Cancer incidence in a rural population of South Africa, 1998-2002

Biogenic amine testing in the South African public health care system

Background

Phaeochromocytoma, paraganglioma and neuroblastoma are catecholamine secreting neuroendocrine tumours. Biochemical screening for suspected cases of these tumours involves the measurement of catecholamines and their metabolites in either urine or plasma. The South African National Health Laboratory service (NHLS) measures urine fractionated metanephrines (UMF) and normetanephrines (UNF), urine vanillylmandelic acid (UVMA) and urine homovanillic acid (UHVA).

Objectives

To analyse the demographic, biochemical and testing patterns of patients' UMF, UNF, UVMA and UHVA in the NHLS.

Methods

Data from January 2015 to December 2016 for all patients undergoing UMF, UNF, UVMA and UHVA testing was extracted from the NHLS central data warehouse. Neuroendocrine tumours were biochemically diagnosed when results were >2x multiples of the upper reference limits. Multiple testing was defined as ≥2 tests within a 14-day period. Ethnicity was determined through hot-deck imputation.

Results

Biochemically abnormal test results were identified by UMF/UNF measurements in 98.2 % of cases. In 1.8 % of cases, the addition of UVMA resulted in a previously unidentified biochemical positive. Adult white and coloured populations have significantly less biochemically positive UMF results compared to the African population. Multiple testing resulted in discordant results for 12.8 % of UMF and 13.1 % of UNF testing.

Conclusion

UVMA testing for phaeochromocytoma and paraganglioma offers little benefit over testing with UMF alone. Requesting consecutive multiple samples is preferred, however, a single 24-h fractionated UMF/UNF is efficient and cost-effective for phaeochromocytoma and paraganglioma screening, with further testing recommended when clinically indicated. African individuals are more likely to have raised catecholamines and requires further investigation.

Gastric cancer in Sub-Saharan Africa - a systematic review of primary data

Introduction

Gastric cancer (GC) is the third leading cause of global cancer-related mortality. Despite the shifting burden of GC to low-and middle-income countries, the data regarding incidence, treatment, and outcomes in these settings are sparse. The primary aim of this systematic review was to aggregate all available data on GC in sub-Saharan Africa (SSA) to describe the variability in incidence across the region.

Methods

Studies reporting population-based primary data on GC in SSA were considered. The inclusion was limited to primary studies published between January 1995 and March 2022 which comprised of adult patients in SSA with GC. Studies without accessible full text in either French or English language were excluded. Unadjusted GC incidence rates with their standard errors for each study were recalculated from the crude numerators and denominators provided in individual studies.

Results

A total of 5,626 articles were identified in the initial search, of which, 69 studies were retained. Reported incidence rates ranged from a high of 5.56 GC cases per 100,000 in Greater Meru Kenya to a low of 0.04 GC cases per 100,000 people in Benin City Nigeria. The overall crude pooled incidence was 1.20 GC cases per 100, 000 (95%CI 1.15-1.26) with a variability of 99.83% (I2 p < 0.001). From the 29 high-quality population-based registry studies the crude pooled incidence was 1.71 GC cases per 100,000 people (95%CI 1.56-21.88) with a variability of 99.60%.

Conclusion

This systemic review demonstrates that GC incidence is highly variable across SSA. The limited data on GC treatment, mortality, and survival presents a significant challenge to providing a complete epidemiologic description of the burden of GC in SSA. There is a need for further robust data collection, exploration, and research studies on cancer care in SSA, with continued assessment of primary data availability.

Recent trends in hereditary breast cancer incidence by race and age in KwaZulu-Natal, South Africa: An 11-year single-centre retrospective study (2011-2021)

Breast cancer incidence has increased globally in the last decade, especially in low- and middle-income countries. In Sub-Saharan Africa, breast cancer trends have been described only in a few populations owing to the scarcity of population-specific data. Using data collected between 2011 and 2021 at Inkosi Albert Luthuli Central Hospital, this retrospective study describes demographic and genetic trends for hereditary breast cancer patients in the KwaZulu-Natal province, South Africa. Six hundred and forty-five patients were included, of whom 44.3% were Black, 36.8% Indian, 15.6% White and 3.2% Coloured. The number of annual new cases increased from eight in 2011 to 145 in 2021, with a notable increase among Blacks. The mean onset age was 46 years, and Black patients were diagnosed ~10 years earlier than White and Indian patients. Triple-negative breast cancers accounted for 20.3% of hereditary cases, and 51.1% of them were Black. Bilateral and recurrent breast cancers constituted 7.4%, while pathogenic sequence variants in BRCA1/2 were reported in 10.4% of all patients, and the majority were Blacks and Indians. Overall, the KwaZulu-Natal province has seen an increase in hereditary breast cancer incidence in the past decade. Despite testing negative for pathogenic sequence variants, Black women frequently presented with breast cancers that are BRCA1-like, while Indians presented with extensive family history. This suggests that South African patients may require unique approaches to interventions, such as early detection and awareness programs among Blacks and increased genetic screening among Indians.

The effect of acute acid exposure on immunomodulatory protein secretion, cell survival, and cell cycle progression in tumour cell lines

Cancer develops when multiple systems fail to suppress uncontrolled cell proliferation. Breast cancers and oesophageal squamous cell carcinoma (OSCC) are common cancers prone to genetic instability. They typically occur in acidic microenvironments which impacts on cell proliferation, apoptosis, and their influence on surrounding cells to support tumour growth and immune evasion. This study aimed to evaluate the impact of the acidic tumour microenvironment on the production of pro-tumorigenic and immunomodulatory factors in cancer cell lines. Multiple factors that may mediate immune evasion were secreted including IL-6, IL-8, G-CSF, IP-10, GDF-15, Lipocalin-2, sICAM-1, and myoglobin. Others, such as VEGF, FGF, and EGF that are essential for tumour cell survival were also detected. Treatment with moderate acidity did not significantly affect secretion of most proteins, whereas very low pH did. Distinct differences in apoptosis were noted between the cell lines, with WHCO6 being better adapted to survive at moderate acid levels. Conditioned medium from acid-treated cells stimulated increased cell viability and proliferation in WHCO6, but increased cell death in MCF-7. This study highlights the importance of acidic tumour microenvironment in controlling apoptosis, cell proliferation, and immune evasion which may be different at different anatomical sites. Immunomodulatory molecules and growth factors provide therapeutic targets to improve the prognosis of individuals with cancer.

The SARS-COV-2 Seroprevalence among Oncology Patients

Patients with cancer are presumed to be vulnerable to an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe clinical outcomes due to the immunocompromised state mediated by their underlying malignancies and therapy. The aim of this study was to estimate the SARS-CoV-2 seroprevalence, following second to fourth waves in solid tumour patients attending the Steve Biko Academic Hospital (SBAH) for diagnosis and treatment of cancer. We used the single-prick COVID-19 IgG/IgM Rapid Test Cassettes to detect SARS-CoV-2 IgG/IgM antibodies in 760 patients with solid tumours who were asymptomatic and who had never tested positive for coronavirus disease 2019 (COVID-19). Out of the 760 patients, 277 were male (36.4%), 483 were female (63.6%), and the mean age was 55 years (range 18−92). The estimated total seroprevalence was 33.2%. The seroprevalence status of the COVID-19 IgG/IgM antibodies rose significantly from the second wave (11.3%) to the third (67.38%) and then the fourth (69.81%) waves with roughly similar counts. A significant number of the seropositive patients were asymptomatic to COVID-19 (96%). There was a higher rate of seropositivity in cancer patients with hypertension (p < 0.05). Patients with breast, gynaecologic, and prostate cancers exhibited increased SARS-CoV-2 seropositivity. Although oncology patients may be susceptible to SARS-CoV-2 infection, our data indicate that these patients remained asymptomatic throughout various waves with an overall COVID-19 IgG/IgM antibody seropositivity of 33.16%, suggesting no risk of severe or fatal cases of COVID-19.

The University of Cape Town’s paediatric cancer database: Results from the first years (2019–2021)

Background: The paediatric oncology multidisciplinary team at the University of Cape Town (UCT) developed a research-ready data set.Aim: This study aimed to describe the early results detailing the epidemiological profile of childhood cancer patients and evaluated factors associated with presentation and outcome.Setting: The UCT paediatric oncology platform at the Red Cross War Memorial Children’s Hospital (RCWMCH) and Groote Schuur Hospital (GSH).Methods: A REDCap database was developed with a Cancer Association of South Africa (CANSA) grant. A database administrator consented all new patients and recorded demographic and social information.Results: There were 212 children consented from 2019 to 2021: 109 girls and 103 boys. The age range was from 1 day to 15.98 years, with a median of 5.18 years. Only 32 (15%) of these families had medical insurance, 34 (16%) lived in informal housing and 25 (12%) did not have access to piped water. Seventy-four families (35%) reported a relative with cancer, including seven first degree relatives. With a median follow-up of 12.4 months, the estimated 2-year overall survival (OS) and event-free survival (EFS) was 77% and 72%, respectively. Overall survival was significantly different (p = 0.013) by disease group, varying from 100% for Wilms tumour and germ cell tumours to 52% for rhabdomyosarcoma. Most patients with solid tumours (72%) had advanced disease at diagnosis. Outcomes were poorer for children living in informal housing and without piped water.Conclusion: A real-time database can provide a research-ready data set for interrogating cohort-specific factors impacting childhood cancer outcomes. 

Mapping Evidence on the Burden of Breast, Cervical, and Prostate Cancers in Sub-Saharan Africa: A Scoping Review

Background

Cancer remains a major public health problem, especially in Sub-Saharan Africa (SSA) where the provision of health care is poor. This scoping review mapped evidence in the literature regarding the burden of cervical, breast and prostate cancers in SSA.

Methods

We conducted this scoping review using the Arksey and O'Malley framework, with five steps: identifying the research question; searching for relevant studies; selecting studies; charting the data; and collating, summarizing, and reporting the data. We performed all the steps independently and resolved disagreements through discussion. We used Endnote software to manage references and the Rayyan software to screen studies.

Results

We found 138 studies that met our inclusion criteria from 2,751 studies identified through the electronic databases. The majority were retrospective studies of mostly registries and patient files (n = 77, 55.8%), followed by cross-sectional studies (n = 51, 36.9%). We included studies published from 1990 to 2021, with a sharp increase from 2010 to 2021. The quality of studies was overall satisfactory. Most studies were done in South Africa (n = 20) and Nigeria (n = 17). The majority were on cervical cancer (n = 93, 67.4%), followed by breast cancer (67, 48.6%) and the least were on prostate cancer (48, 34.8%). Concerning the burden of cancer, most reported prevalence and incidence. We also found a few studies investigating mortality, disability-adjusted life years (DALYs), and years of life lost (YLL).

Conclusions

We found many retrospective record review cross-sectional studies, mainly in South Africa and Nigeria, reporting the prevalence and incidence of cervical, breast and prostate cancer in SSA. There were a few systematic and scoping reviews. There is a scarcity of cervical, breast and prostate cancer burden studies in several SSA countries. The findings in this study can inform policy on improving the public health systems and therefore reduce cancer incidence and mortality in SSA.

Prostate Cancer Patterns and Trends in the Eastern Cape Province of South Africa; 1998-2017

Background

Globally, prostate cancer is rated the second most common cancer and the sixth leading cause of death. In South Africa, it is ranked as leading cancer among men. This study describes prostate cancer patterns and trends in the rural Eastern Cape Province population.

Methodology

Secondary data were used from which a sample of 723 prostate cancer (C61) patients was extracted from the database into STATA version 14.0 for descriptive analysis. A direct standardization method was used to estimate age-specific and age-standardized incidence rates. Keyfitz method was used to calculate the standard error and confidence interval, whereas the Joinpoint program the annual percentage change.

Results

The mean age was 64 years, with a standard deviation of 9.9. Trends in prostate cancer incidence increased significantly (p = 0.026) from 7.4% in 2010 to 12.6% in 2017. Incidence rates varied across the region, with the lowest of 4.5 per 100,000 in 1998 to the highest of 21.4 per 100,000 in 2017 period. Lusikisiki had the highest incidence rates of 53.4 per 100,000 population (95% CI 0.8–61.4), while Centane with 21.7 per 100,000 (95% CI 2.3–27.6) rated the second. Other magisterial areas showed a constant increase (p > 0.05) throughout the observation period except for Idutywa and Willowvale, with no apparent increase. Conversely, in Butterworth, incidence rates decreased from 15.2 per 100 000 (95% CI 8.6–21.9) to 11.5 per 100,000 (95% CI 6.2–16.7).

Conclusion

As experienced globally and regionally, prostate cancer has become a public health concern in this population. Incidence variations across the surveillance area in the Eastern Cape were noted with hotspots.

Model of delivery of cancer care in South Africa's Eastern Cape and Mpumalanga provinces: a situational analysis protocol

INTRODUCTION

Cancer contributes to a significant proportion of morbidity and mortality globally. Low-income and middle-income countries such as South Africa tend to be characterised by poor and inequitable access to cancer services. Cancer resources are more likely to be found in urban areas, tertiary centres and quaternary hospitals. However, little is known about the linkages to care, continuity of care and packages of cancer care in rural South African settings. This study describes cancer service delivery for South Africa's Eastern Cape and Mpumalanga provinces.

METHODS AND ANALYSIS

A mixed-methods qualitative and quantitative research methods of three substudies which include semistructured interviews with patients, focus group discussions with health providers and a quantitative record review that will be carried out at both Rob Ferreira hospital, Witbank hospital and Nelson Mandela Academic hospital in Mpumalanga and Eastern Cape province, respectively. Instruments assess demographic characteristics, explore packages of cancer care, explore challenges experienced by health professionals, and maps out the referral pathway of patients with a cancer diagnosis in the study sites. Numerical, quantitative data will be explored for normality using the Shapiro-Wilk test and reported using either the mean, SD and range or the median and IQR depending on the normality of the distribution. Qualitative data will be analysed using the phenomenological approach.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Human Research Ethics Committee of Walter Sisulu University (040/2020) and the University of the Witwatersrand (M210211), South Africa. To the research team's knowledge, this is the first study presenting the model of cancer delivery in South Africa's Eastern Cape and Mpumalanga province. This will thus provide better understanding of cancer service delivery systems, packages of cancer care from primary care to quaternary care.

Age-standardised incidence rate and epidemiology of colorectal cancer in Africa: a systematic review and meta-analysis

OBJECTIVES

Colorectal cancer (CRC) is the second-leading cause of cancer deaths globally, with low-income and middle-income countries (LMICs) disproportionately affected. Estimates of CRC rates in LMIC are scarce. We aimed to (1) estimate sex-specific incidence of CRC, (2) estimate temporal trend and (3) determine regional variations of CRC rates on the African continent.

DESIGN

Systematic review and meta-analysis METHODS: PubMed (MEDLINE), OVID (MEDLINE), Scopus and Cochrane Library databases were systematically searched from inception to 12 December 2020. We included population-based studies that reported the incidence or prevalence estimates of CRC in Africa. Studies not conducted in humans or did not directly report the rates of CRC were excluded. Random effects model was used to pool the estimates. The methodological quality of studies was assessed with the Newcastle-Ottawa Scale.

OUTCOME MEASURES

Overall and sex-specific annual age-standardised incidence rates (ASIR) of CRC per 100 000 population.

RESULTS

The meta-analysis included 14 studies consisting of 3365 individuals with CRC (mean age, 58 years, 53% male). The overall ASIR of CRC in Africa per 100 000 population was 5.25 (95% CI 4.08 to 6.75). The rates were slightly higher in males (4.76) than in females (4.18), but not significantly different. Subgroup analysis indicated greater point estimates in North Africa (8.66) compared with sub-Saharan Africa (5.91); and higher estimates in Eastern (8.29) and Northern (8.66) Africa compared with Western (3.55) and Southern (3.57) Africa, but not statistically significant. The overall trend in ASIR has remained constant at nearly 5 per 100 000 population for the last 6 decades.

CONCLUSION

CRC estimates in Africa are heterogeneous and could be underestimated. High-quality data collection systems such as population-based cancer registries may facilitate accurate estimation of country-specific rates and provide critical information which would be lucrative to the consideration of resources needed for screening, early detection, treatment and improving overall patient outcomes.

Increasing Cervical Cancer Incidence in Rural Eastern Cape Province of South Africa From 1998 to 2012: A Population-Based Cancer Registry Study

PURPOSE

In this study, we aimed to investigate trends in the age-standardized and age-specific incidence rates in two distinct regions (the northern and southern areas) of South Africa covered by a population-based cancer registry. In addition, trends in coverage of the cervical cancer screening program were assessed using routine health service data.

METHODS

Occurrences (topography C53.0-C53.9) for the period 1998-2012 were extracted from a cancer registry database from which basic descriptive statistics and frequencies were analyzed for all variables using CanReg4. Trends over time were estimated using a direct standardization method and world standard population as a reference. Screening coverage annualized figures for women age ≥ 30 years by sub–health district were extracted from the District Health Information System.

RESULTS

In the northern area, annual age-standardized incidence rates per 100,000 women increased from 24.0 (95% CI, 21.1 to 27.0) in 1998-2002 to 39.0 (95% CI, 35.6 to 42.5) in 2008-2012, with a screening coverage rate of 15% by 2012. In contrast, no increase was observed in incidence in the southern area, with rates of 20.0 (95% CI, 18.5 to 21.4) in 1998-2002 and 18.8 (95% CI, 16.2 to 21.4) in 2008-2012, and the southern area had a higher screening coverage of 41% in 2012. Overall, the percentage distribution of stage at diagnosis showed that 28.5% of occurrences were diagnosed at disease stages I and II and 35%, at III and IV; 36% had with missing stage information (2003-2012). In 77% of occurrences, a histologically verified diagnosis was made, compared with only 12.3% by cytology.

CONCLUSION

This study has demonstrated an almost two-fold increase in the incidence rate in the northern area but little change in the southern area of the cancer registry.

Establishing and Evaluating Cancer Surveillance System in KwaZulu-Natal, South Africa

Background:

The increasing cancer burden remains a public health challenge. Quality and accurate population data is important to improve cancer control, screening, and treatment programmes for the sub-Saharan Africa region.

Aim:

The aim of this study was to establish hospital-based cancer surveillance system, thereby reporting the burden that cancer diagnosis and treatment place on 3 hospitals – an approach of health systems strengthening.

Methods:

A hospital-based cancer surveillance was established in 3 public health facilities that provide oncology services in KwaZulu-Natal. An active method was used for finding cancer cases. The cancer surveillance database was evaluated according to the criteria recommended for cancer registries. Analyses of data included descriptive and crude incidence rates.

Results:

A total of 2307 newly diagnosed cancer cases were reported in 2018, with a majority from Inkosi Albert Luthuli Central hospital (65.3%), followed by Greys hospital (30.8%) and then Addington hospital (3.94%). Most of the cancer cases were from the 2 major urban areas of the province (eThekwini and uMgungundlovu district). The most commonly diagnosed cancers from all combined 3 facilities for both sexes were breast, cervix, colorectal, Kaposi Sarcoma, and lung. Approximately half of the cancer cases had no staging, and 12.8% of the cases were diagnosed at stage 4. The mostly prescribed treatments for the patients were radiotherapy and chemotherapy.

Conclusions:

Based on our hospital-based surveillance, cancer burden is high in the 3 facilities. Strengthening cancer screening and diagnostic policies and procedures that will allow expansion of accurate cancer surveillance system is essential in KwaZulu-Natal and South Africa as a whole.

Active case-finding method improves completeness and accuracy of data reported to the rural Eastern Cape Cancer Registry in South Africa

The quality and accuracy of the data provided by cancer registries has a significant impact on decision making. Over decades, high-income countries have been successful in monitoring their cancer burden because of well-established data abstraction techniques such as digital systems. Conversely, in low- and middle-income countries, sparsely distributed cancer registries, using alternative less costly, but imprecise methods are struggling to capture all cancer cases. A population-based cancer registry in South Africa covering a resource-limited rural population is faced with challenges in case finding yet the quality and accuracy of the data provided has a significant impact on decision making. The objective of this study was to assess data quality using two data quality attributes ‘completeness and accuracy’ and also to determine the benefits of using active and passive case-finding methods for cancer registration in this population. Data used were collected between January 2014 and December 2015 from four hospitals to compare the quality of both active and passive case-finding methods. From all four hospitals during the same period, a first set of data obtained through passive reporting was compared with a second set of data obtained through active case finding. Covering multiple facilities during active case finding can significantly improve quality of data, while passive case finding is challenged by data collection being confined to one specific health facility, only. Better investment in active case finding is recommended in settings with resource-distribution disparities.

A phase III study on neoadjuvant chemotherapy versus neoadjuvant toripalimab plus chemotherapy for locally advanced esophageal squamous cell carcinoma: Henan Cancer Hospital Thoracic Oncology Group 1909 (HCHTOG1909)

Background

Neoadjuvant chemotherapy (NAC) and neoadjuvant chemoradiotherapy (NACR) are the standard treatments for esophageal squamous cell carcinoma (ESCC). However, the 5-year overall survival (OS) rate is still far from satisfactory. In recent years, immune checkpoint inhibitors (ICIs) have shown promising results in the treatment of ESCC. More than 20 phase II clinical trials have been launched to explore combinations of ICIs in the neoadjuvant setting for ESCC. Based on our phase II clinical trial, a two-arm phase III trial was launched in Henan Cancer Hospital. ICIs combined with NAC may usher in a new era and may benefit locally advanced, resectable ESCC patients.

Methods

A two-arm phase III trial was launched in April 2020 in Henan Cancer Hospital. Patient recruitment will be completed within 18 months. The primary endpoint is event-free survival (EFS). The secondary endpoints include pathologic complete response (pCR), disease-free survival (DFS) rate, overall response rate (ORR), R0 resection rate, major pathologic response (MPR), adverse events (AEs), complication rate and quality of life (QOL). A biobank of pretreatment, resected tumor tissue and paired blood samples will be built for translational research in the future.

Discussion

This RCT directly compares NAC with neoadjuvant toripalimab plus chemotherapy in terms of EFS for locally advanced ESCC. The results may usher in a new era of resectable ESCC treatment.

Trial registration

NCT04280822 (https://www.clinicaltrials.gov/ct2/show/NCT04280822). Registered title: “A Phase III, Randomized Controlled Study of Neo-adjuvant Toripalimab (JS001) in Combination with Chemotherapy versus Neo-adjuvant Chemotherapy for Resectable Esophageal Squamous Cell Carcinoma”. Version 1.0/Nov. 21, 2019.

A phase II, single-centre trial of neoadjuvant toripalimab plus chemotherapy in locally advanced esophageal squamous cell carcinoma

Background

Esophageal squamous cell carcinoma (ESCC) remains a challenging malignancy with poor prognosis and limited therapeutic methods. However, recent clinical trials of immune checkpoint inhibitors (ICIs) have shown promising results in the treatment of lethal malignancies. The second-line treatment of late-stage ESCC was approved based on the results of KEYNOTE-180, KEYNOTE-181 and ATTRACTION-1, ATTRACTION-3. Combining ICIs with chemotherapy in neoadjuvant therapy may benefit patients with locally advanced, resectable ESCC.

Methods

A two-arm phase II trial was launched in July 2019 in Henan Cancer Hospital. The primary outcome measure will be completed within 21 months. The pathological complete response (pCR) rate is the primary endpoint, and the secondary endpoints include overall survival (OS), disease-free survival (DFS), the toxicities of the neoadjuvant toripalimab plus chemotherapy, the relationship between combined positivity score (CPS) of specimen and the treatment response, the relationship between lymphocyte infiltration and the treatment response, the progression-free survival (PFS) rate, and adverse events (AEs). It was assumed that the pCR rate of this trial might be 25%. Therefore, the 30 enrolled patients could reject the hypothesis at 75% (α=0.1).

Discussion

The study will determine the safety and efficacy of neoadjuvant immunochemotherapy for ESCC and provide enough evidence for phase III clinical trials.

Trial registration

Clinical Trials.gov, NCT03985670, Registered: October 24, 2019, https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0008Z9D&selectaction=Edit&uid=U0002MIY&ts=2&cx=-i71o4q. Registry name: “Teripalimab Plus Chemotherapy in Local Advanced Esophageal Cancer”.

Gender Differences in Oesophageal Squamous Cell Carcinoma in a South African Tertiary Hospital

(1) Oesophageal squamous cell carcinoma is common in Africa and has a male preponderance. The gender-based differences in clinical presentation and risk factor exposure are poorly studied in the African context. Our aim was to compare males and females with this disease. We analyzed the differences in clinical features and risk factor exposure between males and females with oesophageal cancer. (2) Data from patients presenting to a tertiary hospital in South Africa with oesophageal squamous cell carcinoma were analyzed. Data collected included patient demographics, clinical presentation, pathology and risk factor exposure. (3) Three hundred and sixty three patients were included in the study. The male to female ratio was 1.4:1. The mean age was 66 years for females and 61 years for males (p < 0.0001). A significantly larger percentage of males were underweight compared to females (60% vs. 32%, p < 0.001). There were no differences between the genders with regards to performance status, dysphagia grade and duration and tumor length, location and degree of differentiation. There were significant differences between risk factor exposure between the two genders. Smoking and alcohol consumption was an association in more than 70% of males but in less than 10% of females There was no difference survival. (4) Female patients with oesophageal squamous cell carcinoma (OSCC) are older and have a higher body mass index (BMI) than their male counterparts. Traditionally purported risk factors of smoking and alcohol consumption are infrequent associations with OSCC in female patients and other environmental risk factors may be more relevant in this gender.

Global burden of oesophageal and gastric cancer by histology and subsite in 2018

OBJECTIVES

To provide updated estimates of the global burden of oesophageal and gastric cancer by subsite and type.

METHODS

Using data from population-based cancer registries, proportions of oesophageal adenocarcinoma (OAC) and squamous cell carcinoma (OSCC) out of all oesophageal as well as cardia gastric cancer (CGC) and non-CGC (NCGC) out of all gastric cancer cases were computed by country, sex and age group. Proportions were subsequently applied to the estimated numbers of oesophageal and gastric cancer cases from GLOBOCAN 2018. Age-standardised incidence rates (ASR) were calculated.

RESULTS

In 2018, there were an estimated 572 000 new cases of oesophageal cancer worldwide, 85 000 OACs (ASR 0.9 per 100 000, both sexes combined) and 482 000 OSCCs (ASR 5.3). Out of 1.03 million gastric cancers, there were an estimated 181 000 cases of CGC (ASR 2.0) and 853 000 cases of NCGC (ASR 9.2). While the highest incidence rates of OSCC, CGC and NCGC were observed in Eastern Asia (ASRs 11.1, 4.4 and 17.9, respectively), rates of OAC were highest in Northern Europe (ASR 3.5). While globally OSCC and NCGC remain the most common types of oesophageal and gastric cancer, respectively, rates of OAC exceed those of OSCC in an increasing number of high-income countries.

CONCLUSIONS

These updated estimates of the global burden of oesophageal and gastric cancer by subtype and site suggest an ongoing transition in epidemiological patterns. This work will serve as a cornerstone for policy-making and will aid in developing appropriate cancer control strategies.

Landscape of copy number aberrations in esophageal squamous cell carcinoma from a high endemic region of South Africa

Background

Esophageal squamous cell carcinoma (ESCC) is an aggressive cancer with one of the highest world incidences in the Eastern Cape region of South Africa. Several genome wide studies have been performed on ESCC cohorts from Asian countries, North America, Malawi and other parts of the world but none have been conducted on ESCC tumors from South Africa to date, where the molecular pathology and etiology of this disease remains unclear. We report here tumor associated copy number changes observed in 51 ESCC patients’ samples from the Eastern Cape province of South Africa.

Methods

We extracted tumor DNA from 51 archived ESCC specimens and interrogated tumor associated DNA copy number changes using Affymetrix® 500 K SNP array technology. The Genomic Identification of Significant Targets in Cancer (GISTIC 2.0) algorithm was applied to identify significant focal regions of gains and losses. Gains of the top recurrent cancer genes were validated by fluorescence in situ hybridization and their protein expression assessed by immunohistochemistry.

Results

Twenty-three significant focal gains were identified across samples. Gains involving the CCND1, MYC, EGFR and JAG1 loci recapitulated those described in studies on Asian and Malawian cohorts. The two most significant gains involved the chromosomal sub-bands 3q28, encompassing the TPRG1 gene and 11q13.3 including the CTTN, PPFIA1and SHANK2 genes. There was no significant homozygous loss and the most recurrent hemizygous deletion involved the B3GAT1 gene on chromosome 11q25. Focal gains on 11q13.3 in 37% of cases (19/51), consistently involved CTTN and SHANK2 genes. Twelve of these cases (23,5%), had a broader region of gain that also included the CCND1, FGF19, FGF4 and FGF3 genes. SHANK2 and CTTN are co-amplified in several cancers, these proteins interact functionally together and are involved in cell motility. Immunohistochemistry confirmed both Shank2 (79%) and cortactin (69%) protein overexpression in samples with gains of these genes. In contrast, cyclin D1 (65%) was moderately expressed in samples with CCND1 DNA gain.

Conclusions

This study reports copy number changes in a South African ESCC cohort and highlights similarities and differences with cohorts from Asia and Malawi. Our results strongly suggest a role for CTTN and SHANK2 in the pathogenesis of ESCC in South Africa.

Out-patient visits for gastrointestinal cancer at a quaternary South African hospital-trends and geospatial distribution

BACKGROUND

This study sought to determine trends in out-patient visits for gastrointestinal cancer (GC) at a quaternary hospital in KwaZulu-Natal (KZN), South Africa; and identify geographical regions which contribute most to GC-related out-patient clinic utilization at this hospital.

METHOD

Data for GC-related outpatient visits over an 11-year period was obtained from the hospital's administrative database. Trends were analyzed using simple regression and trend line analyses. Patient residential postal codes from the administrative database were used to determine the geospatial distribution of complex GC in KZN.

RESULTS

Strong increasing trends in GC-related out-patient visits were noted for age >65 years old (R²=0.8014), male (R²=0.7020), female (R²=0.7292), lower GC (R²=0.7094), and rural residence (R²=0.7008). Moderate increasing trends in GC-related out-patient visits were noted for age ≤65 years old (R²=0.6556), upper GC (R²=0.6498), and urban residence (R²=0.6988). The magnitude at which the number of out-patient visits increased was greater for urban residence when compared with rural residence (p=0.006). Urban centers and some regions along the North and South coast of KZN contributed the most toward GC-related out-patient visits.

CONCLUSION

Out-patient visits for complex GC in KZN are increasing. Several regions have been identified for anti-cancer interventions and decentralized out-patient services.

Systematic review and meta-analysis of esophageal cancer in Africa: Epidemiology, risk factors, management and outcomes

BACKGROUND

Esophageal cancer (EC) is associated with a poor prognosis, particularly so in Africa where an alarmingly high mortality to incidence ratio prevails for this disease.

AIM

To provide further understanding of EC in the context of the unique cultural and genetic diversity, and socio-economic challenges faced on the African continent.

METHODS

We performed a systematic review of studies from Africa to obtain data on epidemiology, risk factors, management and outcomes of EC. A non-systematic review was used to obtain incidence data from the International Agency for Research on Cancer, and the Cancer in Sub-Saharan reports. We searched EMBASE, PubMed, Web of Science, and Cochrane Central from inception to March 2019 and reviewed the list of articles retrieved. Random effects meta-analyses were used to assess heterogeneity between studies and to obtain odds ratio (OR) of the associations between EC and risk factors; and incidence rate ratios for EC between sexes with their respective 95% confidence intervals (CI).

RESULTS

The incidence of EC is higher in males than females, except in North Africa where it is similar for both sexes. The highest age-standardized rate is from Malawi (30.3 and 19.4 cases/year/100000 population for males and females, respectively) followed by Kenya (28.7 cases/year/100000 population for both sexes). The incidence of EC rises sharply after the age of 40 years and reaches a peak at 75 years old. Meta-analysis shows a strong association with tobacco (OR 3.15, 95%CI: 2.83-3.50). There was significant heterogeneity between studies on alcohol consumption (OR 2.28, 95%CI: 1.94-2.65) and on low socioeconomic status (OR 139, 95%CI: 1.25-1.54) as risk factors, but these could also contribute to increasing the incidence of EC. The best treatment outcomes were with esophagectomy with survival rates of 76.6% at 3 years, and chemo-radiotherapy with an overall combined survival time of 267.50 d.

CONCLUSION

Africa has high incidence and mortality rates of EC, with preventable and non-modifiable risk factors. Men in this setting are at increased risk due to their higher prevalence of tobacco and alcohol consumption. Management requires a multidisciplinary approach, and survival is significantly improved in the setting of esophagectomy and chemoradiation therapy.

Esophageal cancer genetics in South Africa

Esophageal cancer (EC) is an extremely aggressive cancer with one of the highest mortality rates. The cancer is generally only diagnosed at the later stages and has a poor 5-year survival rate due to the limited treatment options. China and South Africa are two countries with a very high prevalence rate of EC. EC rates in South Africa have been on the increase, and esophageal squamous cell carcinoma is the predominant subtype and a primary cause of cancer-related deaths in the black and male mixed ancestry populations in South Africa. The incidence of EC is highest in the Eastern Cape Province, especially in the rural areas such as the Transkei, where the consumption of foods contaminated with Fusarium verticillioides is thought to play a major contributing role to the incidence of EC. China is responsible for almost half of all new cases of EC globally. In China, the prevalence of EC varies greatly. However, the two main areas of high prevalence are the southern Taihang Mountain area (Linxian, Henan Province) and the north Jiangsu area. In both countries, environmental toxins play a major role in increasing the chance that an individual will develop EC. These associative factors include tobacco use, alcohol consumption, nutritional deficiencies and exposure to environmental toxins. However, genetic polymorphisms also play a role in predisposing individuals to EC. These include single-nucleotide polymorphisms that can be found in both protein-coding genes and in non-coding sequences such as miRNAs. The aim of this review is to summarize the contribution of genetic polymorphisms to EC in South Africa and to compare and contrast this to the genetic polymorphisms observed in EC in the most comprehensively studied population group, the Chinese.

Cancer incidence in older adults in selected regions of sub-Saharan Africa, 2008-2012

Although the countries of Sub-Sharan Africa represent among the most rapidly growing and aging populations worldwide, no previous studies have examined the cancer patterns in older adults in the region as a means to inform cancer policies. Using data from Cancer Incidence in Five Continents, we describe recent patterns and trends in incidence rates for the major cancer sites in adults aged ≥60 years and in people aged 0-59 for comparison in four selected population-based cancer registries in Kenya (Nairobi), the Republic of South Africa (Eastern Cape Province), Uganda (Kyadondo country), and Zimbabwe (Harare blacks). Over the period 2008-2012, almost 9,000 new cancer cases were registered in older adults in the four populations, representing one-third of all cancer cases. Prostate and esophageal cancers were the leading cancer sites in older males, while breast, cervical and esophageal cancers were the most common among older females. Among younger people, Kaposi sarcoma and non-Hodgkin lymphoma were common. Over the past 20 years, incidence rates among older adults have increased in both sexes in Uganda and Zimbabwe while rates have stabilized among the younger age group. Among older adults, the largest rate increase was observed for breast cancer (estimated annual percentage change: 5% in each country) in females and for prostate cancer (6-7%) in males. Due to the specific needs of older adults, tailored considerations should be given to geriatric oncology when developing, funding and implementing national and regional cancer programmes.

The Role of Tumor Microenvironment in Chemoresistance: 3D Extracellular Matrices as Accomplices

BACKGROUND

The functional interplay between tumor cells and their adjacent stroma has been suggested to play crucial roles in the initiation and progression of tumors and the effectiveness of chemotherapy. The extracellular matrix (ECM), a complex network of extracellular proteins, provides both physical and chemicals cues necessary for cell proliferation, survival, and migration. Understanding how ECM composition and biomechanical properties affect cancer progression and response to chemotherapeutic drugs is vital to the development of targeted treatments.

METHODS

3D cell-derived-ECMs and esophageal cancer cell lines were used as a model to investigate the effect of ECM proteins on esophageal cancer cell lines response to chemotherapeutics. Immunohistochemical and qRT-PCR evaluation of ECM proteins and integrin gene expression was done on clinical esophageal squamous cell carcinoma biopsies. Esophageal cancer cell lines (WHCO1, WHCO5, WHCO6, KYSE180, KYSE 450 and KYSE 520) were cultured on decellularised ECMs (fibroblasts-derived ECM; cancer cell-derived ECM; combinatorial-ECM) and treated with 0.1% Dimethyl sulfoxide (DMSO), 4.2 µM cisplatin, 3.5 µM 5-fluorouracil and 2.5 µM epirubicin for 24 h. Cell proliferation, cell cycle progression, colony formation, apoptosis, migration and activation of signaling pathways were used as our study endpoints.

RESULTS

The expression of collagens, fibronectin and laminins was significantly increased in esophageal squamous cell carcinomas (ESCC) tumor samples compared to the corresponding normal tissue. Decellularised ECMs abrogated the effect of drugs on cancer cell cycling, proliferation and reduced drug induced apoptosis by 20⁻60% that of those plated on plastic. The mitogen-activated protein kinase-extracellular signal-regulated kinase (MEK-ERK) and phosphoinositide 3-kinase-protein kinase B (PI3K/Akt) signaling pathways were upregulated in the presence of the ECMs. Furthermore, our data show that concomitant addition of chemotherapeutic drugs and the use of collagen- and fibronectin-deficient ECMs through siRNA inhibition synergistically increased cancer cell sensitivity to drugs by 30⁻50%, and reduced colony formation and cancer cell migration.

CONCLUSION

Our study shows that ECM proteins play a key role in the response of cancer cells to chemotherapy and suggest that targeting ECM proteins can be an effective therapeutic strategy against chemoresistant tumors.

Neoadjuvant chemotherapy with or without neoadjuvant radiotherapy compared with neoadjuvant chemoradiotherapy for esophageal cancer

Background

Although it was controversial for treating locally advanced resectable esophageal squamous cell carcinoma (ESCC), neoadjuvant chemoradiotherapy (NACR) was more widely accepted rather than neoadjuvant chemotherapy (NAC) worldwide. With the development of paclitaxel, a high response rate to NAC was reported in many studies. Our hypothesis is that lots of patients could get a response from NAC alone and avoid unnecessary NACR. Those who had no response from NAC could still response from the followed radiotherapy. We attempted to circumvent the controversy over the use of NAC, NACR and made a combined version, NAC ± neoadjuvant radiotherapy (NAR).

Methods

The retrospective study compared NAC ± NAR with NACR between June 30, 2015 and October 31, 2016. Sixty consecutive borderline resectable ESCC were included: thirty-one in NAC ± NAR group and 29 in NACR group. The toxicities, response rates, operative data, complications, length of stay, and overall survival (OS) rates were evaluated.

Results

The response rate to NAC ± NAR was 93.5%; to NACR was 86.2%. There was no grade 3-4 non-hematologic adverse events after NAC ± NAR, but three in the NACR group. Arrhythmias (6.5% vs. 37.9%, P=0.003), pneumonitis (25.8% vs. 51.7%, P=0.039) and anastomotic leakage (0% vs. 13.8%, P=0.049) were more likely in NACR group. Postoperative hospitalization stays were significantly prolonged in the NACR (9 vs. 16 d, P<0.001). A point estimate of the 2-year OS rate of the NAC ± NAR group was 84.0%, the NACR group 80.7% (P=0.410).

Conclusions

Compared with NACR, the NAC ± NACR provided the same survival benefits but low post operation complication rate. In the future, it might be a choice for locally advanced ESCC.

Estimating the incidence of breast cancer in Africa: a systematic review and meta-analysis

Background

Breast cancer is estimated to be the most common cancer worldwide. We sought to assemble publicly available data from Africa to provide estimates of the incidence of breast cancer on the continent.

Methods

A systematic search of Medline, EMBASE, Global Health and African Journals Online (AJOL) was conducted. We included population- or hospital-based registry studies on breast cancer conducted in Africa, and providing estimates of the crude incidence of breast cancer among women. A random effects meta-analysis was employed to determine the pooled incidence of breast cancer across studies.

Results

The literature search returned 4648 records, with 41 studies conducted across 54 study sites in 22 African countries selected. We observed important variations in reported cancer incidence between population- and hospital-based cancer registries. The overall pooled crude incidence of breast cancer from population-based registries was 24.5 per 100 000 person years (95% confidence interval (CI) 20.1-28.9). The incidence in North Africa was higher at 29.3 per 100 000 (95% CI 20.0-38.7) than Sub-Saharan Africa (SSA) at 22.4 per 100 000 (95% CI 17.2-28.0). In hospital-based registries, the overall pooled crude incidence rate was estimated at 23.6 per 100 000 (95% CI 18.5-28.7). SSA and Northern Africa had relatively comparable rates at 24.0 per 100 000 (95% CI 17.5-30.4) and 23.2 per 100 000 (95% CI 6.6-39.7), respectively. Across both registries, incidence rates increased considerably between 2000 and 2015.

Conclusions

The available evidence suggests a growing incidence of breast cancer in Africa. The representativeness of these estimates is uncertain due to the paucity of data in several countries and calendar years, as well as inconsistency in data collation and quality across existing cancer registries.

Esophageal cancer male to female incidence ratios in Africa: A systematic review and meta-analysis of geographic, time and age trends

Esophageal squamous cell carcinoma (ESCC) remains the predominant histological subtype of esophageal cancer (EC) in many transitioning countries, with an enigmatic and geographically distinct etiology, and consistently elevated incidence rates in many Eastern and Southern African countries. To gain epidemiological insights into ESCC patterns across the continent, we conducted a systematic review and meta-analysis of male-to-female (M:F) sex ratios of EC age-standardised (world) incidence rates in Africa according to geography, time and age at diagnosis. Data from 197 populations in 36 countries were included in the analysis, based on data from cancer registries included in IARC's Cancer Incidence in Five Continents, Cancer in Africa and Cancer in Sub-Saharan Africa reports, alongside a systematic search of peer-reviewed literature. A consistent male excess in incidence rates overall (1.7; 95% CI: 1.4, 2.0), and in the high-risk Eastern (1.6; 95% CI: 1.4, 1.8) and Southern (1.8; 95% CI: 1.5, 2.0) African regions was observed. Within the latter two regions, there was a male excess evident in 30-39 year olds that was not observed in low-risk regions. Despite possible referral biases affecting the interpretability of the M:F ratios in place and time, the high degree of heterogeneity in ESCC incidence implies a large fraction of the disease is preventable, and directs research enquiries to elucidate early-age exposures among young men in Africa.

Global Incidence and mortality of oesophageal cancer and their correlation with socioeconomic indicators temporal patterns and trends in 41 countries

Oesophageal cancers (adenocarcinomas [AC] and squamous cell carcinomas [SCC]) are characterized by high incidence/mortality in many countries. We aimed to delineate its global incidence and mortality, and studied whether socioeconomic development and its incidence rate were correlated. The age-standardized rates (ASRs) of incidence and mortality of this medical condition in 2012 for 184 nations from the GLOBOCAN database; national databases capturing incidence rates, and the WHO mortality database were examined. Their correlations with two indicators of socioeconomic development were evaluated. Joinpoint regression analysis was used to generate trends. The ratio between the ASR of AC and SCC was strongly correlated with HDI (r = 0.535 [men]; r = 0.661 [women]) and GDP (r = 0.594 [men]; r = 0.550 [women], both p < 0.001). Countries that reported the largest reduction in incidence in male included Poland (Average Annual Percent Change [AAPC] = -7.1, 95%C.I. = -12,-1.9) and Singapore (AAPC = -5.8, 95%C.I. = -9.5,-1.9), whereas for women the greatest decline was seen in Singapore (AAPC = -12.3, 95%C.I. = -17.3,-6.9) and China (AAPC = -5.6, 95%C.I. = -7.6,-3.4). The Philippines (AAPC = 4.3, 95%C.I. = 2,6.6) and Bulgaria (AAPC = 2.8, 95%C.I. = 0.5,5.1) had a significant mortality increase in men; whilst Columbia (AAPC = -6.1, 95%C.I. = -7.5,-4.6) and Slovenia (AAPC = -4.6, 95%C.I. = -7.9,-1.3) reported mortality decline in women. These findings inform individuals at increased risk for primary prevention.

Palliative chemotherapy and targeted therapies for esophageal and gastroesophageal junction cancer

BACKGROUND

Almost half of people with esophageal or gastroesophageal junction cancer have metastatic disease at the time of diagnosis. Chemotherapy and targeted therapies are increasingly used with a palliative intent to control tumor growth, improve quality of life, and prolong survival. To date, and with the exception of ramucirumab, evidence for the efficacy of palliative treatments for esophageal and gastroesophageal cancer is lacking.

OBJECTIVES

To assess the effects of cytostatic or targeted therapy for treating esophageal or gastroesophageal junction cancer with palliative intent.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Web of Science, PubMed Publisher, Google Scholar, and trial registries up to 13 May 2015, and we handsearched the reference lists of studies. We did not restrict the search to publications in English. Additional searches were run in September 2017 prior to publication, and they are listed in the 'Studies awaiting assessment' section.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) on palliative chemotherapy and/or targeted therapy versus best supportive care or control in people with esophageal or gastroesophageal junction cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. We assessed the quality and risk of bias of eligible studies according to the Cochrane Handbook for Systematic Reviews of Interventions. We calculated pooled estimates of effect using an inverse variance random-effects model for meta-analysis.

MAIN RESULTS

We identified 41 RCTs with 11,853 participants for inclusion in the review as well as 49 ongoing studies. For the main comparison of adding a cytostatic and/or targeted agent to a control arm, we included 11 studies with 1347 participants. This analysis demonstrated an increase in overall survival in favor of the arm with an additional cytostatic or targeted therapeutic agent with a hazard ratio (HR) of 0.75 (95% confidence interval (CI) 0.68 to 0.84, high-quality evidence). The median increased survival time was one month. Five studies in 750 participants contributed data to the comparison of palliative therapy versus best supportive care. We found a benefit in overall survival in favor of the group receiving palliative chemotherapy and/or targeted therapy compared to best supportive care (HR 0.81, 95% CI 0.71 to 0.92, high-quality evidence). Subcomparisons including only people receiving second-line therapies, chemotherapies, targeted therapies, adenocarcinomas, and squamous cell carcinomas all showed a similar benefit. The only individual agent that more than one study found to improve both overall survival and progression-free survival was ramucirumab. Palliative chemotherapy and/or targeted therapy increased the frequency of grade 3 or higher treatment-related toxicity. However, treatment-related deaths did not occur more frequently. Quality of life often improved in the arm with an additional agent.

AUTHORS' CONCLUSIONS

People who receive more chemotherapeutic or targeted therapeutic agents have an increased overall survival compared to people who receive less. These agents, administered as both first-line or second-line treatments, also led to better overall survival than best supportive care. With the exception of ramucirumab, it remains unclear which other individual agents cause the survival benefit. Although treatment-associated toxicities of grade 3 or more occurred more frequently in arms with an additional chemotherapy or targeted therapy agent, there is no evidence that palliative chemotherapy and/or targeted therapy decrease quality of life. Based on this meta-analysis, palliative chemotherapy and/or targeted therapy can be considered standard care for esophageal and gastroesophageal junction carcinoma.

Exploring grassroots feedback about cancer challenges in South Africa: a discussion of themes derived from content thematic analysis of 316 photo-narratives

INTRODUCTION

Cancer is an important health problem in Africa with projections that incidence could double by 2030. While sparse, the literature on cancer control in African low- and middle-income countries suggests poor cancer planning, overburdened services and poor outcomes. South Africa has established oncology health care services but also has low cancer awareness, poor cancer surveillance and widespread service challenges.

METHODS

Data for this study was derived from 316 photovoice interviews with cancer patients, families of cancer patients and oncology workers across South Africa. The objectives of the study were to collect first-hand feedback about cancer challenges and to develop recommendations for the improvement of cancer control strategies.

RESULTS

9 themes of cancer challenges were distinguished via thematic content analysis of the photo-narratives. The identified themes of cancer challenges were physical and treatment challenges, emotional, poor services, transport, finances, information, powerlessness, stigma, and schooling challenges.

CONCLUSION

The findings of this study offer the patient and family perspective of cancer challenges as a valid contribution to our body of cancer knowledge. The 9 themes of cancer challenges profile the emotional, physical and social impact of cancer on patients and families, and offer detailed subjective information about problem occurrence in the trajectory of care. Recommendations following from the 9 themes of cancer challenges include training for improved patient-centred care standards, the need for cancer surveillance, innovative and locally appropriate cancer awareness campaigns, private and government health care partnerships and the development of psychosocial services. The advocating of findings and recommendations to influence cancer control strategies in South Africa, is indicated.

Self-Expandable Metal Stents in Esophageal Cancer in a High HIV Prevalence Area: A Survival Analysis and Evaluation of Prediction Scores

INTRODUCTION

Esophageal cancer (EC) and human immunodeficiency virus (HIV) are common in parts of South Africa. Squamous cell carcinoma of the esophagus in KwaZulu-Natal, South Africa presents generally in advanced stages and is mostly palliated by the deployment of self-expandable metal stent (SEMS). This study analyses these relationships between coexistent HIV infection, SEMS deployment, and survival scores.

METHODOLOGY

Information on patients managed with SEMS between October 2013 and December 2014 was retrieved from a prospective database of EC and followed up until April 2015. Data collected included demographics, HIV status, clinical presentation, prognostic indicators, management, and survival. Prognostic factors were calculated in relation to outcome.

RESULTS

One hundred five patients with EC had median ages of 61 (SD±11.4) and median body mass index of 17.45. Squamous cell carcinoma of the esophagus was diagnosed in 90 patients and adenocancer in 7 patients. Tumors were located in the proximal (10), middle (64), and distal (29) esophagus. Stage IV EC had a significant shorter survival of fewer than 3 months compared with stage III cancer (P=0.009). A C-reactive protein >150 mg/L was 3.6 times more likely to predict survival of fewer than 3 months than a value <50 mg/L (P=0.035). A proximal stent position significantly predicted shorter survival (P=0.035). The Steyerberg prognostic score proved ineffective in predicting survival of <3 months in our setting. Of the 84 patients tested for HIV, 23 were positive. Thirteen patients were on highly active antiretroviral therapy surviving significantly longer than those without this medication (P=0.036).

CONCLUSIONS

Stage IV cancer and C-reactive protein >150 predicted survival of <3 months significantly better than the Steyerberg prediction score or other markers. Highly active anti-retroviral therapy had a positive impact on survival; however, SEMS placement in the proximal esophagus was associated with shorter survival.

The shifting epidemiology of colorectal cancer in sub-Saharan Africa

The perception that colorectal cancer is rare in sub-Saharan Africa is widely held; however, it is unclear whether this is due to poor epidemiological data or to lower disease rates. The quality of epidemiological data has somewhat improved, and there is an ongoing transition to western dietary and lifestyle practices associated with colorectal cancer. The impact of these changes on the incidence of colorectal cancer is not as evident as it is with other non-communicable diseases such as diabetes. In this Viewpoint, we discuss the epidemiology of colorectal cancer in sub-Saharan Africa. Colorectal cancer in this region frequently occurs at an early age, often with distinctive histological characteristics. We detail the crucial need for hypothesis-driven research on the risk factors for colorectal cancer in this population and identify key research gaps. Should colorectal cancer occur more frequently than assumed, then commensurate allocation of resources will be needed for diagnosis and treatment.

A phase III, multicenter randomized controlled trial of neo-adjuvant chemotherapy paclitaxel plus cisplatin versus surgery alone for stage IIA-IIIB esophageal squamous cell carcinoma

BACKGROUND

The survival benefits of neoadjuvant chemotherapy (NAC) for esophagus squamous cell carcinoma (ESCC) remains controversial. The surgical procedure was not well defined in NAC strategy, in past trials. The different surgical procedure and different levels of lymphadenectomy may decrease the survival benefits from NAC. The new chemotherapy regimen with paclitaxel is promising. The purpose of this study is to confirm the superiority of paclitaxel, cisplatin and McKeown esophagectomy with total two-field lymphadenectomy compared with surgery alone for ESCC.

METHODS

A two-arm phase III trial was launched in June 2015. A total of 528 patients will be recruited from eight Chinese institutions within 2.5 years. The overall survival (OS) is the primary endpoint, and the secondary endpoints include disease-free survival (DFS), R0 resection rate, complication rate, perioperation mortality, days of hospitalization, quality of life (QOL), NAC response rate, pathologic response rate, toxicities of NAC, prognostic factors, predictive factors, progression-free survival (PFS), and adverse events.

DISCUSSION

The study will provide the final conclusion of NAC for ESCC in China.

TRIAL REGISTRATION

NCT02442440 (https://register.clinicaltrials.gov/).

An Estimate of the Incidence of Prostate Cancer in Africa: A Systematic Review and Meta-Analysis

BACKGROUND

Prostate cancer (PCa) is rated the second most common cancer and sixth leading cause of cancer deaths among men globally. Reports show that African men suffer disproportionately from PCa compared to men from other parts of the world. It is still quite difficult to accurately describe the burden of PCa in Africa due to poor cancer registration systems. We systematically reviewed the literature on prostate cancer in Africa and provided a continent-wide incidence rate of PCa based on available data in the region.

METHODS

A systematic literature search of Medline, EMBASE and Global Health from January 1980 to June 2015 was conducted, with additional search of Google Scholar, International Association of Cancer Registries (IACR), International Agency for Research on Cancer (IARC), and WHO African region websites, for studies that estimated incidence rate of PCa in any African location. Having assessed quality and consistency across selected studies, we extracted incidence rates of PCa and conducted a random effects meta-analysis.

RESULTS

Our search returned 9766 records, with 40 studies spreading across 16 African countries meeting our selection criteria. We estimated a pooled PCa incidence rate of 22.0 (95% CI: 19.93-23.97) per 100,000 population, and also reported a median incidence rate of 19.5 per 100,000 population. We observed an increasing trend in PCa incidence with advancing age, and over the main years covered.

CONCLUSION

Effective cancer registration and extensive research are vital to appropriately quantifying PCa burden in Africa. We hope our findings may further assist at identifying relevant gaps, and contribute to improving knowledge, research, and interventions targeted at prostate cancer in Africa.

Global incidence of oesophageal cancer by histological subtype in 2012

OBJECTIVE

The two major histological types of oesophageal cancer--adenocarcinoma (AC) and squamous cell carcinoma (SCC)--are known to differ greatly in terms of risk factors and epidemiology. To date, global incidence estimates for individual subtypes are still lacking. This study for the first time quantified the global burden of oesophageal cancer by histological subtype.

DESIGN

Where available, data from Cancer Incidence in Five Continents Vol. X (CI5X) were used to compute, age-specific, sex-specific and country-specific proportions of AC and SCC. Nine regional averages were computed for countries without CI5X data. The proportions were then applied to all oesophageal cancer cases from GLOBOCAN 2012 and age-standardised incidence rates calculated for both histological types.

RESULTS

Worldwide, an estimated 398,000 SCCs and 52,000 ACs of the oesophagus occurred in 2012, translating to incidence rates of 5.2 and 0.7 per 100,000, respectively. Although SCCs were most common in South-Eastern and Central Asia (79% of the total global SCC cases), the highest burden of AC was found in Northern and Western Europe, Northern America and Oceania (46% of the total global AC cases). Men had substantially higher incidence than women, especially in the case of AC (male to female ratio AC: 4.4; SCC: 2.7).

CONCLUSIONS

These first global estimates of oesophageal cancer incidence by histology suggested a high concentration of AC in high-income countries with men being at much greater risk. This quantification of incidence will aid health policy makers to plan appropriate cancer control measures in the future.

Appraising the quality of sub-Saharan African cancer registration systems that contributed to GLOBOCAN 2008: a review of the literature and critical appraisal

OBJECTIVE

To critically appraise the quality of sub-Saharan African cancer registration systems that submitted data to GLOBOCAN 2008 with respect to population coverage using publicly available information and to show the use of GLOBOCAN statistics in determining global health priorities.

DESIGN

Sources of cancer registration data for twenty-six sub-Saharan African cancer registries were identified from GLOBOCAN 2008 factsheets. Additional information was extracted from International Agency for Research on Cancer publications. A literature search was conducted to identify studies that reported additional information on data collection methods and provided 27 studies. The websites of the 10 largest funders of development assistance for health were searched for GLOBOCAN citations.

SETTING AND PARTICIPANTS

Twenty-six sub-Saharan African cancer registration systems submitting data to GLOBOCAN 2008 in relation to 21 countries.

MAIN OUTCOME MEASURES

Information on 15 quality variables were extracted and compared with the international gold standard for cancer registration systems.

RESULTS

Population coverage of the cancer registries ranged from from 2.3% of the population in Kenya to 100% in The Gambia, with a heavy urban bias in all countries. However, 20 countries (300 million people) had no cancer registration systems. Nineteen of the 26 registries failed to meet more than five of the 15 quality criteria and only one country met more than 10. Seven of the 10 largest funders of development assistance for health cite GLOBOCAN statistics in support of policy priorities.

CONCLUSIONS

GLOBOCAN 2008 estimates are based on data drawn from poor quality cancer registration systems, with limited or no population registry coverage. It is essential the GLOBOCAN 2012 estimates should provide information on the quality of the data collection and explain the limitations of the estimates. Development organisations and the World Health Organization need to take a more cautious approach when using these data to determine priorities and allocating resources.

Inactivation of GSK3β and activation of NF-κB pathway via Axl represents an important mediator of tumorigenesis in esophageal squamous cell carcinoma

Deregulation of Axl in esophageal squamous cell carcinoma (OSCC) with potential therapeutic implications is described for the first time. This paper also sheds light on the understanding of how Axl regulates OSCC development in vitro and in vivo. Axl expression leads to an Akt-dependent regulation of glycogen synthase kinase 3β activity and the nucluear factor kappaB (NF-κB) pathway, affecting the epithelial–mesenchymal transition.

The receptor tyrosine kinase Axl has been described as an oncogene, and its deregulation has been implicated in the progression of several human cancers. While the role of Axl in esophageal adenocarcinoma has been addressed, there is no information about its role in esophageal squamous cell carcinoma (OSCC). In the current report, we identified, for the first time, deregulation of Axl expression in OSCC. Axl is consistently overexpressed in OSCC cell lines and human tumor samples, mainly in advanced stages of the disease. Blockage of Axl gene expression by small interfering RNA inhibits cell survival, proliferation, migration, and invasion in vitro and esophageal tumor growth in vivo. Additionally, repression of Axl expression results in Akt-dependent inhibition of pivotal genes involved in the nuclear factor-kappaB (NF-κB) pathway and in the induction of glycogen synthase kinase 3β (GSK3β) activity, resulting in loss of mesenchymal markers and induction of epithelial markers. Furthermore, treatment of esophageal cancer cells with the Akt inhibitor wortmannin inhibits NF-κB signaling, induces GSK3β activity, and blocks OSCC cell proliferation in an Axl-dependent manner. Taken together, our results establish a clear role for Axl in OSCC tumorigenesis with potential therapeutic implications.

Trends in cancer incidence in rural Eastern Cape Province; South Africa, 1998-2012

There are few cancer trend data reported in sub-Saharan Africa notably due to the scarcity of population-based cancer registries (PBCRs). The Eastern Cape Province PBCR is amongst the few registries in sub-Saharan Africa that reports data for a rural population. Trends in cancer incidence are reported for the period 1998-2012. Registered cases, age-standardized rates (ASRs) and standardized rate ratios are presented for the most common cancers in both males and females in three periods (1998-2002, 2003-2007 and 2008-2012). In males, the most commonly diagnosed cancer during the 15 year period was cancer of the oesophagus; incidence rates showed a significant decline over the 15 year period, entirely due to a 30% decrease between 2003-2007 and 2008-2012, to an ASR of 23.2 per 100,000 population. This was followed by prostate cancer, the incidence of which was more than doubled to a level of 9.9/100,000. In women, cancer of the cervix uteri has become the most common malignancy, with a significant increase in incidence during the period to 29.0/100,000. Oesophageal cancer is second in frequency, with (as in males) a significant decline in the final 10 years to an incidence of 14.5/100,000 in 2008-2012. The incidence of breast cancer increased by 61%, although the absolute rate remains low (12.2/100,000). The incidence rates of colorectal cancer are low, and the increases in incidence, although relatively large (35% in men, 63% in women) were not statistically significant. Kaposi sarcoma showed a dramatic increase in incidence in both sexes (3.5-fold in men, 11-fold in women) although the incidence remains relatively low by southern African standards. Cancer prevention and control activities in the area need to be informed by these data and strengthened.

Cancer in Africa 2012

BACKGROUND

Noncommunicable diseases, and especially cancers, are recognized as an increasing problem for low and middle income countries. Effective control programs require adequate information on the size, nature, and evolution of the health problem that they pose.

METHODS

We present estimates of the incidence and mortality of cancer in Africa in 2012, derived from "GLOBOCAN 2012," published by the International Agency for Research on Cancer.

RESULTS

There were 847,000 new cancer cases (6% of the world total) and 591,000 deaths (7.2% of the world total) in the 54 countries of Africa in 2012, with about three quarters in the 47 countries of Sub-Saharan Africa. While the cancer profiles often differ markedly between regions, the most common cancers in men were prostate (16.4% of new cancers), liver (10.7%), and Kaposi sarcoma (6.7%); in women, by far the most important are cancers of the breast (27.6% of all cancers) and cervix uteri (20.4%).

CONCLUSIONS

There are still deficiencies in surveillance systems, particularly in Sub-Saharan Africa and, specifically, of their most vital component, population-based cancer registries. With the number of annual cancer cases and deaths likely to increase by at least 70% by 2030, there is a pressing need for a coordinated approach to improving the extent and quality of services for cancer control in Africa, and better surveillance systems with which they can be planned and monitored.

IMPACT

The results are the best data currently available and provide a reasonable appraisal of the cancer situation in Africa.

Prostate cancer in South Africa: pathology based national cancer registry data (1986-2006) and mortality rates (1997-2009)

Prostate cancer is one of the most common male cancers globally; however little is known about prostate cancer in Africa. Incidence data for prostate cancer in South Africa (SA) from the pathology based National Cancer Registry (1986-2006) and data on mortality (1997-2009) from Statistics SA were analysed. World standard population denominators were used to calculate age specific incidence and mortality rates (ASIR and ASMR) using the direct method. Prostate cancer was the most common male cancer in all SA population groups (excluding basal cell carcinoma). There are large disparities in the ASIR between black, white, coloured, and Asian/Indian populations: 19, 65, 46, and 19 per 100 000, respectively, and ASMR was 11, 7, 52, and 6 per 100 000, respectively. Prostate cancer was the second leading cause of cancer death, accounting for around 13% of male deaths from a cancer. The average age at diagnosis was 68 years and 74 years at death. For SA the ASIR increased from 16.8 in 1986 to 30.8 in 2006, while the ASMR increased from 12.3 in 1997 to 16.7 in 2009. There has been a steady increase of incidence and mortality from prostate cancer in SA.

Kaposi's Sarcoma in HIV-infected patients in South Africa: Multicohort study in the antiretroviral therapy era

The incidence of Kaposi's Sarcoma (KS) is high in South Africa but the impact of antiretroviral therapy (ART) is not well defined. We examined incidence and survival of KS in HIV-infected patients enrolled in South African ART programs. We analyzed data of three ART programs: Khayelitsha township and Tygerberg Hospital programs in Cape Town and Themba Lethu program in Johannesburg. We included patients aged >16 years. ART was defined as a regimen of at least three drugs. We estimated incidence rates of KS for patients on ART and not on ART. We calculated Cox models adjusted for age, sex and time-updated CD4 cell counts and HIV-1 RNA. A total of 18,254 patients (median age 34.5 years, 64% female, median CD4 cell count at enrolment 105 cells/μL) were included. During 37,488 person-years follow-up 162 patients developed KS. The incidence was 1,682/100,000 person-years (95% confidence interval [CI] 1,406-2,011) among patients not receiving ART and 138/100,000 person-years (95% CI 102-187) among patients on ART. The adjusted hazard ratio comparing time on ART with time not on ART was 0.19 (95% CI 0.13-0.28). Low CD4 cell counts (time-updated) and male sex were also associated with KS. Estimated survival of KS patients at one year was 72.2% (95% CI 64.9-80.2) and higher in men than in women. The incidence of KS is substantially lower on ART than not on ART. Timely initiation of ART is essential to prevent KS and KS-associated morbidity and mortality in South Africa and other regions in Africa with a high burden of HIV.

Childhood cancer in Africa

The majority of children with cancer live in low- and middle-income countries (LMICs) with little or no access to cancer treatment. The purpose of the paper is to describe the current status of childhood cancer treatment in Africa, as documented in publications, dedicated websites and information collected through surveys. Successful twinning programmes, like those in Malawi and Cameroon, as well as the collaborative clinical trial approach of the Franco-African Childhood Cancer Group (GFAOP), provide good models for childhood cancer treatment. The overview will hopefully influence health-care policies to facilitate access to cancer care for all children in Africa.

A proposed method to determine fumonisin exposure from maize consumption in a rural South African population using a culturally appropriate FFQ

OBJECTIVE

To develop an FFQ for estimating culture-specific maize intake that can distinguish between home-grown and commercial maize. Home-grown maize is more likely to be contaminated with fumonisins, mycotoxins that are associated with increased risk of oesophageal cancer.

DESIGN

An existing FFQ developed for use in urban Xhosa populations was used as the initial framework for the maize-specific FFQ (M-FFQ). The existing questionnaire contained 126 food items divided into ten food groups (bread, cereals, vegetables, fruit, meat, dairy, snacks, condiments, beverages and fat). The M-FFQ was developed based on additional data obtained from a literature search, 24 h recalls (n 159), in-depth interviews (n 4), focus group discussions (n 56) and expert consultation. Food items available in local shops (n 3) were compared with information obtained from focus group discussions.

SETTING

Five villages in two rural isiXhosa-speaking areas of the Eastern Cape Province, known to have a high incidence of oesophageal cancer, were randomly selected.

SUBJECTS

Women aged 18-55 years were recruited by snowball sampling and invited to participate.

RESULTS

The final M-FFQ comprised twenty-one maize-based food items, including traditional Xhosa dishes and beverages. The questionnaire focused on maize-specific dishes and distinguished between home-grown maize and commercial maize consumption.

CONCLUSIONS

A culturally specific dietary assessment method was designed to determine maize consumption and therefore fumonisin exposure. The questionnaire will be tested against 24 h recalls and other methods to determine its validity, after which it will be used in various epidemiological studies to determine fumonisin exposure.

Mycological analysis and multimycotoxins in maize from rural subsistence farmers in the former Transkei, South Africa

Maize harvested in the Centane region of the former Transkei, Eastern Cape Province, South Africa, by subsistence farmers has been shown over many seasons to be contaminated with fumonisin mycotoxins. However, there are limited data on the presence of other mycotoxins. Two multimycotoxin LC-MS/MS methods were applied to good and moldy maize samples, as separated by the farmers themselves from the 2011 harvest. One method involved extract cleanup on multitoxin immunoaffinity columns before LC-MS/MS analysis for aflatoxins, fumonisins, deoxynivalenol (DON), zearalenone (ZEN), and T-2 and HT-2 toxins. The other method was based on a "dilute-and-shoot" approach for the above mycotoxins and a wide range of other fungal secondary metabolites. Both methods showed high incidences of fumonisins B1 and B2 (FB1 and FB2) in good maize (100% for both by the first method, means were 2083 and 927 μg/kg for the two analogues; 93% for both by the second method, positive means of 2764 and 1050 μg/kg, respectively). All samples of moldy maize were contaminated (mean FB1 of 27.64 and 35.98 mg/kg, respectively; mean FB2 of 10.58 and 14.14 mg/kg, respectively). Comparison of the two methods for FB1 and FB2 over the entire range of samples gave R(2) values 0.9144 and 0.8859, respectively. Low levels of DON were found by both methods (positive means of 12 and 4.7 μg/kg in good maize, respectively, and of 14 and 5.8 μg/kg in moldy maize, respectively). ZEN was determined with positive means of 108 and 25 μg/kg in good maize, respectively, and of 111 and 135 μg/kg in moldy maize, respectively. No aflatoxins, OTA, or T-2 or HT-2 toxins were detected. A wide range of other Fusarium , Aspergillus , Alternaria , and Penicillium mycotoxins and secondary metabolites were determined.

An exploration of Xhosa speaking patients' understanding of cancer treatment and its influence on their treatment experience

Cultural beliefs often influence people in seeking appropriate health care. In South Africa, misperceptions and fear about medical interventions contribute to the fact that many indigenous people prefer to make use of traditional healers. This qualitative study explores Xhosa patients' perception of cancer and cancer treatment modalities, and their need for support. Language creates an image of the unknown to which people attach meaning. Oncology social workers play an important role in educating people about cancer and the treatment thereof, as doctors seldom have time to deal with the psychosocial aspects of cancer. Health care providers need to be sensitive to patients' perceptions to render the best possible cancer care.

Estimating the incidence of colorectal cancer in Sub-Saharan Africa: A systematic analysis

Background

Nearly two–thirds of annual mortality worldwide is attributable to non–communicable diseases (NCDs), with 70% estimated to occur in low– and middle–income countries (LMIC). Colorectal cancer (CRC) accounts for over 600 000 deaths annually, but data concerning cancer rates in LMIC is very poor. This study analyses the data available to produce an estimate of the incidence of colorectal cancer in Sub–Saharan Africa (SSA).

Methods

Data for this analysis came from two main sources: a systematic search of Medline, EMBASE and Global Health which found 15 published data sets, and an additional 42 unpublished data sets which were sourced from the IARC and individual cancer registries. Data for case rates by age and sex, as well as population denominators were extracted and analysed to produce an estimate of incidence.

Results

The crude incidence of CRC in SSA for both sexes was found to be 4.04 per 100 000 population (4.38 for men and 3.69 for women). Incidence increased with age with the highest rates in Southern Africa, particularly in South Africa. The rates of CRC in SSA were much lower than those reported for high–income countries.

Conclusion

Few health services in SSA are equipped to provide timely diagnosis and treatment of cancer in SSA. In addition, data collection systems are weak, meaning that the available statistics may underestimate the burden of disease. In order to improve health care services it is vital that accurate measurements of disease burden are available to policy makers.

Impact of antiretroviral therapy on the incidence of Kaposi's sarcoma in resource-rich and resource-limited settings

PURPOSE OF REVIEW

Given the recent availability of antiretroviral therapy (ART) in resource-limited settings and the significant burden exacted by Kaposi's sarcoma in these areas, we reviewed data regarding the impact of ART on Kaposi's sarcoma incidence. We summarized the sizeable literature in resource-rich settings as well as emerging data from resource-limited regions. Importantly, we delineated ways impact can be defined, including individual patient-level effectiveness; population-level effectiveness; change in population-level incidence; and residual risk of Kaposi's sarcoma.

RECENT FINDINGS

In resource-rich settings, there are now ample data demonstrating beneficial individual patient-level and population-level effects of ART on Kaposi's sarcoma incidence. There is, however, considerable variability between studies and important methodologic shortcomings. Data from resource-limited settings are much more limited; although they preliminarily indicate individual patient-level effectiveness, they do not yet provide insight on population-level effects.

SUMMARY

ART has had a substantial impact on Kaposi's sarcoma incidence in resource-rich settings, but more attention is needed on validly quantifying this effect in order to determine whether additional interventions are needed. Emerging data from resource-limited regions also suggest beneficial impact of ART on Kaposi's sarcoma incidence, but - given the scope of Kaposi's sarcoma in these settings - more data are needed to understand the breadth and magnitude of the effect.