# Comparable Access, Different Outcomes: Breast Cancer Survival Among Syrian Refugees and Turkish Patients in Türkiye

## TL;DR

Syrian refugee women in Türkiye diagnosed with breast cancer tend to have more advanced disease but similar survival rates as Turkish women once in treatment.

## Contribution

The study shows that in a universal healthcare system, survival differences between Syrian refugees and Turkish citizens are not due to unequal treatment but later diagnosis.

## Key findings

- Syrian refugee women were younger and more likely to have metastatic breast cancer at diagnosis.
- After adjusting for stage and tumor biology, survival rates were similar between Syrian refugees and Turkish women.
- Treatment delivery was comparable between the two groups, indicating equitable care after diagnosis.

## Abstract

Breast cancer outcomes can vary between different population groups. Women who have been forced to leave their countries because of war or conflict may face additional challenges when seeking medical care. Türkiye hosts the largest population of Syrian refugees in the world and provides access to cancer treatment through its public healthcare system. In this study, we compared Syrian refugee women with Turkish women who were treated for breast cancer at two cancer centers in southeastern Türkiye. We examined how the disease was diagnosed, how patients were treated, and how long they survived after diagnosis. Syrian women were generally younger when they were diagnosed and were more likely to have cancer that had already spread to other parts of the body. However, once patients entered the healthcare system, both groups received similar cancer treatments. When we considered factors such as the stage of the disease and the biological characteristics of the tumor, refugee status itself was not linked to worse survival. These findings suggest that the main challenge is not unequal treatment after diagnosis but the later stage of disease at the time cancer is detected. Improving early diagnosis and access to screening may help reduce these differences.

Background: Breast cancer outcomes are influenced by tumor biology, stage at diagnosis, and access to timely care. Refugee populations may experience disparities in cancer outcomes despite formal access to healthcare services. Türkiye hosts the largest population of Syrian refugees globally and provides universal access to oncology care, offering a unique context to examine equity in breast cancer outcomes. Methods: We performed a retrospective cohort study of female patients diagnosed with invasive breast cancer between 2013 and 2022 at two tertiary oncology centers in Gaziantep, Türkiye. Patients were grouped as Syrian refugees or Turkish citizens based on recorded nationality. Baseline clinicopathologic features and stage at diagnosis were compared between groups. Overall survival (OS) was estimated by the Kaplan–Meier method and compared using log-rank tests. Survival analyses were performed overall and stratified by stage category (I–III vs. IV). Cox proportional hazards regression was used to evaluate the association between ethnicity and OS with adjustment for stage and molecular subtype (and other prespecified covariates as appropriate). Treatment delivery patterns (systemic therapy and radiotherapy) were descriptively compared to evaluate access after entry into care. Results: Among 499 patients (150 Syrian refugees; 349 Turkish citizens), Syrian patients were younger at diagnosis and more frequently presented with de novo metastatic disease. In the overall cohort with survival data (n = 430), unadjusted OS differed by ethnicity; however, survival differences were attenuated after stratification by stage. In stage I–III disease, OS did not significantly differ between groups, and in stage IV disease, median OS was comparable between ethnicities. In multivariable analysis adjusting for stage and molecular subtype, ethnicity was not independently associated with OS, whereas stage and molecular subtype remained prognostic. Treatment delivery patterns in both the non-metastatic and metastatic settings were broadly similar between groups. Conclusions: Within a universal healthcare system, the dominant disparity between Syrian refugees and Turkish citizens was more advanced stage at presentation. After accounting for stage and tumor biology, ethnicity itself was not independently associated with overall survival, suggesting that efforts to reduce outcome gaps should prioritize earlier diagnosis and linkage to care.