The every woman study™ low- and middle-income countries edition protocol: A multi-country observational study to assess opportunities and challenges to improving survival and quality of life for women with ovarian cancer.

BACKGROUND: Ovarian cancer is a challenging disease to diagnose and treat effectively with five-year survival rates below 50%. Previous patient experience research in high-income countries highlighted common challenges and opportunities to improve survival and quality of life for women affected by ovarian cancer. However, no comparable data exist for low-and middle-income countries, where 70% of women with the disease live. This study aims to address this evidence gap. METHODS: This is an observational multi-country study set in low- and middle-income countries. We aim to recruit over 2000 women diagnosed with ovarian cancer across multiple hospitals in 24 countries in Asia, Africa and South America. Country sample sizes have been calculated (n = 70-96 participants /country), taking account of varying national five-year disease prevalence rates. Women within five years of their diagnosis, who are in contact with participating hospitals, are invited to take part in the study. A questionnaire has been adapted from a tool previously used in high-income countries. It comprises 57 multiple choice and two open-ended questions designed to collect information on demographics, women's knowledge of ovarian cancer, route to diagnosis, access to treatments, surgery and genetic testing, support needs, the impact of the disease on women and their families, and their priorities for action. The questionnaire has been designed in English, translated into local languages and tested according to local ethics requirements. Questionnaires will be administered by a trained member of the clinical team. CONCLUSION: This study will inform further research, advocacy, and action in low- and middle-income countries based on tailored approaches to the national, regional and global challenges and opportunities. In addition, participating countries can choose to repeat the study to track progress and the protocol can be adapted for other countries and other diseases.

Dying Undiagnosed: Challenges of Management of Ovarian Tumours in a Resource-Poor Setting in North-western Nigeria.

Background: Ovarian cancer is the second most prevalent but most lethal gynaecologic malignancy in our institution. This study aimed at determining the rate of non-diagnosis in suspected lesions and reviewing the management challenges of ovarian tumours highly suspicious for malignancy in our hospital. Methodology: A three-year retrospective review of patients' records from the ward, clinic, theatre, and histopathology laboratory was carried out. Cases with high indices of suspicion for ovarian cancer (ovarian tumour with malignant radiologic features with any of ascites, pleural effusion, as well as cachexia, anaemia, or evidence of metastasis) were included. In-depth interviews were carried out with a consultant from each specialty of Radiology, Radio-oncology, Pathology, and Gynaecologic oncology at the gynaecologic oncology multidisciplinary team meeting. Results: One hundred and twenty-two cases of highly suspicious ovarian malignancies were seen with a mean age of 40.6 years. Of these, 28 (23%) had surgery and 77% did not have any form of histological diagnosis. Of those that had surgery, 13 (46.4%) had upfront surgery and 15 (53.6%) neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). Only two cases had documented complete (R0) debulking. Among those that had upfront surgery, one case (7.7%) was an ovarian fibroid and one (7.7%) was a fibrosarcoma while two cases (15.4%) were borderline ovarian tumours. Chemotherapy was commenced based on malignant cells on ascitic or pleural fluid cytology in three cases. Of all the malignant cases, epithelial carcinomas were commonest accounting for 48%. Aside from the general late presentation of cases, insufficient funds for treatment, poor coverage of health insurance for cancer care, unavailability of routine immunohistochemistry, lack of germline and somatic testing, non-availability or prohibitive cost of some chemotherapeutic agents, unavailability of maintenance therapies, inadequate capacity to manage toxicities, inadequate skill across all specialties, unavailability / erratic function of computerized tomography scans and unavailable positron emission tomography, lack of interventional radiology facility amongst others were all identified as challenges to management. Conclusion: Most patients with tumours highly suspicious for ovarian cancers did not get a histologic diagnosis and probably died undiagnosed. Management of ovarian cancer remains a challenge despite advances in surgical and chemotherapeutic options. Health insurance for all, infrastructure development, and training of all disciplines involved is recommended.

Giant Ovarian Endometrioma: A Case Report.

Ovarian endometrioma is quite common among women of reproductive age but rarely exceed 6 cm in diameter. Ovarian endometrioma exceeding 10 cm in dimension, often referred to as giant endometrioma, is rare and can pose a diagnostic dilemma to clinicians. We present a 33-year-old single nullipara referred to our facility with a 3-year history of recurrent abdominal pain, abdominal swelling, and difficulty in breathing. The challenges in making diagnosis of a huge ovarian endometrioma are highlighted and the literature on huge ovarian endometrioma reviewed.

Ureteric Injuries Following Obstetrics and Gynaecologic Surgeries: A Single-Center Experience.

Background: Ureteric injuries are not uncommon in obstetric and gynaecologic surgeries. Some specific procedures predispose to these injuries. Recognition is often delayed. This study aims to present a single-center experience on the presentation, risk factors, and management of ureteric injuries. Methodology: We retrospectively reviewed case files of patients primarily presenting or referred to our urology division with ureteric injuries following obstetrics or gynaecologic surgeries from June 2005 to May 2015. Data extracted included the time of presentation or recognition, the specific offending surgery, the laterality, and site involved, the repair performed, and outcome. Results: Twenty-three patients had injuries (with a total of 25 ureters involved owing to 2 bilateral injuries). Caesarian-section is the commonest offending surgery in 13 (56.5%). The reasons for early recognition were sudden anuria in two and urinary leakage in the operating field in four patients constituting 26.0%, while 17 (74.0%) were recognized in the post-operative period. Urinary fistulae were the commonest presentation in 13 (76.5%) patients recognized postoperatively. Transection and ligation are the commonest mechanisms of injury. The distal third was the site involved in all patients, while ureteroneocystostomy alone was the most predominant repair in 18 (72.0%). Ureteroneocystostomy with Psoas hitch and Boari flap reconstruction was offered in six (24.0%) suggesting greater than5cm ureteral loss. Conclusions: Ureteric injuries often occur following obstetrics and gynaecologic surgeries. Caesarian-section is the commonest predisposing surgery in our center. Prompt recognition and repair is recommended.

Impact of the COVID-19 pandemic on surgical practice, training, and research in Nigeria.

INTRODUCTION: the rising rate of SARS-CoV-2 infections has caused perceptible strain on the global health system. Indeed, this disease is also a litmus test for the resilience of the structures in the African health system including surgery. Therefore, this study aimed to determine the impact of the COVID-19 pandemic on surgical practice, training and research in Nigeria. METHODS: it was a cross-sectional study conducted over three weeks in Nigeria among doctors in 12 surgery-related specialties. Consenting participants filled a pre-tested online form consisting of 35 questions in 5 sections which assessed demographics, infection control measures, clinical practice, academic training, research program, and future trends. Data were analyzed using Statistical Package for Social Sciences Version 20. RESULTS: a total of 384 respondents completed the form. Their mean age was 38.3 years. Lockdown measures were imposed in the state of practice of 89.0% of respondents. Most participants reported a decrease in patient volume in outpatient clinics (95.5%) and elective operations (95.8%) compared to reports for emergency operations (50.2%). They also noted a decrease in academic training [Bedside teaching (92.1%), seminar presentation (91.1%) and journal presentation (91.8%)] and research (80.5%). Except in bedside teaching, those who had other virtual academic programmes were thrice the number of those who used in-person mode for the events. CONCLUSION: COVID-19 pandemic has caused a significant change in pattern and a decrease in the volume of patients seen by surgeons in their practice as well as a decrease in the frequency of academic programs and research activities in Nigeria.

An Assessment of Ovarian Cancer Histotypes Across the African Diaspora.

OBJECTIVE: Ovarian cancer in Black women is common in many West African countries but is relatively rare in North America. Black women have worse survival outcomes when compared to White women. Ovarian cancer histotype, diagnosis, and age at presentation are known prognostic factors for outcome. We sought to conduct a preliminary comparative assessment of these factors across the African diaspora. METHODS: Patients diagnosed with ovarian cancer (all histologies) between June 2016-December 2019 in Departments of Pathology at 25 participating sites in Nigeria were identified. Comparative population-based data, inclusive of Caribbean-born Blacks (CBB) and US-born Blacks (USB), were additionally captured from the International Agency for Research on Cancer and Florida Cancer Data Systems. Histology, country of birth, and age at diagnosis data were collected and evaluated across the three subgroups: USB, CBB and Nigerians. Statistical analyses were done using chi-square and student's t-test with significance set at p<0.05. RESULTS: Nigerians had the highest proportion of germ cell tumor (GCT, 11.5%) and sex-cord stromal (SCST, 16.2%) ovarian cancers relative to CBB and USB (p=0.001). CBB (79.4%) and USB (77.3%) women were diagnosed with a larger proportion of serous ovarian cancer than Nigerians (60.4%) (p<0.0001). Nigerians were diagnosed with epithelial ovarian cancers at the youngest age (51.7± 12.8 years) relative to USB (58.9 ± 15.0) and CBB (59.0± 13.0,p<0.001). Black women [CBB (25.2 ± 15.0), Nigerians (29.5 ± 15.1), and USB (33.9 ± 17.9)] were diagnosed with GCT younger than White women (35.4 ± 20.5, p=0.011). Black women [Nigerians (47.5 ± 15.9), USB (50.9 ± 18.3) and CBB (50.9 ± 18.3)] were also diagnosed with SCST younger than White women (55.6 ± 16.5, p<0.01). CONCLUSION: There is significant variation in age of diagnosis and distribution of ovarian cancer histotype/diagnosis across the African diaspora. The etiology of these findings requires further investigation.