October is Breast Cancer Awareness Month and I recently hosted the ‘Wear it Pink’ photocall at Westminster for MPs to get silly photos, in outlandish pink gear, to highlight the campaign. While increased awareness, earlier presentation and modern treatments have improved Breast Cancer care in Scotland and the UK, this is not the case everywhere. Having worked with Medical Aid for Palestinians (MAP) as a surgical volunteer in Gaza for a year and a half in 1991 and 92, I returned last year for the first time in 25 years to see how we could contribute to the improvement of breast cancer treatment there and in the West Bank and, then again, just a few weeks ago.

What struck me once I made my way through checkpoints at Erez crossing was how crowded and claustrophobic the Gaza Strip is after 10 years of virtual siege. The spread of Gaza City outwards to accommodate the population of almost two million people, squashed into a strip of land 8 by 40 kilometres, is eating into the arable land within the strip, while the Israeli security wall and associated no-man’s land shrinks it around the edges. The pervasive smell of sewage as a result of the near doubling of the population and refusal of Israeli permission to expand the sewage treatment plant, means raw sewage is just pumped out into the sea; one of Gaza’s most important resources. The water has been undrinkable for several years. The beaches could be beautiful and the plentiful seafood could have made tourism a major source of income and economic activity but the blockade of Gaza by land, sea and air have made that impossible. Gaza fishing boats, a traditional source of income as well as food, face the impact of the sewage effluent as well as the fact that, while boats from the south of the Strip can now fish out to the main reef at 9 miles, those from Gaza City harbour face a 6 mile limit.

When we lived in Gaza, 25 years ago, it was still under direct occupation by the Israeli Defence Force and Settlers which meant there were clashes every few days, resulting in patients with gunshot wounds needing surgery. Since the Israeli withdrawal, it is easier to move about in Gaza but the external security wall and a decade of blockade impact on every aspect of daily life, including cancer treatment. For those requiring chemotherapy, it is not always possible to maintain an unbroken course of treatment and there are always chronic drug shortages - WHO report that 35% of all essential medicines are out of stock in Gaza.

As I documented last year, radiotherapy, a key element of breast cancer treatment, but also crucial for many other tumours, is not available within Gaza so patients need to travel to East Jerusalem. However, not only is it expensive for patients to travel and stay in Jerusalem for over a month, many are simply denied access to Israel and permission to travel - in August, 45% of all patients were denied permission or received no response. During the clinic we carried out on the first day, I met an elderly lady who had been trying to get permission to travel for radiotherapy for six months without success and came to the clinic concerned that a nodule in her Mastectomy scar might already be a sign of recurrence: a sad phenomenon which is not uncommon among those with the highest risk disease. It is hard to imagine what threat she could possibly pose to Israeli security.

It is not just those who are denied permission who are affected as the routine denial of permission is skewing treatment, with the majority of surgeons opting for mastectomy and clearance of the axillary nodes so most patients won’t need radiotherapy in the first place. This aggressive approach for all patients, regardless of the size and extent of disease, has significant ramifications due to the cultural impact for a woman of losing her breast and the high incidence of lymphoedema or arm swelling. It also feeds into a nihilism among patients about the potential to treat breast cancer and the fear of destructive treatment keeps women in Gaza from coming forward until the disease is very advanced. At our first clinic in Gaza, once our radiologist performed detailed ultrasound scans, sadly patient after patient was found to have heavy nodal involvement. As these patients had already been seen by other breast surgeons, this highlighted the need to develop a more detailed diagnostic pathway so the medical team can make the most appropriate treatment plan for each patient - this is one of the key aspects that the MAP project would seek to address.

Palestinian Ministry of Health data shows that approximately 1 in 3 breast cancer patients in the OPT are node negative and the key aim of my trip was to introduce the technique of Sentinel Node Biopsy (SNB), which involves removing just one or two nodes for testing in women who appear to be node negative and carries a very low risk of side effects. In the UK, we would use a combination of blue dye and a radiocolloid injected into the breast to identify the first nodes in the axillary lymph chain, i.e. the most likely to have any cancer deposits. Unfortunately, the Israeli authorities do not allow the import of radiocolloid into the OPT - describing it as a security threat, despite the fact that Technitium has a half-life of a mere 4 hours which means the radioactivity is essentially gone the following day.

It felt like a homecoming for me as I operated in Al Ahli hospital in Gaza City, where I had worked back in the early ‘90s, and received an affectionate welcome from old friends and colleagues. Its lush garden remains a wee green oasis in this city of concrete and sand. Over the next three years, the MAP project will take multidisciplinary breast cancer specialists, from across the Scottish Breast Cancer networks, to the West Bank and Gaza. The aim is to help develop an overarching vision for Breast Cancer care, to help support quality improvement measures and particularly to provide training and mentoring through our Multidisciplinary Teams.

It is, however, not possible to ignore the political nature of the constraints faced by Palestinians in their daily lives, nor how that affects healthcare. There are many other parts of the world where cancer treatment is unavailable but the difference in Gaza is that the obstruction is political in nature. The decade long siege affects every aspect of life and results in survival from breast cancer being around half that of women in the UK, or even just a few kilometres along the coast in Ashkelon. The international community need to put the Israel-Palestine conflict back on the agenda. In this centenary year of the Balfour Declaration, the UK must recognise that, while a Jewish State has been created in Israel, the second half of that declaration, which promised to protect the Palestinian people, most certainly has not been delivered.