Determinants of late detection and advanced-stage diagnosis of breast cancer in Nigeria.

OBJECTIVE: To describe the risk factors for late detection and advanced-stage diagnosis among patients who detected their BC early. METHOD: Using secondary data, we analyzed the impact of socio-demographic factors, premorbid experience, BC knowledge, and health-seeking pattern on the risk of late detection and advanced-stage diagnosis after early BC detection. Test of statistical significance in SPSS and EasyR was set at 5% using Sign-test, chi-square tests (of independence and goodness of fit), odds ratio, or risk ratio as appropriate. RESULT: Most socio-demographic factors did not affect detection size or risk of disease progression in the 405 records analyzed. High BC knowledge, p-value = 0.001, and practicing breast self-examination (BSE) increased early detection, p-value = 0.04, with a higher probability (OR 1.6 (95% CI 1.1-2.5) of detecting <2cm lesions. Visiting alternative care (RR 1.5(95% CI 1.2-1.9), low BC knowledge (RR 1.3(95% CI 1.1-1.9), and registering concerns for hospital care increased the risk of advanced-stage diagnosis after early detection (64% (95% CI 55-72)). Adhering to the monthly BSE schedule reduced the risk of advanced-stage diagnosis by -25% (95% CI -49, -1.1) in the presence of socioeconomic barriers. CONCLUSION: Strategies to increase BC knowledge and BSE may help BC downstaging, especially among women with common barriers to early diagnosis.

Molecular and phenotypic profiling of colorectal cancer patients in West Africa reveals biological insights.

Understanding the molecular and phenotypic profile of colorectal cancer (CRC) in West Africa is vital to addressing the regions rising burden of disease. Tissue from unselected Nigerian patients was analyzed with a multigene, next-generation sequencing assay. The rate of microsatellite instability is significantly higher among Nigerian CRC patients (28.1%) than patients from The Cancer Genome Atlas (TCGA, 14.2%) and Memorial Sloan Kettering Cancer Center (MSKCC, 8.5%, P < 0.001). In microsatellite-stable cases, tumors from Nigerian patients are less likely to have APC mutations (39.1% vs. 76.0% MSKCC P < 0.001) and WNT pathway alterations (47.8% vs. 81.9% MSKCC, P < 0.001); whereas RAS pathway alteration is more prevalent (76.1% vs. 59.6%, P = 0.03). Nigerian CRC patients are also younger and more likely to present with rectal disease (50.8% vs. 33.7% MSKCC, P < 0.001). The findings suggest a unique biology of CRC in Nigeria, which emphasizes the need for regional data to guide diagnostic and treatment approaches for patients in West Africa.

High-burden Cancers in Middle-income Countries: A Review of Prevention and Early Detection Strategies Targeting At-risk Populations.

Cancer incidence is rising in low- and especially middle-income countries (MIC), driven primarily by four high-burden cancers (breast, cervix, lung, colorectal). By 2030, more than two-thirds of all cancer deaths will occur in MICs. Prevention and early detection are required alongside efforts to improve access to cancer treatment. Successful strategies for decreasing cancer mortality in high-income countries are not always effective, feasible or affordable in other countries. In this review, we evaluate strategies for prevention and early detection of breast, cervix, lung, and colorectal cancers, focusing on modifiable risk factors and high-risk subpopulations. Tobacco taxation, human papilloma virus vaccination, cervical cancer screen-and-treat strategies, and efforts to reduce patient and health system-related delays in the early detection of breast and colorectal cancer represent the highest yield strategies for advancing cancer control in many MICs. An initial focus on high-risk populations is appropriate, with increasing population coverage as resources allow. These strategies can deliver significant cancer mortality gains, and serve as a foundation from which countries can develop comprehensive cancer control programs. Investment in national cancer surveillance infrastructure is needed; the absence of national cancer data to identify at-risk groups remains a barrier to the development of context-specific cancer control strategies.

Presentation intervals and the impact of delay on breast cancer progression in a black African population.

BACKGROUND: The help-seeking interval and primary-care interval are points of delays in breast cancer presentation. To inform future intervention targeting early diagnosis of breast cancer, we described the contribution of each interval to the delay and the impact of delay on tumor progression. METHOD: We conducted a multicentered survey from June 2017 to May 2018 hypothesizing that most patients visited the first healthcare provider within 60 days of tumor detection. Inferential statistics were by t-test, chi-square test, and Wilcoxon-Signed Rank test at p-value 0.05 or 95% confidence limits. Time-to-event was by survival method. Multivariate analysis was by logistic regression. RESULTS: Respondents were females between 24 and 95 years (n = 420). Most respondents visited FHP within 60 days of detecting symptoms (230 (60, 95% CI 53-63). Most had long primary-care (237 of 377 (64 95% CI 59-68) and detection-to-specialist (293 (73% (95% CI 68-77)) intervals. The primary care interval (median 106 days, IQR 13-337) was longer than the help-seeking interval (median 42 days, IQR 7-150) Wilcoxon signed-rank test p = 0.001. There was a strong correlation between the length of primary care interval and the detection-to-specialist interval (r = 0.9, 95% CI 0.88-0.92). Patronizing the hospital, receiving the correct advice, and having a big tumor (> 5 cm) were associated with short intervals. Tumors were detected early, but most became advanced before arriving at the specialist clinic. The difference in tumor size between detection and arriving at a specialist clinic was 5.0 ± 4.9 cm (95% CI 4.0-5.0). The hazard of progressing from early to locally advanced disease was least in the first 30 days (3%). The hazard was 31% in 90 days. CONCLUSION: Most respondents presented early to the first healthcare provider, but most arrived late at a specialist clinic. The primary care interval was longer than the help-seeking interval. Most tumors were early at detection but locally advanced before arriving in a specialist clinic. Interventions aiming to shorten the primary care interval will have the most impact on time to breast cancer presentation for specialist oncology care in Nigeria.

Treatment of colorectal cancer in Sub-Saharan Africa: Results from a prospective Nigerian hospital registry.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer worldwide. Mortality for CRC is improving in high income countries, but in low and middle income countries, rates of disease and death from disease are rising. In Sub-Saharan Africa, the ratio of CRC mortality to incidence is the highest in the world. This study investigated the nature of CRC treatment currently being offered and received in Nigeria. METHODS: Between April 2013 and October 2017, a prospective study of consecutively diagnosed cases of CRC was conducted. Patient demographics, clinical features, and treatment recommended and received was recorded for each case. Patients were followed during the study period every 3 months or until death. RESULTS: Three hundred patients were included in our analysis. Seventy-one percent of patients received a recommended surgical operation. Of those that didn't undergo surgery as recommended, 37% cited cost as the main reason, 30% declined due to personal reasons, and less than 5% absconded or were lost to follow up. Approximately half of patients (50.5%) received a chemotherapy regimen when it was recommended, and 4.1% received radiotherapy when this was advised as optimal treatment. With therapy, the median overall survival for patients diagnosed with stage III and stage IV CRC was 24 and 10.5 months respectively. Overall, we found significantly better median survival for patients that received the recommended treatment (25 vs 7 months; P < .01). CONCLUSIONS: A number of patients were unable to receive the recommended treatment, reflecting some of the burden of untreated CRC in the region. Receiving the recommended treatment was associated with a significant difference in outcome. Improved healthcare financing, literacy, training, access, and a better understanding of tumor biology will be necessary to address this discrepancy.

Impact of Primary Care Delay on Progression of Breast Cancer in a Black African Population: A Multicentered Survey.

BACKGROUND: Reports are scanty on the impact of long primary care interval in breast cancer. Exploratory reports in Nigeria and other low-middle-income countries suggest detrimental impact. The primary aim was to describe the impact of long primary care interval on breast cancer progression, and the secondary aim was to describe the factors perceived by patients as the reason(s) for long intervals. METHOD: Questionnaire-based survey was used in 9 Nigerian tertiary institutions between May 2017 and July 2018. The study hypothesis was that the majority of patients stayed >30 days, and the majority experienced stage migration in primary care interval. Assessment of the impact of the length of interval on tumor stage was done by survival analysis technique, and clustering analysis was used to find subgroups of the patient journey. RESULTS: A total of 237 patients presented to primary care personnel with tumor ≤5cm (mean 3.4±1.2cm). A total of 151 (69.3%, 95% CI 62.0-75.0) stayed >30 days in primary care interval. Risk of stage migration in primary care interval was 49.3% (95% CI 42.5%-56.3%). The most common reasons for long intervals were symptom misinformation and misdiagnosis. Clustering analysis showed 4 clusters of patients' experience and journey: long interval due to distance, long interval due to misinformation, long interval due to deliberate delaying, and not short interval-prepared for treatment. CONCLUSION: The majority of patients stayed longer than 30 days in primary care interval. Long primary care interval was associated with a higher risk of stage migration, and more patients reported misinformation and misdiagnosis as reasons for a long interval.

Surgical outcome of cutting diathermy versus scalpel skin incisions in uncomplicated appendectomy: A comparative study.

BACKGROUND: It is traditionally believed that diathermy skin incisions produce a comparatively poorer surgical outcome despite recent evidences to the contrary. This study set out to compare diathermy and scalpel skin incisions with respect to immediate post-operative pain, surgical-site infection and surgical scar cosmesis. METHODOLOGY: This was a randomised, double-blinded study comparing cutting diathermy and scalpel skin incisions in patients undergoing open appendectomies for uncomplicated appendicitis. The post-operative pain was rated with the Visual Analogue Pain Scale 6, 12 and 24 h postoperatively, and 30 day wound infection was rated with the Southampton score. Scar cosmesis was assessed at 3 months, by a plastic surgery trainee, using the Patient and Observer Scar Assessment Scale (POSAS). The patients also self-evaluated their scars using POSAS. RESULTS: A total of 64 patients were randomised to cutting diathermy (32) and scalpel (32) skin incision groups. The mean pain score was higher in the diathermy incised wounds, but this was not statistically significant (P = 0.094). There was one wound infection recorded in the scalpel incision group and none in the diathermy incision group (P = 0.524). At 3 months post-surgery, there was no difference between the diathermy and scalpel incised wounds in mean (±SD) objective POSAS scores (15.64 [±5.98] vs. 17.79 [±6.37], P = 0.228) or subjective POSAS scores (22.44 [±13.13] vs. 22.21 [±13.17], P = 0.951), respectively. The mean scar satisfaction score, as assessed by the patients, was better for the diathermy incised wounds, but this was not statistically significant (P = 0.406). CONCLUSION: In patients undergoing open appendectomy for uncomplicated acute appendicitis, skin incision with a cutting diathermy is not inferior to the scalpel in surgical outcome, with respect to post-operative pain, wound infection and surgical scar cosmesis.

Establishing a Cancer Research Consortium in Low- and Middle-Income Countries: Challenges Faced and Lessons Learned.

PURPOSE: There is an increasing effort in the global public health community to strengthen research capacity in low- and middle-income countries, but there is no consensus on how best to approach such endeavors. Successful consortia that perform research on HIV/AIDS and other infectious diseases exist, but few papers have been published detailing the challenges faced and lessons learned in setting up and running a successful research consortium. METHODS: Members of the African Research Group for Oncology (ARGO) participated in generating lessons learned regarding the foundation and maintenance of a cancer research consortium in Nigeria. RESULTS: Drawing on our experience of founding ARGO, we describe steps and key factors needed to establish a successful collaborative consortium between researchers from both high- and low-income countries. In addition, we present challenges we encountered in building our consortium, and how we managed those challenges. Although our research group is focused primarily on cancer, many of our lessons learned can be applied more widely in biomedical or public health research in low-income countries. CONCLUSIONS: As the need for cancer care in LMICs continues to grow, the ability to create sustainable, innovative, collaborative research groups will become vital. Assessing the successes and failures that occur in creating and sustaining research consortia in LMICs is important for expansion of research and training capacity in LMICs.