Decrease in liver cancer incidence rates in Bamako, Mali over 28 years of population-based cancer registration (1987-2015).

BACKGROUND: Primary liver cancer is common in West Africa due to endemic risk factors. However, epidemiological studies of the global burden and trends of liver cancer are limited. We report changes in trends of the incidence of liver cancer over a period of 28 years using the population-based cancer registry of Bamako, Mali. AIM: To assess the trends and patterns of liver cancer by gender and age groups by analyzing the cancer registration data accumulated over 28 years (1987-2015) of activity of the population-based registry of the Bamako district. METHODS: Data obtained since the inception of the registry in 1987 through 2015 were stratified into three periods (1987-1996, 1997-2006, and 2007-2015). Age-standardized rates were estimated by direct standardization using the world population. Incidence rate ratios and the corresponding 95% confidence intervals (CI) were estimated using the early period as the reference (1987-1996). Joinpoint regression models were used to assess the annual percentage change and highlight trends over the entire period (from 1987 to 2015). RESULTS: Among males, the age-standardized incidence rates significantly decreased from 19.41 (1987-1996) to 13.12 (1997-2006) to 8.15 (2007-2015) per 105 person-years. The incidence rate ratio over 28 years was 0.42 (95%CI: 0.34-0.50), and the annual percentage change was -4.59 [95%CI: (-6.4)-(-2.7)]. Among females, rates dropped continuously from 7.02 (1987-1996) to 2.57 (2007-2015) per 105 person-years, with an incidence rate ratio of 0.37 (95%CI: 0.28-0.45) and an annual percentage change of -5.63 [95%CI: (-8.9)-(-2.3)]. CONCLUSION: The population-based registration showed that the incidence of primary liver cancer has steadily decreased in the Bamako district over 28 years. This trend does not appear to result from biases or changes in registration practices. This is the first report of such a decrease in an area of high incidence of liver cancer in Africa. This decrease may be explained by the changes and diversity of diet that could reduce exposure to aflatoxins through dietary contamination in this population.

Disparity in breast cancer mortality by age and geography in 10 racially diverse US cities.

OBJECTIVES: Assess geographic variation in breast cancer racial mortality disparity by age cohorts in US and ten cities with large African American populations. METHODS: Non-Hispanic Black (NHB) and Non-Hispanic White (NHW) female breast cancer mortality rates and NHB:NHW rate ratio (RR) (disparity) were calculated by four age group categories: <40, 40-49, 50-64 and 65+ with time period 1999-2013. RESULTS: In all 10 cities and the US, the most pronounced breast cancer disparities, measured by RR, were seen among younger women. In age group <40, the RR ranges from 1.71 in Houston to 5.37 in Washington, DC. For age group 50-64, the disparity was less pronounced, ranging from 1.24 in New York to 1.72 in Chicago. For 65+ age group, there was wide city to city variation in breast cancer mortality disparity. Three cities had higher mortality for NHW compared to NHB; Baltimore 0.78, Washington DC 0.94 and New York 0.98. One city had no statistically significant racial variation in breast cancer mortality in this age group and six cities had increased NHB: NHW mortality disparities. CONCLUSIONS: While the mortality rate for breast cancer is lower among younger women, the NHB:NHW disparities, as measured by rate ratios, are most pronounced in these age groups. Given the absence of available data regarding incidence, stage and subtypes, further research is necessary and such research is important, given the possible policy implications of these results with respect to screening guidelines and coverage for mammography and breast cancer treatment in particular for younger NHB women.

Racial Differences in the Association Between Apolipoprotein E Risk Alleles and Overall and Total Cardiovascular Mortality Over 18 Years.

OBJECTIVES: To examine the difference in the association between apolipoprotein (APO)E allele and overall and cardiovascular mortality between African Americans (AAs) and European Americans (EAs). DESIGN: Longitudinal, cohort study of 18 years. SETTING: Biracial urban US population sample. PARTICIPANTS: 4,917, 68% AA and 32% EA. MEASUREMENTS: APOE genotype and mortality based on National Death Index. RESULTS: A higher proportion of AAs than of EAs had an APOE ε2 allele (ε2ε2/ε2ε3/ε2ε4; 22% vs 13%) and an APOE ε4 allele (ε3ε4/ε4ε4; 33% vs 24%). After adjusting for known risk factors, the risk of mortality was 19% less with the APOE ε2 allele (hazard ratio (HR) = 0.81, 95% confidence interval (CI) = 0.76-0.87), and the risk of cardiovascular mortality was 35% less (HR = 0.65, 95% CI = 0.58-0.76) than with the ε3ε3 allele. The risk of mortality was 10% greater with the APOE ε4 allele (HR = 1.10, 95% CI = 1.04-1.16), and the risk of cardiovascular mortality was 20% greater (HR = 1.20, 95% CI = 1.07-1.29) than with the ε3ε3 allele. No difference in the association between APOE allele and mortality was observed between AAs and EAs. CONCLUSION: The APOE ε4 allele increased the risk of overall and cardiovascular mortality, whereas the APOE ε2 allele decreased the risk of overall and cardiovascular mortality. There was no racial difference in the association between these alleles and mortality.

Changes in the racial disparity in breast cancer mortality in the ten US cities with the largest African American populations from 1999 to 2013: The reduction in breast cancer mortality disparity in Chicago.

PURPOSE: Assess progress made to reduce racial disparity in breast cancer mortality in Chicago compared to nine other cities with largest African American populations and the US. METHODS: The Non-Hispanic Black (NHB) and Non-Hispanic White (NHW) female breast cancer mortality rates and rate ratios (RR) (disparity) were compared between 1999 and 2005 and 2006 and 2013. RESULTS: Between the two periods, the NHB breast cancer mortality rate in Chicago decreased by 13.9% (95% CI [-13.81, -13.92] compared to 7.7% (95% CI [-7.52, -7.83]) for NHW. A drop of 20% in the disparity was observed, from 51% (RR: 1.51, 95% CI [-7.52, -7.83]) to 41% (RR: 1.41, 95% CI [1.30, 1.52]). Whereas from 1999 to 2005 Chicago's disparity was above that of the U.S., from 2006 to 2013, it is now slightly lower. For the remaining nine cities and the US, the mortality disparity either grew or remained the same. CONCLUSIONS: Chicago's improvement in NHB breast cancer mortality and disparity reduction occurred in the context of city-wide comprehensive public health initiatives and shows promise as a model for other cities with high health outcome disparities.

Recall and Cancer Detection Rates for Screening Mammography: Finding the Sweet Spot.

OBJECTIVE: The purpose of this study is to identify the optimal screening mammography recall rate range on the basis of cancer detection rates among breast imaging specialists at an academic institution. MATERIALS AND METHODS: Medical outcome audit data collected in accordance with the Mammography Quality Standards Act from September 1, 2007, through August 31, 2012, were reviewed. Cancer detection rates were calculated from 984 screen-detected cancers identified in 188,959 total digital screening mammograms. The percentages of minimally invasive and early-stage cancers were also calculated. The 75 annual recall rates were analyzed two ways. First, they were separated into recall groups to assess cancer detection rate variation by the recall categories using rate ratios: less than 10%, 10% to less than 12%, 12% to less than 14%, and 14% or higher. Next, a linear regression with bootstrap bias correction was performed to assess changes in cancer detection rate with each unit increase in the recall rate up to 20%, with the recall category of less than 7% taken as reference. Annual cancer detection rates for a physician were grouped according to annual percentage recall rate. RESULTS: Statistically significantly higher cancer detection rates were seen for recall rates 12% or higher, with rate ratios of 1.75 (95% CI, 1.40-2.19) and 2.06 (95% CI, 1.72-2.46) for the recall groups 12% to less than 14% and 14% and higher, respectively, compared with the less than 10% group. When taking the category 12% to less than 14% as the reference, there were no statistically significant differences between recall groups 12% to less than 14% and 14% or higher in cancer detection rate. A statistically significant increase in the cancer detection rate with each unit increase in the recall rate was seen only for recall rates 12% or higher. CONCLUSION: These observations suggest that the sweet spot for optimal cancer detection is in the recall rate range 12% to less than 14% with the incremental benefit above this to be relatively small. A recall rate less than 10% may be too low.

Breast cancer risk after full-term pregnancies among African women from Nigeria, Cameroon, and Uganda.

BACKGROUND: The breast cancer (BC) risk profiles of African women differ significantly from those of women of European ancestry. African women are younger at the age of onset and tend to have high parity. The purpose of this study was to examine the relationship between full-term pregnancy (FTP) and the risk of BC. METHODS: A case-control study was conducted among 1995 women with invasive BC and 2631 controls in Nigeria, Cameroon, and Uganda. Odds ratios (ORs) for individual ages at FTP according to the time since delivery were calculated and adjusted for confounders. A fitted spline model was used to assess the impact of the number of pregnancies on BC risk. RESULTS: In comparison with a nulliparous woman, a parous woman with her first FTP at 20 years showed an OR of 0.76 (95% confidence interval [CI], 0.57-0.99) for developing BC in the following 5 years. Ten years later, this risk was 0.76 (95% CI, 0.58-0.99) and 0.76 (95% CI, 0.58-0.98) for women aged 25 and 30 years, respectively. Similarly, a parous woman with 1 pregnancy had an OR of 0.69 (95% CI, 0.49-0.96), whereas the OR was 0.66 (95% CI, 0.48-0.91) with 2 or 5 pregnancies and 0.67 (95% CI, 0.47-0.94) with 6 pregnancies in comparison with nulliparous women. CONCLUSIONS: In contrast to studies in women of European ancestry, this study showed no transient increase in the risk of developing BC after FTP among African women. Further studies are needed to examine the impact of reproductive factors on early-onset BC in African women.

Changes in the pattern of breast cancer burden among African American women: evidence based on 29 states and District of Columbia during 1998 to 2010.

PURPOSE: Assessment of breast cancer (BC) pattern in individual states with respect to ethnicity. METHODS: Population-based cancer registries from the Cancer Incidence in Five Continents databases (1998-2007) supplemented with Surveillance, Epidemiology, and End Results data from 2008 to 2010 were used. RESULTS: The age-specific burden showed a clear convergence of BC burden among African American (AA) and Caucasian American (CA) in most states. This was primarily because of a decrease in the BC rate among CA aged 50 years or older and an increase among AA of the same age group. The 2003-2007/1998-2002 rate ratio for CA was 0.91 (95% confidence interval [CI], 0.90-0.91) in the South, whereas it was 1.06 (95% CI, 1.04-1.08) for AA. This convergence was confirmed in states with available data for the period 2008 to 2010. The AA/CA rate ratio among women aged younger than 40 years was 0.99 (95% CI, 0.99-1.04) in the Northeast, 1.29 (95% CI, 1.25-1.33) in the South, and 1.10 (95% CI, 1.04-1.17) in the West. This pattern correlates with the estrogen receptor positive and progesterone receptor positive pattern. The strongest disparity in estrogen receptor negative was observed in Louisiana which with Detroit, have had the highest rates of estrogen receptor negative. CONCLUSIONS: The changes in postmenopausal hormone use and mammography screening might have played a role in the observed convergence.

Ethnic and geographic variations in corpus uteri cancer burden: evidence based on data from 29 states and the District of Columbia. CI5 IX, X and SEER data (1998-2010).

PURPOSE: To assess the pattern of corpus uteri cancer (CUC) in individual states of the USA according to ethnicity. METHODS: Population-based cancer registries from 29 states and the District of Columbia with information on ethnicity for African-American women (AA) and Caucasian-American women (CA) were extracted from the Cancer Incidence in Five Continents (1998-2002, 2003-2007) and the Surveillance, Epidemiology, and End Results Program (SEER; 2008-2010) databases. Rate ratios (RRs) were calculated with respect to ethnicity, age, state, and region. RESULTS: In southern states, AA had a lower CUC burden among women aged <60 years (AA/CA RR = 0.67; 95 % CI 0.64-0.70), whereas it was higher among women aged ≥60 years (AA/CA RR = 1.22; 95 % CI 1.19-1.26). In other regions, the lower CUC burden among AA aged <60 years was true in all states; however, the CUC burden among AA aged ≥60 years was similar to that of CA. Data for the most recent period (2008-2010) indicate that the age-dependent crossover in CUC burden was not anymore restricted to the South, but also occurred in other regions. Overall, women in the South have had the lowest CUC burden compared with that in all other regions, irrespective of ethnicity and age. CONCLUSIONS: Significant geographic and ethnic variations in the CUC burden exist in the USA. The incidence of hysterectomy could be a factor underlying the geographic variations in CUC burden and particular attention should be given to older AA in southern states.

Discordance in hormone receptor status among primary, metastatic, and second primary breast cancers: biological difference or misclassification?

INTRODUCTION: Discordance in hormone receptor status has been observed between two breast tumors of the same patients; however, the degree of heterogeneity is debatable with regard to whether it reflects true biological difference or the limited accuracy of receptor assays. METHODS: A Bayesian misclassification correction method was applied to data on hormone receptor status of two primary breast cancers from the Surveillance, Epidemiology, and End Results database between 1990 and 2010 and to data on primary breast cancer and paired recurrent/metastatic disease assembled from a meta-analysis of the literature published between 1979 and 2014. RESULTS: The sensitivity and specificity of the estrogen receptor (ER) assay were estimated to be 0.971 and 0.920, respectively. After correcting for misclassification, the discordance in ER between two primary breast cancers was estimated to be 1.2% for synchronous ipsilateral pairs, 5.0% for synchronous contralateral pairs, 14.6% for metachronous ipsilateral pairs, and 25.0% for metachronous contralateral pairs. Technical misclassification accounted for 53%-83% of the ER discordance between synchronous primary cancers and 11%-25% of the ER discordance between metachronous cancers. The corrected discordance in ER between primary tumors and recurrent or metastatic lesions was 12.4%, and there were more positive-to-negative changes (10.1%) than negative-to-positive changes (2.3%). Similar patterns were observed for progesterone receptor (PR), although the overall discordance in PR was higher. CONCLUSION: A considerable proportion of discordance in hormone receptor status can be attributed to misclassification in receptor assessment, although the accuracy of receptor assays was excellent. Biopsy of recurrent tumors for receptor retesting should be conducted after considering feasibility, cost, and previous ER/PR status.

Anthropometry, silhouette trajectory, and risk of breast cancer in Mexican women.

BACKGROUND: Obesity has been associated with breast cancer risk in the Caucasian population but the association remains unclear in the Hispanics. Previous studies conducted among Hispanics in the U.S. have shown inconsistent results. PURPOSE: The association between anthropometry, body shape evolution across lifetime, and the risk of breast cancer was assessed using a multi-center population-based case-control study conducted in Mexico. METHODS: One thousand incident cases and 1074 matched control women aged 35-69 years were recruited between 2004 and 2007, and analyzed in 2011-2012. Conditional logistic regression models were used. RESULTS: Height was related to an increased risk of breast cancer in both premenopausal (p trend=0.03) and postmenopausal women (p trend=0.002). In premenopausal women, increase in BMI; waist circumference (WC); hip circumference (HC); and waist-hip ratio (WHR) were inversely associated with breast cancer risk (p trends<0.001 for BMI and WC, 0.003 for HC, and 0.016 for WHR). In postmenopausal women, decreased risks were observed for increased WC (p trend=0.004) and HC (p trend=0.009) among women with time since menopause <10 years. Further analysis of body shape evolution throughout life showed strong and significant increase in risk of breast cancer among women with increasing silhouettes size over time compared to women with no or limited increase. CONCLUSIONS: These findings suggest that anthropometric factors may have different associations with breast cancer risk in Hispanic women than in Caucasian women. This study also shows the importance of considering the evolution of body shape throughout life.

Breast cancer in pre-menopausal women in West Africa: analysis of temporal trends and evaluation of risk factors associated with reproductive life.

BACKGROUND: In West Africa, trends and risk factors for breast cancer (BC) have been rarely studied. METHODS: Here we have analyzed trends of BC over two periods in two population-based cancer registries, in Mali-Bamako (1987-1997; 1998-2009) and in The Gambia (1988-1997; 1998-2006). We have conducted a case-control study (n = 253 cases, 249 controls) on risk factors associated with reproductive life stratified by menopausal status in Bamako. RESULTS: Between the two periods, BC incidence rates increased by 20% (incidence rate ratio (IRR) 1.20 (95% CI [1.07-1.35])) in Bamako, with an annual percentage change of 2% (95% CI [0.4-3.6]). The increase was of 30% in women under 55 years (IRR 1.30 (95% CI [1.14-1.60])). A similar pattern was observed in The Gambia for women under 50 years (IRR 1.47 (95% CI [1.07-2.01])). Overall, pre-menopausal breast cancer was predominant in both countries. In contrary to what is well established, case-control study showed that late age at menarche (>14 years) increased the risk of BC among pre-menopausal women (OR: 2.02 (95% CI [1.08-3.78])) while it tended to be protective in post-menopausal women (OR: 0.61 (95% CI [0.29-1.29])). Later age at a first pregnancy (>20 years) was associated with a reduction of risk in pre-menopausal women (OR: 0.41 (95% CI [0.18-0.89])). CONCLUSION: These results indicate that the burden of pre-menopausal BC is increasing in West African countries. These cancers appear to be associated with distinct reproductive risk factors, highlighting the need for better understanding the biological bases of early BC in African populations.

Increase in female liver cancer in the Gambia, West Africa: evidence from 19 years of population-based cancer registration (1988-2006).

BACKGROUND: Hepatocellular carcinoma (HCC) is a common malignancy worldwide with a high burden in West Africa. Male to female ratios show consistent bias toward males, the biological bases and variations of which are not well understood. We have used data from the Gambian National Cancer Registry to compare trends in incidence of HCC in both genders. METHODS AND FINDINGS: Two periods were compared, 1988-1997 (early) and 1998-2006 (recent). In addition, the regression program joinpoint was used to assess trends over 19 years. Differences with self-reported ethnicity were assessed for the recent period using population data from 2003 census. Male to female ratio showed a significant decrease between the two periods from 3.28∶1 (95% CI, [2.93-3.65]) to 2.2∶1 (95% CI, [1.99-2.43]). Although rates in males were relatively stable (38.36 and 32.84 for, respectively, early and recent periods), they increased from 11.71 to 14.9 in females with a significant Annual Percentage Change of 3.01 [0.3-5.8] over 19 years and an increase in number of cases of 80.28% (compared to 26% in males). Significant variations in HCC risk, but not in gender ratio were observed in relation with ethnicity. CONCLUSION: This analysis of the only national, population-based cancer registry in West Africa shows a significant increase in HCC in females over recent years. This increase may be the consequence of major changes in lifestyle or viral risk factors, in particular obesity and hepatitis C, which have both been documented to increase in West Africa during recent years.

Population-based breast (female) and cervix cancer rates in the Gambia: evidence of ethnicity-related variations.

Since 1987, the Gambia National Cancer Registry has provided nationwide cancer registration for the Gambia. We used data from 1998 to 2006 to assess age-standardized incidence rates (ASRs) of 2 common cancers in women, breast and cervix. With an ASR of 15.42 (95% CI [14.18-16.66]) for cervix and 5.86 (95% CI [5.12-6.59]) for breast per 10(5) person-years, these cancers ranked first and third, respectively, among Gambian women (the second most common being liver, ASR 14.90). Incidence of both cancers, breast and cervix, increased rapidly at young ages to reach a peak at ages 40-44 years. Significant differences were observed in relation to ethnicity. Using the Mandinka (42% of the population) as a reference, breast cancer incidence rates were 2.16-fold higher (95% CI [1.33-3.52]) in Jola (10% of the population), specially at early-onset ages (before 40 years). For cervix cancer, highest rates were observed in Fula (18% of the population; risk ratio (RR): 1.84 (95% CI [1.44-2.36])). In contrast, a significantly lower risk was observed in the Serrahuleh (9% of the population; RR: 0.54 (95% CI [0.31-0.96]). This study revealed a preponderance of early-onset breast cancer among Gambian women similar to that seen in African women in more developed countries but also demonstrates large ethnic variations. It points to the need for further studies on cancer determinants to improve prevention, early detection and therapeutic management of these diseases in a low-resource setting in West Africa.