Seth Wiafe

Developing cancer control plans in Africa: examples from five countries

The creation and implementation of national cancer control plans is becoming increasingly necessary for countries in Africa, with the number of new cancer cases per year in the continent expected to reach up to 1·5 million by 2020. Examples from South Africa, Egypt, Nigeria, Ghana, and Rwanda describe the state of national cancer control plans and their implementation. Whereas in Rwanda the emphasis is on development of basic facilities needed for cancer care, in those countries with more developed economies, such as South Africa and Nigeria, the political will to fund national cancer control plans is limited, even though the plans exist and are otherwise well conceived. Improved awareness of the increasing burden of cancer and increased advocacy are needed to put pressure on governments to develop, fund, and implement national cancer control plans across the continent.

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.

Evaluation of the impact of a breast cancer awareness program in rural Ghana: A cross‐sectional survey

Community awareness is crucial to early detection of breast cancer in low‐ and middle‐income countries. In Ghana 60% of the cases are detected at late stages. Breast Care International (BCI) is a Ghanaian non‐governmental organization dedicated to raising breast cancer awareness. A cross‐sectional survey was designed to assess the impact of BCI program on knowledge, attitudes and practices (KAP) toward breast cancer among women from rural communities of Ghana. A total of 232 women were interviewed in June 2011 in the Ashanti region; of these 131 participants were from a community that received the BCI program in August 2010 (intervention group) and 101 from another community that received the program post‐survey (referent group). Data analysis was performed using Epi‐Info version 3.5.3. Knowledge about breast cancer among participants who received the program was better than among those who did not. Only 53.5% of participants from the referent group knew that breast cancer usually appears as painless breast lump when compared to 82.3% from the intervention group. Participants who attended the program were significantly more likely to obtain higher knowledge scores (odds ratio (OR) = 2.10, 95% confidence interval (CI) = 1.14–3.86) and to state practicing breast self‐examination (OR = 12.29, 95% CI = 5.31–28.48). The BCI program improved KAP toward breast cancer. Further research is warranted to provide stronger evidence that the program improves breast cancer early detection.

A Spatial Needs Assessment of Indigent Acute Psychiatric Discharges in California

State and local mental health agencies have responsibility for the psychiatric care of Medicaid beneficiaries and indigents meeting pre-defined criteria. A significant uninsured caseload may prove draining to agencies and hospitals mandated to provide emergency services, resulting in limited access. A spatial needs assessment was conducted to find areas having a greater relative proportion of indigent psychiatric hospitalizations. Robust descriptive and inferential spatial techniques were applied to California 1999–2003 public-use Zip-Code-level hospital discharge data to create maps. These maps reveal a more stable view of spatial variation in the proportion of indigent discharges compared to all psychiatric discharges. Synthetic estimation techniques were also applied to U.S. Census data to estimate the proportion of severe mental illness among households at less than 200% poverty level compared to estimated mental illness among all households. Visually comparing these maps suggests areas of potential mismatch. These results and methods may inform public decision-making.

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.

Novel measurement of spreading pattern of influenza epidemic by using weighted standard distance method: retrospective spatial statistical study of influenza, Japan, 1999–2009

BackgroundAnnual influenza epidemics occur worldwide resulting in considerable morbidity and mortality. Spreading pattern of influenza is not well understood because it is often hampered by the quality of surveillance data that limits the reliability of analysis. In Japan, influenza is reported on a weekly basis from 5,000 hospitals and clinics nationwide under the scheme of the National Infectious Disease Surveillance. The collected data are available to the public as weekly reports which were summarized into number of patient visits per hospital or clinic in each of the 47 prefectures. From this surveillance data, we analyzed the spatial spreading patterns of influenza epidemics using weekly weighted standard distance (WSD) from the 1999/2000 through 2008/2009 influenza seasons in Japan. WSD is a single numerical value representing the spatial compactness of influenza outbreak, which is small in case of clustered distribution and large in case of dispersed distribution.ResultsWe demonstrated that the weekly WSD value or the measure of spatial compactness of the distribution of reported influenza cases, decreased to its lowest value before each epidemic peak in nine out of ten seasons analyzed. The duration between the lowest WSD week and the peak week of influenza cases ranged from minus one week to twenty weeks. The duration showed significant negative association with the proportion of influenza A/H3N2 cases in early phase of each outbreak (correlation coefficient was −0.75, P = 0.012) and significant positive association with the proportion of influenza B cases in the early phase (correlation coefficient was 0.64, P = 0.045), but positively correlated with the proportion of influenza A/H1N1 strain cases (statistically not significant). It is assumed that the lowest WSD values just before influenza peaks are due to local outbreak which results in small standard distance values. As influenza cases disperse nationwide and an epidemic reaches its peak, WSD value changed to be a progressively increasing.ConclusionsThe spatial distribution of nationwide influenza outbreak was measured by using a novel WSD method. We showed that spreading rate varied by type and subtypes of influenza virus using WSD as a spatial indicator. This study is the first to show a relationship between influenza epidemic trend by type/subtype and spatial distribution of influenza nationwide in Japan.

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.

Evaluation of the impact of a breast cancer awareness program in rural Ghana: A cross-sectional survey: Breast Cancer Awareness Program in Rural Ghana

Community awareness is crucial to early detection of breast cancer in low‐ and middle‐income countries. In Ghana 60% of the cases are detected at late stages. Breast Care International (BCI) is a Ghanaian non‐governmental organization dedicated to raising breast cancer awareness. A cross‐sectional survey was designed to assess the impact of BCI program on knowledge, attitudes and practices (KAP) toward breast cancer among women from rural communities of Ghana. A total of 232 women were interviewed in June 2011 in the Ashanti region; of these 131 participants were from a community that received the BCI program in August 2010 (intervention group) and 101 from another community that received the program post‐survey (referent group). Data analysis was performed using Epi‐Info version 3.5.3. Knowledge about breast cancer among participants who received the program was better than among those who did not. Only 53.5% of participants from the referent group knew that breast cancer usually appears as painless breast lump when compared to 82.3% from the intervention group. Participants who attended the program were significantly more likely to obtain higher knowledge scores (odds ratio (OR) = 2.10, 95% confidence interval (CI) = 1.14–3.86) and to state practicing breast self‐examination (OR = 12.29, 95% CI = 5.31–28.48). The BCI program improved KAP toward breast cancer. Further research is warranted to provide stronger evidence that the program improves breast cancer early detection.

Evaluation of the impact of a breast cancer awareness program in rural Ghana

Community awareness is crucial to early detection of breast cancer in low‐ and middle‐income countries. In Ghana 60% of the cases are detected at late stages. Breast Care International (BCI) is a Ghanaian non‐governmental organization dedicated to raising breast cancer awareness. A cross‐sectional survey was designed to assess the impact of BCI program on knowledge, attitudes and practices (KAP) toward breast cancer among women from rural communities of Ghana. A total of 232 women were interviewed in June 2011 in the Ashanti region; of these 131 participants were from a community that received the BCI program in August 2010 (intervention group) and 101 from another community that received the program post‐survey (referent group). Data analysis was performed using Epi‐Info version 3.5.3. Knowledge about breast cancer among participants who received the program was better than among those who did not. Only 53.5% of participants from the referent group knew that breast cancer usually appears as painless breast lump when compared to 82.3% from the intervention group. Participants who attended the program were significantly more likely to obtain higher knowledge scores (odds ratio (OR) = 2.10, 95% confidence interval (CI) = 1.14–3.86) and to state practicing breast self‐examination (OR = 12.29, 95% CI = 5.31–28.48). The BCI program improved KAP toward breast cancer. Further research is warranted to provide stronger evidence that the program improves breast cancer early detection.

Abstract C11: Impact of pathologic specimen quality on classifying molecular subtypes of breast cancer: A pilot study from three hospitals in Ghana, Africa

Background: Breast cancer is a heterogeneous disease with clinically, molecularly and pathologically defined subtypes that have different etiologies, clinical presentations and outcomes. African women reportedly have especially high rates of breast cancers that are estrogen receptor (ER) or progesterone receptor (PR) negative, or triple negative [ER, PR and human epidermal growth factor receptor-2 (HER-2) negative], with the proportion reported for triple negative breast cancers ranging from 28-82%, compared to 11-20% among Caucasian populations. However, it is unclear to what extent pathology and specimen handling affect receptor measurements in Africa. Here we sought to determine pathology specimen quality of breast tumor tissues from three hospitals in Ghana where we are conducting a molecular epidemiologic study of breast cancer. Methods: We acquired 15 formalin-fixed paraffin-embedded (FFPE) archived breast cancer tissue blocks with specimens obtained at biopsy (N=5) or surgery (N=10) from three hospitals in Ghana. Blocks were re-embedded and four 0.5um whole sections were cut for hematoxylin and eosin stains, and immunohistochemistry (IHC) using previously validated protocols for ER (clone 1D5), PR (clone PgR1294) and HER2 (polyclonal), all obtained from Dako (Carpinteria CA). Specimens were considered ER or PR positive if 10% or more cells stained positive, while HER2 was considered positive if intensity of staining was 3+. Results: Specimens were noted to be embedded in high-melting temperature paraffin. To perform ER, PR, and HER2 IHC staining, deparaffinization procedures were optimized for hard paraffin. Zonal and gradient staining patterns were noted in surgical specimens, features that are likely due to delayed/prolonged fixation. Zonal/gradient staining issues were not identified in the needle biopsies, which were smaller compared to specimens collected at surgery and generally placed in buffered formalin immediately after collection. IHC assays of the tumor specimens revealed that 67% were ER-positive, 20% PR-positive, and 66% HER2 positive. The proportion negative for all three markers was 13%. Conclusion: In contrast to previous reports for African breast cancer patients, within our sample of FFPE breast cancers from Ghana we found a higher prevalence of ER positive tumors and a lower prevalence of tumors negative for all three markers. These results suggest that the high rates of hormone receptor negativity previously reported in African populations may be inaccurate due to various sources of error, particularly fixation time and IHC staining protocols. Future studies focusing on proper documentation of sample collection procedures and optimization of IHC methods are required to determine the true prevalence of molecular subtypes of breast cancer among African women. Such efforts are essential for breast cancer surveillance, identifying etiologic factors for prevention efforts and developing more effective treatment programs. Citation Format: Jonine D. Figueroa, Lawrence Edusei, Ernest Adjei, Nicholas Titiloye, Kris Ylaya, Beatrice Addai, Joe Nat Clegg-Lamptey, Baffour Awuah, Kofi Nyarko, Daniel Ansong, Seth Wiafe, Louise A. Brinton, Stephen Hewitt. Impact of pathologic specimen quality on classifying molecular subtypes of breast cancer: A pilot study from three hospitals in Ghana, Africa. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C11. doi:10.1158/1538-7755.DISP13-C11