Atara Ntekim

Optimal management of cervical cancer in HIV‐positive patients: a systematic review

The clinical management of cervical cancer in HIV‐positive patients has challenges mainly due to the concerns on immune status. At present, their mode of management is similar to HIV‐seronegative patients involving the use of chemotherapy and radiotherapy concurrently as indicated. HIV infection, cancer, radiotherapy, and chemotherapy lower immunity through reduction in CD4 cell counts. At present there are no treatment guidelines for HIV‐positive patients. This study was done to systematically review the literature on cervical cancer management in HIV‐positive patients and treatment outcomes. A systematic literature search was done in the major databases to identify studies on the management of HIV‐positive patients with cervical cancer. Identified studies were assessed for eligibility and inclusion in the review following the guidelines of The Cochrane Handbook for Systematic Reviews and CRDs (Centre for Reviews and Dissemination) guidance for undertaking reviews in health care. Eight eligible studies were identified from the literature. Three of them were prospective while five were retrospective studies. Notably, the average age at diagnosis of cervical cancer in HIV‐positive patients was a decade lower than in seronegative patients. There was no difference in distribution of stages of disease at presentation between HIV‐positive and negative patients. Mild acute toxicity (Grades 1 and 2) was higher in HIV‐positive patients than in HIV‐negative patients in hematopoietic system. In the grades 3 and 4 reactions, anemia was reported in 4% versus 2% while gastrointestinal reactions were reported in 5% versus 2% respectively. In general, patients who were started early on HAART had higher rates of treatment completion. The study supports the suggestion that HAART should be commenced early at cervical cancer diagnosis in HIV‐positive patients diagnosed with cervical cancer to ensure less toxicity and better treatment compliance.

High Dose Rate Brachytherapy in the Treatment of Cervical Cancer: Preliminary Experience with Cobalt 60 Radionuclide Source—A Prospective Study

Iridium-192 is widely used for high-dose rate brachytherapy. Co-60 source with similar geometric and dosimetric properties are now available. It has a longer half life but higher energy than Iridium-192. If Co-60 source can produce similar results, it will be more economical for low resource settings. Objective To evaluate the acute gastrointestinal and genitourinary toxicity associated with Co-60 source in the brachytherapy of cervical cancer. Methods Seventy patients with cervical cancer received 45 Gy in 22 fractions of pelvic external beam radiotherapy and 19.5 Gy in 3 fractions of HDR with Co-60 source using tandem and ring applicators with 6 courses of cisplatin 50 mg/m2 and 5 fluorouracil 1000 mg/m2 every 3 weeks Toxicity was scored using NCI-CTC version 4.0. Results The median total BED (Gy10) for tumor was 86.2 (84.4–88.8) while that for rectum (BED Gy3) was 124.4 (120–133). Two patients (3%) had grade 3 gastrointestinal toxicity while all others had ≤grade 2 toxicity and this is comparable with previous results. Conclusion Co-60 as HDR brachytherapy source is tolerable and is economical for low resource settings.

Barriers to radiotherapy access at the University College Hospital in Ibadan, Nigeria

Introduction Nigeria has the biggest gap between radiotherapy availability and need, with one machine per 19.4 million people, compared to one machine per 250,000 people in high-income countries. This study aims to identify its patient-level barriers to radiotherapy access. Material and methods This was a cross sectional study consisting of patient questionnaires (n = 50) conducted in January 2016 to assess patient demographics, types of cancers seen, barriers to receiving radiotherapy, health beliefs and practices, and factors leading to treatment delay. Results Eighty percent of patients could not afford radiotherapy without financial assistance and only 6% of the patients had federal insurance, which did not cover radiotherapy services. Of the patients who had completed radiotherapy treatment, 91.3% had experienced treatment delay or often cancellation due to healthcare worker strike, power failure, machine breakdown, or prolonged wait time. The timeliness of a patient’s radiotherapy care correlated with their employment status and distance from radiotherapy center (p < 0.05). Conclusions Barriers to care at a radiotherapy center in a low- and middle-income country (LMIC) have previously not been well characterized. These findings can be used to inform efforts to expand the availability of radiotherapy and improve current treatment capacity in Nigeria and in other LMICs.

Comparison of doses to the rectum derived from treatment planning system with in-vivo dose values in vaginal vault brachytherapy using cylinder applicators

PURPOSE In-vivo measurements to determine doses to organs-at-risk can be an essential part of brachytherapy quality assurance (QA). This study compares calculated doses to the rectum with measured dose values as a means of QA in vaginal vault brachytherapy using cylinder applicators. MATERIAL AND METHODS At the Department of Radiotherapy, University College Hospital (UCH), Ibadan, Nigeria, intracavitary brachytherapy (ICBT) was delivered by a GyneSource high-dose-rate (HDR) unit with (60)Co. Standard 2D treatment plans were created with HDR basic 2.6 software for prescription doses 5-7 Gy at points 5 mm away from the posterior surface of vaginal cylinder applicators (20, 25, and 30 mm diameters). The LiF:Mg, Ti thermoluminescent dosimeter rods (1 x 6 mm) were irradiated to a dose of 7 Gy on Theratron (60)Co machine for calibration purpose prior to clinical use. Measurements in each of 34 insertions involving fourteen patients were performed with 5 TLD-100 rods placed along a re-usable rectal marker positioned in the rectum. The dosimeters were read in Harshaw 3500 TLD reader and compared with doses derived from the treatment planning system (TPS) at 1 cm away from the dose prescription points. RESULTS The mean calculated and measured doses ranged from 2.1-3.8 Gy and 1.2-5.6 Gy with averages of 3.0 ± 0.5 Gy and 3.1 ± 1.1 Gy, respectively, for treatment lengths 2-8 cm along the cylinder-applicators. The mean values correspond to 48.9% and 50.8% of the prescribed doses, respectively. The deviations of the mean in-vivo doses from the TPS values ranged from -1.9 to 2.1 Gy with a p-value of 0.427. CONCLUSIONS This study was part of efforts to verify rectal dose obtained from the TPS during vaginal vault brachytherapy. There was no significant difference in the dose to the rectum from the two methods of measurements.

High-dose-rate brachytherapy in the treatment of uterine cervical cancer using cobalt-60 radionuclide source: Three years treatment outcome

Background: The Iridium-192 radionuclide source is commonly used for high-dose-rate brachytherapy of uterine cervical cancer. The cobalt-60 radionuclide source, which is more economical, is now available with dosimetric properties similar to iridium-192. Objective: To evaluate late gastrointestinal and genitourinary complications, and also the survival pattern in cervical cancer patients treated with cobalt-60 high-dose-rate brachytherapy, three years after treatment. Materials and Methods: Seventy patients, who were treated with high-dose-rate brachytherapy using the cobalt-60 radionuclide source were followed up for three years. All the patients received 45 Gy of external beam radiotherapy in 22 daily fractions, with 19.5 Gy from high-dose-rate brachytherapy, in three fractions, over three weeks, using the cobalt-60 radio nuclide source. The patients also received concurrent cisplatin-based chemotherapy. Late complications were assessed every three months, using Radiation Therapy Oncology Group (RTOG) late toxicity criteria. The pattern of disease control was also assessed. Results: Late complications in the bowel were, six (9%) grade 1, four (6%) grade 2, one (1%) grade 3, and one (1%) grade 4. The late complications affecting the bladder were 5 (7%) grade 1 and 1 (1%) grade 4. Twenty-eight patients (40%) were alive without disease, seven (10%) were alive with disease, seven (10%) died of persistent disease, four (6%) died of metastatic disease, while 24 (34%) were lost to follow-up. Conclusion: The late complications were similar to those reported for Iridium-192 as a source of high-dose brachytherapy. Cobalt-60 high-dose-rate brachytherapy is tolerable, effective, and economical for low resource settings.

Treatment outcome of patients with nasopharyngeal carcinoma in Nigeria: An institutional experience

Nasopharyngeal carcinoma occurs worldwide. The incidence varies according to geographical region, with the highest incidence recorded in Asian countries. In Nigeria, the incidence of nasopharyngeal carcinoma is increasing. Thus, current treatment outcomes must be evaluated to identify areas of possible improvement in the management of this disease. The present study aimed to evaluate the treatment outcome after 2 years in patients with nasopharyngeal carcinoma.

An analysis of dietary fiber and fecal fiber components including pH in rural Africans with colorectal cancer

Background/Aims Colorectal cancer (CRC) is now a major public health problem with heavy morbidity and mortality in rural Africans despite the lingering dietary fiber-rich foodstuffs consumption. Studies have shown that increased intake of dietary fiber which contribute to low fecal pH and also influences the activity of intestinal microbiota, is associated with a lowered risk for CRC. However, whether or not the apparent high dietary fiber consumption by Africans do not longer protects against CRC risk is unknown. This study evaluated dietary fiber intake, fecal fiber components and pH levels in CRC patients. Methods Thirty-five subjects (CRC=21, control=14), mean age 45 years were recruited for the study. A truncated food frequency questionnaire and modified Goering and Van Soest procedures were used. Results We found that all subjects consumed variety of dietary fiber-rich foodstuffs. There is slight preponderance in consumption of dietary fiber by the control group than the CRC patients. We also found a significant difference in the mean fecal neutral detergent fiber, acid detergent fiber, hemicellulose, cellulose and lignin contents from the CRC patients compared to the controls (P<0.05). The CRC patients had significantly more fecal pH level than the matched apparently healthy controls (P=0.017). Conclusions The identified differences in the fecal fiber components and stool pH levels between the 2 groups may relate to CRC incidence and mortality in rural Africans. There is crucial need for more hypothesis-driven research with adequate funding on the cumulative preventive role of dietary fiber-rich foodstuffs against colorectal cancer in rural Africans “today.”

Prevalence of Malnutrition among Cancer Patients in a Nigerian Institution

Background : Cancer is a major health problem. Successful management includes adequate supportive care. Nutritional problems are common among cancer patients and these are not routinely addressed by oncologists during oncology care leading to suboptimal outcome even in developed countries. In Nigeria and other low and medium income countries, the situation is worse as nutritional screening and assessment of cancer patients are not routinely carried out. Objectives : To determine the proportion of cancer patients at risk of malnutrition and compare convergence of risk assessment using SGA and MUST tools. Methods : This was a prospective study carried out among cancer patients who presented for cancer care in the Department of Radiation Oncology, University College Hospital Ibadan, Nigeria. Nutritional assessment tools which included Malnutrition Universal Scoring Tool (MUST) and Subjective Global Assessment (SGA) were used to assess the nutritional status of the participants. Results : A total of 89 patients aged between 18 and 85 years participated in the study. The number of males were 13 (15%) while females were 76(85%). In our study 54 (60.8%) of our patients were at risk of malnutrition using the malnutrition universal scoring tool (MUST) scale while 53(60%) were malnourished using the subjective global assessment (SGA) scale. The reliability for the classifications using the MUST and SGA scales was positive (moderate) [Kappa = 0.584 (p<0.0005), 95% CI (0.410, 0.758)]. Conclusion : There is a high proportion of clinical malnutrition among cancer patients in the study population. According to this study, there was similarity between the classifications of nutritional risk, using the MUST and SGA tools.

Abstract 4918: Is Livin a protagonist of mucinous adenocarcinoma histology in colorectal cancer

The mechanism of cancer resistance to chemotherapy regimen remains uncertain. Colorectal mucinous adenocarcinoma is one of the distinct histological subtypes of the disease implicated in chemotherapeutic resistance associated with nodal and peritoneal metastases and worse disease-free survival as an index of poor prognosis. One of the important acquired capabilities used by the cancer cells to resist anticancer therapies is evasion of apoptosis possibly via inhibitor of apoptosis proteins for which Livin is one. This protein contains baculoviral IAP repeat domains in addition to a RING finger, a protein-protein motif important for binding and inhibition of active caspases that interfere with intrinsic and/or extrinsic pathway and the ensuing blockade of apoptosis. Thus, understanding the molecular events on how cancer cells of mucinous histology evade apoptotic death may provide a novel paradigm for a molecular targeted therapy in the management of colorectal mucinous adenocarcinoma. In this study, the expression pattern and prognostic value of IAP family protein, Livin, in colorectal cancer patients with mucinous histology pre and post-chemotherapy regimen was investigated. Tissue sections from advanced stage colorectal cancer patients who were treated or untreated with neo-adjuvant FOLFOX chemotherapy before curative resection were included in this study. The tissue sections were grouped according to colorectal adenocarcinomas showing mucinous histology and non-mucinous component. Histological study including Haematoxylin and Eosin, and immunohistochemistry for Anti-Livin and DNA mismatched repair proteins were carried out. Immunofluorescence study was performed to clarify the expression pattern of the protein using Anti-Livin antibody. Protein expression quantification study was also used. Results show significant cytoplasmic localisation and expression of Livin protein in the colorectal cancer cells. The Livin protein expression was found to be increased by more than a one-fold post-chemotherapy treatment when compared with pre-chemotherapy treated patients with mucinous histology of colorectal cancer. Younger patients were found to have a greater probability of colorectal mucinous adenocarcinoma diagnosis and worse prognosis. Our findings show that Livin-induced inhibition of apoptosis activity can be a target for novel approaches to treatment and prevention of chemotherapy associated drug resistance in mucinous histology colorectal cancer since Livin overexpression has been associated with metastases and worse disease-free survival. More study is needed Citation Format: Mohammed Faruk, Abdulmumini Hassan Rafindadi, Sani Ibrahim, Surajo Mohammed Aminu, Surajo Mohammed Aminu, Ahmed Adamu, Ahmed Adamu, Yawale Iliyasu, Adamu Abdullahi, Mohammed Sani Shehu, Abdullahi Mohammed, John Idoko, Abdullahi Jibril Randawa, Abdullahi Jibril Randawa, Atara Ntekim, Saad Aliyu Ahmed, Aishatu Suleiman Maude, Almustapha Aliyu Liman, Abubakar Sani, Khalid Zahir Shah, Yahaya Ukwenya, Yahaya Ukwenya, Cheh Augustine Awasum, Kasimu Umar Adoke, James Olowu Enemari, James Olowu Enemari, James Olowu Enemari, Andrew Jonathan Nok. Is Livin a protagonist of mucinous adenocarcinoma histology in colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4918. doi:10.1158/1538-7445.AM2017-4918