Unpacking the Clinical Burden of Leukemia in GCC: Implications

for Patient Care

Hesham Ali Behary Aboelkhir

, Yousra El Alaoui

, Regina Padmanabhan

, Adel Elomri

Halima El Omri

and Abdelfatteh El Oomri

College of Science and Engineering, Hamad Bin Khalifa University, Doha, Qatar

National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar

Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar

Keywords: Leukemia, Healthcare Expenditures, GCC, Global Figures, Clinical Burden.

Abstract: Cancer constitutes a substantial global health challenge, which is poised to intensify primarily due to the

growing elderly population globally. Leukemia, being a type of hematological cancer, presents unique

diagnostic complexities compared to solid cancers, contributing to elevated levels of morbidity and mortality

across various regions worldwide, resulting in a substantial clinical burden. Employing data sourced from the

WHO Global Health Expenditure Database and the Institute for Health Metrics and Evaluation (IHME)

Global Burden of Disease for the year 2019, this study undertakes an analysis of the prevalence, Years of Life

Lost (YLLs), Years Lived with Disability (YLDs), Disability-Adjusted Life Years (DALYs), and healthcare

expenditure in Gulf Cooperation Council (GCC) nations in comparison to the global figures.

1 INTRODUCTION

Global cancers are considered a major contributor to

disease burden worldwide and are expected to

continue growing for the next upcoming decades.

Cancer resulted in a total of 9.6 million deaths and

233.5 million disability-adjusted life years (DALYs)

in 2017 (Sung et al., 2021). Hence, the need for cancer

reduction strategies is regarded as a primary goal

recognized by the United Nations (UN) (Cheatley et

al., 2020).

Notably, leukemia is considered one of the most

concerning cancer types worldwide, and it is divided

into five major subcategories, namely acute myeloid

leukemia (AML), chronic myeloid leukemia (CML),

acute lymphocytic leukemia (ALL), chronic

lymphocytic leukemia (CLL), and others.

According to GLOBOCAN, leukemia was

classified as the 11

leading cause of all cancer-

related mortality (466,003 out of a total 9,958,133

cancer-related deaths) (Sung et al., 2021). Therefore,

an analysis of disease burden, leukemia in particular,

allows a better understanding of leukemia trends and

spreads, in order to assist health practitioners in

disease management and rational allocation of

healthcare resources (Cheatley et al., 2020).

In this study, we investigate the clinical burden of

leukemia through key indicators such as YLLs, YLDs,

DALYs, and healthcare expenditures in GCC

countries in comparison to global statistics. The aim

of this paper is to also understand leukemia’s

incidence and resulting deaths for more structured

prevention measures and improved clinical practice.

2 CLINICAL BURDEN

2.1 Related Works

Leukemia is a deadly hematological disease that not

only affects different age groups and poses a threat to

human development due to increased subsequent

deaths, but it also creates a significant burden on both

the healthcare system and society (Lin et al., 2021).

In 2015, leukemia resulted in 12 million DALYs

globally, with 97% and only 3% coming from YLLs

and YLDs, respectively (Ou et al., 2020). DALY is

used as an index of the combined quantity and quality

of life of a population, equating to the sum of YLDs

and YLLs.

Leukemia can be categorized into two main

categories: Acute and chronic. Unlike the acute type,

chronic leukemia is a class of slower growing cells

444

Aboelkhir, H., El Alaoui, Y., Padmanabhan, R., Elomri, A., El Omri, H. and El Oomri, A.

Unpacking the Clinical Burden of Leukemia in GCC: Implications for Patient Care.

DOI: 10.5220/0012373700003657

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 17th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2024) - Volume 2, pages 444-449

ISBN: 978-989-758-688-0; ISSN: 2184-4305

that can take up to several years to progress.

According to Yao et al., global deaths and DALYs

decreased slightly for chronic lymphocytic leukemia

(CLL) from 1990 to 2019 (Yao et al., 2021).

Moreover, the burden of death and DALY was mainly

affected by socio-demographic index (SDI), such that

the disease burden of CLL decreased in higher SDI

countries, while increasing in lower ones. This could

be due to the quality of healthcare provided in

developed countries compared to developing ones.

Similarly, the average potential years of life lost

(AYLL) was used for ALL to evaluate its societal

burden (Ahmad et al., 2023). Although ALL is

considered as a rare disease, it still represents a

significant health burden corresponding to a high

AYLL due to declining survival rates among adults

and increased incidence rate among children (Ahmad

et al., 2023).

In the same context, a study was performed to

investigate the incidence rate, mortality rate, DALY

and its change trend of AML during the period

extending from 1990 until 2017 in 195 countries. The

analysis revealed a gradual increase in both incidence

and mortality rates of AML, with males and elderly

being more prone to develop the disease (Lin et al.,

2021).

Comparably, a study undertaken to explore the

global burden of CML between 1990 and 2017

revealed a higher incidence and mortality of CML in

males compared to females. In addition, the highest

burden was reported in each of Andean Latin

America, Central Sub-Saharan Africa, and Southeast

Asia (Lin et al., 2021). While the age-standardized

death rate (ASDR) decreased during the period under

study in high SDI regions, the health-related burden

of CML remains a challenge for the low-SDI regions,

suggesting that appropriate strategies are yet to be

developed and adopted in these regions (Ning et al.,

2020).

2.2 Epidemiology

This section focuses on leukemia prevalence and

incidence rate analysis in the Gulf Cooperation

Council (GCC). The latter comprises Bahrain,

Kuwait, Oman, Qatar, Saudi Arabia, and the United

Arab Emirates (UAE), serving as a regional,

intergovernmental alliance with both political and

economic objectives. While these nations share a

common geographical region and numerous

connections, each country exhibits distinctive traits in

its healthcare systems, strategies, and various socio-

economic factors. This individuality underscores the

importance of studying the specific prevalence of

leukemia within this region.

Table 1: Population structure of GCC.

Country

Male-to-

Female

Ratio

Expatriate

(%)

Median

Age

Qatar 2.57 86% 33.8

UAE 2.18 89% 30.3

Kuwait 1.58 68% 37.2

Bahrain 1.54 54% 32.7

Oman 1.44 43% 29

Saudi Arabia 1.36 48% 30.4

Table 1 displays the population composition of GCC

countries. It underscores the significant male-to-

female ratio in all these nations, primarily resulting

from a substantial influx of expatriates who come to

this region for employment opportunities, but often

do not bring their families along. This migration

pattern also contributes to the notable proportion of

individuals aged 15-64, as indicated in Figure 1.

However, it's worth noting that this scenario may be

different for Oman, which has the lowest expatriate

percentage (43%) and the youngest median age (29

years) among all the GCC nations.

Figure 1: The population age structure of GCC countries in

2019.

On a global scale, the incidence rate of Leukemia

stands at approximately 8.3 cases per 100,000 people,

with a slight upward trend observed from 2010 to

2019. When compared to GCC countries, we find a

notably lower incidence rate, ranging from 3.86 to

5.12 cases per 100,000 individuals. Figure 2

illustrates the case of Oman, which experienced a

declining trend during this period. Kuwait, on the

other hand, displayed a decreasing trend up to 2013,

followed by an increasing trend from 2013 to 2019.

Unpacking the Clinical Burden of Leukemia in GCC: Implications for Patient Care

445

Figure 2: Incidence rate of GCC countries compared to

global rates in 2019 across all sexes and all ages.

The incidence rate reflects the number of new

cases diagnosed each year, offering insights into the

annual rate of occurrence. Nevertheless, when it

comes to understanding the overall impact of the

disease, the prevalence rate plays a pivotal role.

Prevalence represents the proportion of the

population that possesses a specific characteristic, in

this case, the ongoing burden of leukemia, over a

defined time period. It takes into account not only

new cases, but also those who have been living with

the condition for long.

Figure 3: Prevalence of leukemia and its subtypes per

100,000 cases in GCC compared with global trends for all

sexes and all ages in 2019.

As depicted in Figure 3, all GCC countries exhibit

lower prevalence rates for overall leukemia, ranging

from 14.72 to 29.55 cases per 100,000 people. These

figures contrast with the global prevalence rate of

41.64 cases per 100,000 individuals. Among the GCC

nations, Kuwait reports the highest prevalence rate

for total leukemia at 29.55 cases per 100,000 people,

while the UAE registers the lowest prevalence rate,

standing at 14.72 cases per 100,000.

Upon analyzing the prevalence of various

subcategories of leukemia in the GCC countries, the

following observations were made:

The prevalence rates for AML in GCC countries

range from 1.08 in Kuwait to 2.45 in the UAE, all of

which are lower than the global rate of 2.55.

In the case of CML, the prevalence rates in GCC

countries range from 0.88 in both Oman and the UAE

to 2.39 in Qatar, which are also lower than the global

rate of 3.25.

For ALL, the prevalence rate in the GCC ranges

from 1.83 in the UAE to 10.56 in Kuwait, all of which

are lower than the global rate of 12.61.

Additionally, Qatar is the exception, with a

prevalence rate of 9.22 for CLL, which exceeds the

global rate of 7.84. This particularity in Qatar's CLL

prevalence rate warrants further analysis to

understand the factors behind this higher pattern.

For other leukemia subtypes, while all GCC

countries exhibit prevalence rates lower than the

global rate of 15.40, only Kuwait's prevalence rate is

close to the global rate at 14.23. The remaining GCC

countries show prevalence rates ranging from 3.83 in

Qatar to 7.87 in the UAE.

To estimate the burden of leukemia, our study

utilizes DALYs (Disability-Adjusted Life Years),

where one DALY signifies the loss of one year of

complete health. DALYs are calculated by summing

the years of life lost due to premature mortality

(YLLs) and the years lived with a disability (YLDs)

attributed to prevalent cases of the disease within a

community (GBD, 2019).

The formula for DALYs is:

DALYs = YLLs + YLDs.

Figure 4: DALYs per 100,000 cases of leukemia in GCC

countries compared to global trends for all sexes and all

ages in 2019.

Figure 4 provides an insight into the total

leukemia burden in GCC countries, which ranges

from 84.77 to 141.26 DALYs per 100,000. These

rates are notably lower than the global average of

150.67 DALYs per 100,000. This is consistent with

the expectation that lower prevalence rates in GCC

countries would result in a lower overall burden.

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446

Nevertheless, we notice that despite having the

lowest prevalence rate of total leukemia among GCC

countries, the UAE has the highest burden.

Conversely, Kuwait, with the highest prevalence rate

of total leukemia, reports the lowest burden. These

discrepancies suggest that additional factors might be

influencing the burden and require further

investigation.

In addition, the burden of myeloid leukemia, both

acute and chronic, in GCC countries exceeds the

global burden. This is especially notable in the UAE

and Bahrain for AML and CML. In Qatar, only the

AML burden exceeds the global average, while in

Saudi Arabia, it's the CML burden that surpasses the

global level. Approximately 98% of the total

leukemia burden, calculated using DALYs, is

attributed to YLLs. This indicates that premature

mortality plays a substantial role in the overall disease

burden.

These findings underscore the need for further

research to understand the factors contributing to

variations in leukemia burden within the GCC

countries, including the unexpected burden

disparities between prevalence rates and the potential

factors influencing YLLs in this context.

Figure 5: YLLs per 100,000 cases of leukemia in GCC

countries compared to the global rates for all sexes and all

ages in 2019.

Figure 6: YLDs per 100,000 cases of leukemia in GCC

countries compared to global rates for all sexes and all ages

in 2019.

3 HEALTH EXPENDITURES

Health expenditure encompasses all financial outlays

related to the provision of healthcare services, family

planning initiatives, nutrition programs, and

assistance for health-related disasters. However, it

does not include expenses for drinking water and

sanitation. Health funding represents a critical

element within healthcare delivery systems (WHO,

2023).

In the GCC region, healthcare expenditure draws

from three primary sources:

• Government Health Expenditure, which

represents the portion of a country's Gross

Domestic Product (GDP) allocated to healthcare

by the government.

• Out-of-Pocket Payments (OOP), which are

direct payments made by individuals to

healthcare providers as compensation for the

services they receive.

• Prepaid Private Spending, which includes the

combined spending through both compulsory

and voluntary private health insurance schemes

(WHO, 2023).

As per Figure 7, it is clear that the healthcare

expenditures in all GCC countries surpass the global

average of 1,108 USD per person, with one exception

being Oman. Oman reports a healthcare expenditure

of 817 USD per person. These differences in

healthcare expenditure levels among GCC countries

can reflect varying economic capacities, healthcare

system structures, and government healthcare

funding policies.

Figure 7: Health expenditure and spending sources in GCC

compared to global trends in 2019.

Among GCC countries, the breakdown of

healthcare expenditure shows some interesting

variations, including the UAE leading the GCC with

the highest healthcare expenditure per person at 1,983

USD. It also has the highest prepaid spending at 693

Unpacking the Clinical Burden of Leukemia in GCC: Implications for Patient Care

447

USD per person. Next, Qatar follows the UAE with a

healthcare expenditure of 1,938 USD per person.

While Kuwait has the highest government health

spending at 1,609 USD per person, it reports the

lowest prepaid private spending at 22 USD per

person. Finally, Bahrain has the highest out-of-pocket

spending at 332 USD per person.

Healthcare expenditure serves several essential

purposes, including reducing the burden of diseases,

addressing capacity constraints, and improving

access to healthcare facilities by reducing waiting

times. The GCC region has implemented various

quality assurance strategies to bring their healthcare

systems in line with global standards, ensuring high-

quality healthcare services in multiple dimensions.

Universal Health Coverage (UHC) is a crucial

index that assesses the effectiveness of healthcare

coverage. It examines service coverage across various

population health needs and evaluates the extent to

which these services contribute to enhanced health

outcomes. UHC is an essential framework for

measuring and promoting equitable access to

healthcare services for all individuals within a

population (WHO, 2023).

Table 2 indicates that all GCC countries are

experiencing an annual increase in the UHC Index.

This positive trend aligns well with some of the

countries that have the highest healthcare spending. It

demonstrates a commitment to expanding and

improving access to healthcare services and

achieving equitable coverage across the GCC region,

even in comparison to countries with significant

healthcare expenditures (The Institute for Health

Metrics and Evaluation, 2019).

Table 2: Comparison between GCC countries and three of

the highest-ranked countries in terms of UHC index from

2010-2019.

Country 2010 2019

Australia 88.3 89.4

UK 86 87.9

USA 81.2 82.1

Kuwait 75 81.8

Qatar 76.3 80.4

Oman 61.6 71.2

Bahrain 66.3 70.6

Saudi 58.5 64.2

UAE 63.3 63.4

4 DISCUSSION

The rising incidence of leukemia in GCC countries

necessitates an increase in healthcare capacity. The

number of hospitals is steadily increasing in all GCC

nations, reflecting a long-term strategy to address the

growing demand for healthcare services. Qatar leads

with the highest hospital-per-population ratio at

0.0019%, followed by Oman (0.0017%), the UAE

(0.0016%), Saudi Arabia (0.0014%), Bahrain

(0.0014%), and Kuwait (0.0006%). This reflects a

commitment to enhancing healthcare infrastructure to

meet the clinical burden of leukemia.

Figure 8: Hospital to population ratio in GCC in 2022.

The number of hospitals in Qatar increased from

30 in 2011 to 57 in 2022, while in Oman, it grew from

65 in 2012 to 88 in 2022. Further analysis on the

capacity of these hospitals is needed in future studies.

Variations in leukemia prevalence in GCC

countries may be attributed to risk factors in

healthcare. These factors fall into three categories:

Metabolic risks, behavioral risks, and environmental

and occupational risks. Table 3 ranks these risk

factors across GCC nations, providing insight into the

differences in leukemia prevalence and trends.

Table 3: Risk Factors Ranking among GCC in 2019.

Risk Factors UAE Qatar

Saudi

Arabia

Oman Bahrain Kuwait

High Body-Mass

Index

1 1 1 1 1 1

High Fasting

Plasma Glucose

4 2 3 3 2 2

High Blood

Pressure

2 5 2 2 3 3

High LDL 5 9 7 5 7 7

Kidney

Dysfunction

8 10 8 9 8 9

Tobacco 3 3 6 8 4 4

Dietary risks 7 6 4 4 6 5

Malnutrition

8 10 7

Low physical

Activity

_ _ 9 _ 10 _

Drug Usage 9

Air pollution 6 4 5 6 5 6

Occupational Risks 10 7

10 9 10

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Table 3 underscores that metabolic risks,

particularly high body-mass index, high fasting

plasma glucose, and high blood pressure are the

dominant risk factors in the GCC region. These

factors consistently rank as the top risks in all GCC

countries. Moreover, Tobacco intake is the third risk

factor in Qatar and the UAE, and the fourth in Bahrain

and Kuwait, while drug usage risk only features in the

top ten risk factors in the UAE.

The age structure of the population is another

factor influencing the variation in leukemia

prevalence and clinical burden across GCC countries.

Leukemia incidence rates tend to rise with age.

Hence, countries with a significant elderly population

may experience a greater leukemia burden as the

proportion of elderly individuals increases. The

GCC countries have a substantial expatriate

population, originating from various regions

worldwide, with a notable concentration from South

Asian countries. This diversity calls for further

studies to investigate potential relationships between

nationality and leukemia incidence, considering

genetic factors based on genome mapping.

5 CONCLUSIONS

In summary, the rising leukemia incidence in GCC

countries necessitates increased healthcare capacity,

with a steady growth in the number of hospitals.

Variations in leukemia prevalence result from factors

like metabolic risks, age structure, and the significant

expatriate population. Metabolic risks, particularly

high body-mass index, are prominent. Further research

is needed to explore the relationship between natio-

nality and leukemia incidence, considering genetic

factors among the diverse expatriate population.

ACKNOWLEDGEMENTS

This article was made possible by National Priorities

Research Program-Standard (NPRP-S) Twelfth (12th)

Cycle grant# NPRP12S-0219-190108, from the Qatar

National Research Fund (a member of the Qatar

Foundation). The findings herein reflect the work, and

are solely the responsibility, of the author[s].

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