Contemporary management of breast cancer in Nigeria: Insights from an institutional database.

High-quality data are needed to guide interventions aimed at improving breast cancer outcomes in sub-Saharan Africa. We present data from an institutional breast cancer database to create a framework for cancer policy and development in Nigeria. An institutional database was queried for consecutive patients diagnosed with breast cancer between January 2010 and December 2018. Sociodemographic, diagnostic, histopathologic, treatment and outcome variables were analyzed. Of 607 patients, there were 597 females with a mean age of 49.8 ± 12.2 years. Most patients presented with a palpable mass (97%) and advanced disease (80.2% ≥ Stage III). Immunohistochemistry was performed on 21.6% (131/607) of specimens. Forty percent were estrogen receptor positive, 32.8% were positive for HER-2 and 43.5% were triple negative. Surgery was performed on 49.9% (303/607) of patients, while 72% received chemotherapy and 7.9% had radiotherapy. At a median follow-up period of 20.5 months, the overall survival was 43.6% (95% CI -37.7 to 49.5). Among patients with resectable disease, 18.8% (57/303) experienced a recurrence. Survival was significantly better for early-stage disease (I and II) compared to late-stage disease (III or IV) (78.6% vs 33.3%, P < .001). Receipt of adjuvant radiotherapy after systemic chemotherapy was associated with improved survival in patients with locally advanced disease (68.5%, CI -46.3 to 86 vs 51%, CI 38.6 to 61.9, P < .001). This large cohort highlights the dual burden of advanced disease and inadequate access to comprehensive breast cancer care in Nigeria. There is a significant potential for improving outcomes by promoting early diagnosis and facilitating access to multimodality treatment.

Early liver metastases after "failure" of adjuvant chemotherapy for stage III colorectal cancer: is there a role for additional adjuvant therapy?

BACKGROUND: The utility of adjuvant chemotherapy after resection of colorectal liver metastasis (CLM) in patients with rapid recurrence after adjuvant chemotherapy for their primary tumor is unclear. The aim of this study was to evaluate the oncologic benefit of adjuvant hepatic arterial plus systemic chemotherapy (HAIC + Sys) in patients with early CLM. METHODS: A retrospective analysis of patients with early CLM (≤12 months of adjuvant chemotherapy for primary tumor) who received either HAIC + Sys, adjuvant systemic chemotherapy alone (Sys), or active surveillance (Surgery alone) following resection of CLM was performed. Recurrence and survival were compared between treatment groups using Kaplan-Meier methods and Cox proportional hazards models. RESULTS: Of 239 patients undergoing resection of early CLM, 79 (33.1%) received HAIC + Sys, 77 (32.2%) received Sys, and 83 (34.7%) had Surgery alone. HAIC + Sys was independently associated with reduced risk of RFS events (adjusted hazard ratio [HRadj]: 0.64, 95%CI:0.44-0.94, p = 0.022) and all-cause mortality (HRadj: 0.54, 95%CI:0.36-0.81, p = 0.003) compared to Surgery alone patients. Largest tumor >5 cm (HRadj: 2.03, 95%CI: 1.41-2.93, p < 0.001) and right-sided colon tumors (HRadj: 1.93, 95%CI: 1.29-2.89, p = 0.002) were independently associated with worse OS. CONCLUSION: Adjuvant HAIC + Sys after resection of early CLM that occur after chemotherapy for node-positive primary is associated with improved outcomes.

Is Hepatectomy Justified for BRAF Mutant Colorectal Liver Metastases?: A Multi-institutional Analysis of 1497 Patients.

OBJECTIVE: To analyze clinical outcomes and prognostic variables of patients undergoing hepatic resection for BRAF mutant (BRAF-mut) colorectal liver metastases (CRLM). BACKGROUND: Outcomes following hepatectomy for BRAF-mut CRLM have not been well studied. METHODS: All patients who underwent hepatectomy for CRLM with complete resection and known BRAF status during 2001 to 2016 at 3 high-volume centers were analyzed. RESULTS: Of 4124 patients who underwent hepatectomy for CRLM, 1497 had complete resection and known BRAF status. Thirty-five (2%) patients were BRAF-mut, with 71% of V600E mutation. Compared with BRAF wild-type (BRAF-wt), BRAF-mut patients were older, more commonly presented with higher ASA scores, synchronous, multiple and smaller CRLM, underwent more major hepatectomies, but had less extrahepatic disease. Median overall survival (OS) was 81 months for BRAF-wt and 40 months for BRAF-mut patients (P < 0.001). Median recurrence-free survival (RFS) was 22 and 10 months for BRAF-wt and BRAF-mut patients (P < 0.001). For BRAF-mut, factors associated with worse OS were node-positive primary tumor, carcinoembryonic antigen (CEA) >200 µg/L, and clinical risk score (CRS) ≥4. Factors associated with worse RFS were node-positive primary tumor, ≥4 CRLM, and positive hepatic margin. V600E mutations were not associated with worse OS or RFS. A case-control matching analysis on prognostic clinicopathologic factors confirmed shorter OS (P < 0.001) and RFS (P < 0.001) in BRAF-mut. CONCLUSIONS: Patients with resectable BRAF-mut CRLM are rare among patients selected for surgery and more commonly present with multiple synchronous tumors. BRAF mutation is associated with worse prognosis; however, long-term survival is possible and associated with node-negative primary tumors, CEA ≤ 200 µg/L and CRS < 4.

Barriers to mammography screening in Nigeria: A survey of two communities with different access to screening facilities.

Delayed presentation of breast cancer is a common theme in most low- and middle-income countries. This study evaluates barriers to mammography screening in two Nigerian communities with different geographic access to screening facilities. A 35 item questionnaire was administered to women, 40 years and older, 1,169 (52.6%) in Ife Central Local Government where mammography services are offered and 1,053 (47.4%) in Iwo Local Government where there are no mammography units. Information on breast cancer screening practices and barriers to mammography screening were compared between the two communities. Most women had heard of breast cancer (Ife 94%, Iwo 97%), but few were aware of mammography (Ife 11.8%, Iwo 11.4%). Mammography uptake in Ife Central was 2.8% and 1.8% in Iwo, despite the former offering mammography services. Knowledge and practice of mammography were not statistically different between the two communities (p = 0.74, 0.1). Lack of awareness was the commonest reason cited for not having mammography in both communities. Others include lack of perceived need and cost. Awareness creation to ensure optimal utilisation of existing facilities, as well as innovative measures to address the barrier of cost, is required to improve breast cancer screening uptake in Nigeria.

Rectal bleeding and implications for surgical care in Nepal.

BACKGROUND: Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world's population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries such as Nepal. The aim of this study was to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region. METHODS: A countrywide survey using the Surgeons OverSeas Assessment of Surgical Need tool was administered from May 25-June 12, 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population. In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology. Individuals were interviewed to determine the period and point prevalence of rectal bleeding and patterns of health-seeking behavior related to surgical care for this problem. Individuals aged >18 y were included in this analysis. RESULTS: A total of 1350 households and 2695 individuals were surveyed with a 97% response rate. Thirty-eight individuals (55% male) of the 1941 individuals ≥ 18 y stated they had experienced rectal bleeding (2.0%, 95% confidence interval 1.4%-2.7%), with a mean age of 45.5 (standard deviation 2.2). Of these 38 individuals, 30 stated they currently experience rectal bleeding. Health Care was sought in 18 participants with current rectal bleeding, with two major procedures performed, one an operation for an anal fistula. For those who sought health care but did not receive surgical care, reasons included no need (4), not available (6), fear and/or no trust (5), and no money for health care (1). For those with current rectal bleeding who did not seek health care, reasons included no need (1), not available (2), fear and/or no trust (6), and no money for health care (3). Twenty-three individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% confidence interval 0.8%-1.8%). CONCLUSIONS: The Nepal health care system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding. Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a health care professional and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer. Further advocacy for preventative medicine and easier access to surgical care in lower-income countries is crucial to avoid emergency surgeries, advanced stage malignancies, or fatalities from treatable conditions.

Breast cancer in elderly patients: a clinicopathological review of a Nigerian database.

Background: Breast cancer in the elderly population has not been evaluated in the Nigerian context. With the rising incidence of breast cancer and the changing demographics, it is likely that an increasing number of elderly patients will be managed in the coming years in Nigeria. This review describes the clinicopathological profile of elderly patients with breast cancer in a Nigerian database. Method: From a prospective institutional database, elderly patients (65 years and above) managed for breast cancer over a 9-year period were reviewed. Details of their socio-demographic characteristics, patterns of presentation, pathology, treatment and outcome were obtained and analysed. Results: Of the 607 patients managed during the study period, there were 87 older patients accounting for 14.3% of the total. There was a progressive rise in the number of patients with breast cancer towards the latter part of the study. Expectedly, they were all post-menopausal, with their ages ranging from 65 to 92 years, with a mean of 71 ± 6.58 years. Systemic hypertension was the commonest co-morbidity (29.8%). The mean tumour size at presentation was 10 cm, with the majority presenting with stage 3 disease. Invasive ductal carcinoma was the predominant histological type 83 (95.4%); 44.4% of those who had immunohistochemistry were oestrogen receptor-positive. Approximately half underwent mastectomy (52.8%), 63 (72.4%) had chemotherapy, 8 (44.4%) had hormonal therapy and only 6 (6.9%) had combined multimodal therapy in addition to surgery. Overall 5-year survival was 42.1%. Conclusion: The pattern of presentation and outcomes of care in this elderly cohort is similar to the general population. Early presentation and use of multimodal treatment is still the mainstay of survival.

Developing a Breast Cancer Screening Program in Nigeria: Evaluating Current Practices, Perceptions, and Possible Barriers.

PURPOSE: In low- and middle-income countries like Nigeria, women present with advanced breast cancer at an earlier age. Given the limited resources, development of screening programs that parallel resource capabilities of low- and middle-income countries is imperative. The objective of this study was to evaluate the perceptions, practices, and barriers regarding clinical breast examination (CBE) screening in a low-income community in Nigeria. MATERIALS AND METHODS: A cross-sectional survey of women age 40 years or older in Ife, Nigeria, using multistaged sampling was performed. Information on sociodemographics, knowledge of breast cancer, screening practices, and willingness to participate in CBE screening was obtained using an interviewer-administered questionnaire. RESULTS: A total of 1,169 women whose ages ranged from 40 to 86 years (mean age, 47.7 years; standard deviation, 8.79 years) were interviewed. The majority of women (94%) knew about breast cancer, whereas 27.5% knew someone who had had breast cancer, the majority of whom (64.5%) had died of the disease. Of the 36% of women who had breast screening recommended to them, only 19.7% had an actual CBE. Of these, only 6% had it in the last year. The majority of women (65.4%) were willing to have regular CBEs and did not care about the sex of the examiner in most instances. Lack of perceived need was the reason cited by women unwilling to participate. CONCLUSION: The majority of women were aware of breast cancer and knew it as a fatal disease. With the relatively encouraging number of those willing to be examined, a carefully designed CBE program coupled with advocacy to correct uneducated beliefs seems promising.