Prevalence of high-risk human papillomavirus genotypes in outpatient Malian women living with HIV: a pilot study.

INTRODUCTION: Long-term exposure to high-risk human papillomavirus (Hr-HPV) is a well-known necessary condition for development of cervical cancer. The aim of this study is to screen for Hr-HPV using vaginal self-sampling, which is a more effective approach to improve women's adherence and increase screening rates. METHODS: This pilot study included a total of 100 Women living with HIV (WLWHIV), recruited from the Center for Listening, Care, Animation, and Counseling of People Living with HIV in Bamako. Hr-HPV genotyping was performed on Self-collected samples using the Cepheid GeneXpert instrument. RESULTS: The median age of WLWHIV was 44 (interquartile range [IQR], 37-50) years. Approximately 92% of the study participants preferred self-sampling at the clinic, and 90% opted to receive result notifications via mobile phone contact. The overall prevalence of Hr-HPV among study participants was 42.6%, and the most frequent Hr-HPV sub-types observed were HPV18/45 (19.1%), HPV31/35/33/52/58 (13.8%), and HPV39/68/56/66 (12.8%), followed by HPV16 (5.3%), and HPV51/59 (5.3%). WLWHIV under 35 years of age had a higher frequency of Hr-HPV compared to their older counterparts, with rates of 30% versus 11.1% (p = 0.03). The duration of antiretroviral treatment showed an inverse association with Hr-HPV negativity, with patients on treatment for 15 (IQR, 10-18) years versus 12 (IQR = 7-14) years for Hr-HPV positive patients (95% CI [1.2-5.8], t = 3.04, p = 0.003). WLWHIV with baseline CD4 T-Cell counts below 200 exhibited a higher frequency of Hr-HPV compared to those with baseline CD4 T-Cell counts above 200 (17.9% versus 1.9%, p = 0.009). However, other demographics and clinical factors, such as marital status, age of sexual debut, parity, education, history of abortion, history of preeclampsia, and cesarean delivery, did not influence the distribution of Hr-HPV genotypes. CONCLUSION: Our findings indicate that WLWHIV under the age of 35 years old exhibited the highest prevalence of Hr-HPV infection, with HPV18/45 being the most prevalent subtype. Additionally, WLWHIV with baseline CD4 T-Cell counts below 200 showed the highest infection rates.

Lack of Association of C677T Methylenetetrahydrofolate Reductase Polymorphism with Breast Cancer Risk in Mali.

Methylenetetrahydrofolate reductase (MTHFR) plays a major role in the metabolism of folates and homocysteine, which in turn can affect gene expression and ultimately promote the development of breast cancer. Thus, mutations in the MTHFR gene could influence homocysteine, methionine, and S-adenosylmethionine levels and, indirectly, nucleotide levels. Imbalance in methionine and S-adenosylmethionine synthesis affects protein synthesis and methylation. These changes, which affect gene expression, may ultimately promote the development of breast cancer. We therefore hypothesized that such mutations could also play an important role in the occurrence and pathogenesis of breast cancer in a Malian population. In this study, we used the PCR-RFLP technique to identify the different genotypic profiles of the C677T MTHFR polymorphism in 127 breast cancer women and 160 healthy controls. The genotypic distribution of the C677T polymorphism in breast cancer cases was 88.2% for CC, 11.0% for CT, and 0.8% for TT. Healthy controls showed a similar distribution with 90.6% for CC, 8.8% for CT, and 0.6% for TT. We found no statistical association between the C677T polymorphism and breast cancer risk for the codominant models CT and TT (p > 0.05). The same trend was observed when the analysis was extended to other genetic models, including dominant (p = 0.50), recessive (p = 0.87), and additive (p = 0.50) models. The C677T polymorphism of MTHFR gene did not influence the risk of breast cancer in the Malian samples.

Decrease in liver cancer incidence rates in Bamako, Mali over 28 years of population-based cancer registration (1987-2015).

BACKGROUND: Primary liver cancer is common in West Africa due to endemic risk factors. However, epidemiological studies of the global burden and trends of liver cancer are limited. We report changes in trends of the incidence of liver cancer over a period of 28 years using the population-based cancer registry of Bamako, Mali. AIM: To assess the trends and patterns of liver cancer by gender and age groups by analyzing the cancer registration data accumulated over 28 years (1987-2015) of activity of the population-based registry of the Bamako district. METHODS: Data obtained since the inception of the registry in 1987 through 2015 were stratified into three periods (1987-1996, 1997-2006, and 2007-2015). Age-standardized rates were estimated by direct standardization using the world population. Incidence rate ratios and the corresponding 95% confidence intervals (CI) were estimated using the early period as the reference (1987-1996). Joinpoint regression models were used to assess the annual percentage change and highlight trends over the entire period (from 1987 to 2015). RESULTS: Among males, the age-standardized incidence rates significantly decreased from 19.41 (1987-1996) to 13.12 (1997-2006) to 8.15 (2007-2015) per 105 person-years. The incidence rate ratio over 28 years was 0.42 (95%CI: 0.34-0.50), and the annual percentage change was -4.59 [95%CI: (-6.4)-(-2.7)]. Among females, rates dropped continuously from 7.02 (1987-1996) to 2.57 (2007-2015) per 105 person-years, with an incidence rate ratio of 0.37 (95%CI: 0.28-0.45) and an annual percentage change of -5.63 [95%CI: (-8.9)-(-2.3)]. CONCLUSION: The population-based registration showed that the incidence of primary liver cancer has steadily decreased in the Bamako district over 28 years. This trend does not appear to result from biases or changes in registration practices. This is the first report of such a decrease in an area of high incidence of liver cancer in Africa. This decrease may be explained by the changes and diversity of diet that could reduce exposure to aflatoxins through dietary contamination in this population.

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.

[Placenta accreta at Timbuktu hospital, Mali: a case report and literature review]. / Placenta accreta a l'hopital de Tombouctou, Mali : a propos d'un cas et revue de la litterature.

INTRODUCTION: placenta accretacauses severe postpartum haemorrhage. Our objective is to describe its diagnostic and therapeutic aspects as well as incidence at Timbuktu hospital. OBSERVATION: We have encountered one case of placenta accreta in six years, an occurrence of 1 in 6160 births. The patient was a 25-year-old multiparous woman with a history of a cesarean section, admitted to labor, without ultrasound performed during pregnancy. A placenta accreta was found during the caesarean section which was ordered due to stagnation of dilation. A cesarean section followed by hysterectomy was performed without complication. Anatomopathological examination confirmed the diagnosis by revealing an increta-type placenta. CONCLUSION: The incidences of placenta accreta are low in our practice. However, thisdiagnosis should always be discussed during prenatal consultationsin cases where anterior placenta is connected to a uterus with scar tissue, in which case an ultrasound is routinely ordered.

INTRODUCTION: le placenta accreta est responsable d'hémorragie grave du post-partum. Notre objectif était de décrire ses aspects diagnostiques, thérapeutiques et son incidence à l'hôpital de Tombouctou. OBSERVATION: nous rapportons un cas de placenta accreta sur six ans soit une incidence de 1/6160. Une multipare de 25 ans avec un antécédent de césarienne, admise en travail d'accouchement, sans échographie réalisée pendant la grossesse. La découverte d'un placenta accreta est faite en peropératoire, après indication d'une césarienne pour stagnation de la dilatation. Une césarienne suivie d'une hystérectomie est faite avec des suites opératoires simples. L'examen anatomopathologique a confirmé le diagnostic en retrouvant un placenta de type increta. CONCLUSION: l'incidence du placenta accreta est faible dans notre pratique. Toutefois ce diagnostic doit toujours être évoqué lors des consultations prénatales en cas de placenta antérieur sur utérus cicatriciel et une échographie demandée systématiquement.

[Giant anal fibroepithelial polyp during pregnancy: a case study]. / Polype fibro-épithélial géant de l'anus sur grossesse: à propos d'un cas.

Anal fibroepithelial polyp is a benign tumor rarely reported during pregnancy. We here report a case of giant anal fibroepithelial polyp in a 31-year old multiparous woman. It developed progressively over the previous 3 years. Clinical examination showed firm sessile bud formation, at the anal margin. The patient had normal ongoing pregnancy (31 weeks of amenorrhea). Endoanal examination was normal. Surgical resection was preformed under spinal anesthesia. The specimen measured 21x12x7cm and was covered by the skin. Histological examination showed anal fibroepithelial polyp without signs of malignancy. The postoperative course was uneventful.

Health system organisation and patient pathways: breast care patients' trajectories and medical doctors' practice in Mali.

BACKGROUND: Information on pathways of women seeking diagnostic services due to breast- related symptoms can help highlight challenges related to the healthcare system in improving early diagnosis of breast cancer. METHODS: We retrospectively analysed the entire patient pathway, from first symptom recognition via initial healthcare visit up to final diagnosis at the pathology service in Mali. Data from questionnaire-based structured patient interviews (n = 124) were used to calculate time to first healthcare visit (median 91 days) and consecutive time to diagnosis (median 21 days) and to extract information on type of initially visited healthcare facility (community healthcare centre, referral hospital, tertiary hospital, private clinic). Median time to first healthcare visit and time to diagnosis and type of initially-visited healthcare facility were cross-tabulated with patient characteristics. An additional survey among (n = 30) medical doctors in the community healthcare centres and referral hospitals in Bamako was conducted to understand current knowledge and referral practice with respect to female patients with breast-related symptoms. RESULTS: Patients who initially visited private clinics had the shortest time to first healthcare visit (median 44 days), but the longest time to diagnosis (median 170 days). Patients visiting community healthcare centres and referral hospitals took longest for a first healthcare visit (median 153 and 206 days, respectively), but the time to diagnosis was shorter (median 95 and 7 days, respectively). The majority of patients (45%) initially visited a tertiary hospital; these patients had shortest total time to diagnosis (median 56 days health seeking and 8 days diagnostic time), but did not follow the recommended pathway for patients in the pyramidal healthcare system in Mali. The doctors' survey showed lower breast cancer knowledge in the community healthcare centres than in the referral hospitals. However, most doctors felt able to recognise suspected cases of cancer and referred patients directly to a hospital. CONCLUSIONS: The role of different healthcare facilities in ensuring triage of patients with breast-related symptoms needs to be defined before any early detection initiatives are implemented. Especially at the entry level of the healthcare system, the access and quality of health services need to be strengthened.

Factors associated with time to first healthcare visit, diagnosis and treatment, and their impact on survival among breast cancer patients in Mali.

OBJECTIVE: To analyse patient and healthcare system related factors influencing the time to first healthcare visit, diagnosis and treatment of breast cancer patients in sub-Saharan Africa and the impact on survival in order to advise on early detection strategies. METHODS: A prospective hospital cohort study was conducted at the only pathology department in Mali, at the University Hospital in Bamako. All the female patients with a breast cancer diagnosis between January and April 2016 were interviewed with a structured questionnaire (N = 64) to gather information about breast symptom recognition and first healthcare visit. Information on beginning of treatment and survival were collected at 18-months follow-up. Simple Cox regression analyses were performed. RESULTS: The median time to first healthcare visit was 4.8 months, from first healthcare visit to diagnosis was 0.9 months and for the patients who started treatment (N = 46) the time from diagnosis to treatment was 1.3 months. Knowledge of breast-self-examination and correct symptom interpretation increased the chance of an earlier healthcare visit. Prolonged time to diagnosis was found with shorter duration to first healthcare visit, for working women compared to housewives and for those living within Bamako. Living outside Bamako and smaller tumour size (T1/T2) prolonged time to treatment. Visit of a traditional healer and larger tumour size (T3/T4) shortened survival time, whereas time to first healthcare visit and subsequent time to diagnosis had no influence on survival. CONCLUSIONS: Down-staging strategies are only useful if the continuum of breast cancer care is warranted for the majority of patients.

Why Do Women with Breast Cancer Get Diagnosed and Treated Late in Sub-Saharan Africa? Perspectives from Women and Patients in Bamako, Mali.

BACKGROUND: Breast cancer, the most common cancer among women worldwide, has a high mortality rate in low-income countries. In sub-Saharan Africa, most breast cancer patients are diagnosed with advanced disease. Some studies have quantified the time delay to diagnosis in sub-Saharan Africa, but very few have used qualitative methods to understand barriers leading to delay. This study analyses barriers throughout a breast cancer patient's pathway from symptom recognition to treatment in Mali. METHOD: Three focus group discussions were conducted. The model of pathways to treatment was used to structure the results into 4 time intervals: appraisal, help-seeking, diagnosis, and treatment, with a focus on barriers during each interval. RESULTS: The main barriers during the appraisal interval were a low level of breast cancer knowledge among women, their families, and medical professionals, and during the help-seeking interval, mistrust in the community health care centers and economic hardship. Barriers during the diagnosis interval were low quality of health care services and lack of social support, and during the pretreatment interval high costs and lack of specialized services. CONCLUSION: Multilevel interventions are needed to ensure access, availability, and affordability of a minimum standard of care for breast cancer patients in sub-Saharan Africa.

Breast cancer in pre-menopausal women in West Africa: analysis of temporal trends and evaluation of risk factors associated with reproductive life.

BACKGROUND: In West Africa, trends and risk factors for breast cancer (BC) have been rarely studied. METHODS: Here we have analyzed trends of BC over two periods in two population-based cancer registries, in Mali-Bamako (1987-1997; 1998-2009) and in The Gambia (1988-1997; 1998-2006). We have conducted a case-control study (n = 253 cases, 249 controls) on risk factors associated with reproductive life stratified by menopausal status in Bamako. RESULTS: Between the two periods, BC incidence rates increased by 20% (incidence rate ratio (IRR) 1.20 (95% CI [1.07-1.35])) in Bamako, with an annual percentage change of 2% (95% CI [0.4-3.6]). The increase was of 30% in women under 55 years (IRR 1.30 (95% CI [1.14-1.60])). A similar pattern was observed in The Gambia for women under 50 years (IRR 1.47 (95% CI [1.07-2.01])). Overall, pre-menopausal breast cancer was predominant in both countries. In contrary to what is well established, case-control study showed that late age at menarche (>14 years) increased the risk of BC among pre-menopausal women (OR: 2.02 (95% CI [1.08-3.78])) while it tended to be protective in post-menopausal women (OR: 0.61 (95% CI [0.29-1.29])). Later age at a first pregnancy (>20 years) was associated with a reduction of risk in pre-menopausal women (OR: 0.41 (95% CI [0.18-0.89])). CONCLUSION: These results indicate that the burden of pre-menopausal BC is increasing in West African countries. These cancers appear to be associated with distinct reproductive risk factors, highlighting the need for better understanding the biological bases of early BC in African populations.