Risk factors for inflammatory and non-inflammatory breast cancer in North Africa.

PURPOSE: Studies of the etiology of inflammatory breast cancer (IBC), a rare but aggressive breast cancer, have been hampered by limited risk factor information. We extend previous studies by evaluating a broader range of risk factors. METHODS: Between 2009 and 2015, we conducted a case-control study of IBC at six centers in Egypt, Tunisia, and Morocco; enrolled were 267 IBC cases and for comparison 274 non-IBC cases and 275 controls, both matched on age and geographic area to the IBC cases. We administered questionnaires and collected anthropometric measurements for all study subjects. We used multiple imputation methods to account for missing values and calculated odds ratios (ORs) and 95% confidence intervals (CIs) using polytomous logistic regression comparing each of the two case groups to the controls, with statistical tests for the difference between the coefficients for the two case groups. RESULTS: After multivariable adjustment, a livebirth within the previous 2 years (OR 4.6; 95% CI 1.8 to 11.7) and diabetes (OR 1.8; 95% CI 1.1 to 3.0) were associated with increased risk of IBC, but not non-IBC (OR 0.9; 95% CI 0.3 to 2.5 and OR 0.9; 95% CI 0.5 to 1.6 for livebirth and diabetes, respectively). A family history of breast cancer, inflammatory-like breast problems, breast trauma, and low socioeconomic status were associated with increased risk of both tumor types. CONCLUSIONS: We identified novel risk factors for IBC and non-IBC, some of which preferentially increased risk of IBC compared to non-IBC. Upon confirmation, these findings could help illuminate the etiology and aid in prevention of this aggressive cancer.

Clinico-pathologic and mammographic characteristics of inflammatory and non-inflammatory breast cancer at six centers in North Africa.

PURPOSE: We describe the clinico-pathologic and mammographic characteristics of inflammatory breast cancer (IBC) and non-IBC cases enrolled in a case-control study. Because IBC is a clinico-pathologic entity with rapid appearance of erythema and other signs, its diagnosis is based on clinical observation and thus, by necessity, subjective. Therefore, we evaluate our cases by photographic review by outside expert clinicians and by degree of adherence to the two most recent definitions of IBC: the international expert panel consensus statement and American Joint Committee on Cancer (AJCC) 8th edition (we used the slightly less restrictive 7th edition definition for our study). METHODS: We enrolled 267 IBC and 274 age- and geographically matched non-IBC cases at 6 sites in Egypt, Tunisia, and Morocco in a case-control study of IBC conducted between 2009 and 2015. We collected clinico-pathologic and mammographic data and standardized medical photographs of the breast. RESULTS: We identified many differences between IBC and non-IBC cases: 54.5% versus 68.8% were estrogen receptor-positive, 39.9% versus 14.8% human epidermal growth factor receptor 2-positive, 91% versus 4% exhibited erythema, 63% versus 97% had a mass, and 57% versus 10% had mammographic evidence of skin thickening. Seventy-six percent of IBC cases adhered to the expert panel consensus statement and 36% to the AJCC definition; 86 percent were confirmed as IBC by either photographic review or adherence to the consensus statement. CONCLUSIONS: We successfully identified distinct groups of IBC and non-IBC cases. The reliability of IBC diagnosis would benefit from expert review of standardized medical photographs and associated clinical information.

Chronic Mastitis in Egypt and Morocco: Differentiating between Idiopathic Granulomatous Mastitis and IgG4-Related Disease.

Idiopathic granulomatous mastitis (IGM) is a benign, frequently severe chronic inflammatory lesion of the breast. Its etiology remains unknown and reported cases vary in their presentation and histologic findings with an optimal treatment algorithm yet to be described owing mainly to the disease's heterogeneity. IgG4-related disease (IgG4-RD) is a newly recognized systemic fibroinflammatory condition characterized by a dense lymphoplasmacytic infiltrate with many IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis. Immunosuppressive therapy is considered to be an effective first-line therapy for IgG4-RD. We sought to clarify and classify chronic mastitis according to the histologic findings of IgG4-RD mastitis with respect to IGM and to develop a robust diagnostic framework to help select patients for optimal treatment strategies. Using the largest collection to date (43 cases from Egypt and Morocco), we show that despite sharing many features, IGM and IgG4-RD mastitis are separate diseases. To diagnostically separate the diseases, we created a classification schema-termed the Michigan Classification-based upon our large series of cases, the consensus statement on IgG4-RD, and the histologic description of IGM in the literature. Using our classification, we discerned 17 cases of IgG4-RD and 8 cases of IGM among the 43 chronic mastitis cases, with 18 indeterminate cases. Thus, our Michigan Classification can form the basis of rational stratification of chronic mastitis patients between these two clinically and histopathologically heterogeneous diseases.

Bisphenol A-associated epigenomic changes in prepubescent girls: a cross-sectional study in Gharbiah, Egypt.

BACKGROUND: There is now compelling evidence that epigenetic modifications link adult disease susceptibility to environmental exposures during specific life stages, including pre-pubertal development. Animal studies indicate that bisphenol A (BPA), the monomer used in epoxy resins and polycarbonate plastics, may impact health through epigenetic mechanisms, and epidemiological data associate BPA levels with metabolic disorders, behavior changes, and reproductive effects. Thus, we conducted an environmental epidemiology study of BPA exposure and CpG methylation in pre-adolescent girls from Gharbiah, Egypt hypothesizing that methylation profiles exhibit exposure-dependent trends. METHODS: Urinary concentrations of total (free plus conjugated) species of BPA in spot samples were quantified for 60 girls aged 10 to 13. Genome-wide CpG methylation was concurrently measured in bisulfite-converted saliva DNA using the Infinium HumanMethylation27 BeadChip (N = 46). CpG sites from four candidate genes were validated via quantitative bisulfite pyrosequencing. RESULTS: CpG methylation varied widely among girls, and higher urinary BPA concentrations were generally associated with less genomic methylation. Based on pathway analyses, genes exhibiting reduced methylation with increasing urinary BPA were involved in immune function, transport activity, metabolism, and caspase activity. In particular, hypomethylation of CpG targets on chromosome X was associated with higher urinary BPA. Using the Comparative Toxicogenomics Database, we identified a number of candidate genes in our sample that previously have been associated with BPA-related expression change. CONCLUSIONS: These data indicate that BPA may affect human health through specific epigenomic modification of genes in relevant pathways. Thus, epigenetic epidemiology holds promise for the identification of biomarkers from previous exposures and the development of epigenetic-based diagnostic strategies.

Urinary bisphenol A concentrations in girls from rural and urban Egypt: a pilot study.

BACKGROUND: Exposure to endocrine active compounds, including bisphenol A (BPA), remains poorly characterized in developing countries despite the fact that behavioral practices related to westernization have the potential to influence exposure. BPA is a high production volume chemical that has been associated with metabolic dysfunction as well as behavioral and developmental effects in people, including children. In this pilot study, we evaluate BPA exposure and assess likely pathways of exposure among girls from urban and rural Egypt. METHODS: We measured urinary concentrations of total (free plus conjugated) species of BPA in spot samples in urban (N = 30) and rural (N = 30) Egyptian girls, and compared these concentrations to preexisting data from age-matched American girls (N = 47) from the U.S. National Health and Nutrition Examination Survey (NHANES). We also collected anthropometric and questionnaire data regarding food storage behaviors to assess potential routes of exposure. RESULTS: Urban and rural Egyptian girls exhibited similar concentrations of urinary total BPA, with median unadjusted values of 1.00 and 0.60 ng/mL, respectively. Concentrations of urinary BPA in this group of Egyptian girls (median unadjusted: 0.70 ng/mL) were significantly lower compared to age-matched American girls (median unadjusted: 2.60 ng/mL) according to NHANES 2009-2010 data. Reported storage of food in plastic containers was a significant predictor of increasing concentrations of urinary BPA. CONCLUSIONS: Despite the relatively low urinary BPA concentrations within this Egyptian cohort, the significant association between food storage behaviors and increasing urinary BPA concentration highlights the need to understand food and consumer product patterns that may be closing the gap between urban and rural lifestyles.

Public and professional educational needs for downstaging breast cancer in Egypt.

We conducted focus groups with women from urban and rural areas in the Nile Delta region to investigate their attitudes regarding breast cancer diagnosis, treatment, and screening. Six 60-min focus groups, each group comprised of 6-10 women with ages between 20-69 years, were conducted. Discussions included breast health, breast cancer diagnosis, treatment, early detection and screening, and communication for breast health. Almost all urban and rural women reported that women do not see physicians until they are seriously ill or have advanced cancer. They reported that oncologists or gynecologists were important to be seen first if a woman suspected breast cancer and primary care physician are not the primary line of cancer diagnosis. Other deterring factors besides distrust in primary care physicians included attitude that breast cancer equals death and lack of knowledge of early detection and screening techniques. Women felt that public education campaigns must be implemented to improve early detection and screening methods for breast cancer. The majority of beliefs regarding breast cancer and screening were common among urban and rural women. Culture-specific and tailored professional and public education programs in developing countries are essential for achieving downstaging cancer.

Androgen receptor polyglutamine tract length in Egyptian male breast cancer patients.

Male breast cancer (MBC) is a rare disease in the U.S., accounting for less than 1% of all breast cancers. Rates of MBC in Africa are more variable than in the U.S., therefore, understanding the risk factors involved in a population like Egypt can clarify the nature of MBC. The polyglutamine tract (QT) is a variable region of the androgen receptor (AR), a nuclear receptor which is important in modulating androgen actions and generally inhibits growth in breast tissue. It is hypothesized that a long QT results in weaker AR activity over the lifetime, resulting in less AR mediated control over cellular division and higher risk of MBC. As a corollary, we expect to see a distribution skewed toward longer QTs in MBC patients compared to controls and overall relatively longer QT's in populations with higher rates of MBC. This study aimed to investigate for the first time the distribution of AR QT lengths among MBC patients in Egypt. Paraffin-embedded tumor tissues from 44 Egyptian MBC patients were analyzed for this polymorphism. Amplification followed by fragment length analysis revealed QT length. For the control series, blood from 43 Egyptian males without a family or personal history of breast or prostate cancers was collected and analyzed similarly. There was no significant difference between patients and controls with respect to mean QT length (P = 0.84; means were 19.5 ± 2.8 and 19.3 ± 4.2, for patients and controls, respectively). Though, short QT lengths were more prevalent among controls (14.0%), but almost absent in cases (2.3%). Although the mean lengths were not different in cases and controls, the near absence of short tracts in cases suggests a possible protective effect of very short QT lengths against MBC. In populations in which there is variable incidence of MBC by region, investigations of the distribution of AR QT lengths are warranted to further delineate its role as a risk factor in MBC.

Patient-mediated factors predicting early- and late-stage presentation of breast cancer in Egypt.

OBJECTIVE: Breast cancer fatality rates are high in low- and middle-income countries because of the late stage at diagnosis. We investigated patient-mediated determinants for late-stage presentation of breast cancer in Egypt. METHODS: A case-case comparison was performed for 343 women with breast cancer, comparing those who had been initially diagnosed at Stage I or II with those diagnosed at Stage III or IV. Patients were recruited from the National Cancer Institute of Cairo University and Tanta Cancer Center in the Nile delta. Patients were either newly diagnosed or diagnosed within the year preceding the study. Interviews elicited information on disease history and diagnosis, beliefs and attitudes toward screening practices, distance to treatment facility, education, income, and reproductive history. RESULTS: Forty-six per cent of the patients had presented at late stage. Women seen in Cairo were more likely to present at late stages than patients in Tanta (OR=5.05; 95% CI=1.30, 19.70). Women without any pain were more likely to present at later stage (OR=2.68; 95% CI=1.18, 6.08). Knowledge of breast self-examination increased the likelihood of women to present in early stages significantly (OR=0.24; 95% CI=0.06, 0.94). CONCLUSIONS: Despite increasing numbers of cancer centers in Egypt during the past 20 years, additional regional facilities are needed for cancer management. In addition, increasing awareness about breast cancer will have significant long-term impact on breast cancer prevention.

Palliative care in Egypt: challenges and opportunities.

Palliative health-care faces many challenges. Developing countries face unique spectrum of difficulties including limited resources. In this article I share our experience in establishing palliative care department in a charity hospital located in Egypt.

Exposure to phthalates among premenstrual girls from rural and urban Gharbiah, Egypt: a pilot exposure assessment study.

BACKGROUND: Phthalates have been identified as endocrine active compounds associated with developmental and reproductive toxicity. The exposure to phthalates in premenstrual Egyptian females remains unknown. The objective of this study was to characterize phthalate exposure of a potentially vulnerable population of premenstrual girls from urban and rural Egypt. MATERIALS AND METHODS: We collected one spot urine sample from 60 10-13 year old females, 30 from rural Egypt, and 30 from urban Egypt from July to October 2009. Samples were analyzed for 11 phthalate metabolites. Additionally, we collected anthropometrics as well as questionnaire data concerning food storage behaviors, cooking practices, and cosmetic use. Phthalate metabolite concentrations were compared between urban and rural Egyptians as well as to age and gender matched Americans. RESULTS: Monoethyl phthalate (MEP), was detected at the highest concentration in urine of Egyptian girls (median: 43.2 ng/mL in rural, 98.8 ng/mL in urban). Concentrations of urinary metabolites of di-(2-ethylhexyl) phthalate and dibutyl phthalate were comparable between Egyptians and age matched US girls. Storage of food in plastic containers was a statistically significant predictor of urinary mono-isobutyl phthalate (MiBP) concentrations when comparing covariate adjusted means. CONCLUSIONS: Urinary concentrations of phthalate metabolites were similar in Egyptian and US populations, suggesting that phthalate exposure also occurs in developing nations. Dietary intake is likely an important route of exposure to phthalates in both urban and rural populations.

Concordance of DNA methylation pattern in plasma and tumor DNA of Egyptian hepatocellular carcinoma patients.

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the fourth leading cause of cancer mortality globally. HCC incidence has doubled in Egypt in the past 10 years, which could be attributed to the high prevalence of hepatitis C virus (HCV) and hepatitis B virus (HBV), although HBV rates have declined after the introduction of the vaccine in 1992. Aberrant DNA methylation may play an important role in hepatocarcinogenesis. Liver biopsy is the current gold standard for methylation studies; however, imaging techniques often suffice for diagnosis making tissue samples increasingly scarce. The efficacy of conducting DNA methylation studies in molecular epidemiology using plasma DNA is still unclear. We compared tumor methylation profile for the tumor suppressor genes APC, FHIT, p15, p16, and E-cadherin in tumor tissues and plasma to test the concordance between the two types of specimen from the same HCC patients. Twenty-eight HCC patients with matching tissue and plasma DNA were recruited from a case-control study in Gharbiah, Egypt. Concordance between the tissue and plasma was statistically significant in all five genes as follows: APC (23/28, 82.1%, p=0.001), FHIT (24/28, 85.7%, p=.0001), p15 (25/28, 89.2%, p=0.045), p16 (19/28, 67.9%, p=0.037), and E-cadherin (22/28, 78.5%, p=0.0008). The average specificity was 90%, 86%, 96%, 86%, and 100%, respectively. There was no significant association between methylation and hepatitis viral infection for any of the genes tested in this study. Plasma DNA can be reliable for testing methylation profile in liver cancer patients in this population. Future studies on a larger sample size should investigate methylation profile in populations with higher rates of HBV, HCV, and other risk factors.

Regional Variation of Pancreatic Cancer Incidence in the Nile Delta Region of Egypt over a Twelve-Year Period.

BACKGROUND: Pancreatic cancer is one of the deadliest forms of cancer, with incidence rates rising in many countries around the world. Geographic variation in pancreatic cancer incidence has not been studied extensively, especially in low- and middle-income countries. The aim of this study was to characterize the distribution of pancreatic cancer incidence in the central Nile Delta region of Egypt and to examine differences by urban and rural patient residence using the nation's only population-based cancer registry. METHODS: Utilizing the Gharbiah province population-based cancer registry, data were abstracted for 1,089 pancreatic cancer cases diagnosed over twelve years from 1999 to 2010. Age- and sex-specific incidence rates were calculated and compared for urban and rural areas of the eight districts of Gharbiah. RESULTS: Age-adjusted incidence of pancreatic cancer within Gharbiah varied considerably by urban/rural patient residence and by district. Incidence rates were 1.3 times higher in urban compared to rural areas (4.45 per 100,000 in urban areas and 3.43 per 100,000 in rural areas). The highest incidence rates were observed in urban centers of Kotour, El Santa, and Kafr El-Zayat districts (12.94, 8.32, and 7.89, respectively). CONCLUSION: Incidence rates varied greatly by urban and rural areas and by district of residence in the Nile Delta region of Egypt. Future studies should examine potential environmental risk factors that may contribute to the geographic distribution of pancreatic cancer in this region.

Changing Incidence of Uterine Cancer in Rural Egypt: Possible Impact of Nutritional and Epidemiologic Transitions.

PURPOSE: Uterine cancer is a top-ranking women's cancer worldwide, with wide incidence variations across countries and by rural and urban areas. Hormonal exposures and access to health care vary between rural and urban areas, globally. Egypt has an overall low incidence of uterine cancer but variable rural and urban lifestyles. Are there changes in the incidence of uterine cancer in rural and urban areas in middle-income countries such as Egypt? No previous studies have addressed this question from a well-characterized and validated population-based cancer registry resource in middle-income countries. The aim of this study was to explore the differences in clinical and demographic characteristics of uterine cancer over the period of 1999 to 2010 in rural and urban Gharbiah province, Egypt. METHODS: Data were abstracted for all 660 patients with uterine cancer included in the Gharbiah Population-based Cancer Registry. Clinical variables included tumor location, histopathologic diagnosis, stage, grade, and treatment. Demographic variables included age, rural or urban residence, parity, and occupation. Crude and age-adjusted incidence rates (IRs) and rate ratios by rural or urban residence were calculated. RESULTS: No significant differences were observed in most clinical and demographic characteristics between rural and urban patients. The age standardized IR (ASR) was 2.5 times higher in urban than in rural areas (6.9 and 2.8 per 100,000 in urban and rural areas, respectively). The rate ratio showed that the IR in urban areas was 2.46 times the rate in rural areas. CONCLUSION: This study showed that the disease IR in rural areas has increased in the past decade but is still low compared with the incidence in urban areas in Egypt, which did not show a significant increase in incidence. Nutritional transitions, obesity, and epidemiologic and lifestyle changes toward Westernization may have led to IRs increasing more in rural than in urban areas in Egypt. This pattern of increasing incidence in Egypt, which used to have a low incidence of uterine cancer, may appear in other middle-income countries that experience emerging nutritional and epidemiologic transitions. The rate of uterine cancer in urban areas in Gharbiah is almost similar to the corresponding rates globally. However, the rate in rural areas in this population has increased over the past decade but is still lower than the corresponding global rates. Future studies should examine the etiologic factors related to increasing rates in rural areas and quantify the improvement in rural case finding.

Patterns of hepatocellular carcinoma incidence in Egypt from a population-based cancer registry.

AIM: Hepatocellular carcinoma (HCC) is increasing worldwide, and is frequently attributed to rising rates of hepatitis C virus infection and interactions between viral and environmental risk factors. Because of Egypt's unique risk factor profile, we analyzed data from the Gharbiah Population-Based Cancer Registry for the period 1999-2003 to characterize demographic and geographic patterns of cases in this province. METHODS: We calculated age- and sex-specific and age- and sex-standardized HCC incidence rates for the eight districts in Gharbiah. We also compared rates from Gharbiah with the USA (US Surveillance Epidemiology and End RESULTS [SEER] database). RESULTS: The analysis revealed a higher incidence in males than in females, significant geographic variations among districts, and a higher incidence in Gharbiah than that reported by SEER. CONCLUSION: The findings of this study document the heterogeneous distribution of HCC at regional and international levels. This population-based registry offers the opportunity for careful representative studies of various etiologies, particularly infectious and/or environmental factors that may contribute to risk.

Differences in MUC4 Expression in Pancreatic Cancers and Pancreatic Cysts in Egypt.

Pancreatic cancer is the fourth cause of cancer deaths in the U.S. with most patients diagnosed at advanced stages followed by short survival. Therefore, biomarkers for early detection are urgently needed. Mucin 4 (MUC4) is a mucin protein encoded by the MUC4 gene and identified in the majority of pancreatic cancers. With increasing clinical identification and diagnosis of pancreatic cysts globally and transformation of some cysts into pancreatic cancer, it is important to evaluate if MUC4 is expressed in pancreatic cysts. Immunohistochemistry assays utilizing heat-induced epitope retrieval (HIER) were performed to examine MUC4 protein expression in 44 paraffin-embedded tissues of pancreatic cancers and 20 pancreatic cysts. All patients were diagnosed and operated upon at the Mansoura University Gastrointestinal Surgery Center in Egypt. Clinical, demographic, and survival information were abstracted from the patients' medical records. Logistic regression was performed to predict expression of MUC4 protein in cancer and cysts, by type of cysts. Pancreatic cyst patients were significantly younger than pancreatic cancer patients (Mean age of 28.7 ± 5.25 vs. 54.84 ± 10.60 years) (p=0.0001). Expression of MUC4 was not different between cancers and pancreatic cysts (p=0.16). However, type of pancreatic cysts was predictive of MUC4 expression. Mucinous cystic neoplasms and serous cystadenoma cysts showed significantly higher MUC4 expression than non-specified and pseudocysts (80%, 75%, 25%, and 0% expression for the 4 types of cysts, respectively) (p=0.022). MUC4 expression may be associated with certain types of cysts. Follow-up of pancreatic cyst patients who show MUC4 expression might reveal clues to early detection of pancreatic cancer.

Changes in Uterine Cancer Incidence Rates in Egypt.

BACKGROUND: Uterine cancer is one of the top-ranking cancers in women with wide international variations in incidence rates. Developed countries have higher incidence rates than the developing countries. Egypt has significantly lower incidence of uterine cancer than other countries in the Middle East. This study aimed at verifying the incidence rate of uterine cancer and characterizing the demographic and clinical profiles of patients residing in the Gharbiah province in the Nile delta region of Egypt. METHODS: Data from 660 uterine cancer patients diagnosed during the period of 1999 to 2010 were abstracted from the Gharbiah Cancer Registry, the only population-based registry in Egypt. The data included age, marital status, number of children, residence, smoking, occupation, date and basis of diagnosis, tumor topography, morphology, stage and grade, and treatment. Crude rate, age-standardized rate (ASR), and age-specific rate were calculated and associated with demographic and clinical characteristics of patients. RESULTS: The study confirmed the low ASR of uterine cancer in Egypt, (4.1 per 100,000 (95% CI: 3.8-4.4)). The incidence rate increased significantly over the 12-year period. The crude rate (CR) was 1.95, 95% CI (1.64-2.25) in 1999-2002; 2.9, 95% CI (2.5-3.2) in 2003-2006; and 3.5, 95% CI (3.1-3.9) in 2007-2010. The rate ratio was 1.5, 95% CI (1.2-1.8) in 2003-2006 and 1.8, 95% CI (1.5-2.2) in 2007-2010 compared to 1999-2002. The majority of patients (83%) were postmenopausal with the highest age-specific rate in the 60-69-year age group (22.07 per 100,000 (95% CI: 19.3-25.2). The majority of patients were diagnosed at early stages (60% localized and 5% regional), had adenocarcinoma (68%), and resided in urban areas (54%). CONCLUSIONS: The study confirmed the low incidence rate of uterine cancer in the Gharbiah province of Egypt and significant increase in incidence in recent years. Future studies should focus on verifying the possible effect of hysterectomy on lowering the incidence, the factors related to the changes in rates between rural and urban areas, and the possible impact of nutritional and epidemiologic transitions on the increasing rates.

Forecasted impacts of a sofosbuvir-based national hepatitis C treatment programme on Egypt's hepatocellular cancer epidemic: simulation of alternatives.

BACKGROUND: Egypt is experiencing a hepatocellular cancer (HCC) epidemic due to widespread hepatitis C virus (HCV) transmission. The use of sofosbuvir-related therapies producing improved treatment success has permitted an updated, nationwide, HCV treatment programme with expanded coverage. This study simulated the multidecade impacts of the new treatment programme on hepatitis and HCC. METHODS: A Markov model of HCV infection and treatment analysed the HCV-related HCC epidemic between 2009 and 2050, using parameters based on peer-reviewed studies and expert opinion. Comparing the 'new' and 'old' scenarios, and with the old treatment programme being replaced or not by the new programme in 2015, the annual number, prevalence and incidence of HCC were simulated for representative Egypt populations including HCV-infected patients aged 15-59 years in 2008, healthy people aged 5-59 years in 2008 and 5-year-old children cohorts entering the population each year beginning in 2009. Averted HCC cases were calculated, and sensitivity analyses were performed. RESULTS: Compared with the old scenario, the estimated number, prevalence and incidence of future HCC cases in the new scenario would peak earlier and at lower levels in 2025 (~29 000), 2023 (~28/100 000) and 2022 (~14/100 000), respectively. The new treatment programme is estimated to avert ~956 000 HCC cases between 2015 and 2050. DISCUSSION: By reducing cancer cases and shortening the peak epidemic period, the new programme should substantially diminish the HCC epidemic across Egypt. Our timeline forecast for Egypt's HCC epidemic, and evaluation of various disease and programme components, should be useful to other countries that are developing policies to address HCV-related liver cancer prevention.

Unique Features of Germline Variation in Five Egyptian Familial Breast Cancer Families Revealed by Exome Sequencing.

Genetic predisposition increases the risk of familial breast cancer. Recent studies indicate that genetic predisposition for familial breast cancer can be ethnic-specific. However, current knowledge of genetic predisposition for the disease is predominantly derived from Western populations. Using this existing information as the sole reference to judge the predisposition in non-Western populations is not adequate and can potentially lead to misdiagnosis. Efforts are required to collect genetic predisposition from non-Western populations. The Egyptian population has high genetic variations in reflecting its divergent ethnic origins, and incident rate of familial breast cancer in Egypt is also higher than the rate in many other populations. Using whole exome sequencing, we investigated genetic predisposition in five Egyptian familial breast cancer families. No pathogenic variants in BRCA1, BRCA2 and other classical breast cancer-predisposition genes were present in these five families. Comparison of the genetic variants with those in Caucasian familial breast cancer showed that variants in the Egyptian families were more variable and heterogeneous than the variants in Caucasian families. Multiple damaging variants in genes of different functional categories were identified either in a single family or shared between families. Our study demonstrates that genetic predisposition in Egyptian breast cancer families may differ from those in other disease populations, and supports a comprehensive screening of local disease families to determine the genetic predisposition in Egyptian familial breast cancer.

Reliability of medical records in diagnosing inflammatory breast cancer in Egypt.

BACKGROUND: Inflammatory breast cancer (IBC) is a rare, aggressive breast cancer diagnosed clinically by the presence of diffuse erythema, peau d'orange, and edema that arise quickly in the affected breast. This study evaluated the validity of medical records in Gharbiah, Egypt in identifying clinical signs/symptoms of IBC. For 34 IBC cases enrolled in a case-control study at the Gharbiah Cancer Society and Tanta Cancer Center, Egypt (2009-2010), we compared signs/symptoms of IBC noted in medical records to those recorded on a standardized form at the time of IBC diagnosis by clinicians participating in the case-control study. We calculated the sensitivity and specificity of medical records as compared to the case-control study for recording these signs/symptoms. We also performed McNemar's tests. RESULTS: In the case-control study, 32 (94.1%) IBC cases presented with peau d'orange, 30 (88.2%) with erythema, and 31 (91.2%) with edema. The sensitivities of the medical records as compared to the case-control study were 0.8, 0.5, and 0.2 for peau d'orange, erythema, and edema, respectively. Corresponding specificities were 1.0, 0.5, and 1.0. p values for McNemar's test were <0.05 for all signs. Medical records had data on the extent and duration of signs for at most 27% of cases for which this information was recorded in the case-control study. Twenty-three of the 34 cases (67.6%) had confirmed diagnosis of IBC in their medical records. CONCLUSION: Medical records lacked information on signs/symptoms of IBC, especially erythema and edema, when compared to the case-control study. Deficient medical records could have implications for diagnosis and treatment of IBC and proper documentation of cases in cancer registries.

Measuring the Effect of Improved Medical Facilities and Focused Training on Data Quality and Completeness: An Example from the Gharbiah Population-Based Cancer Registry, Egypt.

Cancer rates are increasing in low- and middle- income countries. There are a limited number of populationbased cancer registries in Africa and the Egyptian population-based registry in Gharbiah is one of those registries. This registry has followed the standard international registration process and methods since 1999 and has been included in Cancer Incidence in Five Continents volumes IX and X. This article illustrates the reflection of improving medical care in the geographic region of the registry and focused training on enhancing the registry data. The registry area has seen advancement in medical care and cancer diagnostic facilities during the study period. The focused training included 8 different international training sessions over 8 different years for the registrars, administrators, and directors as well as continuing on-the-job training for other registry personnel. These improvements resulted in an overall 40% increase in nonmicroscopic diagnosis of hepatocellular carcinoma, as well as 20%, 10%, and 10% increases in microscopic diagnosis of pancreatic, brain, and lung cancers, respectively, over 9 years. An overall increase of 5% to 10% in subsite diagnosis was also seen for lung, colon, brain, bladder, and breast cancers for the same 9 years. An increase of 3% in grading was seen for solid tumors while 11% was seen for lymphoma. This study showed that low- and middle- income countries can observe higher data quality for cancer registries with improvement in medical care and focused training.