Pitfalls of practicing cancer epidemiology in resource-limited settings: the case of survival and loss to follow-up after a diagnosis of Kaposi's sarcoma in five countries across sub-Saharan Africa.

BACKGROUND: Survival after diagnosis is a fundamental concern in cancer epidemiology. In resource-rich settings, ambient clinical databases, municipal data and cancer registries make survival estimation in real-world populations relatively straightforward. In resource-poor settings, given the deficiencies in a variety of health-related data systems, it is less clear how well we can determine cancer survival from ambient data. METHODS: We addressed this issue in sub-Saharan Africa for Kaposi's sarcoma (KS), a cancer for which incidence has exploded with the HIV epidemic but for which survival in the region may be changing with the recent advent of antiretroviral therapy (ART). From 33 primary care HIV Clinics in Kenya, Uganda, Malawi, Nigeria and Cameroon participating in the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortia in 2009-2012, we identified 1328 adults with newly diagnosed KS. Patients were evaluated from KS diagnosis until death, transfer to another facility or database closure. RESULTS: Nominally, 22% of patients were estimated to be dead by 2 years, but this estimate was clouded by 45% cumulative lost to follow-up with unknown vital status by 2 years. After adjustment for site and CD4 count, age <30 years and male sex were independently associated with becoming lost. CONCLUSIONS: In this community-based sample of patients diagnosed with KS in sub-Saharan Africa, almost half became lost to follow-up by 2 years. This precluded accurate estimation of survival. Until we either generally strengthen data systems or implement cancer-specific enhancements (e.g., tracking of the lost) in the region, insights from cancer epidemiology will be limited.

An innovative system for 3D clinical photography in the resource-limited settings.

BACKGROUND: Kaposi's sarcoma (KS) is the most frequently occurring cancer in Mozambique among men and the second most frequently occurring cancer among women. Effective therapeutic treatments for KS are poorly understood in this area. There is an unmet need to develop a simple but accurate tool for improved monitoring and diagnosis in a resource-limited setting. Standardized clinical photographs have been considered to be an essential part of the evaluation. METHODS: When a therapeutic response is achieved, nodular KS often exhibits a reduction of the thickness without a change in the base area of the lesion. To evaluate the vertical space along with other characters of a KS lesion, we have created an innovative imaging system with a consumer light-field camera attached to a miniature "photography studio" adaptor. The image file can be further processed by computational methods for quantification. RESULTS: With this novel imaging system, each high-quality 3D image was consistently obtained with a single camera shot at bedside by minimally trained personnel. After computational processing, all-focused photos and measurable 3D parameters were obtained. More than 80 KS image sets were processed in a semi-automated fashion. CONCLUSIONS: In this proof-of-concept study, the feasibility to use a simple, low-cost and user-friendly system has been established for future clinical study to monitor KS therapeutic response. This 3D imaging system can be also applied to obtain standardized clinical photographs for other diseases.

Oral manifestations associated with HIV infection: evaluation, assessment, and significance.

During the course of HIV disease, oral lesions frequently are the initial manifestation of underlying immune deterioration. Typically, these lesions are readily accessible and lend themselves to being examined. Therefore, it is important to perform oral examinations routinely both in dental and medical settings. The recognition and treatment of these early signs of immune suppression may have a significant impact on the survival and the quality of life of HIV-infected patients. This article briefly discusses the HIV epidemic and common intraoral manifestations associated with HIV disease progression.

Topodermatographic image analysis for melanoma screening and the quantitative assessment of tumor dimension parameters of the skin.

BACKGROUND: The clinical need to identify and evaluate changes of cutaneous lesions in melanoma screening or follow-up of patients with cancer is of paramount importance. Because skin-lesion changes may be small and numerous, clinical assessment alone does not meet the requirements of quantitative assessment. Using the computer as a diagnostic tool for the image analysis of sequentially captured skin surface images has resulted in the technical problem of insufficient registration reproducibility. This paper describes the technical logistics, setup procedure, and clinical evaluation of the novel technique termed "topodermatography," which performs the quantitative videographic image analysis of skin-lesion changes over time. METHODS: Digitized measurements of skin-surface image parameters were performed using a high-speed processor with an onboard coprocessor, a high-resolution video camera, specifically designed image processing software, and a position framework for the adjustment of the patient's standing position. The topodermatographic image analysis was performed on 109 consecutive patients who were at risk for melanoma (N = 98), had lesions from Kaposi's sarcoma (N = 4), had metastatic skin deposits from melanoma (N = 3), and had breast cancer (N = 4). RESULTS: Skin lesion changes over time could be identified reliably within a few millimeters of diametric enlargement. In this series, a 0.51% early melanoma detection rate was assessed in 19 of 98 patients followed for 12 months. By monitoring manifest neoplastic skin lesions, tumor growth kinetics were analyzed quantitatively to determine the total area of skin involvement, thus facilitating precise response assessment. CONCLUSIONS: Topodermatographic image analysis helps to optimize screening and follow-up procedures for patients with melanoma and populations at risk for melanoma. In addition, metastatic tumor lesions on the skin can be monitored dynamically, facilitating the accurate evaluation of the impact of systemic therapy on multiple skin deposits from melanoma and nonmelanoma cancers.