Adewuyi Sa

The Stagnation and Decay of Radiation Oncology Resources: Lessons From Nigeria

The global incidence of cancer has increased by 20% in the past decade, with low-income and middle-income countries (LMIC) accounting for the majority of cases (1). By 2020, about 70% of new cancer cases will occur in LMIC (2); however, these countries are inadequately prepared for the global cancer epidemic. Radiation therapy is a particularly cost-effective modality for cancer treatment (3). Adequate access to radiation therapy is a crucial component of modern multidisciplinary cancer care. Within a 20-year period of 2005 to 2025, 100 million cancer victims in the developing countries will require radiation therapy, for cure or for the relief of symptoms such as pain and bleeding (4). Estimates show that by 2020, 84 LMICs will need 9169 teletherapy units, 12,149 radiation oncologists, 9915 medical physicists, and 29,140 radiation therapy technologists (5). Despite this enormous need, radiation therapy machine downtime remains high in existing radiation therapy centers of LMIC (4). Although much has been reported on the technical and human resource needs of LMIC, little has been said regarding efforts to stem the decay of existing resources. This report appraises the current status of radiation oncology in Nigeria, documents its recent regressive path, and suggests solutions to salvage and ultimately improve what radiation therapy resources remain.

Current status of radiation oncology facilities in Nigeria

Background: An analysis of the current radiation oncology facilities status in Nigeria was conducted to establish a comprehensive baseline. Nigeria is the most populated African country with a population of at least 160 million people based on 2006 population census and average annual growth rate of 3.1%. It is also one of the least developed countries as regards radiation oncology resources with inadequate radiotherapy facilities. Many of the patients have little or no access to safe and modern radiation therapy. Purpose: To obtain a better understanding of the status of radiation oncological practices in Nigeria and to help sensitize the Nigerian government and its developmental partners on the way forward. Materials and Methods: The data were obtained mainly through surveys on the availability of major items of equipment and personnel which were conducted in September 2011. The study included only commissioned and functioning public radiotherapy facilities which are 5 in the country. Data were related to number and types of megavoltage machines, trained manpower (Radiation Oncologists, Medical Physicists, Oncology Nurses, Radiotherapy technologists, maintenance engineers and mould room Technicians), treatment planning systems TPS, Brachytherapy equipment, CT Simulator and Conventional simulators. Results: Of over 50 Tertiary Health Institutions (Teaching Hospitals and Federal Medical Centers) in the country, only 5 has Radiation Therapy facilities with 1 megavoltage machine each, 2 located in the north, 2 in the south and 1 in the Federal Capital Territory. The population served by each megavoltage machine ranges from 20 to 40 million per machine based on 2006 census. Most patients have little or no access to radiation oncology services. Some differences in equipment and personnel amongst centers were demonstrated and the shortage of radiation therapy resources was grossly evident. There are 18 Radiation Oncologists, 8 Medical physicists, 18 Radiotherapy technologists, 26 Oncology Nurses, 3 linear accelerators, 2 Co-60 machines, 2 orthovoltage therapy machines, 2 conventional simulators, 2 CT simulators, 2 centers with 3D TPS, 3 LDR and 1 HDR brachytherapy machines and 2 mould rooms. Some centers were found to treat patients without simulators or treatment planning system. Conclusion: A large deficiency exists for radiation oncological services in Nigeria. There are significant deficiencies in the availability of all components of radiation therapy in the analysed centers. Cognisance should be taken of the specific short falls in each centre to ensure that there is expansion of existing centers and creation of new centers especially in every geopolitical zone and major teaching hospitals in the country.

Gestational trophoblastic disease in Abuth Zaria, Nigeria: A 5-year review

Gestational trophoblastic diseases (GTD) includes a spectrum of diseases (tumor or tumor-like conditions) characterised by aberrant growth and development of the trophoblasts that may continue even beyond the end of pregnancy. It encompasses the benign trophoblastic disease (complete and partial moles), and the malignant trophoblastic diseases including the invasive mole (chorioadenoma destruens), choriocarcinoma, and Placental Site Trophoblastic Tumor (PSTT). This study was to determine the prevalence, risk factors, clinical presentation, diagnosis, treatment options and outcomes of GTD in Ahmadu Bello University Teaching Hospital (ABUTH) Zaria. A five-year retrospective study of patients with GTD managed at ABUTH, North-west Nigeria, from 1 st January 2008 to 31 st December, 2012 was undertaken. Data of all cases of GTD in the hospital over the 5 year period were obtained. The gynaecology ward and labour ward registers also provided information on the total number of gynaecological admissions and deliveries respectively. The data processing and analysis were carried out using the SPSS software version 16. The data obtained were expressed in percentages, means, and standard deviations. During the period of study there were 8,138 deliveries and 2,453 gynaecological admissions. There were 59 cases of GTD with 41 having choriocarcinoma, 18 molar pregnancies and no case of invasive mole or PSTT. Out of the 41 case folders retrieved, 23 were choriocarcinoma and 18 of molar pregnancies. The prevalence of GTD was 7.2 per 1000 deliveries (0.72% or 1 in 138 deliveries) and constituted 2.4% of gynaecological admissions. Hydatidiform mole (HM) occurred in 1 in 452 deliveries and choriocarcinoma occurred in 1 in 198 deliveries. Ages ranged from 19-49 years with mean of 32.5+ 5.0 years. Most (66.7%) cases of HM were 19-29years while 60.9% of choriocarcinoma cases were 30-39years. Majority of cases were multiparous. The antecedent events predating choriocarcinoma were Hydatidiform mole (31.7%), abortions (29.3%) and 2.4% followed term pregnancy. History of amenorrhea was present in all cases while vaginal bleeding occurred in 97.6%, pallor (87.8%), hyperemesis gravidarum (48.8%) and 4.9% came in shock. Consequently, common complications reported were haemorrhage (90.2%), anemia (87.8%) and shock (12.2%). Pregnancy test was positive in 90.2% of cases and serum beta hCG was done in 24.4% with more than half having a level >12,000miu/ml. All patients had pelvic ultrasound scan and snowstorm appearance occurred in 41% of benign GTD cases. Histology was used to confirm 56.1% cases of choriocarcinoma and 43.9% of molar gestation. Most (94.4%) of HM had suction evacuation while 95.6% of choriocarcinoma cases had chemotherapy, one case (2.4%) had Total Abdominal Hysterectomy. Contraception was used in 78% and common methods were male condom (41.5%) and 36.6% used combined oral contraceptive pills. Less than half (43.9%) had follow up for 6 months and 9.8% were seen for more than a year. Eight patients had subsequent pregnancies and there was one death in the series giving a case fatality of 2.4%. Gestational trophoblastic disease is a significant source of maternal morbidity with increased risk of mortality from complications if not detected early and treated promptly.

Sociodemographic and clinicopathologic characteristics of 249 elderly cancer patients seen at the Radiotherapy and Oncology Department, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Background: The rate of cancer incidence is expected to rise in the ageing population. The objective of this study is to evaluate the sociodemographic and clinicopathologic characteristics of elderly cancer patients as there is a paucity of data in this environment. Patients and Methods: Elderly cancer patients seen between 2006 and 2009 were studied retrospectively. The patients folders were reviewed for relevant clinical information using standardized structured pro forma. Data were analyzed and results were presented in a table. Results: A total of 249 patients were analyzed (mean age 67 years, M:F = 2:3). There is no formal education in 70.7% of the patients. Only 20.5% of the patients had history of alcohol ingestion and 14.1% smoke cigarette. Ten (4%) patients had family history of cancer and 1.2% was seropositive for HIV antibodies. The most common cancer in males was head and neck cancer (14.1%) followed by prostate cancer (10%). In the females, the most common cancer was cervical cancer (31.3%) followed by breast cancer (12.4%). Only 8.4% of the patients presented with early stage disease. Hypertension was the most common comorbidity seen in 35.3% of the patients followed by diabetes mellitus (7.6%). The surgery was done in 36.9% of the patients, while 63.5% of the patients had diverse chemotherapy and 42.2% had radiotherapy. Chemotherapy-induced morbidity and mortality were seen in 36.9% and 26.9% of the patients, respectively. Similarly, radiotherapy-induced morbidity and mortality were seen in 8.8% and 0.4% of the patients, respectively. Conclusion: More female elderly patients are seen. Cervical cancer and head and neck cancers are the most common cancers seen in elderly female and male patients, respectively. Most patients presented with advanced disease, and hypertension is the most common comorbidity. There should be a cautious use of chemotherapy in order to reduce mortality.

Age distribution, site of origin and HIV status of cases of gynaecological malignancies seen at a radiotherapy facility in Northern Nigeria

Background: Gynecological malignancies are very common in Northern Nigeria. Although cervical cancer has been classified as HIV-related malignancy, little information is available on the pattern of presentation of gynecological malignancies in HIV patients. The objective of this study was to analyze the age distribution, site of origin, stage, and HIV status of cases of gynecological malignancies seen at a radiotherapy facility in Northern Nigeria. Patients and Methods: Between January 2006 and December 2011, consecutive patients with histologically confirmed gynecological malignancies were studied retrospectively and evaluated with respect to age, site of tumor, histological type, stage of disease, and retroviral status. Patients′ folders were reviewed using a standardized structured proforma. Results were analyzed using Epi Info software 3.4.1, 2007 edition. Results: A total of 350 gynecological malignant cases were reviewed. The age range was 21-86 years, with a mean age of 49 years, a modal age group of 41-50 years, and a median age of 50 years. The commonest gynecological malignancy observed was cervical cancer (81.7%), followed by ovarian epithelial cancer (6%), endometrial cancer (4%), ovarian germ cell tumor (3.14%), vaginal cancer (2.3%), vulvar cancer (2.3%), and myometrial sarcoma (0.6%). In all, 85.1% patients had locally advanced disease, 9.4% had metastatic disease, and 5.4% had early stage disease at presentation. HIV seropositivity was 10.3%; however, 94.4% of those with HIV had cancer of the cervix. Conclusion: In this review, the peak modal age group for gynecological malignancies is the fifth decade of life. Cervical cancer is the commonest gynecological malignancy seen with preponderance of late stages of the disease at presentation. HIV seropositivity is highest among women with cervical cancer than among women with other cancers, as seen in the facility.

Clinicopathologic characterization of nasopharyngeal carcinoma seen in the radiotherapy and oncology department, ahmadu bello university teaching hospital, Zaria, Nigeria: 2006-2010

Aims and Objective: To evaluate the clinical and pathological characteristics of nasopharyngeal carcinoma (NPC) patients seen in the Radiotherapy and Oncology department, Ahmadu Bello University Teaching Hospital, Nigeria. Materials and Methods: Between January 2006 and December 2010, 45 patients with histologically confirmed NPC were seen and evaluated irrespective of age, co-morbidity and performance status. Patients′ folders were reviewed retrospectively with a structured pro forma. Data were analyzed using Epi Info software and results presented in simple tables. Results: A total of 45 patients had NPC accounting for 2%. The mean age was 42 years (range 15-75 years). The sex ratio was M:F = 2.2:1. 21 of the patients were from North-West geopolitical zone. Hausa-Fulani was the predominant ethnic group in 23 patients. At presentation, 41 had neck mass followed by nasal blockage in 34, cranial nerve deficits in 27 and epistaxis in 25 (55.6%) patients. The commonest cranial nerves affected were vestibulocochlear 17, followed by glossopharyngeal 14. Only 14 patients presented within 12 months of onset of symptoms with a range of 3-60 months. The commonest histologic type seen was WHO-2 (Non-keratinizing Squamous Cell Carcinoma) in 28 patients. Locally advanced disease (IVA and IVB) seen in 25 patients and metastatic disease (IVC) seen in 13 patients. The site of metastases was the bones seen in 6 patients followed by lungs in 5 patients. Only 2 patients were positive for HIV antibodies. 38 patients were treated with chemotherapy and 18 received radiation therapy. Conclusion: Nasopharyngeal cancer is commoner in males. Neck mass with nasal and auditory symptoms were the commonest symptoms. More than half of the patients had cranial nerve deficits at presentation. WHO-2 is the commonest histology and locally advanced and metastatic disease is the commonest stage at presentation.

The burden of gynecological cancer management in Northern Nigeria

Background: Carcinoma of the Cervix is one of the gynecologic cancers. Gynecological cancer is a scourge in the developing nations because of the burden of cervical cancer. Carcinoma of the cervix is the leading cause of cancer death in women. The costs of treatment of cancers generally are very high and this has made care very difficult in the developing nations. The question therefore is who bears the cost and whose responsibilities? Aims and Objective: To study the economic burden of cancers on the patient, and how they source for these funds. To determine how the lack of funds or otherwise has affected their care. To assess their perception of who should bear the cost of this care. Methodology: It is a prospective study of all consecutive patients that attended the Gynecologic clinic of our unit between 2nd January 2010 and 30th June 2010. Data were analyzed using Excel statistical package. Result: A total of 93 patients were interviewed. A majority of 70 (76%) of the patients had Carcinoma of the cervix. The mean age of there husbands was 58 years. Most of them were either farmers (21%) or retired civil/public servants (15%) and earn between 700 - 1700 dollars per year. A large group of the patients were full time House wives (48%), while Petty trading and farming account for 13.3% each. The women earn less than 500 dollars per year. Only 50% received assistance, from family members (35.8%) or relatives (29.6%). More than 50% of them have spent between 1000 - 3000 dollars for their health bills. It was sad to note that 40% of them have no hope of help/assistance from anywhere. A majority of 83.3% believe that the government should come to their aids. Conclusion: In the developing nations, poverty still remains major problem, where people still earn less than a dollar per day. In essence prevention is paramount; otherwise most of our women who escaped maternal mortality may end up being a victim of cancer death.

Tuberculosis of the Female Breast and Reproductive Organs: A DiagnosticDilemma

Background: Tuberculosis is prevalent in developing countries and extra-pulmonary involvement is now a frequent manifestation. However, involvement of the breast and reproductive organs in females is a cause of diagnostic confusion due to the non- specific nature of presenting symptoms which may simulate malignant disease processes. Materials and methods: All females with histological confirmation of tuberculosis involving the breast and reproductive organs were analyzed over a 16 year period. Tissue biopsies were fixed in formalin, processed in paraffin and stained with haematoxylin & eosin and Ziehl Neelsen stain to identify the acid fast bacilli of mycobacterium tuberculosis. Results: 28 females are presented and their ages ranged from 14 to 52 years with a mean age of 29.3. Presenting symptoms were varied and included abdominal/pelvic pain, abdominal swelling, post coital bleeding, vaginal bleeding and discharge, amenorrhoea and infertility while four females presented with breast mass and pain. Duration of symptoms was from one month to 5 years. Clinical diagnosis included dermoid cyst, tubo-ovarian abscess, leaking ectopic gestation, malignant ovarian tumour, fibroadenoma and breast cancer. Eighteen of the females had laparotomy, four had endometrial curettage, another four had excision biopsy/lumpectomy and two had cervical punch biopsy. Only the four females with breast lesions had fine needle aspiration biopsy prior to tissue biopsy. Also, one female was HIV positive and on anti-retroviral drugs. Microscopy of tissue biopsies from the breast, ovary, fallopian tubes, endometrium and cervix revealed granulomata, multinucleated langhan type giant cells and extensive caesation. Conclusion: Tuberculosis may mimic malignant lesions of the breast, ovary and cervix due to the absence of specific diagnostic symptoms and should be a differential diagnosis in breast and gynaecological diseases in reproductive age females. In resource limited setting, early diagnosis by fine needle aspiration technique and tissue histology may reduce attendant morbidity, irreversible sterility and also prevent unnecessary surgery in patients.

Cancer pain and management: Providers' perspective in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Background: Pain is a frequent disturbing symptom of cancer, the prevalence and severity of which depend on the primary tumor, its metastatic sites, and the disease stage. The place of pain management in cancer patients cannot be over emphasized. Proper management results in improved quality of life. Aims: To assess providers′ attitude and practice toward cancer pain management in Ahmadu Bello University (ABU) Teaching Hospital, Zaria, Nigeria. Materials and Methods: This was a cross-sectional descriptive pilot study on provider perspectives on pain management in cancer patients. A structured self-administered questionnaire was completed by 79 medical practitioners of various specialties and ranks. Results: Seventy-nine clinicians were recruited for the study. The majority of the respondents, 36 (46%), believe that pain was the commonest symptom in cancer patients. Most, 61 (78%), of the doctors assessed pain using subjective methods and only 30 (29%) of the respondents were conversant with other treatment options for pain. Fifty (64.3%) use analgesia, and their choices were guided mainly by the response of the patients. Forty-eight (61.5%) of those who admit to the use of analgesia, were actually limited by the side effects of the drugs. More than half (57.6%) believed that pain management in our settings is suboptimal, and the commonest limitation to optimal pain management in our settings was availability and affordability of drugs. Conclusion: Professional education needs to focus on the proper assessment of pain, the management of side effects of analgesics, and the use of adjuvant therapies for pain. A better understanding of the pharmacology of opioid analgesics is also needed.