Voluntary participation and comprehension of informed consent in a genetic epidemiological study of breast cancer in Nigeria

BACKGROUND

Studies on informed consent to medical research conducted in low or middle-income settings have increased, including empirical investigations of consent to genetic research. We investigated voluntary participation and comprehension of informed consent among women involved in a genetic epidemiological study on breast cancer in an urban setting of Nigeria comparing women in the case and control groups.

METHODS

Surveys were administered in face-to-face interviews with 215 participants following their enrollment in the genetic study (106 patients, 109 controls). Audio-taped in-depth interviews were conducted with a sub-sample of 17 (8%) women who completed the survey.

RESULTS

The majority of all participants reported being told that participation in the genetic study was voluntary (97%), that they did not feel pressured to participate in the study (99%), and that they could withdraw from the study (81%). The majority of the breast cancer patients (83%) compared to 58% of women in the control group reported that the study purpose was to learn about the genetic inheritance of breast cancer (OR 3.44; 95% CI =1.66, 7.14, p value = 0.001). Most participants reported being told about study procedures (95%) and study benefits (98%). Sixty-eight percent of the patients, compared to 47% of the control group reported being told about study risks (p-value <0.001). Of the 165 married women, 19% reported asking permission from their husbands to enroll in the breast cancer study; no one sought permission from local elders. In-depth interviews highlight the use of persuasion and negotiation between a wife and her husband regarding study participation.

CONCLUSIONS

The global expansion of genetic and genomic research highlights our need to understand informed consent practices for studies in ethnically diverse cultural environments such as Africa. Quantitative and qualitative empirical investigations of the informed consent process for genetic and genomic research will further our knowledge of complex issues associated with communication of information, comprehension, decisional authority and voluntary participation. In the future, the development and testing of innovative strategies to promote voluntary participation and comprehension of the goals of genomic research will contribute to our understanding of strategies that enhance the consent process.

Mastectomy for management of breast cancer in Ibadan, Nigeria

Background

Modified radical mastectomy remains the standard therapeutic surgical operation for breast cancer in most parts of the world. This retrospective study reviews mastectomy for management of breast cancer in a surgical oncology division over a ten year period.

Methods

We reviewed the case records of consecutive breast cancer patients who underwent mastectomy at the Surgical Oncology Division, University College Hospital (UCH) Ibadan between November 1999 and October 2009.

Results

Of the 1226 newly diagnosed breast cancer patients over the study period, 431 (35.2%) patients underwent mastectomy making an average of 43 mastectomies per year. Most patients were young women, premenopausal, had invasive ductal carcinoma and underwent modified radical mastectomy as the definitive surgical treatment. Prior to mastectomy, locally advanced tumors were down staged in about half of the patients that received neo-adjuvant combination chemotherapy. Surgical complication rate was low. The most frequent operative complication was seroma collection in six percent of patients. The average hospital stay was ten days and most patients were followed up at the surgical outpatients department for about two years post-surgery.

Conclusions

There was low rate of mastectomy in this cohort which could partly be attributable to late presentation of many patients with inoperable local or metastatic tumors necessitating only palliative or terminal care. Tumor down-staging with neo-adjuvant chemotherapy enhanced surgical loco-regional tumor control in some patients. The overall morbidity and the rates of postoperative events were minimal. Long-term post-operative out-patients follow-up was not achieved as many patients were lost to follow up after two years of mastectomy.

Neo-adjuvant capecitabine chemotherapy in women with newly diagnosed locally advanced breast cancer in a resource-poor setting (Nigeria): efficacy and safety in a phase II feasibility study

The majority of clinical trials of neo-adjuvant therapy for breast cancer have been conducted in resource-rich countries. We chose Nigeria, a resource-poor country, as the major site for a phase II feasibility open-label multicenter clinical trial designed to evaluate the efficacy, safety, and tolerability of neo-adjuvant capecitabine in locally advanced breast cancer (LABC). Planned treatment consisted of 24 weeks of capecitabine at a dose of 1,000 mg/m(2) twice daily (2,000 mg/m(2) total per day). The primary endpoints were overall, partial, complete clinical response rate (OCR, PCR, CCR) and complete pathologic response (cPR). A total of 16 patients were recruited from August 2007 to April 2010. The study was terminated early as a result of slow accrual. After the first three cycles of therapy, PCR were seen in five of 16 patients (31%; 95% CI 11-59%). Of the remaining 11 patients, eight had no response (NR) or stable disease (SD), and three had progressive disease (PD). Seven patients proceeded with further therapy of which had SD. OCR at the end of eight cycles was 44% (95% CI 20-70%). Clinical response and radiologic response by ultrasonomammography were highly concordant (spearman correlation 0.70). The most common adverse effect was Grade 1 hand-foot syndrome, which was seen in 75% of patients. Despite several limitations, we successfully carried out this phase II feasibility study of neo-adjuvant capecitabine for LABC in Nigeria. Capecitabine monotherapy showed good overall response rates with minimal toxicity and further studies are warranted.

A meta-analysis identifies new loci associated with body mass index in individuals of African ancestry

Genome-wide association studies (GWAS) have identified 36 loci associated with body mass index (BMI), predominantly in populations of European ancestry. We conducted a meta-analysis to examine the association of >3.2 million SNPs with BMI in 39,144 men and women of African ancestry and followed up the most significant associations in an additional 32,268 individuals of African ancestry. We identified one new locus at 5q33 (GALNT10, rs7708584, P = 3.4 × 10(-11)) and another at 7p15 when we included data from the GIANT consortium (MIR148A-NFE2L3, rs10261878, P = 1.2 × 10(-10)). We also found suggestive evidence of an association at a third locus at 6q16 in the African-ancestry sample (KLHL32, rs974417, P = 6.9 × 10(-8)). Thirty-two of the 36 previously established BMI variants showed directionally consistent effect estimates in our GWAS (binomial P = 9.7 × 10(-7)), five of which reached genome-wide significance. These findings provide strong support for shared BMI loci across populations, as well as for the utility of studying ancestrally diverse populations.

Fine mapping of breast cancer genome-wide association studies loci in women of African ancestry identifies novel susceptibility markers

Numerous single nucleotide polymorphisms (SNPs) associated with breast cancer susceptibility have been identified by genome-wide association studies (GWAS). However, these SNPs were primarily discovered and validated in women of European and Asian ancestry. Because linkage disequilibrium is ancestry-dependent and heterogeneous among racial/ethnic populations, we evaluated common genetic variants at 22 GWAS-identified breast cancer susceptibility loci in a pooled sample of 1502 breast cancer cases and 1378 controls of African ancestry. None of the 22 GWAS index SNPs could be validated, challenging the direct generalizability of breast cancer risk variants identified in Caucasians or Asians to other populations. Novel breast cancer risk variants for women of African ancestry were identified in regions including 5p12 (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.11-1.76; P = 0.004), 5q11.2 (OR = 1.22, 95% CI = 1.09-1.36; P = 0.00053) and 10p15.1 (OR = 1.22, 95% CI = 1.08-1.38; P = 0.0015). We also found positive association signals in three regions (6q25.1, 10q26.13 and 16q12.1-q12.2) previously confirmed by fine mapping in women of African ancestry. In addition, polygenic model indicated that eight best markers in this study, compared with 22 GWAS-identified SNPs, could better predict breast cancer risk in women of African ancestry (per-allele OR = 1.21, 95% CI = 1.16-1.27; P = 9.7 × 10(-16)). Our results demonstrate that fine mapping is a powerful approach to better characterize the breast cancer risk alleles in diverse populations. Future studies and new GWAS in women of African ancestry hold promise to discover additional variants for breast cancer susceptibility with clinical implications throughout the African diaspora.

Development and pilot testing of an online module for ethics education based on the Nigerian National Code for Health Research Ethics

BACKGROUND

The formulation and implementation of national ethical regulations to protect research participants is fundamental to ethical conduct of research. Ethics education and capacity are inadequate in developing African countries. This study was designed to develop a module for online training in research ethics based on the Nigerian National Code of Health Research Ethics and assess its ease of use and reliability among biomedical researchers in Nigeria.

METHODOLOGY

This was a three-phased evaluation study. Phase one involved development of an online training module based on the Nigerian Code of Health Research Ethics (NCHRE) and uploading it to the Collaborative Institutional Training Initiative (CITI) website while the second phase entailed the evaluation of the module for comprehensibility, readability and ease of use by 45 Nigerian biomedical researchers. The third phase involved modification and re-evaluation of the module by 30 Nigerian biomedical researchers and determination of test-retest reliability of the module using Cronbach's alpha.

RESULTS

The online module was easily accessible and comprehensible to 95% of study participants. There were significant differences in the pretest and posttest scores of study participants during the evaluation of the online module (p = 0.001) with correlation coefficients of 0.9 and 0.8 for the pretest and posttest scores respectively. The module also demonstrated excellent test-retest reliability and internal consistency as shown by Cronbach's alpha coefficients of 0.92 and 0.84 for the pretest and posttest respectively.

CONCLUSION

The module based on the Nigerian Code was developed, tested and made available online as a valuable tool for training in cultural and societal relevant ethical principles to orient national and international biomedical researchers working in Nigeria. It would complement other general research ethics and Good Clinical Practice modules. Participants suggested that awareness of the online module should be increased through seminars, advertisement on government websites and portals used by Nigerian biomedical researchers, and incorporation of the Code into the undergraduate medical training curriculum.

A genome-wide association study of breast cancer in women of African ancestry

Genome-wide association studies (GWAS) in diverse populations are needed to reveal variants that are more common and/or limited to defined populations. We conducted a GWAS of breast cancer in women of African ancestry, with genotyping of >1,000,000 SNPs in 3,153 African American cases and 2,831 controls, and replication testing of the top 66 associations in an additional 3,607 breast cancer cases and 11,330 controls of African ancestry. Two of the 66 SNPs replicated (p < 0.05) in stage 2, which reached statistical significance levels of 10(-6) and 10(-5) in the stage 1 and 2 combined analysis (rs4322600 at chromosome 14q31: OR = 1.18, p = 4.3 × 10(-6); rs10510333 at chromosome 3p26: OR = 1.15, p = 1.5 × 10(-5)). These suggestive risk loci have not been identified in previous GWAS in other populations and will need to be examined in additional samples. Identification of novel risk variants for breast cancer in women of African ancestry will demand testing of a substantially larger set of markers from stage 1 in a larger replication sample.

Office based muscle biopsy using Vacora vacuum assisted biopsy system

INTRODUCTION

Muscle biopsy is a minor surgical procedure that has been conducted over several decades in clinical practice. Over the years, the technique to implement this procedure has been modified to make it easier to perform and more tolerable for the patient. This study aimed to assess the feasibility of muscle biopsy as an office based procedure, by using a vacuum Assisted Biopsy System.

METHOD

The procedure was successfully carried out on 57 individuals with/without diabetes, currently involved in the African American Diabetes Mellitus Study. One specimen was collected percutaneously from the vastus lateralis, under local anesthesia. A 16-gauge needle was used.

RESULTS

Muscle biopsies were successfully carried out on all study participants. The study participants reported no complications after the procedure.

CONCLUSION

The findings from our study show that muscle biopsy can be feasibly implemented as an office based procedure, involving minimal muscle invasion, less trauma, hospital stay time, and expenses.

Recurrent BRCA1 and BRCA2 mutations in breast cancer patients of African ancestry

Recurrent mutations constituted nearly three quarters of all BRCA1 mutations and almost half of all BRCA2 mutations identified in the first cohort of the Nigerian Breast Cancer Study. To further characterize breast/ovarian cancer risks associated with BRCA1/BRCA2 mutations in the African diaspora, we genotyped recurrent mutations among Nigerian, African American, and Barbadian breast cancer patients. A replication cohort of 356 Nigerian breast cancer patients was genotyped for 12 recurrent BRCA1/2 mutant alleles (Y101X, 1742insG, 4241delTG, M1775R, 4359insC, C64Y, 1623delTTAAA, Q1090X, and 943ins10 from BRCA1, and 1538delAAGA, 2630del11, and 9045delGAAA from BRCA2) by means of SNaPshot followed by direct sequencing or by direct sequencing alone. In addition, 260 African Americans and 118 Barbadians were genotyped for six of the recurrent BRCA1 mutations by SNaPshot assay. Of all the BRCA1/2 recurrent mutations we identified in the first cohort, six were identified in 11 patients in the replication study. These mutation carriers constitute 3.1 % [95 % Confidence Interval (CI) 1.6-5.5 %] of the replication cohort. By comparison, 6.9 % (95 % CI 4.7-9.7 %) of the discovery cohort carried BRCA1/2 recurrent mutations. For the subset of recurrent mutations we tested in breast cancer cases from Barbados or the United States, only two 943ins10 carriers were identified in African Americans. Nigerian breast cancer patients from Ibadan carry a broad and unique spectrum of BRCA1/2 mutations. Our data suggest that BRCA1/2 mutation testing limited to recurrent mutations is not sufficient to understand the BRCA1/2-associated breast cancer risk in African populations in the diaspora. As the cost of Sanger sequencing is considerably reduced, deploying innovative technologies such as high throughput DNA sequencing of BRCA1/2 and other cancer susceptibility genes will be essential for identifying high-risk individuals and families to reduce the burden of aggressive early onset breast cancer in low-resource settings.

Neoadjuvant capecitabine chemotherapy in women with newly diagnosed locally advanced breast cancer in a resource-poor setting (Nigeria): Efficacy and safety in a phase II feasibility study

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Background: The majority of clinical trials of neoadjuvant therapy for breast cancer have been conducted in resource-rich countries. We chose Nigeria, a resource-poor country, as the major site for a phase II feasibility open label multicenter clinical trial designed to evaluate the efficacy, safety and tolerability of neoadjuvant capecitabine in locally advanced breast cancer. Methods: Planned treatment consisted of 24 weeks of capecitabine at a dose of 1000mg/m2 twice daily (2000mg/m2 total per day). Each cycle consisted of a 14-day period of therapy followed by a 7-day pause, and patients were evaluated after 3 cycles and taken off study if no response was documented. Responding patients were treated for no more than 8 cycles. The primary endpoints were partial, complete clinical response and pathologic complete response. Results: A total of 16 patients were recruited from August 2007 to April 2010. The study was terminated early as a result of slow accrual. After the first 3 cycles of therapy, partial clinical responses were seen in 5 of 16 patients (31%; 95% CI 11% - 59%). Of the remaining 11 patients, 8 had no response or stable disease, and 3 had progressive disease. Seven pateints proceeded with further therapy, two of them with stable disease but exactly in the border line of 25% increase. By physical examination, only 2 of the 6 patients had a documented complete clinical response, while by ultrasonomammography, partial responses were observed in 5 patients. Thus, overall response rate at the end of 8 cycles were 31.1% both by clinical examination and by ultrasonomammography. Clinical response by physical examination and radiologic response by ultrasonomammography were highly concordant (the spearman correlation between the two ratios was 0.70). The most common adverse effect was Grade 1 Hand and Foot Syndrome in 75% of patients. Conclusions: Despite several limitations, we successfully carried out this phase II feasibility study of neoadjuvant capecitabine for locally advanced breast cancer in Nigeria. Capecitabine monotherapy showed good overall response rates with minimal toxicity and further studies are warranted.

Abstract 2606: Absence of association between common genetic polymorphisms in the TERT-CLPTM1L locus and breast cancer risk in women of African descent

Recent genome wide association studies (GWAS) provided evidence that common low-penetrance single nucleotide polymorphisms (SNPs) contribute to breast cancer development. Common SNPs in the TERT (telomerase reverse transcriptase)-CLPTM1L (cleft lip and palate transmembrane 1 like) locus have been reported to be associated with several types of cancer, such as lung cancer/adenocarcinoma, glioma, bladder cancer, prostate cancer, and pancreatic cancer. Researchers also hypothesized that common SNPs in the TERT gene could play a role in breast cancer susceptibility. However, findings are inconsistent, and most studies included Caucasians only. In the present study, we sought to investigate whether common genetic variants in the TERT-CLPTM1L locus could contribute to breast cancer susceptibility in women of African ancestry. A total 2,892 women of African ancestry were participated in the present study, consisting of 1,509 breast cancer cases and 1,383 controls collected from Nigeria, Barbados, and the United States. Eleven SNPs in the TERT-CLPTM1L locus that were previously shown to be associated with cancers were selected and genotyped using the Illumina GoldenGate Genotyping platform, together with 30 ancestry informative markers (AIMs). Test for HWE suggested that the genotypes for all the SNPs were in Hardy-Weinberg proportions and there was no deviation from HWE. We performed unconditional multiple logistic regression to estimate the association between the TERT-CLPTM1L genetic variants and breast cancer risk, adjusting for age, study site, and estimated genetic ancestry. Overall we did not observe any P value &lt; 0.05 after permutation in the analyses of allelic and genotypic models. We also conducted haplotype analysis for a five-SNP LD block, rs4975616-rs3816659-rs402710-rs401681-rs31489 but again failed to obtain significant association in the present study. Our findings do not support an effect of the tested genetic variants in the TERT-CLPTM1L locus on breast cancer susceptibility in women of African ancestry. However, it is worth noting that our current study did not apply a fine-mapping strategy; other genetic variants in LD with previously reported cancer susceptibility polymorphisms might be bona fide causal variants contributing to the risk of breast cancer. Larger independent studies from diverse populations are expected to evaluate the importance of the TERT-CLPTM1L locus in breast cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2606. doi:1538-7445.AM2012-2606

Body fat distribution and breast cancer risk: findings from the Nigerian breast cancer study

PURPOSE

The relationship between overall obesity and breast cancer risk has been well recognized, but the role of central obesity in breast cancer development is uncertain.

METHODS

Between 1998 and 2009, 1,233 invasive breast cancer cases and 1,101 community controls were recruited into the Nigerian Breast Cancer Study at Ibadan, Nigeria. Logistic regressions were used to calculate multivariate odds ratio (OR) and 95% confidence intervals (CI), adjusting for age, body mass index (BMI), and other known risk factors for breast cancer.

RESULTS

The OR for the highest quartile group of waist circumference relative to the lowest was 2.39 (95% CI, 1.59-3.60; P-trend < 0.001). Comparing women with waist/hip ratio (WHR) in the lowest quartile group, the OR for women in the highest quartile category was 2.15 (95% CI, 1.61-2.85; P-trend < 0.001). An inverse association was observed between hip circumference and breast cancer, with an OR of 0.36 for the highest quartile (95% CI, 0.24-0.55; P-trend < 0.001). The effects of these three measures existed in both pre- and postmenopausal women. Of note, we found a significant interaction between WHR and BMI (P-interaction = 0.016): the OR comparing the highest to the lowest WHR quartile was 2.81 (95% CI, 1.90-4.16) for women with BMI < 25 kg/m2 and 1.70 (95% CI, 1.11-2.61) for women with BMI ≥ 25 kg/m2.

CONCLUSIONS

These results suggest that central adiposity, measured by waist circumference and waist/hip ratio, was an important risk factor for breast cancer in Nigerian women, and the effect of central adiposity was strong in normal-weight women.

Evaluation of 19 susceptibility loci of breast cancer in women of African ancestry

Multiple breast cancer susceptibility loci have been identified in genome-wide association studies (GWAS) in populations of European and Asian ancestry using array chips optimized for populations of European ancestry. It is important to examine whether these loci are associated with breast cancer risk in women of African ancestry. We evaluated 25 single nucleotide polymorphisms (SNPs) at 19 loci in a pooled case-control study of breast cancer, which included 1509 cases and 1383 controls. Cases and controls were enrolled in Nigeria, Barbados and the USA; all women were of African ancestry. We found significant associations for three SNPs, which were in the same direction and of similar magnitude as those reported in previous fine-mapping studies in women of African ancestry. The allelic odds ratios were 1.24 [95% confidence interval (CI): 1.04-1.47; P = 0.018] for the rs2981578-G allele (10q26/FGFR2), 1.34 (95% CI: 1.10-1.63; P = 0.0035) for the rs9397435-G allele (6q25) and 1.12 (95% CI: 1.00-1.25; P = 0.04) for the rs3104793-C allele (16q12). Although a significant association was observed for an additional index SNP (rs3817198), it was in the opposite direction to prior GWAS studies. In conclusion, this study highlights the complexity of applying current GWAS findings across racial/ethnic groups, as none of GWAS-identified index SNPs could be replicated in women of African ancestry. Further fine-mapping studies in women of African ancestry will be needed to reveal additional and causal variants for breast cancer.

Genetic susceptibility to type 2 diabetes and breast cancer risk in women of European and African ancestry

BACKGROUND

Epidemiologic studies have reported a positive association between type 2 diabetes (T2D) and breast cancer risk, independent of body weight.

METHODS

We investigated 40 genetic variants known to be associated with T2D in relation to breast cancer risk among 2,651 breast cancer cases and 2,520 controls of African or European ancestry that were pooled from seven studies.

RESULTS

We found that two T2D risk alleles in Caucasian women (rs5945326-G, rs12518099-C) and one in women of African ancestry (rs7578597-T) were positively associated with breast cancer risk at a nominal significance level of 0.05, whereas two T2D risk alleles were inversely associated with breast cancer risk in Caucasian women (rs1111875-C, rs10923931-T). The composite T2D susceptibility score (the number of risk allele) was not significantly associated with breast cancer risk.

CONCLUSION

The association between established T2D genetic susceptibility variants and breast cancer risk in women of African or European ancestry is likely weak, if it does exist.

IMPACT

The pleiotropic effects of known T2D risk alleles cannot explain the association between T2D and breast cancer risk.

Surgeon-patient information disclosure practices in southwestern Nigeria

OBJECTIVE

This study examined the practice of information disclosure to patients by surgeons in Nigeria.

SUBJECTS AND METHODS

A 55-item self-administered semi-structured questionnaire was sent to 150 surgeons in southwestern Nigeria in 2004-2005. The data obtained from the completed questionnaire were analyzed using descriptive statistics.

RESULTS

Of the 150 surgeons, 102 completed the questionnaire, giving a response rate of 68.0%. Of these 102, 85 (85.3%) were men, 44 (43.1%) were consultants and 55 (54.0%) were senior and junior surgical trainees. Most were from surgical subspecialties and obstetrics and gynecology. A documented policy statement about information disclosure was not available in most hospitals. A third, i.e. 35 (34.3%), of the surgeons did not routinely engage patients in discussions about disease diagnosis, management and prognosis. Most, i.e. 73 (71.6%), would rather disclose worsening disease progression to the patient's spouse. Others would disclose such information to the patient's children, family members or clergy. This was presumably to shield the patient from psychological distress. Only 22 (21.6%) of them routinely disclose operative findings to patients or their families. Thirty (29.4%) of them had been involved in disclosing medical errors to their patients in the past while 63 (61.8%) respondents did not know if surgical errors with potentially negative consequences should be disclosed.

CONCLUSION

Most of the surgeons in southwestern Nigeria did not routinely provide detailed information to patients about their illness and possible outcome of illness even in the presence of worsening disease progression and prognosis. When surgical errors with potential negative consequences occurred, the majority did not know if such errors should be disclosed.

Lack of association between common single nucleotide polymorphisms in the TERT-CLPTM1L locus and breast cancer in women of African ancestry

As one of the most common cancers worldwide, breast cancer places an extraordinary burden on the populations of African ancestry. Common SNPs in the TERT-CLPTM1L locus have been reported to be associated with several types of cancer, including breast cancer. We sought to investigate whether the previously reported common single nucleotide polymorphisms (SNPs) in the TERT-CLPTM1L locus could also contribute to the breast cancer risk in women of African ancestry. We genotyped eleven SNPs in 2,892 women of African descent but were unable to detect any significant association between TERT-CLPTM1L SNPs and their predispositions for breast cancer risk. Given the differences in linkage disequilibrium patterns across populations, our findings suggest that larger independent studies from diverse populations are expected to evaluate the importance of the TERT-CLPTM1L locus in breast cancer.

Abstract 3734: Alcohol consumption and breast cancer risk among Nigerian women

Background: Alcohol consumption has been reported as a risk factor for breast cancer. However, little is known about its importance for indigenous African population, among whom the prevalence of breast cancer is relatively low. The purpose of this study was to investigate the relationship between alcohol drinking and breast cancer risk in Nigerian women.

Methods: The study was based on the Nigerian Breast Cancer Study, a case-control study of breast cancer conducted in Ibadan, Nigeria, between 1998 and 2010. In-person interviews were conducted with 1355 invasive breast cancer cases and 1132 community controls, using structured questionnaires to collect detailed epidemiologic data including alcohol drinking. Multivariate logistic regression was performed to estimate odds ratios (OR) and 95% confidence intervals (CI), controlling for age, ethnicity, and type of questionnaire (we revised the questionnaire in the middle of study), with potential effect measure modifications tested.

Results: 5.8% controls and 11.3% cases reported drinking alcohol every week for at least 6 months, with crude OR=2.08 (95% CI: 1.54-2.82, p&lt;0.0001). After adjusting for potential confounding variables, alcohol drinking remained statistically associated with breast cancer risk but the strength of association was attenuated (adjusted OR=1.56, 95% CI: 1.11-2.19, p=0.01). Among women who drink weekly, the average drinks per week were 1.7±0.8 in controls and 3.4±5.8 in cases, and there was a dose-response trend: the crude OR was 1.86 for women who had 1-2 drinks per week and 3.27 for those who had ≥ 2 drinks per week, compared with non-drinkers (p-trend=0.08). The age- and ethnicity-adjusted ORs for 1-2 drinks and ≥ 2 drinks per week were 1.20 (95% CI: 0.49-2.93) and 1.80 (95% CI: 0.36-8.87), respectively. The association between alcohol drinking and breast cancer was particularly stronger in overweight or obese women who have BMI ≥ 25 kg/m2 (adjusted OR=1.92, 95% CI: 1.23-3.01, p=0.004) than in normal weight women (adjusted OR=1.20, 95% CI: 0.71-2.02, p=0.5). Similar association was observed in pre-menopausal and post-menopausal women.

Conclusions: Our study showed that regular alcohol intake is uncommon among Nigerian women. However, regular alcohol drinking may increase breast cancer risk among the Nigerians, particularly overweight women.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3734. doi:10.1158/1538-7445.AM2011-3734

Abstract LB-425: Replication of 18 susceptibility loci of breast cancer in women of African ancestry

Background: Numerous novel susceptibility loci for breast cancer have been identified in genome-wide association studies (GWAS). However, all GWAS of breast cancer have been conducted in populations of European and Asian ancestry and array chips optimized for populations of European ancestry have been used. Thus the question remains whether these genetic associations can be generalized more broadly to other racial/ethnic populations. We addressed this question and examined whether common genetic variants identified from prior GWAS are associated with breast cancer risk in women of African ancestry.

Methods: We evaluated 24 single nucleotide polymorphisms (SNPs) at 1p11, 2q35, 3p24, 5p12, 5q11, 6q22, 6q25, 8q24, 9p21, 10q21, 10q22, 10q26, 11p15, 11q13, 14q24, 16q12, 17q23, and 19p13, in a pooled case-control study of breast cancer, which included 1,543 cases and 1,416 controls. Cases and controls were enrolled in Nigeria, Barbados, and the United States; all were women of African ancestry by self-report. We also selected 30 ancestral informative markers to estimate and control for population admixture in African Americans and African Barbadians. Logistic regression models were used to estimate odds ratio and 95% confidence intervals (CI) for each SNP, after adjusting for study sites and proportion of European admixture.

Results: The mean age (SD) was 47.9 years old (12.1) in cases and 47.0 years old (13.2) in controls; the majority of cases (58.8%) and controls (58.2%) were younger than age 50. The proportion of European admixture was 0.143 in Barbadians and 0.218 in African Americans. Cases and controls had similar proportions of European admixture. Significant associations were observed between two index SNPs (rs10995190 at 10q21 and rs3817198 at 11p15) and breast cancer risk, but the associations were in the opposite direction of the previous studies. The minor allele frequencies for both SNPs were different slightly between this and previous studies but no switch between minor and major alleles. For the remaining 16 loci, no significant associations were observed for the index SNPs from GWAS. We also evaluated two SNPs identified from previous fine-mapping studies in women of African ancestry. We found both SNPs were significantly associated with breast cancer risk in the present study. The allelic odds ratio was 1.24 (95% CI: 1.04-1.47; p=0.018) for the rs2981578-G allele (10q26/FGFR2) and 1.34 (95% CI: 1.10-1.63; p=0.0035) for the rs9397435-G allele (6q25).

Conclusion: This study highlights the complexity of applying current GWAS findings across racial/ethnic groups, as none of GWAS-identified index SNPs could be replicated in women of African ancestry. Our successful replication of SNPs from fine-mapping studies suggests that fine-mapping studies and new GWAS in understudied minority population may be promising to reveal additional and causal variants for breast cancer susceptibility.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-425. doi:10.1158/1538-7445.AM2011-LB-425

Surgeons' opinions and practice of informed consent in Nigeria

BACKGROUND

Informed consent is perhaps more relevant to surgical specialties than to other clinical disciplines. Fundamental to this concept is the provision of relevant information for the patient to make an informed choice about a surgical intervention. The opinions of surgeons in Nigeria about informed consent in their practice were surveyed.

METHODS

A cross-sectional survey of surgeons in Nigeria was undertaken in 2004/5 using self-administered semistructured questionnaires.

RESULTS

There were 102 respondents, 85.3% of whom were men and 58.8% were aged 31-40&emsp14;years. 43.1% were consultants and 54.0% were surgical trainees. 27.4% were in surgical subspecialties, 26.5% in general surgery and 21.6% were obstetricians and gynaecologists. 54.9% agreed that sufficient information is not provided to patients while obtaining their consent for surgical procedures. They listed medicolegal reasons (70.6%), informing patients about benefits, risks and alternatives (64.7%) and hospital policy (50.0%) as some reasons for obtaining consent for surgical procedures. When patients decline to give consent for surgery, 84.3% of them thought that poor communication between surgeons and patients may be contributory. They identified taking a course in bioethics during surgical training and compulsory communication skills course as some ways to improve communication between surgeons and patients.

CONCLUSION

Most Nigerian surgeons seemed to have a good knowledge of the informed consent requirements and process but fall short in practice. There is a need to improve the surgeon-patient relationship in line with modern exigencies to provide interactive environments for fruitful patient communication and involvement.

Case-control study of body size and breast cancer risk in Nigerian women

Previous studies have shown that weight is inversely associated with premenopausal breast cancer and positively associated with postmenopausal disease. Height has been shown to be positively correlated with breast cancer risk, but the association was not conclusive for premenopausal women. These previous studies were conducted primarily in Western countries, where height is not limited by nutritional status during childhood. The authors assessed the association between breast cancer and anthropometric measures in the Nigerian Breast Cancer Study (Ibadan, Nigeria). Between 1998 and 2009, 1,233 invasive breast cancer cases and 1,101 controls were recruited. The multivariate-adjusted odds ratio for the highest quartile group of height relative to the lowest was 2.03 (95% confidence interval (CI): 1.51, 2.72; P-trend < 0.001), with an odds ratio of 1.22 (95% CI: 1.14, 1.32) for each 5-cm increase, with no difference by menopausal status. Comparing women with a body mass index in the lowest quartile group, the adjusted odds ratio for women in the highest quartile category was 0.72 (95% CI: 0.54, 0.94; P-trend = 0.009) for premenopausal and postmenopausal women. Influence of height on breast cancer risk was quite strong in this cohort of indigenous Africans, which suggests that energy intake during childhood may be important in breast cancer development.

Review of fine needle aspiration cytology in the management of goitres in Ibadan, Nigeria

OBJECTIVE

The use of Fine Needle Aspiration Cytology (FNAC) in the investigation of goitres was introduced into our practice more than a decade ago. This is a review of its diagnostic accuracy for thyroid carcinoma seven years after the first evaluation and following the establishment of the 'FNAC Clinic'.

METHOD

This is a retrospective study of patients who had FNAC of goitres and the histopathology of their thyroidectomy specimens between 1995 and 2004. The accuracy of the cytology reports were evaluated against the histology reports. The turnaround time of the patients for surgery was also determined.

RESULTS

There were 130 females and 21 males with an age range of 7-86 years. The diagnostic accuracy of the procedure for carcinoma was 89% with a sensitivity of 35%, specificity of 97%, positive predictive value of 64%, and a negative predictive value of 91%. The average turnaround time for surgery was 178.7 +/- 248.7 days with a range of five days to three and a half years.

CONCLUSION

The diagnostic accuracy of FNAC of goitre for carcinoma improved in the period under review. However, the long surgery turnaround time may reduce the usefulness of the procedure. The accuracy may be improved further by a protocol of ultrasound guidance, capillary collection with no-aspiration technique, on-site review of slides with a repeat of FNA as necessary.

Bioethics in the medical curriculum in Africa

Many new innovations and advances are introduced into life and the sciences at a pace faster than any single individual can keep up with but human beings adjust to these changes at a much slower pace. Development is at snail speed in many developing countries and supersonic in the developed world and yet these have to interrelate. The introduction of medical technology and advances into developing countries is sometimes done haphazardly and often without prior appropriate education and decision making process. This has the potential to create dilemmas among stakeholders and engender conflicts with culture, religion and societal norms. A good grounding in the study of bioethical principles and theories is relevant to addressing current and evolving issues with changing biotechnology and shifting landmarks in today's highly technical clinical medicine. The knowledge and utilization of these principles should limit the occurrence of many scandals in the form and magnitude already recorded in the history of biomedical research and practice. While the debate as to whether ethics can be taught will continue, bioethics education provides the requisite knowledge and skill that are applicable at the bedside and in biomedical research. Some evidence has shown that formal teaching of ethics impacts positively on physicians and medical students' attitudes in the care of patients. In this paper we propose that bioethics as a distinct course should be incorporated into medical curriculum in Africa. The integration of bioethics as a required subject in the medical curriculum would have a positive impact on all aspects of health care and research. Real or assumed obstacles are not justifiable reasons for further delay in implementing this initiative