
Received Date:
10 January 2020
Accepted Date:
3 February 2020
Please cite this article as: Qadir G, Aali M, Amen KM, Mahmood K, Hasan B, Shekha M, Mohammad DK, Najmuldeen HH, Mahmood D, Awla F, Mohammed K, Salihi A, The Status of Cancer Publications in the Kurdistan Region of Iraq, Journal of Cancer Policy (2020), doi: https://doi.org/10.1016/j.jcpo.2020.100221
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
The Status of Cancer Publications in the Kurdistan Region of Iraq Govand Qadir1, Mukhlis Aali1, Karwan M. Amen2,3, Kazhan Mahmood4, Bestoon Hasan5, Mudhir Shekha1,6, Dara K. Mohammad7,8, Hastyar H. Najmuldeen9,10, Dler Mahmood9, Farhang Awla11, Karzan Mohammed12,3 and Abbas Salihi*1,3 1
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Department of Biology, College of Science, Salahaddin University-Erbil, Kurdistan Region, Iraq 2
Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq Department of Medical Analysis, Faculty of Science, Tishk International University, Erbil, Iraq.
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3 4
5
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Department of Midwifery, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq Department of cancer registry, Cancer control unit, Erbil directorate of health, Erbil, Iraq
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Department of Pathological Analysis, College of Science, Knowledge University, Erbil, Kurdistan Region, Iraq 7
College of Agricultural Engineering Sciences, Salahaddin University-Erbil, 44002 Erbil, Kurdistan Region, Iraq.
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Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institutet, 141 83 Stockholm, Sweden 9
Department of biology, College of science, University of Sulaimani, Kurdistan region, Iraq
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11
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Komar Research Center (KRC), Komar University of Science and Technology, Sulaimani, Kurdistan region, Iraq Department of Medical Laboratory Technology, Health Technical College, Erbil Polytechnic University, Erbil, Iraq 12
Research center, Salahaddin University-Erbil, Kurdistan Region, Iraq
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*Corresponding author: Abbas Salihi
Email: [email protected] Cell phone: +964-750-4206970
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Research highlights
Growing and increasingly substantive contribution to oncology literature by researchers in the Kurdistan region of Iraq, the quantity and quality of cancer research remains lacking.
volume of data available for research in the region.
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Governmental funding and survey programs are important to increase the
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The condition of cancer research in the Kurdistan region of Iraq is
progressing. It is not a norm for researchers to network and collaborate
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among academic institutions.
Abstract
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This study evaluates the status and number of publications addressing cancers in the Kurdistan Region of Iraq (KRI). All publications about cancer as a research topic in three cities of the KRI were retrieved from local journals, and the ISI Web of Science, Scopus, and PubMed databases up to December 2019. Out of the net
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total of 269 studies conducted, including both local and international publications, 40.5% were reported from Sulaimani, followed by 37.9% from Erbil, and 21.6% from Duhok. In international journals the highest percentage of studies concerned Sulaimani 25.3%, with 46.2% of these records being in PubMed, followed by 34.5% and 19. 3% of records in PubMed from Erbil and Duhok, respectively. In contrast, more articles published within local journals concerned Erbil and Duhok
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cities 18.2% and 9.3%, respectively). Additionally, we screened the number of authors involved in each particular published article and found that the highest percentage of papers with more than three authors concerned Sulaimani 24.9%, followed by Erbil 16%, then Duhok 8.2%. Generally, the majority of the published articles originated from research based on the clinical data instead of basic studies, and patient data was mainly used in all articles in all selected cities. Moreover, a
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continuous increase in the number of published articles was observed in all the three cities from 2006 until 2019. Interestingly, the highest number of published
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articles was relevant to multiple cancers in both Erbil and Sulaimani, while the second- and third-highest number of published articles were about breast cancer
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and leukemia, respectively. The present study reveals a substantial and increasing contribution from Kurdish researchers in the field of cancer research, although
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there is a huge gap between Kurdistan and the rest of the world in terms of the
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number and quality of cancer research publications.
Keywords: Cancer, Publication, Kurdistan Region, Iraq
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1. Introduction
According to the International Agency for Research on Cancer (IARC), the second-leading cause of death worldwide is cancer, accounting for an estimated 9.6 million deaths in 2018. Globally, around 1 in 6 deaths occurs due to one of the
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most common types of cancer, including lung, liver, stomach, breast, colorectal, prostate, skin (non-melanoma), cervix, and thyroid [1-3]. Nearly 70% of deaths from cancer occur in low- and middle-income countries.
Approximately one-third of deaths from cancer are due to the five leading behavioural and dietary risks: low fruit and vegetable intake, high body mass index, physical inactivity, and use of alcohol and tobacco [4]. Based on current
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evidence, altering or avoiding key risk factors could prevent cancer deaths by 3050% [5]. The burden of cancer for patients and health systems can be reduced by early detection and appropriate management of cancer. There is a high chance of cure for many cancers if diagnosed early and treated adequately [6]. According to World Health Statistics (2012), the projection of new cases is expected to increase significantly, mostly in developing countries. The World
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Health Organization (WHO) has predicted the most considerable rise in the incidence rate of cancer in the Middle East in the upcoming years [1]. The greatest
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impact of cancer will be in developing countries, undergoing social and economic transition. The burden of global cancer is expected to hit 27.1 million people by
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2030, albeit most of these will still be in developed countries [7].
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Within the Middle East, cancer incidence is growing particularly rapidly in Iraq. According to WHO’s Cancer Country Profiles (2014), the top five cancers in
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Iraq are: breast, leukemia, brain/nervous system, colorectal, and non-Hodgkin’s lymphoma for females [8]; and lung, bladder, leukemia, non-Hodgkin’s lymphoma, and brain/nervous system for males [9]. The Kurdistan Region of Iraq
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(KRI, also referred to as ‘Kurdistan’) has been exposed to many environmental and epidemiological changes that predispose its people to increased risk of cancer. This includes the adverse effects of chemical hazards used during Iraq-Iran War (19801988), which played an essential role in increasing all types of cancer, especially
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hematological malignancies [10]. Therefore, conducting cancer research is vital for the development of effective, specific, and sustainable healthcare policies. Within this context, this paper examines the landscape of cancer research in the KRI to identify publication trends as well as gaps and opportunities for future research.
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2. Materials and Methods To map the scientific landscape related to cancer research publication in the KRI, the researchers used data from scientific publications available in local journals
National
University
Ranking
of
the
Kurdistan
Region-Iraq
(http://www.nur-krg.net/documents), Web of Science (WoS), Scopus, and PubMed. In this study, the three major cities of the KRI (Erbil, Duhok, and
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Sulaimania) were entered into advanced search engines followed by the key terms “cancer, tumour, oncology, -oma”. Database searching identified more than 300
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articles. After removing duplicate and triplicate publications, and those referring to other settlements with similar names, 269 full-text articles were assessed for
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eligibility.
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3. Results
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3.1 Total number of papers and journal types
Table 1 demonstrates the information regarding the total number of papers in each city (n=269), with the highest percentage of papers being conducted in
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Sulaimani (40.5%), followed by Erbil (37.9%), then Duhok (21.6%). Table 2 presents the published articles in different types of journals in the three different cities (Erbil, Sulaimani, and Duhok). In Erbil, the highest percentage of articles (18.2%) was published in local
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journals, followed by 15.6% published in journals indexed in Scopus or WoS. Only 4.1% of articles were published in non-indexed journals. In Sulaimani, the highest percentage (25.3%) of articles was published in journals indexed in Scopus or WoS, and the lowest percentage of articles was published in non-indexed journals (7. 4%). In Duhok, the highest percentage (10%) of articles published in journals indexed in Scopus or WoS, followed by 9.3% were published in local journals.
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3.2 Place of study and number of authors In Erbil, more than half (21.9%) of the studies were undertaken in Kurdistan, whereas (16%) were conducted in other countries. In Sulaimani, (27.1%) of studies were conducted in Kurdistan, and (13.4%) were undertaken outside Kurdistan. In Duhok, the majority (18.6%) of the studies were conducted in Kurdistan, and only (3%) in other countries (Table 2).
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Concerning the number of authors, 16%, 24.9%, and 8.2% of papers in Erbil, Sulaimani, and Duhok has more than three authors, while only 5.9%, 4.5%, and
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2.6% of articles has one author in each city (respectively).
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3.3 Types of studies and materials
Table 3 illustrates the types of studies and the nature of materials used in
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published articles in Kurdistan. Generally, clinical studies in both Erbil and Sulaimani were more prevalent than basic studies. In Erbil, basic studies comprised
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only 9.7% compared to clinical studies with 28.3%. Similarly, in Sulaimani, the majority of the studies were clinical 26.8%, although almost half 13.8% were basic studies. However, in Duhok, there were similar proportions of basic or clinical
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studies (9.3% and 12.3%, respectively).
Data from patients were the most common type of materials used in published articles in Erbil, Sulaimani, and Duhok cities, with 33.5%, 29%, and 19%,
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respectively. Moreover, the results showed that Sulaimani had the highest percentage 10.4% of publication using cell line materials, followed by Erbil and Duhok with 4.5% and 1.1%, respectively. Regarding animal models in cancer study, five articles were found in Duhok and Sulaimani.
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3.4 Number of publications Figure 1 shows the number of published articles in the KRI for the period 2006 to 2019. There was a steady increase in the number of published articles in all three cities from 2006 until 2013, except Erbil city in 2010, when the number of published articles reached to seven, and then decreased to only three articles in the subsequent year. However, from 2013 onwards, the number of published articles
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sharply increased in all three cities. The peak number of published articles in Sulaimani was 20 in 2018, and in Erbil it was 19 in 2017. However, in Duhok the
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peak number of published articles was 16 in 2019. Figure 2 shows the number of published articles according to the types of cancer in the three major cities of the
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KRI. The highest number (28 and 26) of published articles was relevant to multiple cancers in both Erbil and Sulaimani. The second-highest number (16 and 17) of
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published articles in both Sulaimani and Erbil was about breast cancer. The third-
cities.
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4. Discussion
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highest number of published articles was regarding leukemia in the aforementioned
Cancer continues to pose a worldwide burden on healthcare, and efforts in the field of cancer research remain restricted in many developing countries. To the best of the authors’ knowledge, this paper is considered the first of its kind in assessing
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the current publication landscape of cancer research in the KRI. It sheds light on the scarcity of publications on cancer in this region and offers insight into barriers that hinder research across the region. This study highlighted that there has been a steady increase in cancer research publications in the KRI, and a notable increase in published articles focusing on types of cancer with particularly high incidence rate in Iraq. For instance, the high
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number of published articles concerning breast cancer and leukemia corresponds with their high incidence rate (per 100,000 population) in the country (13.1 and 4.3, respectively), as reported by the Iraqi Cancer Registry [11]. The total number of publications was not considerably behind that of other parts of Iraq. Hamadeh, Borgan and Sibai [12] reported that out of 1773 publications identified in their review between 2000-2013, only 103 (5.8%) of the articles were from Iraq. In
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addition, Iraq had a lower publication rate per million people (3.0) compared to Lebanon, with the highest rate in the Middle East, followed by Kuwait, Bahrain,
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and Morocco.
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In the last two decades there has been a shift towards Western lifestyle choices among Kurdish people, including in terms of dietary habits, which might affect the
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pattern of increasing cancer incidence in this region. Although the cancer incidence in the KRG is increasing [13], and malignant neoplasm is reported to be the
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second-leading cause of death in Iraq, the total number of publications in the region was noticeably lower compared to the other parts of the globe. Worldwide, the US has the highest percentage of all cancer research publications (32.7%),
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followed by China (24.5%) [14]. The review also highlighted that high income and high “human development index” countries are generally more productive in terms of the number of cancer-related publications they produce, with some notable
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exceptions among low-income countries, such as India and Brazil. This paucity of cancer research in the KRI could be due to several factors.
There are fewer researchers in the Middle East region compared to Western countries [12]. However, recently, the number of research studies and publications (in both local and international scientific journals) are growing, since those who are pursuing an academic career in the KRI (including postgraduate qualifications) are mandated by the Ministry of Higher Education and Scientific Affairs of the 8
Kurdistan Regional Government (KRG) to publish one or two papers in scientific journals. Regional and national spending (if any) on research and development in general and on cancer research in particular might be considered as another influential factor for the low publication rate in the region. This could be as a result of political and economic unrest in the country. However, in developed countries (taking the UK as an example), the charitable organization Cancer Research UK
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spent £423 million on cancer research in 2017-2018 [15]. In addition, the lack of access to reliable and valid data could be playing a
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major role in the dearth of cancer research in the KRI, as reported in other studies [12]. However, as mentioned earlier, the condition of cancer research in the KRF
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has improved in the last four years. Until recently, there were no organized cancer registration programs. Following the incorporation of the KRG into the Iraqi
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National Cancer Registry, the cancer research situation has improved. As a result,
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the hospital data systems have been enhanced, which had enabled researchers to conduct (mainly retrospective) studies to analyze cancer patient data [16].
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5. Conclusion
Albeit this study reveals a growing and increasingly substantive contribution to oncology literature by researchers in the KRI, the quantity and quality of cancer research remains lacking. Governmental funding and survey programs are
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important to increase the volume of data available for research in the region. Furthermore, as the condition of cancer research in the KRG is progressing, it is not a norm for researchers to network and collaborate among academic institutions and other governmental and non-governmental organizations. This should be taken seriously and efforts should be applied to foster more national and international collaboration, which would result in improved access to necessary resources and
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consequently more research publications. Declaration of Competing Interest None. Conflict of Interest Statement We wish to confirm that there are no known conflicts of interest associated with this publication
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and there has been no significant financial support for this work that could have influenced its
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outcome.
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Figure captions:
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Fig 1. Number of published articles (per year) in different cities
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Fig 2. Number of published articles according to type of cancer
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Table 1. Published studies by city Place (city)
Total papers No. 102 109 58 269
Erbil Sulaimani Duhok Total
% 37.9 40.5 21.6 100
Duhok
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49 (18.2%) 21 (7.8%) 25 (9.3%) 11 (4.1%) 20 (7.4%) 6 (2.2%) 42 (15.6%) 68 (25.3%) 27 (10%) 41 (34.5%) 55 (46.2%) 23 (19.3%) 59 (21.9%) 73 (27.1%) 50 (18.6%) 43 (16%) 36 (13.4%) 8 (3%)
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Journal type Local Non-indexed Indexed in Scopus or WoS PubMed Place of study Kurdistan Other country No. of authors 1 2 3 >3
Sulaimani
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Erbil
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Table 2. Information on the published articles
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16 (5.9%) 21 (7.8%) 22 (8.2%) 43 (16%)
12 (4.5%) 9 (3.3%) 21 (7.8%) 67 (24.9%)
7 (2.6%) 10 (3.7%) 19 (7.1%) 22 (8.2%)
Table 3. Type of studies and nature of material used Erbil
Sulaimani
Duhok
Basic
26 (9.7%)
37 (13.8%)
25 (9.3%)
Clinical Materials Animals Cell line Patients
76 (28.3%)
72 (26.8%)
33 (12.3%)
0 12 (4.5%) 90 (33.5%)
3 (1.1%) 28 (10.4%) 78 (29%)
2 (0.7%) 5 (1.1%) 51 (19%)
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Study type
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PII:
S2213-5383(20)30013-8
DOI:
https://doi.org/10.1016/j.jcpo.2020.100221
Reference:
JCPO 100221
To appear in:
Journal of Cancer Policy
Received Date:
10 January 2020
Accepted Date:
3 February 2020
Please cite this article as: Qadir G, Aali M, Amen KM, Mahmood K, Hasan B, Shekha M, Mohammad DK, Najmuldeen HH, Mahmood D, Awla F, Mohammed K, Salihi A, The Status of Cancer Publications in the Kurdistan Region of Iraq, Journal of Cancer Policy (2020), doi: https://doi.org/10.1016/j.jcpo.2020.100221
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
The Status of Cancer Publications in the Kurdistan Region of Iraq Govand Qadir1, Mukhlis Aali1, Karwan M. Amen2,3, Kazhan Mahmood4, Bestoon Hasan5, Mudhir Shekha1,6, Dara K. Mohammad7,8, Hastyar H. Najmuldeen9,10, Dler Mahmood9, Farhang Awla11, Karzan Mohammed12,3 and Abbas Salihi*1,3 1
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Department of Biology, College of Science, Salahaddin University-Erbil, Kurdistan Region, Iraq 2
Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq Department of Medical Analysis, Faculty of Science, Tishk International University, Erbil, Iraq.
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3 4
5
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Department of Midwifery, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq Department of cancer registry, Cancer control unit, Erbil directorate of health, Erbil, Iraq
6
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Department of Pathological Analysis, College of Science, Knowledge University, Erbil, Kurdistan Region, Iraq 7
College of Agricultural Engineering Sciences, Salahaddin University-Erbil, 44002 Erbil, Kurdistan Region, Iraq.
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Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institutet, 141 83 Stockholm, Sweden 9
Department of biology, College of science, University of Sulaimani, Kurdistan region, Iraq
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11
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Komar Research Center (KRC), Komar University of Science and Technology, Sulaimani, Kurdistan region, Iraq Department of Medical Laboratory Technology, Health Technical College, Erbil Polytechnic University, Erbil, Iraq 12
Research center, Salahaddin University-Erbil, Kurdistan Region, Iraq
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*Corresponding author: Abbas Salihi
Email: [email protected] Cell phone: +964-750-4206970
1
Research highlights
Growing and increasingly substantive contribution to oncology literature by researchers in the Kurdistan region of Iraq, the quantity and quality of cancer research remains lacking.
volume of data available for research in the region.
of
Governmental funding and survey programs are important to increase the
ro
The condition of cancer research in the Kurdistan region of Iraq is
progressing. It is not a norm for researchers to network and collaborate
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re
-p
among academic institutions.
Abstract
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This study evaluates the status and number of publications addressing cancers in the Kurdistan Region of Iraq (KRI). All publications about cancer as a research topic in three cities of the KRI were retrieved from local journals, and the ISI Web of Science, Scopus, and PubMed databases up to December 2019. Out of the net
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total of 269 studies conducted, including both local and international publications, 40.5% were reported from Sulaimani, followed by 37.9% from Erbil, and 21.6% from Duhok. In international journals the highest percentage of studies concerned Sulaimani 25.3%, with 46.2% of these records being in PubMed, followed by 34.5% and 19. 3% of records in PubMed from Erbil and Duhok, respectively. In contrast, more articles published within local journals concerned Erbil and Duhok
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cities 18.2% and 9.3%, respectively). Additionally, we screened the number of authors involved in each particular published article and found that the highest percentage of papers with more than three authors concerned Sulaimani 24.9%, followed by Erbil 16%, then Duhok 8.2%. Generally, the majority of the published articles originated from research based on the clinical data instead of basic studies, and patient data was mainly used in all articles in all selected cities. Moreover, a
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continuous increase in the number of published articles was observed in all the three cities from 2006 until 2019. Interestingly, the highest number of published
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articles was relevant to multiple cancers in both Erbil and Sulaimani, while the second- and third-highest number of published articles were about breast cancer
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and leukemia, respectively. The present study reveals a substantial and increasing contribution from Kurdish researchers in the field of cancer research, although
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there is a huge gap between Kurdistan and the rest of the world in terms of the
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number and quality of cancer research publications.
Keywords: Cancer, Publication, Kurdistan Region, Iraq
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1. Introduction
According to the International Agency for Research on Cancer (IARC), the second-leading cause of death worldwide is cancer, accounting for an estimated 9.6 million deaths in 2018. Globally, around 1 in 6 deaths occurs due to one of the
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most common types of cancer, including lung, liver, stomach, breast, colorectal, prostate, skin (non-melanoma), cervix, and thyroid [1-3]. Nearly 70% of deaths from cancer occur in low- and middle-income countries.
Approximately one-third of deaths from cancer are due to the five leading behavioural and dietary risks: low fruit and vegetable intake, high body mass index, physical inactivity, and use of alcohol and tobacco [4]. Based on current
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evidence, altering or avoiding key risk factors could prevent cancer deaths by 3050% [5]. The burden of cancer for patients and health systems can be reduced by early detection and appropriate management of cancer. There is a high chance of cure for many cancers if diagnosed early and treated adequately [6]. According to World Health Statistics (2012), the projection of new cases is expected to increase significantly, mostly in developing countries. The World
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Health Organization (WHO) has predicted the most considerable rise in the incidence rate of cancer in the Middle East in the upcoming years [1]. The greatest
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impact of cancer will be in developing countries, undergoing social and economic transition. The burden of global cancer is expected to hit 27.1 million people by
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2030, albeit most of these will still be in developed countries [7].
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Within the Middle East, cancer incidence is growing particularly rapidly in Iraq. According to WHO’s Cancer Country Profiles (2014), the top five cancers in
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Iraq are: breast, leukemia, brain/nervous system, colorectal, and non-Hodgkin’s lymphoma for females [8]; and lung, bladder, leukemia, non-Hodgkin’s lymphoma, and brain/nervous system for males [9]. The Kurdistan Region of Iraq
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(KRI, also referred to as ‘Kurdistan’) has been exposed to many environmental and epidemiological changes that predispose its people to increased risk of cancer. This includes the adverse effects of chemical hazards used during Iraq-Iran War (19801988), which played an essential role in increasing all types of cancer, especially
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hematological malignancies [10]. Therefore, conducting cancer research is vital for the development of effective, specific, and sustainable healthcare policies. Within this context, this paper examines the landscape of cancer research in the KRI to identify publication trends as well as gaps and opportunities for future research.
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2. Materials and Methods To map the scientific landscape related to cancer research publication in the KRI, the researchers used data from scientific publications available in local journals
National
University
Ranking
of
the
Kurdistan
Region-Iraq
(http://www.nur-krg.net/documents), Web of Science (WoS), Scopus, and PubMed. In this study, the three major cities of the KRI (Erbil, Duhok, and
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Sulaimania) were entered into advanced search engines followed by the key terms “cancer, tumour, oncology, -oma”. Database searching identified more than 300
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articles. After removing duplicate and triplicate publications, and those referring to other settlements with similar names, 269 full-text articles were assessed for
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eligibility.
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3. Results
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3.1 Total number of papers and journal types
Table 1 demonstrates the information regarding the total number of papers in each city (n=269), with the highest percentage of papers being conducted in
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Sulaimani (40.5%), followed by Erbil (37.9%), then Duhok (21.6%). Table 2 presents the published articles in different types of journals in the three different cities (Erbil, Sulaimani, and Duhok). In Erbil, the highest percentage of articles (18.2%) was published in local
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journals, followed by 15.6% published in journals indexed in Scopus or WoS. Only 4.1% of articles were published in non-indexed journals. In Sulaimani, the highest percentage (25.3%) of articles was published in journals indexed in Scopus or WoS, and the lowest percentage of articles was published in non-indexed journals (7. 4%). In Duhok, the highest percentage (10%) of articles published in journals indexed in Scopus or WoS, followed by 9.3% were published in local journals.
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3.2 Place of study and number of authors In Erbil, more than half (21.9%) of the studies were undertaken in Kurdistan, whereas (16%) were conducted in other countries. In Sulaimani, (27.1%) of studies were conducted in Kurdistan, and (13.4%) were undertaken outside Kurdistan. In Duhok, the majority (18.6%) of the studies were conducted in Kurdistan, and only (3%) in other countries (Table 2).
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Concerning the number of authors, 16%, 24.9%, and 8.2% of papers in Erbil, Sulaimani, and Duhok has more than three authors, while only 5.9%, 4.5%, and
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2.6% of articles has one author in each city (respectively).
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3.3 Types of studies and materials
Table 3 illustrates the types of studies and the nature of materials used in
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published articles in Kurdistan. Generally, clinical studies in both Erbil and Sulaimani were more prevalent than basic studies. In Erbil, basic studies comprised
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only 9.7% compared to clinical studies with 28.3%. Similarly, in Sulaimani, the majority of the studies were clinical 26.8%, although almost half 13.8% were basic studies. However, in Duhok, there were similar proportions of basic or clinical
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studies (9.3% and 12.3%, respectively).
Data from patients were the most common type of materials used in published articles in Erbil, Sulaimani, and Duhok cities, with 33.5%, 29%, and 19%,
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respectively. Moreover, the results showed that Sulaimani had the highest percentage 10.4% of publication using cell line materials, followed by Erbil and Duhok with 4.5% and 1.1%, respectively. Regarding animal models in cancer study, five articles were found in Duhok and Sulaimani.
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3.4 Number of publications Figure 1 shows the number of published articles in the KRI for the period 2006 to 2019. There was a steady increase in the number of published articles in all three cities from 2006 until 2013, except Erbil city in 2010, when the number of published articles reached to seven, and then decreased to only three articles in the subsequent year. However, from 2013 onwards, the number of published articles
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sharply increased in all three cities. The peak number of published articles in Sulaimani was 20 in 2018, and in Erbil it was 19 in 2017. However, in Duhok the
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peak number of published articles was 16 in 2019. Figure 2 shows the number of published articles according to the types of cancer in the three major cities of the
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KRI. The highest number (28 and 26) of published articles was relevant to multiple cancers in both Erbil and Sulaimani. The second-highest number (16 and 17) of
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published articles in both Sulaimani and Erbil was about breast cancer. The third-
cities.
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4. Discussion
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highest number of published articles was regarding leukemia in the aforementioned
Cancer continues to pose a worldwide burden on healthcare, and efforts in the field of cancer research remain restricted in many developing countries. To the best of the authors’ knowledge, this paper is considered the first of its kind in assessing
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the current publication landscape of cancer research in the KRI. It sheds light on the scarcity of publications on cancer in this region and offers insight into barriers that hinder research across the region. This study highlighted that there has been a steady increase in cancer research publications in the KRI, and a notable increase in published articles focusing on types of cancer with particularly high incidence rate in Iraq. For instance, the high
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number of published articles concerning breast cancer and leukemia corresponds with their high incidence rate (per 100,000 population) in the country (13.1 and 4.3, respectively), as reported by the Iraqi Cancer Registry [11]. The total number of publications was not considerably behind that of other parts of Iraq. Hamadeh, Borgan and Sibai [12] reported that out of 1773 publications identified in their review between 2000-2013, only 103 (5.8%) of the articles were from Iraq. In
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addition, Iraq had a lower publication rate per million people (3.0) compared to Lebanon, with the highest rate in the Middle East, followed by Kuwait, Bahrain,
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and Morocco.
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In the last two decades there has been a shift towards Western lifestyle choices among Kurdish people, including in terms of dietary habits, which might affect the
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pattern of increasing cancer incidence in this region. Although the cancer incidence in the KRG is increasing [13], and malignant neoplasm is reported to be the
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second-leading cause of death in Iraq, the total number of publications in the region was noticeably lower compared to the other parts of the globe. Worldwide, the US has the highest percentage of all cancer research publications (32.7%),
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followed by China (24.5%) [14]. The review also highlighted that high income and high “human development index” countries are generally more productive in terms of the number of cancer-related publications they produce, with some notable
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exceptions among low-income countries, such as India and Brazil. This paucity of cancer research in the KRI could be due to several factors.
There are fewer researchers in the Middle East region compared to Western countries [12]. However, recently, the number of research studies and publications (in both local and international scientific journals) are growing, since those who are pursuing an academic career in the KRI (including postgraduate qualifications) are mandated by the Ministry of Higher Education and Scientific Affairs of the 8
Kurdistan Regional Government (KRG) to publish one or two papers in scientific journals. Regional and national spending (if any) on research and development in general and on cancer research in particular might be considered as another influential factor for the low publication rate in the region. This could be as a result of political and economic unrest in the country. However, in developed countries (taking the UK as an example), the charitable organization Cancer Research UK
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spent £423 million on cancer research in 2017-2018 [15]. In addition, the lack of access to reliable and valid data could be playing a
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major role in the dearth of cancer research in the KRI, as reported in other studies [12]. However, as mentioned earlier, the condition of cancer research in the KRF
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has improved in the last four years. Until recently, there were no organized cancer registration programs. Following the incorporation of the KRG into the Iraqi
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National Cancer Registry, the cancer research situation has improved. As a result,
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the hospital data systems have been enhanced, which had enabled researchers to conduct (mainly retrospective) studies to analyze cancer patient data [16].
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5. Conclusion
Albeit this study reveals a growing and increasingly substantive contribution to oncology literature by researchers in the KRI, the quantity and quality of cancer research remains lacking. Governmental funding and survey programs are
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important to increase the volume of data available for research in the region. Furthermore, as the condition of cancer research in the KRG is progressing, it is not a norm for researchers to network and collaborate among academic institutions and other governmental and non-governmental organizations. This should be taken seriously and efforts should be applied to foster more national and international collaboration, which would result in improved access to necessary resources and
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consequently more research publications. Declaration of Competing Interest None. Conflict of Interest Statement We wish to confirm that there are no known conflicts of interest associated with this publication
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and there has been no significant financial support for this work that could have influenced its
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Figure captions:
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Fig 1. Number of published articles (per year) in different cities
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Fig 2. Number of published articles according to type of cancer
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Table 1. Published studies by city Place (city)
Total papers No. 102 109 58 269
Erbil Sulaimani Duhok Total
% 37.9 40.5 21.6 100
Duhok
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49 (18.2%) 21 (7.8%) 25 (9.3%) 11 (4.1%) 20 (7.4%) 6 (2.2%) 42 (15.6%) 68 (25.3%) 27 (10%) 41 (34.5%) 55 (46.2%) 23 (19.3%) 59 (21.9%) 73 (27.1%) 50 (18.6%) 43 (16%) 36 (13.4%) 8 (3%)
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Journal type Local Non-indexed Indexed in Scopus or WoS PubMed Place of study Kurdistan Other country No. of authors 1 2 3 >3
Sulaimani
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Erbil
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Table 2. Information on the published articles
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16 (5.9%) 21 (7.8%) 22 (8.2%) 43 (16%)
12 (4.5%) 9 (3.3%) 21 (7.8%) 67 (24.9%)
7 (2.6%) 10 (3.7%) 19 (7.1%) 22 (8.2%)
Table 3. Type of studies and nature of material used Erbil
Sulaimani
Duhok
Basic
26 (9.7%)
37 (13.8%)
25 (9.3%)
Clinical Materials Animals Cell line Patients
76 (28.3%)
72 (26.8%)
33 (12.3%)
0 12 (4.5%) 90 (33.5%)
3 (1.1%) 28 (10.4%) 78 (29%)
2 (0.7%) 5 (1.1%) 51 (19%)
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Study type
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