By Humaid O. Al-Shamsi, MD, MRCP(UK), FRCP(C), FACP
Cancer care in the United Arab Emirates (UAE) has swiftly evolved over the past two decades with the establishment of several state-of-the-art facilities offering holistic services that comply with international standards and qualifications. This was coupled with an uprise in Emirati specialists returning home after training in North America and Europe, as well as the continued import of international talent looking to establish a fulfilling career in the UAE—all made possible through the vision and unconditional support from the country’s leadership. However, one clear gap in such an advance was the absence of comprehensive bone marrow transplant (BMT) services in the country, and several recent calls have been made by a local taskforce to address this persisting need.1 Patients in need of BMT have historically sought the procedure abroad in India, Turkey, Europe and the United States; but, such medical tourism does not come without its own ‘side effects’. Beyond the obvious economic and logistic burdens it entails, continuity of care is usually challenged, especially for a procedure with extensive pre- and post-treatment needs. Treatment interruptions and variation of protocols initiated abroad and continued locally are common consequences of poor communication and documentation between the various stakeholders involved. Patient experiences and general well-being are also compromised when care is offered in an environment that is culturally mismatched.2,3 More recently, and to make matters worse, this sole solution suffered a major disruption as COVID-19 mobility challenges started to unfold. Not only were patients unable to travel to seek medical care, but even when they did this required extensive precautions for immunocompromised individuals.3 The majority of patients eventually had to wait for a ‘window’ of opportunity to travel, while their underlying disease continued to progress.
I joined the Burjeel Cancer Institute at Burjeel Medical City in Abu Dhabi during the second wave of the COVID-19 pandemic (October 2020), and my first task was to establish a comprehensive cancer center that catered to the local and regional patient population. The mission was eventually a success and concluded with the center becoming the first and only European Society of Medical Oncology (ESMO) designated center of integrated oncology and palliative care in the UAE. During the conceptualization phase, we realized that our plan would not be a complete success if we did not address the most critical unmet need in the country, a national and self-sustained comprehensive BMT unit. We embarked on this challenging yet rewarding journey in February 2021 (Fig 1.).
Fig 1. Roadmap of bone marrow transplant unit establishment. BMT, bone marrow transplant; SOP, standard operating procedures; MDT, multidisciplinary team.
We needed to make sure that our unit was set up quickly while strictly following international standards, specifically the European Society for Blood and Marrow Transplantation (EBMT) recommendations. We first put together a core team of expert hematologists, alongside leads from our nursing, laboratory, pharmacy, infectious disease, quality assurance, and human resource functions. We then acknowledged the need for insights from external experts with prior experience in BMT unit construct and set up collaborations with specialists from Saudi Arabia and India, facilitated through regular video conferencing.4 Owing to the critical and urgent need to set up our unit, they served as an advisory expert panel on a volunteering basis, which was a true testament of how the oncology community could come together to support each other in the most critical of times.
Constructing a purposely built floor, with 13 positive pressure rooms and high-efficiency particulate absorbing filters, went as smooth as one would expect. However, recruiting the dedicated BMT unit team members was not an easy task in such difficult times. For instance, we had to get private charted flights from India and undergo complex approvals to transport the required nursing and technical teams to the UAE. Our human resources department also had to optimize their search, identification, interview, and on-boarding process to ensure that we had all the needed functions in a timely manner. Similarly, our purchasing department had to double their staff and effort to overcome logistical barriers and common delays during the pandemic in order to provide essential equipment, such as an apheresis machine. We then had to establish practical local collaborations for our outsourcing needs. For example, rules in the UAE do not allow for having hospital-based blood banks, so we had to set up a working arrangement with the central Abu Dhabi blood bank to ensure our need for 24-hour access to blood products was met. We also realized that establishing a cellular therapy unit for cryopreservation and stem cell processing required time. We thus conducted a systematic review of outcomes with noncryopreservation to ensure we had the evidence-base to proceed with preservation at 2-6°C until such unit was set up. We then had to connect the dots and ensure our BMT unit was optimally serviced by all departments of relevance, including intensive care, emergency, specialty care (cardiology, infectious disease, pulmonary, and gastroenterology), laboratory, pharmacy, radiology, and radiation oncology. The overall function of the unit, and requirements from such departments, are governed through written institutional protocols, with standard operating procedures and guidelines. Regular interdisciplinary team meetings became the norm to ensure the process was bullet proof and to recognize the efforts of all those involved, while also serving as a morale booster during critical and stressful times. Additionally, the Department of Health in Abu Dhabi was instrumental in our successful and quick launch, with prompt responsiveness and a seamless audit process.
Before our launch towards the end of August 2021, we had already started our community reach and discussions with various colleagues and medical groups in the country to ensure a smooth referral pathway once we were ready to kick-off. We also established a virtual UAE-wide weekly BMT multidisciplinary team meeting to ensure we had a platform to discuss cases and share experiences with our local colleagues, and the same was set up with regional experts who have long-standing experience with HSCT, such as Lebanon for case reviews. To help the local community, we decided to provide the first 10 BMT cases for free as the service is not yet coded and covered by insurance providers in the UAE. We immediately received eight referrals once we announced our launch, both from within and outside the UAE. We did a very thorough review of the referred cases and selected low-risk ones to ensure the safety of all patients treated initially.
Our first case had a set back after a patient tested positive for COVID-19 on the third day of mobilization, despite extensive precautions—with the unit staff being tested twice weekly for COVID-19, and the patient testing negative on three swabs the day prior, the day of, and the day after admission. Mobilization was terminated and the patient was discharged home where he developed symptoms after one week and was later admitted for oxygen support. None of the BMT unit staff were infected and a careful review of the case did not reveal any breach in our protocols and suggested the patient had been infected prior to admission. We did not let this set back affect our momentum and eagerness to commence our service, and we continued to evaluate potential candidates. We subsequently admitted two patients who underwent mobilization and autologous transplantation with successful engraftment at 10 and 12 days and both were discharged home. One of the two patients had come to us from Lebanon, which is witnessing a healthcare system crisis, and we offered full logistic support for the patient and his family to come to the UAE and for his stay afterwards.
Overall, this experience taught me personally that with determination, resilience, teamwork, and collaboration we can achieve our goals even in the hardest of times. It is now also the key driver for our excitement as we plan to expand our service to include allogenic and cellular therapy, which were once a dream target, but are now getting closer to becoming a reality.
Dr. Humaid O. Al-Shamsi is director of the Department of Oncology and Innovation and Research Center at the Burjeel Cancer Institute, Burjeel Medical City in Abu Dhabi. He is also president of the Emirates Oncology Society and is a professor in the College of Medicine at the University of Sharjah. Follow him on Twitter @alshamsi2000. Disclosure.
- Al-Shamsi H, Darr H, Abu-Gheida I, et al. The State of Cancer Care in the United Arab Emirates in 2020: Challenges and Recommendations, A report by the United Arab Emirates Oncology Task Force. Gulf J Oncolog. 2020;1(32):71-87.
- Al-Shamsi HO, Abu-Gheida I, Rana SK, et al. Challenges for cancer patients returning home during SARS-COV-19 pandemic after medical tourism - a consensus report by the emirates oncology task force. BMC Cancer. 2020;20(1):641.
- Al-Shamsi HO, Al-Hajeili M, Alrawi S. Chasing the Cure Around the Globe: Medical Tourism for Cancer Care From Developing Countries. J Glob Oncol. 2018;4:1-3.
- Al-Hashmi H, Alsagheir A, Estanislao A, et al. Establishing hematopoietic stem cell transplant programs; overcoming cost through collaboration. Bone Marrow Transplant. 2020;55(4):695-697.
- Devi S. Economic crisis hits Lebanese health care. Lancet. 2020 Feb 22;395(10224):548.