Ultra-Orthodox women and Arab women from East Jerusalem are diagnosed with breast cancer at a much more advanced stage and with worse outcomes than the general population, according to research by Professor Shani Paluch-Shimon, Director of the Breast Oncology Department at Hadassah Medical Organization, together with psycho-oncologist Professor Michal Braun, head of the psychology service at the comprehensive breast care center at Hadassah. Their research studies health care disparities among different groups of women in Jerusalem, in an ongoing, longitudinal prospective study funded by the Breast Cancer Research Foundation (BCRF).
“In Israel, we are the only center that does patient-level healthcare disparity research into breast cancer management and outcomes,” said Prof. Paluch-Shimon.
Prof. Paluch-Shimon and Prof. Braun with their team are leading multiple innovative research projects geared at tailoring breast cancer care for Hadassah’s diverse patients.
Results are sometimes surprising. For example, despite the worse health outcomes, when it comes to psychosocial factors, such as quality of life, mental health and spiritual wellness, the two minorities groups represent different and even opposing outcomes. Ultra-Orthodox women fare better than other groups, while Arab women suffer the most from depression, loneliness and anxiety.
“The research is significant as it can help us tailor what we do and what we provide for our patients,” said Prof. Paluch-Shimon. “We try to understand what the systemic values and cultural habits are so we can think of public health intervention as well.”
Prof. Paluch-Shimon and Prof. Braun identify language barriers, cultural modesty norms, and communication gaps with medical staff as key obstacles for Arab and Ultra-Orthodox Jewish women, as well as conflicts with their communities regarding the ability to share emotions, and being open regarding illness. For both “God is a very strong attachment figure,” explained Prof. Braun.
Prof. Braun added that “while Ultra-Orthodox women are a minority group, they are a strong group as they have community members and informal support systems helping bridge gaps for them.”
They highlight the need to collaborate with community doctors to bridge potential cultural gaps and overcoming nuances of language barriers between the tertiary center and primary care providers in east Jerusalem.
The team is now looking to expand this research to other communities in Israel to see if the Jerusalem model holds, Prof. Braun said.
And while treatment is becoming culturally adaptive, it is also becoming more personalized and effective for each patient. Screening, diagnosis, and treatment must be adapted to the unique genetic and molecular features of both the patient and their specific tumor.
Artificial intelligence is an important new tool which accelerates personalized breast cancer care by analyzing complex genetic, imaging, and tissue data to help doctors detect tumors earlier, predict precise treatment responses, and tailor therapies to each patient’s unique biology.
“Personalized medicine and artificial intelligence are the future of breast cancer treatment,” said Prof. Paluch-Shimon.
She is leading a separate research project together with the pathology team, to help in identifying BRCA mutations. BRCA1 and BRCA2 are tumor-suppressor genes responsible for repairing cellular DNA damage, and testing for mutations in them is uniquely vital as it impacts treatment, surgical management, screening and follow up for further breast cancers and other malignancies as well as an impact on family members.
Prof. Paluch-Shimon’s team is examining pathology slides of women already diagnosed with a BRCA mutation to develop an AI-based prediction model which will determine whether a patient has a BRCA mutation just by looking at their pathology slide. Traditional models of genetic counseling and testing pose a bottleneck to getting to the genetic data in a timely manner.
“This saves a lot of time and informs us which patients should be fast-tracked for testing,” Prof. Paluch-Shimon said. “We’re trying to see whether we can predict response to treatment via this model as well.”
While the project is still at an early stage, its outcome could have global impact. “Physicians in low-resource countries could simply scan a slide and send it overseas for the model to predict. “It may not prevent us needing to do a blood test but it may also help us identify which patients are likely to have a BRCA mutation and accelerate testing,” she added.
For Prof. Paluch-Shimon, risk assessment and screening needs to be personalized and tailored to each patient.
“We encourage all women to fill a questionnaire and do a screening to see what their risk is.”
Gesturing to a shelf in her office filled with photos of babies of her patients, she has happy news: “Most women living with breast cancer or breast cancer survivors, who want to have children will be able to do so. These photos are the happy proof.”