By Firas Y. Kreidieh, MD; Raghid N. Charara, MD; and Nagi S. El Saghir, MD, FACP
Breast Center of Excellence, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon

	Sidon Sea Castle, a thirteenth-century fortress in Lebanon, is lit with pink lights to celebrate breast cancer awareness and survivorship during October 2014.

In October 2014, the Lebanese Breast Cancer Foundation together with the American University of Beirut Medical Center and the Municipality of Sidon, South Lebanon, held an awareness event called “Sidon Sea Castle in Pink,” which received significant media attention in Lebanon and the Arab world. Sidon Sea Castle in Pink consisted of lighting up the landmark Sea Castle in pink, a symbol for awareness and survivorship of breast cancer. The campaign included a celebration with pink balloons and distribution of educational flyers on “Knowledge: Road Map To Cure 2014.” A considerable number of civil society leaders, policymakers, government and parliament officials, as well as breast cancer survivors and volunteers, attended the event.

Sidon Sea Castle, built on an island connected to the mainland by a causeway, is among the most prominent and breathtaking archaeological sites in Lebanon. The fortress was built by the Crusaders in the early thirteenth century and remains a landmark tourist attraction. Throughout history, Sidon Sea Castle survived many wars, served as a shelter from attacks on the city, and faced great difficulties in weather including earthquakes, strong waves, and severe storms over thousands of years. Despite these events, the Castle remained glorious, standing, and beautiful. Roman columns were used as horizontal reinforcement and provide support to the castle. Sidon Sea Castle in Pink was suggested as an example for standing up against difficulties that can be associated with cancer.

During the ceremony, we stressed the importance of screening in early detection and breast cancer prevention, which can best be improved through reinforcement of public health education and raising awareness in the community. Discovering breast cancer at an early stage allows management with modern partial breast surgery, conservative sentinel surgery for the axilla, together with radiation therapy. Also, if an early-detected breast cancer contains intense hormone receptors, the patient may even be spared adjuvant chemotherapy. Such management strategies produce high rates of cures with non-disfigurative breast surgery for early-stage breast cancer. Results of management and outcome of breast cancer in Lebanon made the public receive these massages very positively. They dispel fears from breast cancer, and even help fight fatalistic beliefs that cancer is “incurable.” People and policymakers expressed signs of relief at the news that more than 90% of patients with stage I breast cancer in Lebanon are alive and well after 10 years of follow-up, as reported in a recent study published from the American University of Beirut (El Saghir NS, et al. Outcome of breast cancer patients treated outside of clinical trials. J Cancer. 2014;5:491-8). Local research and outcome studies are very useful tools to convince people to enroll in cancer screening, and go forward and seek medical attention at the earliest suspicion of symptoms or signs of disease.

For 15 years, breast cancer awareness campaigns have been conducted by the Lebanese Ministry of Public Health, medical societies, and nongovernmental organizations, and have lead to a marked improvement in downstaging of breast cancer at diagnosis, which, coupled with advances and availability of modern therapy in the country, improved breast cancer survival. In Lebanon, whose population is estimated at 4 million people, and where a total of 8,000 new cancer cases are diagnosed each year, the annual age-standardized rate (ASR) of breast cancer in women is 69/100,000/year. The total number of new breast cancer cases is 1,700 each year, of whom 50% are younger than 50. Women older than 40 are recommended to perform breast self-exam and to have an annual clinical breast exam and a screening mammography (Adib S, El Saghir NS, Ammar W. Guidelines for breast cancer screening in Lebanon Public Health Communication. J Med Liban. 2009;57:72-4). Health awareness, education, and empowerment of women to take care of themselves helps them notice any changes that may occur in their breasts and encourages them to seek immediate medical attention; this is particularly important in areas with limited resources and low- and middle-income countries.

Approaching cancer awareness and health, especially when there is proof that diagnosing cancer at an early stage leads to improved outcomes, with an optimistic and cheerful mood is a very helpful way to promote prevention and early detection of cancer. Breast cancer October campaigns in pink have been popular and spread throughout almost all countries. Awareness and education of women are the most important tools to reduce the burden of breast cancer worldwide, particularly in low- and middle-income countries. The yearly series of images from Lebanon of Raouché Mediterranean Twin Rocks, Presidential Palace, Human Pink Ribbon, and Sidon Sea Castle in Pink were widely disseminated by the media to all Middle Eastern and Arab countries (read coverage in English and Arabic). The sharing of experiences shall help to encourage and improve international communities as well.