Cervical Cancer in Sub-Saharan Africa: A Multinational Population-Based Cohort Study of Care and Guideline Adherence.

BACKGROUND: Cervical cancer (CC) is the most common female cancer in many countries of sub-Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS). METHODS: Our observational study covered nine population-based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44-125 patients diagnosed from 2010 to 2016 were selected in each. Cancer-directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (U.S.) Guidelines. RESULTS: Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline-adherent, 2.4% with minor deviations, and 8.2% with major deviations. CDT was not documented or was without curative potential in 22%; 15.7% were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease. Adherence was not assessed in 46.9% (no stage or follow-up documented, 11.9%, or records not traced, 35.1%). The largest share of guideline-adherent CDT was observed in Nairobi (49%) and the smallest in Maputo (4%). In patients with FIGO stage I-III disease (n = 190), minor and major guideline deviations were associated with impaired OS (hazard rate ratio [HRR], 1.73; 95% confidence interval [CI], 0.36-8.37; HRR, 1.97; CI, 0.59-6.56, respectively). CDT without curative potential (HRR, 3.88; CI, 1.19-12.71) and no CDT (HRR, 9.43; CI, 3.03-29.33) showed substantially worse survival. CONCLUSION: We found that only one in six patients with cervical cancer in SSA received CDT with curative potential. At least one-fifth and possibly up to two-thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of many patients. IMPLICATIONS FOR PRACTICE: Despite evidence-based interventions including guideline-adherent treatment for cervical cancer (CC), there is huge disparity in survival across the globe. This comprehensive multinational population-based registry study aimed to assess the status quo of presentation, treatment guideline adherence, and survival in eight countries. Patients across sub-Saharan Africa present in late stages, and treatment guideline adherence is remarkably low. Both factors were associated with unfavorable survival. This report warns about the inability of most women with cervical cancer in sub-Saharan Africa to access timely and high-quality diagnostic and treatment services, serving as guidance to institutions and policy makers. With regard to clinical practice, there might be cancer-directed treatment options that, although not fully guideline adherent, have relevant survival benefit. Others should perhaps not be chosen even under resource-constrained circumstances.

Clinical presentation and diagnosis of adult patients with non-Hodgkin lymphoma in Sub-Saharan Africa.

Non-Hodgkin lymphoma (NHL) is the sixth most common cancer in Sub-Saharan Africa (SSA). Comprehensive diagnostics of NHL are essential for effective treatment. Our objective was to assess the frequency of NHL subtypes, disease stage and further diagnostic aspects. Eleven population-based cancer registries in 10 countries participated in our observational study. A random sample of 516 patients was included. Histological confirmation of NHL was available for 76.2% and cytological confirmation for another 17.3%. NHL subclassification was determined in 42.1%. Of these, diffuse large B cell lymphoma, chronic lymphocytic leukaemia and Burkitt lymphoma were the most common subtypes identified (48.8%, 18.4% and 6.0%, respectively). We traced 293 patients, for whom recorded data were amended using clinical records. For these, information on stage, human immunodeficiency virus (HIV) status and Eastern Cooperative Oncology Group Performance Status (ECOG PS) was available for 60.8%, 52.6% and 45.1%, respectively. Stage at diagnosis was advanced for 130 of 178 (73.0%) patients, HIV status was positive for 97 of 154 (63.0%) and ECOG PS was ≥2 for 81 of 132 (61.4%). Knowledge about NHL subclassification and baseline clinical characteristics is crucial for guideline-recommended treatment. Hence, regionally adapted investments in pathological capacity, as well as standardised clinical diagnostics, will significantly improve the therapeutic precision for NHL in SSA.

Cancer in Mozambique: Results from two population-based cancer registries.

Results from two recently established population-based registries in Mozambique are reported: Beira in the central region (2014-2017) and Maputo, the capital city, in the South (2015-2017). The results are compared to those from Maputo (Lourenço Marques at the time) in 1956-1960 (appearing Cancer Incidence in Five Continents Vol 1), and with estimated incidence rates from other regions of Africa. The elevated prevalence of HIV infection (12.6% of adults in 2018) results in high rates for HIV-related cancers, and the greater prevalence in central Mozambique, compared to the south, largely explains the rather higher rates of Kaposi sarcoma (males), non-Hodgkin lymphoma, squamous cell carcinoma of conjunctiva and cervical cancer in Beira than in Maputo. Burkitt lymphoma is the commonest childhood cancer in Beira, with high rates typical of East Africa, while the low rates in Maputo are more typical of Southern Africa. Overall, 44% of cancers in Maputo and 52% in Beira are estimated to be caused by infectious agents. In the last 60 years, cancers more frequent in developed countries, such as breast and prostate, are emerging in Mozambique. The incidence of the former in Maputo has increased fivefold since 1956-1960, that of prostate cancer 2.5-fold, and that of large bowel cancer doubled. The results reported here were used to make national estimates of incidence, mortality and prevalence in Globocan 2018. The two registries were important in providing data to establish priority actions in the National Cancer Control Plan, and are a valuable resource to monitor progress toward its goals.

Cancer in Mozambique: Results from two population-based cancer registries

Results from two recently established population-based registries in Mozambique are reported: Beira in the central region (2014-2017) and Maputo, the capital city, in the South (2015-2017). The results are compared to those from Maputo (Lourenço Marques at the time) in 1956-1960 (appearing Cancer Incidence in Five Continents Vol 1), and with estimated incidence rates from other regions of Africa. The elevated prevalence of HIV infection (12.6% of adults in 2018) results in high rates for HIV-related cancers, and the greater prevalence in central Mozambique, compared to the south, largely explains the rather higher rates of Kaposi sarcoma (males), non-Hodgkin lymphoma, squamous cell carcinoma of conjunctiva and cervical cancer in Beira than in Maputo. Burkitt lymphoma is the commonest childhood cancer in Beira, with high rates typical of East Africa, while the low rates in Maputo are more typical of Southern Africa. Overall, 44% of cancers in Maputo and 52% in Beira are estimated to be caused by infectious agents. In the last 60 years, cancers more frequent in developed countries, such as breast and prostate, are emerging in Mozambique. The incidence of the former in Maputo has increased fivefold since 1956-1960, that of prostate cancer 2.5-fold, and that of large bowel cancer doubled. The results reported here were used to make national estimates of incidence, mortality and prevalence in Globocan 2018. The two registries were important in providing data to establish priority actions in the National Cancer Control Plan, and are a valuable resource to monitor progress toward its goals.