Joel Yarney

Breast cancer in Sub-Saharan Africa: opportunities for prevention

Although breast cancer is a growing health problem in sub-Saharan Africa, reasons for its increased occurrence remain unclear. We reviewed the published literature to determine the magnitude of the increase in breast cancer, associated risk factors (including for breast cancer subtypes), and ways to reduce incidence and mortality. Some of the increased breast cancer occurrence likely reflects that women are living longer and adopting lifestyles that favor higher incidence rates. However, a greater proportion of breast cancers occur among premenopausal women as compared to elsewhere, which may reflect unique risk factors. Breast cancers diagnosed among African women reportedly include a disproportionate number of poor prognosis tumors, including hormone receptor negative, triple negative, and core basal phenotype tumors. However, it is unclear how lack of standardized methods for tissue collection, fixation, and classification contribute to these rates. Given appropriate classifications, it will be of interest to compare rates with other populations and to identify risk factors that relate to specific tumor subtypes. This includes not only risk factors that have been recognized in other populations but also some that may play unique roles among African women, such as genetic factors, microbiomata, xenoestrogens, hair relaxers, and skin lighteners. With limited opportunities for effective treatment, a focus is needed on identifying etiologic factors that may be amenable to intervention. It will also be essential to understand reasons why women delay seeking care after the onset of symptoms and for there to be educational campaigns about the importance of early detection.

Characteristics of users and implications for the use of complementary and alternative medicine in Ghanaian cancer patients undergoing radiotherapy and chemotherapy: a cross- sectional study.

BackgroundThere is widespread use of Complementary and Alternative Medicine (CAM) in Ghana, driven by cultural consideration and paradigm to disease causation. Whether there is concurrent use of conventional medicine and CAM in cancer patients is unknown. This study investigates the prevalence, pattern and predictors of CAM use in cancer patients. Overlapping toxicity, sources of information, and whether users inform their doctor about CAM use is examined.MethodCross-sectional study using a questionnaire administered to cancer patients, who were receiving radiotherapy and or chemotherapy or had recently completed treatment at a single institution was used.ResultsNinety eight patients participated in the study with a mean age of 55.5 (18–89), made up of 51% females. Married individuals formed 56% of the respondents, whilst 49% had either secondary or tertiary education. Head and neck cancer patients were 15.3%, breast (21.4%), abdomen/pelvic cancers constituted (52%).Seventy seven (78.6%) patients received radiotherapy only, 16.3% received radiation and chemotherapy and 5.3% had chemotherapy only.Ninety five patients were diagnosed of cancer within the past 24 months,73.5% were CAM users as follows; massage(66.3%), herbal(59.2%), mega vitamins(55.1%), Chinese medicine(53.1%),and prayer(42.9%). Sixty eight percent were treated with curative intent. Overlapping toxicity was reported. Majority (83.3%) of users had not informed their doctor about CAM use.On univariate analysis, female (p=0.004) and palliative patients, p=0.032 were more likely to be CAM users. Multivariate analysis identified female (p<0.01), as significant for use, whilst head and neck site was significant for non use (p<0.028). Young, married and highly educated individuals are more likely to use CAM.Friends and Media are the main sources of information on CAM. There was increase in CAM use after the diagnosis of cancer mainly for Chinese Medicine and vitamins.ConclusionThere is high CAM usage among Cancer patients, comparable to use in the general population, there is concurrent use of CAM and conventional medicine with reported overlapping toxicity but without informing Oncologist about use. Women and palliative patients are more likely to use CAM. Doctor patient communication on herbal-radiotherapy and drug treatment interaction needs to be strengthened. Standardization and regulation of CAM use is paramount.

Hormone Receptor and HER-2 Expression in Breast Cancers Among Sub-Saharan African Women

To the Editor: Recent technological advances in immunology and molecular biology have broadened the options available for the diagnosis and treatment of estrogen receptor (ER)-positive breast cancer, thereby increasing survival when used in the adjuvant setting (1). Until recently, hormone receptor status of breast cancer was not determined in most parts of Sub-Saharan Africa because the technology was not available; patients were therefore placed blindly on tamoxifen. This practice was considered acceptable given our limitations and the minimum side effect profile of tamoxifen. With the availability of a wide variety of options in hormonal manipulation in the management of breast cancer, the need to determine the ER status of patients cannot be overemphasized. Human epidermal receptor type two (HER-2) is overexpressed in 20–25% of human breast cancer. HER-2 positive and ER-positive progesterone receptor (PgR)-negative(ER+ ⁄ PgR)) tumors are believed to be more aggressive (2,3). Data on ER and HER-2 expression were unavailable in Ghana, a Sub-Saharan African country until recently. We therefore conducted a study to determine the incidence of ER positivity and HER-2 expression in breast cancers in Ghana. We also determined if there was an association between age and ER expression and if ER+ ⁄ PgR+ breast cancers behaved differently from ER+ ⁄ PgR) tumors. Pathology report obtained from Medlab (which is registered in South Africa) of patients who had undergone modified radical mastectomy or lumpectomy with axillary node dissection indicating infiltrating ductal carcinoma in which hormone receptor studies with or without HER-2 status were reported was analyzed with respect to ER positivity, PgR positivity, HER-2 expression, as well as ER ⁄ PgR expression. Estrogen receptor and HER-2 status were determined by immunohistochemistry. Quick score was used in the analysis with a score of at least 3, accepted as positive (4). Regarding HER-2 status, a 3+ score was regarded as positive expression. Between February 2004 and 2007, out of 610 patients with a diagnosis of infiltrating ductal carcinoma of the breast referred to the Radiation Oncology Centre, Korle-bu Teaching Hospital in Accra, Ghana, only 74 patients with an age range of 28 to 82 years could be evaluated, out of whom 53 had reports on HER-2 status as well. Estrogen receptor positivity was found in 43.2% (32 patients) of tumors. The percentage of tumors expressing the PgR was 17.6%, while 19% were HER-2-positive (3+), the equivocal status of 2+ was seen in 8.6% of specimens. Majority of the women studied (51.3%) were less than 50 years [age distribution shown in (Table 1)]; being less than 50 years had no bearing on ER status, (p = 0.06) (Table 2). Breast cancer in African women has been shown to occur at a younger age and tend to be of a higher grade compared to Caucasians (5). The observed figure of 56.8% representing ERnegative tumors is lower than 61.9% reported by Newman et al. (6) among African-American women less than 40 years but higher than 37.9% reported by Elledge et al. (7) in all age groups. In both instances, the observed percentage of ER-negative patients (56.8%) is much higher than 44.1% and

Optimal radiotherapy utilisation rate in developing countries: An IAEA study

Optimal radiotherapy utilisation rate (RTU) is the proportion of all cancer cases that should receive radiotherapy. Optimal RTU was estimated for 9 Middle Income Countries as part of a larger IAEA project to better understand RTU and stage distribution.

Clinicopathologic features and determinants of Gleason score of prostate cancer in Ghanaian men

OBJECTIVE Prostate cancer is reported to be more aggressive in Blacks. We studied the clinicopathologic features of prostate cancer in Ghana, in order to determine the factors responsible for them and to find out if there is any relationship between them. METHOD Patients referred with a biopsy proven diagnosis of carcinoma of the prostate to the Cancer Center of Korle Bu Teaching Hospital, Accra, Ghana, from 2003 to 2007 were studied. Information with respect to age at diagnosis, presenting symptoms, initial PSA (iPSA), Gleason score, and disease extent were studied. Age was partitioned into 50-65 and >65 years, Gleason score into 2-6, 7, and 8-10, iPSA into 4-20 ng/ml and >20, and disease extent into T1, T2, vs. T3, T4, M1, and the relationship between them was determined. Various presenting symptoms were described. Known risk factors and screening in a context of high grade disease is discussed. RESULTS A total of 170 patients were studied. Mean age was 65.4 years. Majority of patients (73.7%) presented with an iPSA > 20 ng/ml, whilst 22 (14.1%) had PSA < 10 ng/ml. Gleason score ≥ 7 was found in 95 (56%) of patients. Asymptomatic patients constituted 24.0%, the rest had bone pain (22.6%), urinary (50.4%), and neurologic symptoms (3.0%).There was a statistically significant relationship between age and Gleason score (P = 0.049), PSA and Gleason score (P = 0.0001), and between extent of disease and Gleason score (P = 0.0002). High fat diet and low intake of fruits and vegetables are probable risk factors in Ghana. CONCLUSION Majority of patients present with symptomatic disease at a relatively older age. These patients tend to have high Gleason score partly attributable to advanced disease, age, PSA at the time of diagnosis, and race. Screening with PSA should be recommended and individualized in this group of patients in order to allow diagnosis of less aggressive disease until better screening tools are identified.

Metastatic Primary Leiomyosarcoma of the Pancreas to the Liver: Report of a Surgically Treated Case.

Leiomyosarcomas are malignant tumors of smooth cell origin [1]. They can thus arise from any organ with mesenchymal component especially the gastrointestinal, female genital tract, and soft tissues of the extremities. Leiomyosarcomas of gastrointestinal origin maybe more commonly found in the stomach, small intestine, and retroperitoneum [2]. Though rarely seen, leiomyosarcomas maybe of primary pancreatic origin (0.1–0.6% of pancreatic tumors). It occurs more commonly in the fifth decade and males are affected almost twice compared to females [3]. They are highly malignant with extreme metastatic potential [3]. Immunohistochemistry is required to demonstrate smooth muscle markers actin and desmin for diagnosis to be confirmed [1]. Prognosis is generally bad as most tumors are diagnosed when disease is metastatic. Tumors found early and which are amendable to surgery have had a better prognosis [3]. Metastatic disease presents 40–80% of the time and is heralded by short survival due to the aggressive nature of disease [4]. Only 37 cases excluding this one have been reported since 1951 with very few literature reviews. It is seldom mentioned in the oncology textbooks especially in regards to management. We present the 38th case of primary leiomyosarcoma of the pancreas presenting with liver metastases who is alive 24 months postpancreatic surgery. Patient signed for consent for the case to be published in a medical journal for educative purposes.

Cervical Cancer in the Greater Accra and Ashanti Regions of Ghana

Purpose Cervical cancer is a common cancer among women worldwide. An estimated 528,000 new cases and 266,000 deaths occurred in 2012. More than 85% of invasive cervical cancer cases occur in low- and middle-income countries. Cervical cancer ranks as the most common cancer among women in Ghana. We conducted a retrospective study to assess the descriptive epidemiology of cervical cancer in Ghana. We describe cervical cancer incidence and mortality rates for the regions served by two large hospitals in Ghana. Patients and Methods Information for women diagnosed with invasive cervical cancer between 2010 and 2013 was collected from the Komfo Anokye and Korle Bu Teaching Hospitals through review of medical, computer, and pathology records at the oncology units and the obstetrics and gynecology departments. Telephone interviews were also conducted with patients and relatives. Data were analyzed using summary statistics. Results A total of 1,725 women with cervical cancer were included in the study. Their ages ranged from 11 to 100 years (mean, 56.9 years). The histology of the primary tumor was the basis of diagnosis in 77.5% of women and a clinical diagnosis was made in 22.5% of women. For the 1,336 women for whom tumor grade was available, 34.3% were moderately differentiated tumors. Late stage at presentation was common. The incidence and mortality rates of cervical cancer increased with age up until the 75 to 79–year age group and began to decrease at older ages. The Greater Accra region had higher overall incidence and mortality rates than the Ashanti region. Conclusion Our study suggests that improvements in the application of preventive strategies could considerably reduce the burden of cervical cancer in Ghana and other low- and middle-income countries. The study provides important information to inform policy on cancer prevention and control in Ghana.

Design considerations for identifying breast cancer risk factors in a population-based study in Africa

Although breast cancer is becoming more prevalent in Africa, few epidemiologic studies have been undertaken and appropriate methodologic approaches remain uncertain. We therefore conducted a population‐based case–control study in Accra and Kumasi, Ghana, enrolling 2,202 women with lesions suspicious for breast cancer and 2,161 population controls. Biopsy tissue for cases prior to neoadjuvant therapy (if given), blood, saliva and fecal samples were sought for study subjects. Response rates, risk factor prevalences and odds ratios for established breast cancer risk factors were calculated. A total of 54.5% of the recruited cases were diagnosed with malignancies, 36.0% with benign conditions and 9.5% with indeterminate diagnoses. Response rates to interviews were 99.2% in cases and 91.9% in controls, with the vast majority of interviewed subjects providing saliva (97.9% in cases vs. 98.8% in controls) and blood (91.8% vs. 82.5%) samples; lower proportions (58.1% vs. 46.1%) provided fecal samples. While risk factor prevalences were unique as compared to women in other countries (e.g., less education, higher parity), cancer risk factors resembled patterns identified elsewhere (elevated risks associated with higher levels of education, familial histories of breast cancer, low parity and larger body sizes). Subjects with benign conditions were younger and exhibited higher socioeconomic profiles (e.g., higher education and lower parity) than those with malignancies, suggesting selective referral influences. While further defining breast cancer risk factors in Africa, this study showed that successful population‐based interdisciplinary studies of cancer in Africa are possible but require close attention to diagnostic referral biases and standardized and documented approaches for high‐quality data collection, including biospecimens.

Skin lighteners and hair relaxers as risk factors for breast cancer: results from the Ghana breast health study

Skin lighteners and hair relaxers, both common among women of African descent, have been suggested as possibly affecting breast cancer risk. In Accra and Kumasi, Ghana, we collected detailed information on usage patterns of both exposures among 1131 invasive breast cancer cases and 2106 population controls. Multivariate analyses estimated odds ratios (ORs) and 95% confidence intervals (CIs) after adjustment for breast cancer risk factors. Control usage was 25.8% for ever use of skin lighteners and 90.0% for use of hair relaxers for >1 year. The OR for skin lighteners was 1.10 (95% CI 0.93-1.32), with higher risks for former (1.21, 0.98-1.50) than current (0.96, 0.74-1.24) users. No significant dose-response relations were seen by duration, age at first use or frequency of use. In contrast, an OR of 1.58 (95% CI 1.15-2.18) was associated with use of hair relaxers, with higher risks for former (2.22, 1.56-3.16) than current (1.39, 1.00-1.93) users. Although numbers of burns were inconsistently related to risk, associations increased with duration of use, restricted to women who predominately used non-lye products (P for trend < 0.01). This was most pronounced among women with few children and those with smaller tumors, suggesting a possible role for other unmeasured lifestyle factors. This study does not implicate a substantial role for skin lighteners as breast cancer risk factors, but the findings regarding hair relaxers were less reassuring. The effects of skin lighteners and hair relaxers on breast cancer should continue to be monitored, especially given some biologic plausibility for their affecting risk.

Prostate brachytherapy in Ghana: our initial experience

Purpose This study presents the experience of a brachytherapy team in Ghana with a focus on technology transfer and outcome. The team was initially proctored by experienced physicians from Europe and South Africa. Material and methods A total of 90 consecutive patients underwent either brachytherapy alone or brachytherapy in combination with external beam radiotherapy for prostate carcinoma between July 2008 and February 2014 at Korle Bu Teaching Hospital, Accra, Ghana. Patients were classified as low-risk, intermediate, and high-risk according to the National Comprehensive Cancer Network (NCCN) criteria. All low-risk and some intermediate risk group patients were treated with seed implantation alone. Some intermediate and all high-risk group patients received brachytherapy combined with external beam radiotherapy. Results The median patient age was 64.0 years (range 46-78 years). The median follow-up was 58 months (range 18-74 months). Twelve patients experienced biochemical failure including one patient who had evidence of metastatic disease and died of prostate cancer. Freedom from biochemical failure rates for low, intermediate, and high-risk cases were 95.4%, 90.9%, and 70.8%, respectively. Clinical parameters predictive of biochemical outcome included: clinical stage, Gleason score, and risk group. Pre-treatment prostate specific antigen (PSA) was not a statistically significant predictor of biochemical failure. Sixty-nine patients (76.6%) experienced grade 1 urinary symptoms in the form of frequency, urgency, and poor stream. These symptoms were mostly self-limiting. Four patients needed catheterization for urinary retention (grade 2). One patient developed a recto urethral fistula (grade 3) following banding for hemorrhoids. Conclusions Our results compare favorably with those reported by other institutions with more extensive experience. We believe therefore that, interstitial permanent brachytherapy can be safely and effectively performed in a resource challenged environment if adequate training and proctoring is provided.