Impact of 10-Day Fulbright Specialist Program and Project Pink Blue Education Sessions on Medical Oncology Knowledge Among Physicians Who Treat Cancer in Nigeria.

Despite an estimated population of over 201 million and over 115,950 yearly diagnosed new cases of cancer, Nigeria does not have dedicated medical oncologists. Most oncology care is delivered through surgical and clinical oncologists, who are trained in both radiation and medical oncology and they number fewer than 50 in the country. With a limited number of oncology professionals, cancer patients in Nigeria experience poor health outcomes, with an estimated cancer mortality rate of 75,000 deaths per year. Participants from 15 Nigerian states were selected to attend the medical oncology training. Through the support of Fulbright Specialist Program and Project PINK BLUE, two of the authors delivered 10 days of lectures based on ASCO, ESMO, and NCCN guidelines. Mean scores of both the pre- and post-course tests as well as a 1-year follow-up test were compared using GraphPad Prism 7.0a by paired t-tests. Forty-four clinical oncologists were selected for participation. Twenty-five (57%) completed the pre- and post-course tests. Of the 25 that completed both tests, percentage of correct answers increased from 45 to 59% (2-sided p-value < 0.0001). Improvements were seen in attending doctors 45 to 59% (p = 0.0046) and resident doctors 45 to 59% (0.0007). Eleven doctors responded to the 1-year follow-up test. Although not statistically significant, a numerical pattern for the benefits was maintained 1 year after the program (45% pre-course versus 52% post-course correct answers, Fisher's exact, p = 0.4185). In the short term, the training improved medical oncology knowledge in Nigeria, regardless of the participant's carrier stage. Long-term benefits were not sustained in a small sample of participants, and continuing education strategies are necessary. Similar models may be employed across Africa.

Clinico-pathologic characterisation of metastatic prostate cancer in the Radiotherapy and Oncology Department, Ahmadu Bello University Teaching Hospital, Zaria-Nigeria: 2006-2009.

AIMS AND OBJECTIVES: To evaluate the Clinico-pathologic Characteristics of Metastatic prostate cancer patients seen in the Radiotherapy and Oncology Department, Ahmadu Bello University Teaching Hospital, Nigeria. MATERIALS AND METHODS: Between January 2006 and December 2009, a period of 4 years, 72 new patients with prostate cancers were seen of which 43 patients had distant metastases. Only patients with histologic confirmation of prostate cancer and having metastases were included in the study irrespective of age, co-morbidity and performance status. Patients' folders were reviewed retrospectively with a structured pro forma. Information retrieved from patient's folder included age, histology, Gleason score, co-morbidities, interval between diagnosis and referral to oncology unit, interval between referral and presentation at oncology unit, PSA at diagnosis and presentation at oncology unit, sites of metastases, bones sites involved in bone metastases, types of treatment received and follow up status. Results were analysed using Epi Info soft ware Version 3.4.1; 2007 Edition. RESULTS: 43 patients had distant metastases from prostate cancer during initial evaluation at presentation in the radiotherapy and oncology centre. The mean age was 66.2 years (range, 47-82 years, median age 66 years and modal age group was 65-69 years). Co-morbidity was seen in 18 patients, with hypertension being the commonest (HT=14, DM=2 and HIV 2 patients). No morbidity seen in 25 patients. The range of duration from diagnosis to referral was 1-84 months. Only 20 patients presented at radiotherapy and oncology centre within 6 months of diagnosis and 18 patients presented after 12 months of diagnosis. 33 patients presented within 1 month of being referred for further management. 6 patients reported within 2 months and 2 patients within 3 months and another 2 patients within 4 months. Only 27 patients had PSA done at diagnosis. No PSA was done in 16 patients. The PSA range at diagnosis was 10.0-232 ng/ml, mean PSA was 67.46 ng/ml while only 40 patients did PSA on presentation for further management with a range of 1-245 ng/ml and a mean of 57.95 ng/ml. The histology report revealed adenocarcinoma and transitional carcinoma in 42 and 1 patients respectively. The Gleason score range was 6-10, with a mean score of 7.8. The Gleason score was not reported in 3 patients. Multiple organs involvement by metastases was seen in 16 patients. Bone metastases was the commonest (35), followed by lungs (8), liver (7), Virchow's lymph nodes (6), brain (5), and soft tissue (5). The lumbar vertebrae was the commonest site of bone metastases (32) followed by the sacrum (17), pelvis (11), and long bones (7). 3 patients had metastases to the ribs and 2 patients each to the skull, sternum and cervical spines. All the patients received hormonal therapy, 30 patients received palliative radiotherapy, 29 patients had surgical castration, 25 patients had radical radiotherapy to pelvis, 18 patients had systemic chemotherapy and definitive surgery was done in 16 patients. Only 6 patients received Ibandronate due to cost. 13 patients are alive and attending follow up, 11 confirmed dead and 19 lost to follow up. CONCLUSION: The patients were referred for management late after surgery. Bones, predominately the lumbosacral spines was the commonest organ involved in metastases. Skeletal survey with bone scan and plain x-rays especially lumbosacral spines should be part of the staging investigation for all patients with advanced stage. There is need for more awareness on other treatment modalities emphasizing the multidiscipline and multimodality management of prostate cancer.

Radiotherapy in cancer management at Mulago Hospital, Kampala, Uganda.

Five hundred and seven cancer patients who received radiotherapy using the newly upgraded facilities at the Mulago Hospital over a 16 month period following the inception of the services are reviewed. Previously available facilities had been limited to teletherapy using only a 300 KV orthovoltage X-ray machine which had proved inadequate to cope with the current needs at the department. The International Atomic Energy Agency (IAEA) in Vienna recently upgraded the available services through the provision of facilities for cobalt-60 teletherapy, brachytherapy and computerised treatment planning and dosimetry as well as providing training for all cadres of the radiotherapy department. We review the impact of this new service on the referral pattern and types of patients who received radiotherapy since inception. Over 60% of all the patients were women who presented with carcinoma of the cervix and breast. Apart from the apparent increase in cases of cervical carcinoma, the current AIDS pandemic in Uganda did not appear to reflect any increase in the incidence of other AIDS-related cancers such as Kaposi's sarcoma and non-Hodgkins lymphomas treated at the department. The need for more patients and earlier referrals to the department is stressed in order to maximise the use of the improved radiotherapy services.

Radiotherapy of childhood malignancies in Nigeria.

Malignant tumours in children rank fourth after carcinoma of the cervix, breast, and head and neck tumours among the malignancies managed by radiotherapy in Nigeria. The management of these tumours constitute a myriad of problems which are probably responsible for the overall poor survival results observed. This paper analyzed and discussed the epidemiology, presentation and radiotherapeutic management of 122 paediatric malignancies seen and managed between 1981-84 at the radiotherapy unit of the Lagos University Teaching Hospital, Nigeria. This unit was up till 1986 the only radiotherapy service available in Nigeria and the rest of the Anglophone West African states. The potential beneficial role of a multidisciplinary approach in the management of these tumours is stressed. Several other factors which may improve the quality of care and survival among this group of patients are discussed. The recent upgrading of radiotherapy services in Nigeria through the Technical cooperation assistance programme of the International Atomic Energy Agency in Vienna has further improved the scope of radiotherapy facilities in the country. This is expected to result in improved standards of patient care, and survival.

A short course postoperative radiotherapy regime for keloid scars in Nigeria.

The unsatisfactory high rate of recurrence following the traditional approach for the radiotherapy of keloid scars in Nigeria, led to the design of this study which employed a short course post operative radiotherapy regime. Two hundred and forty four patients with four hundred and fifty four (454) keloidal scars treated with superficial X-ray therapy within 72 hours following surgical excision at the Lagos University Teaching Hospital Lagos, Nigeria, between January, 1984 and December, 1988 were analyzed. The commonest site treated was the ear lobe (36.8%). Radiation dose ranged between 5-6Gy in single sessions and 12-15Gy in 3 fractions over 5 days. A complete response rate of 93% at 24 months was achieved. The treatment was well tolerated with no serious complications reported to date.

A regional training programme for radiotherapists and allied professionals for the west African health community.

With 47% of the population under 15 years of age and the control of infectious and other communicable diseases, cancer will likely constitute a major health problem in West Africa in future. Radiotherapy facilities and trained manpower to run them are very limited within the subregion. This paper quantifies the severity of the situation and discusses a practical approach aimed at coping with the situation through the organisation of a training programme for radiotherapists, medical physicists and radiation technologists as part of the strategies for cancer control in West Africa. A curriculum is proposed for the training of radiotherapists.

Supporting cancer care in the developing countries: role of IAEA/WHO.

Cancer management can be expensive and constitutes a major problem in many developing countries where management standards are poor due to many factors, including non-availability of sufficient funds, equipment, and trained personnel. The incidence of cancer is rising worldwide. This is more so in the developing countries, many of whom are less equipped to deal with the problems. Radiation therapy is one of the major treatment modalities for cancer, and it is estimated that about 60% of all cancer patients require this treatment at one time or another during the course of their disease. Unfortunately, radiotherapy facilities are lacking or grossly inadequate in many developing countries. Over the past 8 years the IAEA and WHO have shown more interest in the problem and treatment of cancer in the developing countries. This paper reviews the role of these international organizations, with emphasis on research activities, education (seminars, workshops, training courses), and technical assistance programs. These include establishment or upgrading of radiotherapy facilities, provision of experts, etc. Scientific papers are published with a view to disseminating current information and research findings in the developing countries. The achievements up to date are assessed and discussed.

An overview of the situation in radiotherapy with emphasis on the developing countries.

Radiotherapy services are closely linked to the level of medical care which, in turn, is an important component of the overall health care program, with its development related to social, economic, and educational factors. As a basis for understanding the situation regarding adequate coverage of the population by radiotherapy services, general information about the world population (currently 5 billion), age distribution, frequency of cancer occurrence, and causes of death is presented. For an appreciation of the obstacles that must be overcome, the situation with regard to Gross National Product (GNP), transfer of economic resources, and per capita expenditures for health services is shown. For example, in the developing world, most countries spend less than 5% of their GNP for health, and on a macro scale at least 20 billion U.S. dollars per year are being transferred from the poor nations of the southern hemisphere to the northern hemisphere. Information about the wide range of population coverage with radiotherapy resources and the trend regarding high-energy radiotherapy machines is presented. For example, in North America (USA) there are six high-energy machines for each one million persons, and each machine is used to treat about 230 new patients per year. In other parts of the world, such as large areas of Africa and South-East Asia, there may only be one high-energy radiotherapy machine for 20 to 40 million people, and one machine may be used to treat more than 600 new patients per year. Many cancer patients have no access to radiotherapy services. When estimates of the need for radiotherapy services in the developing world as a consequence of cancer incidence are compared with the current health expenditures, it is concluded that a combined effort of national authorities, donor and financial institutions, professional and scientific societies, and international organizations is required. The knowledge, skills, and technology are available in many excellent radiotherapy centers throughout the world. The key issues are priority and the commitment of sufficient resources.

An overview of cancer management by radiotherapy in Anglophone West Africa.

The problems associated with cancer management particularly by radiotherapy in the developing countries are well known. This paper attempts to present the case as it is in Anglophone West Africa, and to quantify the severity of the problem through a critical analysis of available data based on the experience at the oldest radiotherapy center in West Africa between January 1981 and December 1988. In the whole of the Anglophone West African states with a population estimated at 140 million people, there was only one functional radiotherapy center until 1986 when another unit was commissioned. The paper analyzes the types of tumors managed, radiotherapy facilities available, staffing, and the other operational problems encountered by the Radiotherapy Department of the Lagos University Teaching Hospital in Nigeria. Suggestions are made for the overall improvement of radiotherapy services in the region.

Combination chemotherapy as the first line in the management of locally advanced epidermoid carcinoma of the head and neck region in Nigerians.

Of cancer patients in Nigeria, 92% report at a late stage before treatment. Those with tumours of the head and neck region in particular, pose serious problems with management. Their advanced disease means that they are often inoperable and results of treatment by radiation are poor because the dose is limited to what the tissues can tolerate and also because the larger the tumour volume involved, the less the amount of radiation dose possible, so the response is poor. The problem is made worse by inadequate radiotherapy facilities. At the time of the study only one moderately equipped radiotherapy centre served the whole of Nigeria (with a population of 100 million) and neighbouring Ghana, Sierra-Leone and the Cameroons. There is usually a patient waiting list of about 3-4 months at any time, thus making prompt treatment impossible. These local problems and the search for an alternative approach led to this prospective study, which took place between 1980 and 1984. Two hundred and five adult patients with histologically proven, and locally advanced, epidermoid carcinoma in the head and neck region were given combination chemotherapy with Vincristine, Bleomycin and Methotrexate as the first line of management. There was a tumour regression rate of 68% (complete + partial), such that further treatment with surgery, radiotherapy, or a combination of both was then possible.

Primary fibrosarcoma of the scalp: a review of a ten-year record from Lagos, Nigeria.

Primary fibrosarcoma of the scalp is very rare and, although the tumour is slow growing, it often results in major cosmetic and other problems. Repeated surgical excisions for recurrent disease are often necessary. We report our experience of the management of this rare tumour at the Lagos University Teaching Hospital, Nigeria: a national referral centre for malignant tumours requiring radiotherapy. Five patients were seen over a 10-year period. An 80% recurrence-free interval was obtained at 2 years with surgery and radiotherapy.

Radiation therapy in the management of chemodectomas in Nigeria.

Chemodectomas constitute a very rare group of tumours. They have been described at various sites in the body and their management, particularly the glomus jugulare tumours is of interest, as surgery in some cases may be hazardous and possibly fatal as a result of severe haemorrhage associated with these tumours. Radiotherapy has been advocated as the treatment of choice particularly for the glomus jugulare tumour. Our experience in the management of this rare group of tumours seen at the only Radiotherapy Unit in Nigeria between 1975 and 1979 is analysed. Radiation therapy techniques, doses given and complications noticed are analysed. There was complete control of the disease in four out of four (100%) of the cases at 1 year and three out of four (75%) at 3 years. Results from other reports in the literature are reviewed.

The bacteriology of infected malignant ulcers.

Infected ulcerated malignant tumours are often foul smelling and covered with necrotic tissue. We have studied 70 patients with infected ulcers; 30 of the underlying lesions in these patients were carcinoma of the breast, and 19 were a variety of skin cancers. Anaerobes were the predominant organisms isolated from individual ulcers. Of the 179 anaerobes isolated, 37 were Bacteroides asaccharolyticus, 31 each were B melaninogenicus and anaerobic streptococci, 29 B fragilis, and 17 B ureolyticus. Among the facultative organisms Escherichia coli was the commonest and was isolated mainly from patients with carcinoma of the breast. Most infections were mixed, yielding both anaerobes and aerobes and this made interpretation of the role of individual pathogens difficult to assess.

The treatment of Kaposi's sarcoma by combination chemotherapy in Nigeria.

Kaposi's sarcoma is known to be multicentric in origin. It starts predominantly on the skin but visceral organs can be involved as well. Previous experience in the management of this condition in Lagos, Nigeria has been based mainly on the use of local radiotherapy. A better understanding of the natural history and clinicopathological features of this disease has given prominence to the use of chemotherapy and this is now being advocated as the first line of management in most cases in place of radiotherapy. Experience and results of the use of multiple chemotherapy in 10 cases seen at the Lagos University Teaching Hospital between 1976 and 1982 are discussed. Seven patients (70%) showed complete tumour regression, two (20%) had partial response and one (10%) did not respond.