Presentation, patterns of care, and outcomes of patients with prostate cancer in sub-Saharan Africa: A population-based registry study.

BACKGROUND: Although prostate cancer (PCa) is the most commonly diagnosed cancer in men of sub-Saharan Africa (SSA), little is known about its management and survival. The objective of the current study was to describe the presentation, patterns of diagnosis, treatment, and survival of patients with PCa in 10 countries of SSA. METHODS: In this observational registry study with data collection from 2010 to 2018, the authors drew a random sample of 738 patients with PCa who were registered in 11 population-based cancer registries. They described proportions of patients receiving recommended care and presented survival estimates. Multivariable Cox regression was used to calculate hazard ratios comparing the survival of patients with and without cancer-directed therapies (CDTs). RESULTS: The study included 693 patients, and tumor characteristics and treatment information were available for 365 patients, 37.3% of whom had metastatic disease. Only 11.2% had a complete diagnostic workup for risk stratification. Among the nonmetastatic patients, 17.5% received curative-intent therapy, and 27.5% received no CDT. Among the metastatic patients, 59.6% received androgen deprivation therapy. The 3- and 5-year age-standardized relative survival for 491 patients with survival time information was 58.8% (95% confidence interval [CI], 48.5%-67.7%) and 56.9% (95% CI, 39.8%-70.9%), respectively. In a multivariable analysis, survival was considerably poorer among patients without CDT versus those with therapy. CONCLUSIONS: This study shows that a large proportion of patients with PCa in SSA are not staged or are insufficiently staged and undertreated, and this results in unfavorable survival. These findings reemphasize the need for improving diagnostic workup and access to care in SSA in order to mitigate the heavy burden of the disease in the region.

Cervical cancer in Ethiopia - predictors of advanced stage and prolonged time to diagnosis.

INTRODUCTION: In Ethiopia, most cervical cancer patients present at advanced cancer stages, long time after they experience first symptoms. We investigated possible predictors of long time spans between symptom onset and pathologic diagnosis (patient intervals). We also aimed to seek out predictors for advanced cancer stage diagnosis. METHODS: We conducted a retrospective cohort study among 1575 cervical cancer patients who were registered at Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia between September 2008 and September 2012. Cox proportional hazards regression was used to find predictors of long patient intervals. Cumulative odds ordinal logistic regression was used to identify predictors of cancer stage at diagnosis. RESULTS: Median patient interval was 30 weeks, with the interval substantially longer in patients residing in rural than urban areas. Longer patient intervals were associated with more advanced cancer stages at pathologic diagnosis. HIV-positive women had an almost 1.5 times increased risk of diagnosis at a more advanced stage. CONCLUSION: Cervical cancer patients are diagnosed after long time periods leading to advanced stages at diagnosis. Measures to raise awareness about cervical cancer, to increase screening and to shorten the time interval from recognition of symptoms to diagnosis are urgently needed.

Addis Ababa population-based pattern of cancer therapy, Ethiopia.

Cancer in Sub-Saharan Africa is becoming an important challenge for health services due to rising numbers of patients. In Addis Ababa with around 3.5 million inhabitants, more than 2000 cases are diagnosed annually. In this retrospective population-based cohort study we assessed completeness of and waiting time for cancer-therapy among patients registered in the Addis Ababa City Cancer Registry (AACCR), Ethiopia. Patient hospital files were retrieved to complete the data from AACCR. A total of 588 files were found (51% of those diagnosed from January to March 2012 and 2014). We analyzed completeness and waiting time of chemotherapy and radiotherapy; with completeness defined as ≥85% therapy received according to local guidelines. Analysis was done for the five most common cancer-types commonly treated with chemotherapy (breast, colorectal, non-Hodgkin`s lymphoma, lung and ovarian) and the four most common cancer-types commonly treated with radiotherapy (breast, cervical, head and neck and rectal). In our study, half of the patients (54.1%) received adequately dosed chemotherapy and 24.5% of patients received adequately dosed radiotherapy. The median waiting time was 2.1 months (Range: 0 to 20.72) for chemotherapy and 7 months (Range: 0.17 to 21.8) for radiotherapy. This study underscores the need for health system measures to improve cancer-directed therapy in Ethiopia, especially concerning radiotherapy.

Adequacy of Pathologic Reports of Invasive Breast Cancer From Mastectomy Specimens at Tikur Anbessa Specialized Hospital Oncology Center in Ethiopia.

Purpose Although information from pathology reports is essential to the care of individuals with cancer and to population-level cancer control, no systematic evidence exists regarding the adequacy of breast pathology reporting in Ethiopia. This study audited pathology reports of mastectomy specimens from patients evaluated at the Tikur Anbessa Specialized Hospital Oncology Center in Addis Ababa, Ethiopia. Methods Mastectomy pathology reports from February 2014 through January 2016 were assessed for gross and microscopic information considered by the Breast Cancer Initiative 2.5 (BCI 2.5; formerly the Breast Health Global Initiative) guideline to be necessary for care of patients with breast cancer stratified according to basic, limited, and enhanced resource settings. Results Fewer than two thirds (61.6%) of the 417 reports we reviewed included all four of the BCI 2.5 basic pathology data elements we could evaluate with available data (tumor category, lymph node category, histologic type, and histologic grade). Only 1.0% of reports included all three pathology data elements recommended for limited resource settings (estrogen receptor status, margin status, and lymphovascular invasion). Several elements were significantly more likely to be noted in reports from nonpublic hospitals than from public hospitals. Although only three of 417 reports included checklists or templates, all three of these reports included all of the basic pathology information, and they all included at least two of the three limited pathology elements not already on the basic list. Conclusion More than one third (38.4%) of mastectomy pathology reports did not meet BCI 2.5 standards for basic resource settings. Quality measurement and improvement programs and capacity-building interventions by national pathology and oncology organizations, collaboration with medical and public health organizations in neighboring countries, adoption of synoptic reporting templates, use of electronic pathology reporting, and histotechnology and histopathology training collaborations with laboratories in high-resource regions are recommended.

Vulvar cancer in Ethiopia: A cohort study on the characteristics and survival of 86 patients.

Vulvar cancer (VC) is strongly associated with human papilloma virus (HPV) infections and immunosuppression (e.g., HIV). However, there is limited information on VC patient characteristics and survival in parts of sub-Saharan Africa, including Ethiopia, where chronic HPV and HIV infections are prevalent. The aim of this study is to provide a first view on VC patient characteristics in a sub-Saharan African setting.We present a retrospective analysis of records of 86 VC patients diagnosed between January 2010 and October 2015 at Addis Ababa University Hospital and other major health facilities in Ethiopia. Follow-up for vital status was obtained by telephone contact with patients or relatives. The primary endpoint was all-cause mortality.The median age of the patients was 39 (range: 20-85) years, 83% with known HIV status were positive and 81% presented with FIGO stages 2 or 3. The median follow-up time for surviving patients was 17 months (range: 0.1-65.0 months). The 1- and 2-year survival rates were 80% and 51%, respectively. Approximately 37% of patients received surgery, 38% received radiotherapy, and 33% received chemotherapy. Patients who received therapy had better survival than those who did not [adjusted hazard ratios: surgery, 0.44 (95% CI, 0.19-1.03); radiotherapy, 0.36 (95% CI, 0.14-0.90); chemotherapy, 0.42 (95% CI, 0.15-1.12)].A substantial proportion of VC patients in Ethiopia present at a late stage and receive suboptimal treatment. HIV infections appear to be a common comorbid condition. These conditions result in poor outcomes.

Cervical Cancer in Ethiopia: The Effect of Adherence to Radiotherapy on Survival.

BACKGROUND: Discontinuation of radiotherapy (RT) for cervical cancer (CC) in sub-Saharan Africa is common because of patient- and health service-related reasons. This analysis describes toxicities and the effect of adherence on survival. MATERIALS AND METHODS: A total of 788 patients with CC (2008-2012) who received RT at Addis Ababa University Hospital were included. External beam RT without brachytherapy was performed according to local guidelines. We previously described survival and prognostic factors. Now we analyzed adherence and survival according to total doses received. Adjustment via multivariate cox regression analysis was done. RESULTS: One-year overall survival (OS) after radical RT (n = 180) for International Federation of Gynecology and Obstetrics (FIGO) stages IIA-IIIA was 89% for discontinuation (<72 Gy) and 96% for adherence (≥72 Gy; hazard ratio [HR], 1.3; 95% confidence interval [CI], 0.5-3.3). One-year OS after nonradical RT (n = 389) for FIGO stages IIIB-IVA was 71% for discontinuation (<40 Gy) and 87% for adherence (44-50 Gy; HR, 3.1; 95% CI, 1.4-6.9). One-year OS for FIGO stages IIIB-IVB (n = 219) after one compared with two or more palliative single fractions of 10 Gy were 14% and 73% respectively (HR, 7.3; 95% CI, 3.3-16). Reasons for discontinuation were toxicities, economic background, and RT machine breakdown. Grade 1-2 late toxicities were common (e.g., 30% proctitis, 22% incontinence). Grade 3 early and late toxicities were seen in 5% and 10% respectively; no grade 4 toxicities occurred. CONCLUSION: Patients who adhered to guideline-conforming RT had optimum survival. Better supportive care, brachytherapy to reduce toxicities, socioeconomic support, and additional radiation capacities could contribute to better adherence and survival. IMPLICATIONS FOR PRACTICE: This study presents the effect of adherence on survival of 788 patients with cervical cancer receiving external beam radiotherapy without brachytherapy in Ethiopia. Discontinuation of planned radiotherapy according to local guidelines considerably reduced survival for all International Federation of Gynecology and Obstetrics (FIGO) stages treated (hazard ratios were 1.3, 3.1, and 7.3 for FIGO stages IIA-IIIA and IIIB-IVA and the palliative approach, respectively). Early toxicity (5% grade 3) should be treated to improve adherence. Economic difficulties and machine breakdown should also be addressed to reduce discontinuation and improve survival.

The prevalence of estrogen receptor-negative breast cancer in Ethiopia.

BACKGROUND: In contrast with breast cancers (BCs) in other parts of the world, most previous studies reported that the majority of BCs in sub-Saharan Africa are estrogen-receptor (ER) negative. However, a recent study using the US SEER database showed that the proportion of ER-negative BC is comparable between US-born blacks and West-African born blacks but substantially lower in East African-born blacks, with over 74% of patients Ethiopians or Eritreans. In this paper, we provide the first report on the proportion of ER-negative BC in Ethiopia, and the relation to progesterone-receptor (PgR) status. METHODS: We analysed 352 female patients with ER results available out of 1208 consecutive female BC patients treated at Addis Ababa-University Hospital, Ethiopia, from June 2005 through December 2010. The influences of age, stage, and histology on the probability of ER-negative tumours were assessed by a log-linear regression model. RESULTS: Of the 352 patients, only 35% were ER-negative. The proportion of ER-negative tumours decreased with advancing age at diagnosis and was not affected by histology or stage. For age, the proportion decreased by 6% for each additional 5 years (stage-adjusted prevalence ratio PR=0.94, 95% CI: 0.89-1.00). About 31% were ER- and PgR-negative, and 69% were ER- and/or PgR-positive. CONCLUSIONS: Contrary to most previous reports in other parts of sub-Saharan Africa, the majority of patients in Ethiopia are ER-positive rather than ER-negative. These findings are in line with low proportions of ER-negative BCs from East African immigrants within the SEER database, and they have clinical implications for management of BC patients in Ethiopia and other parts of sub-Saharan Africa where ER-status is not ascertained as part of routine management of the disease. Since the majority of patients showed ER-positive BC, Tamoxifen-therapy should be given to all patients even with unknown ER status.

Cervical cancer in Ethiopia: survival of 1,059 patients who received oncologic therapy.

BACKGROUND: Almost 500,000 women are newly diagnosed with cervical cancer (CC) every year, the majority from developing countries. There is little information on the survival of these patients. Our primary objective was to evaluate consecutive CC patients presenting over 4 years at the only radiotherapy center in Ethiopia. METHODS: All patients with CC from September 2008 to September 2012 who received radiotherapy and/or surgery were included (without brachytherapy). Vital status was obtained through telephone contact or patient cards. RESULTS: Of 2,300 CC patients, 1,059 patients with standardized treatment were included. At the end of the study, 249 patients had died; surviving patients had a median follow-up of 16.5 months; the 10% and 90% percentiles were 3.0 and 32.7 months, respectively. Mean age was 49 years (21-91 years). The majority of patients presented with International Federation of Gynecology and Obstetrics stage IIb-IIIa (46.7%). Because of progression during the waiting time (median 3.8 months), this proportion declined to 19.3% at the beginning of radiotherapy. The 1- and 2-year overall survival probabilities were 90.4% and 73.6%. If assuming a worst-case scenario (i.e., if all patients not available for follow-up after 6 months had died), the 2-year survival probability would be 45.4%. CONCLUSION: This study gives a thorough 4-year overview of treated patients with CC in Ethiopia. Given the limited treatment availability, a relatively high proportion of patients survived 2 years. More prevention and early detection at all levels of the health care system are needed. Increasing the capacity for external-beam radiation as well as options for brachytherapy would facilitate treatment with curative intention.