Abstract
<title>Abstract</title> <p>Background Cancer immunotherapy has transformed oncological practice globally, yet its penetration in conflict-affected and resource-constrained Middle Eastern and North African (MENA) countries remains poorly documented. Lebanon, Sudan, and Iraq represent a uniquely vulnerable triad, each experiencing compounding crises of armed conflict, economic collapse, and systemic healthcare deterioration that collectively impede the adoption of precision oncological therapies. Objective This pilot study aims to (a) generate preliminary, field-derived evidence on the availability, patterns of use, and barriers to cancer immunotherapy among oncology healthcare professionals in Lebanon, Sudan, and Iraq, and (b) evaluate the feasibility of the recruitment strategy, survey instrument, and analytical approach in preparation for a future, adequately powered, full-scale multi-national study. Methods A descriptive and analytical cross-sectional pilot design was employed, using a structured electronic questionnaire disseminated to oncology healthcare professionals across the three countries. Consistent with established methodological guidance for pilot and feasibility studies (Julious, 2005; Hertzog, 2008; Lancaster et al., 2004), which recommend pilot sample sizes in the range of 10-30 participants prior to full-scale investigation, recruitment through highly targeted professional networks yielded n=23 participants. Descriptive statistics, Likert-scale mean scoring with standard deviations, and Spearman rank-order correlation were applied; no inferential country-to-country comparison was attempted, consistent with pilot-phase reporting standards. Results The pilot cohort comprised 23 oncology professionals from Lebanon (n=12; 52.2%), Sudan (n=10; 43.5%), and Iraq (n=1; 4.3%). Immunotherapy was regularly available in only 43.5% of clinical settings. The highest-rated barrier was medication cost (mean=4.17 ± 1.31/5), followed by political and economic instability (mean=3.83 ± 1.43), pharmaceutical supply chain disruptions (mean=3.74 ± 1.36), lack of diagnostic infrastructure (mean=3.57 ± 1.41), and insufficient professional training (mean=2.96 ± 1.73). A total of 86.9% of participants agreed or strongly agreed that political and economic instability significantly reduced access to innovative cancer therapies. Predictive biomarker testing was never available in 43.5% of settings. The most critical recommended intervention was establishing national oncology protocols and reimbursement frameworks (47.8%). The pilot also confirmed the practical feasibility of the electronic instrument (100% completion rate among respondents who initiated the survey) while exposing the recruitment bottlenecks that a full-scale study must address. Conclusion This pilot study provides preliminary, hypothesis-generating evidence of a substantial immunotherapy access deficit in three crisis-affected MENA nations, and demonstrates that the survey instrument and analytical framework are feasible and ready for deployment at scale. The findings support the design of a fully powered, multi-center follow-up study — with a proposed target of n≥150 (50 per country) informed by the recruitment lessons of this pilot — and underscore the urgency of multilateral action, including international drug subsidies, protection of oncological infrastructure during armed conflict, and regional reimbursement frameworks.</p>