Pathologically confirmed breast cancer in Malawi: a descriptive study: Clinical profile of breast cancer.

BACKGROUND: Breast cancer is the most common female cancer in Africa, yet no published studies have investigated breast cancer in Malawi. Understanding the clinical profile of breast cancer is important to develop early diagnosis efforts. AIM: To describe clinical and pathological characteristics of breast specimens from a pathology laboratory at a national teaching hospital. METHODS: Secondary analysis of pathology reports from July 2011 to September 2013. RESULTS: Among 85 breast cancer cases, 55% were < 50 years. Median tumor size was 4 cm and 49% were grade 3. Median symptom duration was eight months. CONCLUSIONS: Malawian women with breast cancer commonly have long symptom durations prior to diagnosis, young age, and poorly differentiated tumors. Improved clinical and pathological characterization, including hormone receptor status, are urgently needed to better understand this disease in Malawi.

Cancer incidence in Blantyre, Malawi 1994-1998.

In this paper, we report the first results from the population-based cancer registry for Blantyre district, Malawi, for the period 1994-1998. In this 5-year period, 1245 cases were recorded in males (an estimated age-standardized incidence of 92.0 per 100,000) and 1003 in females (an age standardised rate (ASR) of 88.8 per 105). The overall percentage of cases with histological verification was just 41.8%, indicating that case-finding outside the laboratory had been quite successful; nevertheless the rather low rates suggest possible underdiagnosis of cancer, as well as cases missed. As in other reports from the region, the contemporary pattern is dominated by Kaposi's sarcoma (KS) (55.2% cancers in men, 28% in women), the effect of the evolving epidemic of AIDS. The incidence of cervix cancer in women is high (ASR 26.2 per 105), and there are moderately high rates of oesophageal cancer (ASR 15.4 per 105 in men, 9.3 per 105 in women). In childhood, the cancer profile is dominated by Burkitt's lymphoma, which accounts for 42.4% of cancers; KS is now the second most frequent cancer of childhood.

Validation of the WHO diagnostic algorithm and development of an alternative scoring system for the management of women presenting with vaginal discharge in Malawi.

OBJECTIVE: To evaluate the performance of the WHO algorithm for the detection of cervical infection in women presenting with vaginal discharge and modify the risk assessment score for optimum effectiveness in Malawi. METHODS: 550 consecutive women presenting with non-ulcerative genitourinary complaints were interviewed and examined. Cervical infection was defined as presence of Neisseria gonorrhoeae on culture and/or Chlamydia trachomatis by EIA. Other laboratory investigations included wet mount microscopy, serology for syphilis and HIV, LED testing of cervical and vaginal secretions, and pH testing of vaginal fluid. Sensitivity, specificity, and positive predictive values (PPV) of different algorithms were determined in the analysis. RESULTS: Cervical infection was identified in 19.5% of women (17.1% gonorrhoea, 3.7% chlamydial infection). The sensitivity/specificity/PPV of the WHO risk assessment were 43%/73%/28%, respectively by history and 62%/61%/27% with the addition of speculum examination. Using Malawi results to modify the risk assessment improved the performance to 61%/68%/31% respectively by history alone, which increased to 73%/64%/33% with bimanual examination and 72%/56%/29% with speculum examination. CONCLUSION: The sensitivity of the WHO risk assessment is low for the detection of cervical infection in Malawi. Although the Malawi risk assessment performed somewhat better on history alone, this study identified external and bimanual examination variables that improved the diagnostic performance of the algorithm in settings where speculum examination is not possible. Although the PPVs of the algorithms are low, country specific risk assessments can provide a framework for management until simple, affordable diagnostic tests for the definitive diagnosis of cervical infection are available.

Sexually transmitted diseases: a survey of case management in Malawi.

A national survey of sexually transmitted disease (STD) case management was carried out at 39 health care facilities in Malawi in 1994. Fifty-four health care providers were observed managing 150 patients presenting with selected STD syndromes and 103 providers were interviewed. STD case management was assessed by calculation of WHO/GPA prevention indicators (PIs) from observation data. The overall rate for PI-6, which measures correct assessment and treatment of STD patients was 11% (81% for history taking, 46% in physical examination, and 13% correct antibiotic treatment according to national guidelines). The score for PI-7, which measures overall patient counselling was 29% (65% for partner notification and 40% for condom advice). Although Haemophilus ducreyi is at least as common as Treponema pallidum as the causative agent for genital ulcers, only 16% of patients with genital ulcers were treated effectively for chancroid vs 56% for syphilis. Female patients received less comprehensive care than male STD patients. Only 20% of STD patients were offered condoms. Overall, the survey results support the policy decision to adopt syndromic management of STDs, and provide baseline information for planning and evaluation of a national control programme.

Spectrum of childhood cancers in Malawi 1985-1993.

An analysis of seven hundred and ninety one children aged 0.2 to 14 years with confirmed malignant disease recorded by the Malawi National Cancer Registry over a period of 9 years is presented. Childhood cancer constituted 6.9% of all malignancies recorded during the study period. The top ten neoplasms in descending order of frequency were: non-Hodgkin's lymphoma 434 (54.9%), retinoblastoma 89 (11.3%), nephroblastoma 50 (6.3%), epithelial carcinoma 45 (5.7%), Hodgkin's disease 38 (4.8%), soft tissue sarcoma (excluding Kaposi): 34(4.3%), Kaposi's sarcoma 32 (4.0%), malignant tumours (not specified): 20 (2.5%), acute leukaemias 18(2.3%) and osteogenic sarcoma 16 (2.0%). Some differences noted in the pattern of neoplasms in this study from those of developed and developing African countries are discussed. The findings highlight the most common childhood malignancies in Malawi where intense research should be directed so that meaningful and cost effective therapeutic intervention programmes can be planned and developed.

Efficacy of BCG vaccine against leprosy and tuberculosis in northern Malawi.

Protection afforded by BCG (bacillus Calmette-Guérin) vaccines against tuberculosis and leprosy varies widely between different populations. In the only controlled trial which assessed protective efficacy of BCG (Danish and Pasteur strains) against both diseases, there was slightly more protection against leprosy than against tuberculosis. We have studied the protective efficacy of BCG (Glaxo, freeze dried) vaccine against these two diseases in Karonga District, northern Malawi. BCG vaccination was introduced into this population in 1974. Prior information about BCG scar status was available for 83,455 individuals followed up between 1979 and 1989. 414 new cases of leprosy and 180 new cases of tuberculosis were found in this population over that period. Protection was estimated at 50% or greater against leprosy, and there was no evidence for lower protection against multibacillary (84%; 95% confidence interval 26% to 97%) than against paucibacillary (51%; 30% to 66%) disease. There was no statistically significant protection by BCG against tuberculosis in this population. These findings add to the evidence that BCG vaccines afford greater protection against leprosy than against tuberculosis.

Efficacy of BCG vaccine against leprosy and tuberculosis in northern Malawi

Protection afforded BCG vaccines against tuberculosis and leprosy varies widely between different populations. In the only controlled trial which assessed protective efficacy of BCG (Danish and Pasteur strains) against both diseases; there was slightly more protection against leprosy than against tuberculosis. Protection was estimated at 50 percent or greater against leprosy; and there was no evidence for lower protection against multibacillary than against paucibacillary disease. There was no statistically significant protection by BCG against tuberculosis in this population

HIV-1 and pregnant women: associated factors; prevalence; estimate of incidence and role in fetal wastage in central Africa

The major goals of this study were to measure the current prevalence and estimate the annual incidence of HIV-1 infection in young pregnant women from urban Malawi; to identify factors that were associated with HIV-1 infection; and to examine adverse pregnancy outcomes. Four hundred and sixty-one consecutive pregnant women were studied when they presented for prenatal care. The overall seroprevalence for HIV-1 infection in these urban populations was 17.6 percent (81 out of 461) during early 1989. Based on previous seroprevalence in similar unselected pregnant women; the estimated annual incidence of HIV-1 seroconversion in urban pregnant women ranged from 3 to 4 percent per annum between 1985 and 1987 and from 7 to 13 percent between 1987 and 1989. HIV-1 infection was significantly associated with reactive syphilis serology. Reported history of sexually transmitted disease was also correlated with HIV-1 infection but was not statistically significant. Other variables; such as history of transfusion; history of tuberculosis; parity or occupation were not associated with HIV-1 infection. History of spontaneous abortion was significantly associated with reactive syphilis serology; HIV-1 infection and history of sexually transmitted disease. In logistic regression analysis; HIV-1 infection remained the only significant variable that was correlated with spontaneous abortion. This study suggests that HIV-1 infection may play a role in fetal wastage

Female Genital Tuberculosis in Malawi--a report of 90 cases.

PIP: The clinicopathological findings in 90 cases of female genital tuberculosis from Malawi, Eastern Africa, are described. Infertility and menstruation abnormalities are the most common presenting features, found in 36.7% and 48.9% of the patients, respectively. The distribution of the presenting symptoms corresponds to that reported in studies from other areas with similar socioeconomic and geographic characteristics. Amenorrhea (38.9%) dominated the menstrual disorders. 11% of the patients with amenorrhea also complained of infertility. Of the patients whose age was recorded, over 2/3 are in their 30s and 40s; only 3 are over 50. Amenorrhea is associated with extensive destruction of the endometrium by caseating tuberculosis granulomata. Delay in seeking medical help would explain the high frequency of tuberculosis lesions in the cervix and vagina in African and Asian countries.^ieng

Rhinoscleroma in Malawi and Eastern Zaire.

The first ten cases of rhinoscleroma from Malawi and six from Eastern Zaire are reported. Most of the patients were aged between 20 and 40 years (age range 3-60) and presented with either a nasal "tumour' or abnormalities of the nasal septum. Histological examination of biopsy material revealed features diagnostic of rhinoscleroma - a mixture of mature plasma cells and lareg foamy macrophages (Mikulicz cells) containing intra-cellular Gram negative bacilli. The organisms were best seen in sections stained by the Warthin-Starry technique. This study suggests that rhinosceleroma is perhaps more common in Malawi and Zaire than has been realised.

Rhinoscleroma in Malawi and Eastern Zaire

"The first ten cases of rhinoscleroma from Malawi and six from Eastern Zaire are reported. Most of the patients were aged between 20 and 40 years (age range 3-60) and presented with either a nasal ""tumour' or abnormalities of the nasal septum. Histological examination of biopsy material revealed features diagnostic of rhinoscleroma - a mixture of mature plasma cells and large foamy macrophages (Mikulicz cells) containing intra-cellular Gram negative bacilli. The organisms were best seen in sections stained by the Warthin-Starry technique. This study suggests that rhinoscleroma is perhaps more common in Malawi and Zaire than has been realised."