Adeyinka G. Falusi

Population Differences in Breast Cancer: Survey in Indigenous African Women Reveals Over-Representation of Triple-Negative Breast Cancer

PURPOSE Compared with white women, black women experience a disproportionate burden of aggressive breast cancer for reasons that remain unknown and understudied. In the first study of its kind, we determined the distribution of molecular subtypes of invasive breast tumors in indigenous black women in West Africa. PATIENTS AND METHODS The study comprised 507 patients diagnosed with breast cancer between 1996 and 2007 at six geographic regions in Nigeria and Senegal. Formalin-fixed and paraffin-embedded sections were constructed into tissue microarrays and immunostained with 15 antibodies. Five molecular subtypes were determined, and hierarchical cluster analysis was conducted to explore subgroups for unclassified cases. RESULTS The mean (+/- standard deviation) age of 378 patients in the first cohort was 44.8 +/- 11.8 years, with the majority of women presenting with large (4.4 +/- 2.0 cm) high-grade tumors (83%) in advanced stages (72% node positive). The proportions of estrogen receptor (ER) -positive, progesterone receptor-positive, and human epidermal growth factor receptor 2 (HER2) -positive tumors were 24%, 20%, and 17%, respectively. Triple negativity for these markers was predominant, including basal-like (27%) and unclassified subtype (28%). Other subtypes were luminal A (27%), luminal B (2%), and HER2 positive/ER negative (15%). The findings were replicated in the second cohort of 129 patients. The unclassified cases could be grouped into a bad prognosis branch, with expression of vascular endothelial growth factor, B-cell lymphoma extra-large protein, and Cyclin E, and a good prognosis branch, with expression of B-cell lymphoma protein 2 and Cyclin D1. CONCLUSION These findings underscore the urgent need for research into the etiology and treatment of the aggressive molecular subtypes that disproportionately affect young women in the African diaspora.

Red cell glucose-6-phosphate dehydrogenase status and pyruvate kinase activity in a Nigerian population

Summary Glucose‐6‐phosphate dehydrogenase A− (G6PD A−) deficiency is a common enzymopathy in Africa that sporadically leads to manifest haemolytic anaemia. It is not exactly known how far the haematological status of individuals with either homozygous or heterozygous G6PD A− deficiency differs from that of individuals with normal G6PD activity. In a field study in Nigeria, we determined G6PD gene variants, the corresponding G6PD and pyruvate kinase (PK) activities, and basic haematological parameters in clinically healthy individuals, who were, in part, asymptomatically infected by malaria parasites. Red blood cell counts and haemoglobin levels were lower in G6PD A− deficient than in G6PD normal subjects. PK activities were higher in G6PD deficients, indicating a younger red cell population in these individuals. These findings suggest that G6PD A− deficiency is accompanied by chronic subclinical haemolysis. As a consequence, the reduced life span of red cells leads to an impaired diagnosis of G6PD heterozygosity when applying routine biochemical methods.

Impact of subpatent multi-species and multi-clonal plasmodial infections on anaemia in children from Nigeria

Childhood anaemia in sub-Saharan Africa is often caused by Plasmodium falciparum malaria. The influence of subpatent, multi-species and polyclonal infections with malaria parasites on haematological parameters was assessed in 1996/97 in clinically healthy children in Nigeria. Of the 228 children studied, 64% were anaemic by the WHO age-dependent criteria. A univariate analysis of risk factors indicated that the prevalence of anaemia was dependent on the number of Plasmodium species detected by species-specific PCR (P < 0.0001). Furthermore, the prevalence of anaemia increased gradually with the complexity (P < 0.003) as well as with the extent of P. falciparum parasitaemia (P < 0.0001). A logistic regression analysis revealed that individuals with an enlarged spleen tended to be anaemic. The number of Plasmodium species by which an individual was infected was independently associated with anaemia (P < 0.03). ANOVA revealed that the age-corrected values for haemoglobin (Hb) and red blood cells (RBCs) were mainly influenced by the occurrence of mixed infections. Haematological parameters were also influenced by the number of different P. falciparum clones by which an individual was infected. Hb levels and RBC counts were further diminished by additional infections with P. malariae and/or P. ovale. However, the effect of multi-species infections on haematological parameters exceeded that of multi-clonal infections.

High prevalence of BRCA1 and BRCA2 mutations in unselected Nigerian breast cancer patients

Inherited mutations in the BRCA1 and BRCA2 genes are the strongest genetic predictors of breast cancer and are the primary causes of familial breast/ovarian cancer syndrome. The frequency, spectrum and penetrance of mutant BRCA1/BRCA2 alleles have been determined for several populations, but little information is available for populations of African ancestry, who suffer a disproportionate burden of early onset breast cancer. We have performed complete sequence analysis of all BRCA1 and BRCA2 exons and intron–exon boundaries for 434 Nigerian breast cancer patients from the University College Hospital in Ibadan, Nigeria. In contrast to previous suggestions that BRCA1/BRCA2 mutation frequencies are low or undetectable in African American populations, we find that Nigerian breast cancer patients have an exceptionally high frequency of BRCA1 and BRCA2 mutations (7.1 and 3.9%, respectively). Sixteen different BRCA1 mutations were detected, seven of which have never been reported previously, while thirteen different BRCA2 mutations were seen, six of which were previously unreported. Thus, our data support enrichment for genetic risk factors in this relatively young cohort. To improve breast cancer outcomes, we suggest that family‐based models of risk assessment and genetic counseling coupled with interventions to reduce breast cancer risk should be broadly disseminated in Nigeria and other underserved and understudied populations.

The contribution of alpha+-thalassaemia to anaemia in a Nigerian population exposed to intense malaria transmission.

Summary The proportion to which α‐thalassaemia contributes to anaemia in Africa is not well recognized. In an area of intense malaria transmission in South‐West Nigeria, haematological parameters of α‐thalassaemia were examined in 494 children and 119 adults. The –α3.7 type of α+‐thalassaemia was observed at a gene frequency of 0.27. Nine and 36.5% of individuals were homozygous and heterozygous, respectively. P.falciparum‐infection was present in 78% of children and in 39% of adults. The α‐globin genotypes did not correlate with the prevalence of P. falciparum‐infection. α+‐thalassaemic individuals had significantly lower mean values of haemoglobin, mean corpuscular volume, and mean corpuscular haemoglobin than non‐thalassaemic subjects. Anaemia was seen in 54.7% of children with a normal α‐globin genotype, in 69.9% of heterozygous (odds ratio: 1.99, 95% confidence interval: 1.32–3.00, P= 0.001), and in 88.4% of homozygous α+‐thalassaemic children (odds ratio: 7.72, 95% confidence interval: 2.85–20.90, P= 0.0001). The findings show that α+‐thalassaemia contributes essentially to mild anaemia, microcytosis, and hypochromia in Nigeria.

Concentrations of Chloroquine and Malaria Parasites in Blood in Nigerian Children

ABSTRACT Consumption of chloroquine (CQ) and subtherapeutic drug levels in blood are considered to be widespread in areas where malaria is endemic. A cross-sectional study was performed with 405 Nigerian children to assess factors associated with the presence of CQ in blood and to examine correlations of drug levels with malaria parasite species and densities. Infections with Plasmodium species and parasite densities were determined by microscopy and PCR assays. Whole-blood CQ concentrations were measured by high-performance liquid chromatography. Plasmodium falciparum, P. malariae, and P. ovale were observed in 80, 16, and 9% of the children, respectively, and CQ was detected in 52% of the children. CQ concentrations were >17 and <100 nmol/liter in 25% of the children, 100 to 499 nmol/liter in 14% of the children, and ≥500 nmol/liter in 13% of the children. Young age, attendance at health posts, and absence of parasitemia were factors independently associated with CQ in blood. With increasing concentrations of CQ, the prevalence of P. falciparum infection and parasite densities decreased. However, at concentrations corresponding to those usually attained during regular prophylaxis (≥500 nmol/liter), 62% of children were still harboring P. falciparum parasites. In contrast, no infection with P. malariae and only one infection with P. ovale were observed in children with CQ concentrations of ≥100 nmol/liter. These data show the high prevalence of subcurative CQ concentrations in Nigerian children and confirm the considerable degree of CQ resistance in that country. Subtherapeutic drug levels are likely to further promote CQ resistance and may impair the development and maintenance of premunition in areas where malaria is endemic.

Plasmodium falciparum Infection: Influence on Hemoglobin Levels in α-Thalassemia and Microcytosis

Plasmodium falciparum malaria, alpha-thalassemia, and anemia are frequent in African children. In 494 nonhospitalized Nigerian children, P. falciparum infection rates, alpha-globin genotypes, and hematologic parameters were determined. P. falciparum infection was observed in 78% of the children. The gene frequency of alpha-thalassemia was 0.28. Infection rates and parasitemia were similar for the 3 alpha-globin genotypes. In contrast to nonthalassemic and heterozygous persons, infection in children with homozygous alpha-thalassemia did not influence hemoglobin values. Because microcytosis and anemia are common features of alpha-thalassemia, their significance in P. falciparum infection was examined. Microcytosis was significantly associated with protection from hemoglobin decrease due to P. falciparum. Moreover, the rate of infection was lower in microcytic than in normocytic anemia.

Genome-wide association studies in women of African ancestry identified 3q26.21 as a novel susceptibility locus for oestrogen receptor negative breast cancer.

Multiple breast cancer loci have been identified in previous genome-wide association studies, but they were mainly conducted in populations of European ancestry. Women of African ancestry are more likely to have young-onset and oestrogen receptor (ER) negative breast cancer for reasons that are unknown and understudied. To identify genetic risk factors for breast cancer in women of African descent, we conducted a meta-analysis of two genome-wide association studies of breast cancer; one study consists of 1,657 cases and 2,029 controls genotyped with Illumina’s HumanOmni2.5 BeadChip and the other study included 3,016 cases and 2,745 controls genotyped using Illumina Human1M-Duo BeadChip. The top 18,376 single nucleotide polymorphisms (SNP) from the meta-analysis were replicated in the third study that consists of 1,984 African Americans cases and 2,939 controls. We found that SNP rs13074711, 26.5 Kb upstream of TNFSF10 at 3q26.21, was significantly associated with risk of oestrogen receptor (ER)-negative breast cancer (odds ratio [OR]=1.29, 95% CI: 1.18-1.40; P = 1.8 × 10 − 8). Functional annotations suggest that the TNFSF10 gene may be involved in breast cancer aetiology, but further functional experiments are needed. In addition, we confirmed SNP rs10069690 was the best indicator for ER-negative breast cancer at 5p15.33 (OR = 1.30; P = 2.4 × 10 − 10) and identified rs12998806 as the best indicator for ER-positive breast cancer at 2q35 (OR = 1.34; P = 2.2 × 10 − 8) for women of African ancestry. These findings demonstrated additional susceptibility alleles for breast cancer can be revealed in diverse populations and have important public health implications in building race/ethnicity-specific risk prediction model for breast cancer.

Fine-mapping of Breast Cancer Genome-wide Association Studies Loci in Women of African Ancestry Identifies Novel Susceptibility Markers

Numerous single nucleotide polymorphisms (SNPs) associated with breast cancer susceptibility have been identified by genome-wide association studies (GWAS). However, these SNPs were primarily discovered and validated in women of European and Asian ancestry. Because linkage disequilibrium is ancestry-dependent and heterogeneous among racial/ethnic populations, we evaluated common genetic variants at 22 GWAS-identified breast cancer susceptibility loci in a pooled sample of 1502 breast cancer cases and 1378 controls of African ancestry. None of the 22 GWAS index SNPs could be validated, challenging the direct generalizability of breast cancer risk variants identified in Caucasians or Asians to other populations. Novel breast cancer risk variants for women of African ancestry were identified in regions including 5p12 (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.11-1.76; P = 0.004), 5q11.2 (OR = 1.22, 95% CI = 1.09-1.36; P = 0.00053) and 10p15.1 (OR = 1.22, 95% CI = 1.08-1.38; P = 0.0015). We also found positive association signals in three regions (6q25.1, 10q26.13 and 16q12.1-q12.2) previously confirmed by fine mapping in women of African ancestry. In addition, polygenic model indicated that eight best markers in this study, compared with 22 GWAS-identified SNPs, could better predict breast cancer risk in women of African ancestry (per-allele OR = 1.21, 95% CI = 1.16-1.27; P = 9.7 × 10(-16)). Our results demonstrate that fine mapping is a powerful approach to better characterize the breast cancer risk alleles in diverse populations. Future studies and new GWAS in women of African ancestry hold promise to discover additional variants for breast cancer susceptibility with clinical implications throughout the African diaspora.

Evidence for a reduced effect of chloroquine against Plasmodium falciparum in alpha-thalassaemic children.

Alpha‐thalassaemia is common in malaria‐endemic regions and is considered to confer protection from clinical disease due to infection with Plasmodium falciparum. In vitro, sensitivity to chloroquine (CQ) of P. falciparum infecting alpha‐thalassaemic erythrocytes is reduced. We examined, in a cross‐sectional study of 405 Nigerian children, associations between alpha‐globin genotypes, blood concentrations of CQ, and P. falciparum parasitaemia. Of the children, 44% were alpha+‐thalassaemic (36.8% heterozygous, 7.6% homozygous). CQ in blood and P. falciparum‐infection were observed in 52 and 80%, respectively. CQ was more frequently found in homozygous alpha+‐thalassaemic (71%) than in non‐thalassaemic children (50%; odds ratio, 2.42; 95% confidence interval, 1.01–5.8). Among children with CQ in blood and despite similar drug concentrations, alpha+‐thalassaemic individuals had fewer infections below the threshold of microscopy which were detectable by PCR only, and they had a higher prevalence of elevated parasitaemia than non‐thalassaemic children. No such differences were discernible among drug‐free children. CQ displays a lowered efficacy in the suppression of P. falciparum parasitaemia in alpha+‐thalassaemic children; hence protection against malaria due to alpha+‐thalassaemia may be obscured in areas of intense CQ usage. Moreover, alpha+‐thalassaemia may contribute to the expansion of CQ resistance.