Catastrophic Health Expenditure and Associated Factors Among Hospitalized Cancer Patients in Addis Ababa, Ethiopia

Background

Out-of-pocket (OOP) health expenditures for cancer care expose households to unanticipated economic consequences. When the available health services are mainly dependent on OOP expenditure, the household faces catastrophic health expenditure (CHE). This study aimed to estimate the incidence and intensity of CHE in hospitalized cancer patients and identify coping strategies and associated factors.

Method and Material

Hospital-based cross-sectional study design was conducted on 305 cancer inpatients in Addis Ababa between November 2021 and February 2022. All patients with cancer who were hospitalized during the data collection period were included in the study. The incidence of CHE was estimated at the 40% threshold of households' non-food expenditure and the intensity of CHE was captured based on the amount by which household expenditure exceeded the threshold and mean positive overshoot, the mean level by which CHE exceeds the threshold used. Multivariate logistic regression was used to assess the relationship between CHE levels and the independent variables.

Results

The incidence of CHE at the 40% threshold of households' non-food expenditure was 77.7%, while the O and MPO were 36.2% and 46.6%, respectively. CHE for cancer care was significantly associated with patient residence, increased number of chemotherapy cycles, increased duration of hospital admission, lack of insurance enrolment, and lower-income quintiles. Saving and selling assets were identified as the primary coping mechanisms.

Conclusion

The incidence and intensity of CHE among inpatients with cancer were high and which could lead to impoverishment of households. Improved quality and coverage of health insurance and decentralizing cancer care to regions standards similar to Addis Ababa will save households from incurring CHE.

A Qualitative Study on Psychosocial Challenges of Patients With Cancer in Ethiopia Using the Social-Ecological Model

Cancer diagnosis and treatment can be physically arduous, disrupting patients' social and work lives. Understanding the extent of these problems is key to addressing patients' needs, but specific psychosocial challenges have not yet been well studied in resource-limited settings. A qualitative study was conducted in the capital and two regions of Ethiopia with the aim of exploring psychosocial challenges among cancer patients. A total of 14 in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were done with cancer patients, health professionals, community representatives, and religious leaders. Four separate interview guides were used to facilitate the interviews and discussions. All transcribed documents, field notes, and reflexive memos were entered into NVivo 12 software, and deductive thematic analysis using the social-ecological model was applied to summarize the main findings. At an individual level, emotional distress, suicidal risk, denial, and refusal of treatment were identified immediately after diagnosis while hopelessness, feeling depressed, and fear of death were commonly reported psychosocial challenges during the course of treatment. Involvement of family members in major treatment decisions was recognized at an interpersonal level. Our result also revealed that cancer patients had strong social support from family members and close friends. In the community, traditional medicine and religious rituals were considered an alternative treatment for cancer. The findings indicate that counselling and psychoeducation are crucial for cancer patients, family members, and close friends. Awareness creation programmes should be delivered through collaboration with religious leaders and traditional healers.

"How can a woman live without having a breast?": challenges related to mastectomy in Ethiopia

BACKGROUND

Although mastectomy is the standard treatment modality for breast cancer patients in Ethiopia, our previous study revealed that one in five patients do not receive the recommended procedure, half due to patient refusal or lack of returning to the hospital. Therefore, this study aimed to explore reasons for refusing mastectomy and identify challenges among breast cancer patients in Ethiopia.

METHODS

An explorative qualitative study was conducted in four hospitals located in the towns of Woliso, Butajira, Hossana, and Assela. A total of 14 in-depth interviews (IDIs) and eight focus group discussions (FGDs) were held with breast cancer patients, patient relatives, and health professionals. Four semi-structured interview guides were used to facilitate the IDIs and FDGs. All recorded IDIs and FGDs were transcribed and translated verbatim and entered in NVivo 12 software. Emerging ideas were categorised and explained using an inductive content analysis approach.

RESULTS

Our participants reported that particularly elderly and very young women refuse to have mastectomy. The main reasons identified in this study were summarised into six themes: (i) fear of the surgical procedure, (ii) religious beliefs and practice, (iii) utilisation of traditional treatments, (iv) in relation to having a baby and breastfeeding their children (young patients often request to remove only the lump, leaving their breast tissue intact), (v) lack of awareness about the disease, and (vi) sociocultural factors and advice from the community that influence women, since breasts are considered an attribute of femininity, beauty, and motherhood. In addition, knowing someone who died after mastectomy emerged as a main reason for not having breast cancer surgery.

CONCLUSIONS

High refusal rate for mastectomy has direct implication on increased breast cancer mortality. Hence, expansion of radiotherapy service is instrumental to initiate breast-conserving surgery as an alternative surgical procedure, especially for young women with early-stage breast cancer. Involving religious leaders, traditional healers, and breast cancer survivors could be an effective strategy to persuade newly diagnosed breast cancer patients. Addressing individual patient psychosocial needs and preferences may substantially improve retention of breast cancer patients in the health system.

Incidence and pattern of childhood cancer in Addis Ababa, Ethiopia (2012-2017)

BACKGROUND

Cancer is becoming a major public health problem globally and a leading cause of death in children in developed countries. However, little is known about the epidemiology of childhood cancer in Ethiopia. This study, therefore, assessed childhood cancer incidence patterns in Addis Ababa using the Addis Ababa city population-based cancer registry data from 2012 to 2017.

METHODS

Invasive cancer cases diagnosed in ages 0-14 years from 2012 to 2017 were obtained from the Addis Ababa City population-based Cancer Registry. Cases were grouped according to the International Classification of Childhood Cancer, 3rd edition (ICCC-3) based on morphology and primary anatomic site. Age-standardized incidence rates (ASR) were calculated by the direct method using the world standard population.

RESULTS

The overall average annual incidence rate during 2012-2017 in children was 84.6 cases per million, with rates higher in boys (98.97 per million) than in girls (69.7 per million). By age, incidence rates per million increased from 70.8 cases in ages 0-4 years to 88.4 cases in ages 5-9 years to 110.0 cases 10-14 years. Leukaemia was the most common childhood cancer in both boys (29.1%) and girls (26.8%), followed by lymphoma in boys (24.7%) and renal tumours (13.1%) in girls. The overall cancer incidence rate decreased from 87.02 per million in 2012 to 51.07 per million in 2017.

CONCLUSION

The burden of childhood cancer is considerably high in Addis Ababa. The observed distribution of childhood cancer in Addis Ababa differs from other African countries. This study highlights the need for further research and understanding of the variations in cancer patterns and risk factors across the region.

Immunohistochemistry-derived subtypes of breast cancer distribution in four regions of Ethiopia

Purpose

Different biological characteristics, therapeutic responses, and disease-specific outcomes are associated with different molecular subtypes of breast cancer (BC). Although there have been different studies on BC in the Ethiopian capital city of Addis Ababa, there have been few studies in other parts of the nation, and none have evaluated biological characteristics in other locations in the context of the extensive ethnic and genetic diversity found in Ethiopia. This study was carried out to evaluate the distribution of immunohistochemistry (IHC) subtypes of BCs throughout four Ethiopian regions.

Methods

A total of 227 formalin-fixed paraffin-embedded (FFPE) tissue blocks were collected from tertiary hospitals in four Ethiopian regions between 2015 and 2021. The IHC staining was performed for subtyping, ER, PR, HER2, and Ki-67 proliferation markers.

Results

The mean age at diagnosis was 43.9 years. The percentage of ER and PR-negative tumors were 48.3% and 53.2%, respectively. The IHC subtypes showed the following distribution: 33.1% triple-negative breast cancer (TNBC), 27.6% luminal B, 25.2% luminal A, and 14.1% HER2 enriched. In multiple logistic regression analysis, grade III and HER2 positivity were associated with larger tumor size, and also originating from Jimma compared to Mekele.

Conclusion

Patients with ER-negative, PR-negative, and TNBC were found in 48.3%, 53.2%, and 33.1% of cases, respectively, showing that half the patients could potentially benefit from endocrine treatment. A considerably high prevalence of TNBC was reported in our study, demanding additional research that includes genetic predisposition factors. Additionally, aggressive tumors were found in a high percentage of younger age groups, which must be considered when planning personalized treatment strategies.

The expression of matrix metalloproteinase 2, 9 and 11 in Ethiopian breast cancer patients

INTRODUCTION

Matrix metalloproteinases (MMPs) play a pathophysiological role in cancer initiation and progression. Numerous studies have examined an association between MMP-2, MMP-9, and MMP-11 expression and clinicopathological characteristics of breast cancer (BC); however, no research has been done on the MMP expression levels in BC cases from Ethiopia.

MATERIALS AND METHODS

A total of 58 formalin-fixed paraffin-embedded breast tissue samples encompassing 16 benign breast tumors and 42 BC were collected. The RNA was extracted and quantitative reverse-transcription PCR was performed. GraphPad Prism version 8.0.0 was used for statistical analysis.

RESULTS

The MMP-11 expression levels were significantly higher in breast cancer cases than in benign breast tumors (P = 0.012). Additionally, BC cases with positive lymph nodes and ER-positive receptors had higher MMP-11, MMP-9, and MMP-2 expression than cases with negative lymph nodes and ER-negative, respectively. The MMP-11 and MMP-9 expressions were higher in grade III and luminal A-like tumors than in grade I-II and other subtypes, respectively.

CONCLUSION

The MMP-11 expression was higher in BC than in benign breast tumors. Additionally, MMP-11, MMP-9, and MMP-2 were higher in BC with positive lymph nodes and estrogen receptors. Our findings suggest an important impact of MMPs in BC pathophysiology, particularly MMP-11.

Association of Bacterial Composition and Diversity in the Cervical Tumor Microbiome with HPV Genotype in a Large, International Patient Cohort

PURPOSE/OBJECTIVE(S)

Tumor bacterial composition is strongly associated with response to cancer therapy, and is impacted by environment, including geography. Human papillomavirus (HPV) genotypic diversity composition and load are dynamic during pelvic radiation (RT) and correlate with differential responses to RT in cervical cancer patients. In this multi-institutional, collaborative study, we aimed to explore associations between bacterial composition, HPV serotypes, and geographical distribution in an international patient population.

MATERIALS/METHODS

Cervical swabs were collected from 287 patients diagnosed with cervical cancer/ dysplasia in four locations: Houston, USA (TX; N = 94), Ethiopia (ETH; N = 85), Puerto Rico (PR; N = 71), and Botswana (BOT; N = 37). Swabs were collected prior to treatment and were subjected to 16S V4 rRNA gene sequencing and HPV genotyping. We compared HPV types and geography via Chi-squared test. We analyzed bacterial composition, alpha diversity (ANOVA), and beta diversity (principal coordinates analysis [PCoA] with PERMANOVA) for HPV type and geography. We used Linear Discriminant Effect Size (LEfSe) analysis to distinguish taxa associated with HPV types.

RESULTS

Overall, the global bacterial composition for patients with cancer or dysplasia did not significantly vary by location. However, the proportion of patients with each HPV type varied by location (p<0.01); HPV16 was most frequent in TX (54%), BOT (70%) and ETH (61%), while HPV18 was most frequent in PR (62%). The proportion of patients with HPV low-risk/negative tumors was highest in ETH (25%) compared to other sites (2% - 14%). Patients with HPV 16 had significantly higher bacterial alpha diversity across locations (all p<0.01). The bacterial composition also differed by HPV type across locations (p = 0.01). On LEfSe, bacterial genera enriched in HPV 16 samples were Bacteroides, Clostridium, and Prevotella. Non-HPV16 tumors were enriched in species of Lactobacillus and Gardnerella and HPV 18 and high-risk type tumors were enriched in Escherichia.

CONCLUSION

In thislarge, international cohort of cervical cancer and dysplasia patients, bacterial composition was more closely associated with cervical HPV genotype than with geography. This finding has implications for the development of biomarkers and interventions aimed at improving chemotherapy and radiation response through manipulation of the microbiome.

Characteristics of Women Seeking Cervical Cancer Cytology Screening in a Private Health Facility

Background and Objectives: Over 80% of cervical cancer cases in sub-Saharan Africa are detected at late stages, predominantly due to the lack or inaccessibility of prevention services. Public health facilities in Ethiopia offer free cervical cancer screening for eligible women. Besides the public health facilities, private providers also offer a variety of screening services at the patients' expense. As the overall cervical cancer screening uptake in Ethiopia is still far below the 90% WHO target, coordination between all actors of the health system is key. This includes a close cooperation between the public and private sectors to combine the advantages of both to the benefit of all patients as well as media campaigns and community involvement to promote the self-initiation of screening. Materials and Methods: To gain insights into the utilization of cervical cancer screening in the private health sector, we conducted an institution-based cross-sectional study at Arsho medical laboratories in Addis Ababa. Every woman who came there for cervical cancer screening between 1 May and 30 June 2020 was asked to participate in a questionnaire-based, face-to-face interview about their socio-demographic background, cervical cancer screening experience and self-initiation of screening. A total of 274 women participated in the interviews. We further assessed the reproductive status of the patients, their risk factors for cervical cancer, source of information about the screening and barriers to cervical cancer screening. Results: The ages of the participants ranged between 20-49 years. The majority (over 70%) were married. A total of 37.6% reported self-initiating the screening. More than three-quarters of all interviewed women reported mostly using the private health care sector for all kinds of health services. Conclusions: While the Ethiopian government efforts on scaling up cervical cancer screening focus mainly on public health facilities, the private sector often does not get as much attention from policy makers. Efforts should be made to extend the government's interest in cervical cancer screening and implementation research to the private healthcare sector.

Treatment and Survival Among Patients With Colorectal Cancer in Sub-Saharan Africa: A Multicentric Population-Based Follow-Up Study

BACKGROUND

The burden of colorectal cancer (CRC) is increasing in Sub-Saharan Africa (SSA). However, little is known about CRC treatment and survival in the region.

METHODS

A random sample of 653 patients with CRC diagnosed from 2011 to 2015 was obtained from 11 population-based cancer registries in SSA. Information on clinical characteristics, treatment, and/or vital status was obtained from medical records in treating hospitals for 356 (54%) of the patients ("traced cohort"). Concordance of CRC treatment with NCCN Harmonized Guidelines for SSA was assessed. A Cox proportional hazards model was used to examine the association between survival and human development index (HDI).

RESULTS

Of the 356 traced patients with CRC, 51.7% were male, 52.8% were from countries with a low HDI, 55.1% had colon cancer, and 73.6% were diagnosed with nonmetastatic (M0) disease. Among the patients with M0 disease, however, only 3.1% received guideline-concordant treatment, 20.6% received treatment with minor deviations, 31.7% received treatment with major deviations, and 35.1% received no treatment. The risk of death in patients who received no cancer-directed therapy was 3.49 (95% CI, 1.83-6.66) times higher than in patients who received standard treatment or treatment with minor deviations. Similarly, the risk of death in patients from countries with a low HDI was 1.67 (95% CI, 1.07-2.62) times higher than in those from countries with a medium HDI. Overall survival at 1 and 3 years was 70.9% (95% CI, 65.5%-76.3%) and 45.3% (95% CI, 38.9%-51.7%), respectively.

CONCLUSIONS

Fewer than 1 in 20 patients diagnosed with potentially curable CRC received standard of care in SSA, reinforcing the need to improve healthcare infrastructure, including the oncology and surgical workforce.

Implementation of Brachytherapy for Patients With Cervical Cancer in Ethiopia: A 3-Year Practice Report

PURPOSE

Although cervical cancer is the second most commonly diagnosed cancer in Ethiopia, brachytherapy (BT) was not a component in patient treatment until 2015. The purpose of this study was to identify the patterns of utilization as well as to describe the practice of BT in Ethiopia.

MATERIALS AND METHODS

A retrospective descriptive data analysis of 138 patients with cervical cancer treated with a curative potential using BT from 2015 to 2018 at Tikur Anbassa Specialized Hospital, which housed the only BT facility in Ethiopia during the study period.

RESULTS

During the first 3-year period of BT service commencement, each year n = 37, n = 36, and n = 65 patients with cervical cancer were treated, respectively, with curative intention treatment. The median age of these 138 patients was 50 years (range, 22-75). All the patients were in International Federation of Gynecology and Obstetrics stage Ib-IIIb group, and stage IIb (66.4%) was the predominant. Majority (79%) of the patients were treated primarily with radiotherapy (RT), while 21% received RT after surgery. More than half of these patients (62%) received a total RT dose of 82 Gy in equivalent dose in 2 Gy fractions (EQD2), while the rest received a dose ranging from 76 to 86 Gy. Concurrent cisplatin with RT was given only for 36% of the patients for undocumented reasons. The overall treatment time including both external-beam RT and BT was greater than 8 weeks in 21% of the patients.

CONCLUSION

The utilization of BT service increased gradually and BT enabled the delivery of a higher RT dose to patients with cervical cancer (mostly stage IIB). However, there was protracted treatment duration and low concurrent chemotherapy utilization.

Regional Variation in the Tumor Microenvironment, Immune Escape and Prognostic Factors in Breast Cancer in Sub-Saharan Africa

The low overall survival rates of patients with breast cancer in sub-Saharan Africa (SSA) are driven by regionally differing tumor biology, advanced tumor stages at diagnosis, and limited access to therapy. However, it is not known whether regional differences in the composition of the tumor microenvironment (TME) exist and affect patients' prognosis. In this international, multicentre cohort study, 1,237 formalin-fixed, paraffin-embedded breast cancer samples, including samples of the "African Breast Cancer-Disparities in Outcomes (ABC-DO) Study," were analyzed. The immune cell phenotypes, their spatial distribution in the TME, and immune escape mechanisms of breast cancer samples from SSA and Germany (n = 117) were investigated using histomorphology, conventional and multiplex IHC, and RNA expression analysis. The data revealed no regional differences in the number of tumor-infiltrating lymphocytes (TIL) in the 1,237 SSA breast cancer samples, while the distribution of TILs in different breast cancer IHC subtypes showed regional diversity, particularly when compared with German samples. Higher TIL densities were associated with better survival in the SSA cohort (n = 400), but regional differences concerning the predictive value of TILs existed. High numbers of CD163+ macrophages and CD3+CD8+ T cells accompanied by reduced cytotoxicity, altered IL10 and IFNγ levels and downregulation of MHC class I components were predominantly detected in breast cancer samples from Western SSA. Features of nonimmunogenic breast cancer phenotypes were associated with reduced patient survival (n = 131). We therefore conclude that regional diversity in the distribution of breast cancer subtypes, TME composition, and immune escape mechanisms should be considered for therapy decisions in SSA and the design of personalized therapies. See related Spotlight by Bergin et al., p. 705.

Clinicopathological Features of Invasive Breast Cancer: A Five-Year Retrospective Study in Southern and South-Western Ethiopia

Background: Breast cancer (BC) is the most common type of cancer in Ethiopia. The incidence of BC is also rising, but the exact figure is still poorly known. Therefore, this study was conducted to address the gap in epidemiological data on BC in southern and southwestern Ethiopia. Materials and Methods: This is a five-year (2015-2019) retrospective study. The demographic and clinicopathological data were collected from biopsy reports of different kinds of breast carcinomas in the pathology department of Jimma University Specialized Hospital and Hawassa University Specialized Referral Hospital. Histopathological grades and stages were conducted using Nottingham grading and TNM staging system, respectively. Collected data were entered and analyzed using SPSS Version-20 software. Results: The mean age of patients at diagnosis was 42.27 (SD = 13.57) years. The pathological stage of most BC patients was stage III, and most of them had tumor sizes greater than 5 cm. Most patients had moderately differentiated tumor grade, and mastectomy was the most common type of surgery at the time of diagnosis. Invasive ductal carcinoma was the most common histological type of BC, followed by invasive lobular carcinoma. Lymph node involvement was seen in 60.5% of cases. Lymph node involvement was associated with tumor size (χ² = 8.55, p = 0.033) and type of surgery (χ² = 39.69, p < 0.001). Conclusions: This study showed that BC patients in southern and southwestern Ethiopia displayed advanced pathological stages, relatively young age at diagnosis, and predominant invasive ductal carcinoma histological patterns.

Adjuvant Docetaxel in Node-Negative Breast Cancer Patients: A Randomized Trial of AGO-Breast Study Group, German Breast Group, and EORTC-Pathobiology Group

BACKGROUND

In node-negative breast cancer (NNBC), a high risk of recurrence is determined by clinico-pathological or tumor-biological assessment. Taxanes may improve adjuvant chemotherapy.

METHODS

NNBC 3-Europe, the first randomized phase-3 trial in node-negative breast cancer (BC) with tumor-biological risk assessment, recruited 4146 node-negative breast cancer patients from 2002 to 2009 in 153 centers. Risk assessment was performed by clinico-pathological factors (43%) or biomarkers (uPA/PAI-1, urokinase-type plasminogen activator/its inhibitor PAI-1). High-risk patients received six courses 5-fluorouracil (500 mg/m²), epirubicin (100 mg/m²), cyclophosphamide (500 mg/m²) (FEC), or three courses FEC followed by three courses docetaxel 100 mg/m² (FEC-Doc). Primary endpoint was disease-free survival (DFS).

RESULTS

In the intent-to-treat population, 1286 patients had received FEC-Doc, and 1255 received FEC. Median follow-up was 45 months. Tumor characteristics were equally distributed; 90.6% of tested tumors had high uPA/PAI-1-concentrations. Planned courses were given in 84.4% (FEC-Doc) and 91.5% (FEC). Five-year-DFS was 93.2% (95% C.I. 91.1-94.8) with FEC-Doc and 93.7% (91.7-95.3) with FEC. Five-year-overall survival was 97.0% (95.4-98.0) for FEC-Doc and 96.6% % (94.9-97.8) for FEC.

CONCLUSIONS

With adequate adjuvant chemotherapy, even high-risk node-negative breast cancer patients have an excellent prognosis. Docetaxel did not further reduce the rate of early recurrences and led to significantly more treatment discontinuations.

Abstract P1-11-11: HER2-directed therapy in early breast cancer – improvement over 20 years

Introduction: HER2-positive breast cancer is considered aggressive, but due to the development of targeted drugs in the past 20 years, a substantial improvement of therapy results can be postulated. Proven evidence is provided by data of randomized clinical trials. The present study aimed at demonstrating the improvement of therapy results over time using single-center real world data.

Material and Methods: In our center, we prospectively built a consecutive tumor and data base from 2000 to 2020 and identified patients with early HER2-positive breast cancer (n=396). The cohort was divided in four groups by year of diagnosis according to the changing therapy concepts: A) 2000-2004 (no HER2-directed therapy, n=83), B) 2005-2011 (trastuzumab, n=96), C) 2012-2017 (trastuzumab/pertuzumab, n=135), D) 2018-2020 (T-DM1 in patients with non-pCR), n=55). HER2 was measured by IHC and ISH corresponding to the ASCO-CAP guidelines. HER2-directed therapy was indicated according to the respective national guidelines (AGO). The median follow-up was 58 months in the entire cohort (1-266), group A 84 months (10-266), group B 94 months (2-201), group C 56 months (1-118), group D 32 months (8-53). The primary endpoint was overall survival (OS), and secondary endpoint was iDFS. Kaplan-Meier estimates were calculated and multivariate analyses were performed using SPSS 28 (IBM, Armonk, NY, USA).

Results: Overall, 57% of the 396 patients had an age of 50 years or more, 85% had a NST histology, 54% of the tumors were larger than 2cm, 45% were node-positive; 34% were steroid hormone receptor negative. HER2-directed therapy was delivered to 7 of 83 pts in group A (8.4%), to 62 of 96 pts in group B (64.6%), to 119 of 135 in group C (88.15%), and to 50 of 55 pts in group D (90.91%), resp.. Overall, in the first 3 years we observed 19 deaths and the probability for OS was 89.7 % for group A, 92.2 % for group B, 96.4 % for group C and 100% for group D, resp.; iDFS was 77.4% in A, 86.8% in B, 94.9% in C and 95.2% in D, resp.. After adjustment for nodal status, grading and steroid hormone receptor status, we calculated the effect size of the incremental improvement of treatment for OS and iDFS as HRs referred to group A (Table 1).

Conclusion: With this prospectively established single center cohort, we are able to confirm a significant improvement of the treatment results in patients with HER2-positive early breast cancer over the last 20 years applying individualized HER2-directed therapies.

Table 1. Multivariate analyses of OS and iDFS adjusted for nodal status, grading and hormone receptor status.

Citation Format: Christoph Thomssen, Julia Engel, Kristin Reinhardt, Hans-Georg Strauß, Regina Große, Susanne Barrot, Marcus Bauer, Lisa van Uden, Sandy Kaufhold, Kathleen Schüler, Vanessa Wieder, Eva J. Kantelhardt, Martina Vetter. HER2-directed therapy in early breast cancer – improvement over 20 years [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-11-11.

Prevalence and risk factors for tobacco, khat, and alcohol consumption among high school students in Ethiopia

BACKGROUND

Tobacco, khat, alcohol, and marijuana are the main risk factors for non-communicable diseases. There are limited studies on substance use in Ethiopia, especially among secondary school students. This study aims to determine the epidemiology of substance use among secondary school students in Ethiopia.

METHODS

This cross-sectional study was conducted in March 2020 in four large regions of Ethiopia and the capital Addis Ababa. We collected data from 3,355 grade 9 and grade 10 students in 36 randomly selected high schools. Data were collected on tobacco, khat, alcohol and other substances. Mixed effect logistic regression models were fitted to determine the predictors of cigarette smoking.

RESULTS

157 (4.7%) of the participants ever smoked cigarettes and 81 (2.4%) were current smokers. 106 (3.2%) ever used smokeless tobacco, 1,342 (41.8%) had ever drunk alcohol, 290 (8.7%) ever used khat, 137 (4.8%) chewed khat regularly and 76 (2.3%) ever used marijuana. There was a significant regional variation in substance use patterns; cigarette and khat use was the highest in southern regions, whereas alcohol use was highest in the northern areas. Availability of cigarette and khat shops within a 100-meter radius of the school compound was reported by 1,229 (37.5%) and 816 (25%) students, respectively. Three hundred fifty-four (10.9%) students had ever seen someone smoking a cigarette in the school compound. Ever use of smokeless tobacco (Adjusted Odds Ratio (AOR) = 9.4, 95%CI: 4.9-17.9), ever use of shisha (AOR = 8, 95% CI: 3.9-16.3), ever use of khat (AOR = 4.1, 95%CI: 2.5-6.8), ever use of alcohol (AOR = 2.3, 95%CI: 1.4-3.7), having a friend who smoked a cigarette (AOR = 2, 95%CI: 1.2-3.5), and ever seen someone smoking a cigarette in the school compound (AOR = 1.9, 95%CI: 1.1-3.4) were associated with ever use of cigarettes.

CONCLUSION

Substance use prevalence in Ethiopia has regional variations and prevention strategies should be tailored to the needs of the regions. Although this study reported a lower prevalence of cigarette smoking, students could access cigarettes and khat in nearby school areas. The existing tobacco control laws that prohibit selling tobacco products to children and adolescents under 21 years of age and ban establishing tobacco shops close to school compounds should be enforced.

Quality of life assessment in breast cancer patients during palliative treatment in Indonesia

Background

This study aimed to prospectively assess quality of life (QOL), QOL domains, and pain severity in advanced stage breast cancer patients during palliative oncology treatment in Indonesia.

Methods

Advanced stage breast cancer patients > 18 years (n = 160) who began palliative oncology treatment were enrolled in the study using convenience sampling. They completed the EORTC QLQ-C15-PAL questionnaire and pain severity (Visual Analogue Scale, VAS) score at three-time points (baseline (T0), three-(T1) and six-months (T2) follow-up). The repeated measures analysis of variance (ANOVA) model was used to assess the QOL, QOL domains, and pain severity changes over time adjusted for age, place of residence, marital status, and Karnofsky Performance Status score at baseline. We classified the change over time in three qualitative groups (deterioration, improvement, or trivial/no difference). We considered it clinically relevant if patients had a 10-point difference.

Results

The mean age of included patients (n = 159) was 50 years. Most lived in an urban area (72.3%), had low education (71.7%), and were married (81.8%). The repeated measures ANOVA showed that the QOL score, emotional functioning, fatigue, dyspnea, appetite loss, constipation, and VAS pain score remained stable over the 6-months period. In contrast: physical functioning declined (medium to large deterioration (-19.8 (95% CI -27.2 to -12.5)) between T0 to T2), however there was an improvement in the insomnia domain (medium improvement (-13.4 (95% CI -19.9 to -6.9)) between T0 to T2).

Conclusions

Our findings indicated that advanced stage breast cancer patients adapted well to palliative oncology treatment over six months of observation. There was deterioration in physical functioning, but improvement in insomnia. However, more attention is needed from clinicians to achieve improvement in the overall QOL score and specific QOL domains.

Key messages

• Focusing on improvement overall QOL score and specific QOL domains will lead to better advanced stage breast cancer patients’ satisfaction and care.

• Information is limited on palliative treatment satisfaction in low and lower middle-income countries, therefore this study has important impact on further policy considerations in Indonesia.

Climate-sensitive health counselling: a quantitative survey on addressing climate change

Background

Climate change and its mitigation have significant health implications. Hence, medical associations call on physicians to inform the population about health risks of climate change and possible health co-benefits of climate action. However, so far it is unclear what preferences the general public has about climate-sensitive health counselling (CSHC). Therefore, we developed a survey tool to a) characterize experiences of CSHC, b) identify preferences about communication methods and themes, and c) determine associations of socioeconomic characteristics and climate change attitudes with CSHC preferences.

Methods

The tool development for this cross-sectional online-based survey was embedded in a bigger research project on the conceptualization of CSHC, which follows an exploratory mixed-methods design. Results of preceding qualitative interviews about CSHC were integrated into the tool development. After two pilot tests, the tool was administered from April to June 2022 through the population-based HeReCa panel (Health Related Beliefs and Health Care Experiences in Germany), comprising 3200 participants from 5 federal states. Sociodemographic data is available for all participants.

Results

The final tool entails 46 items, sorted into 7 sections. Two sections serve as dependent variables for the association analysis: 13 items about the acceptability of different communicative approaches of CSHC and 18 items on preferences for themes in CSHC. Three sections serve as independent variables for the analysis: attitudes on climate change, level of engagement, and sociodemographic data. Two sections assess experiences with CSHC and preferred information channels to serve as descriptive results.

Conclusions

A rigorous methodology proved helpful for survey development within a mixed methods study. In triangulation with qualitative data, results of the survey will help physicians to deliver CSHC tailored to the preferences of different sociodemographic groups.

Key messages

Burden of Cancer and Utilization of Local Surgical Treatment Services in Rural Hospitals of Ethiopia: A Retrospective Assessment from 2014 to 2019

BACKGROUND

Global cancer estimations for Ethiopia announced 77 352 new cases in 2020 based on the only population-based registry in Addis Ababa. This study characterizes cancer patients in rural Ethiopia at 8 primary and secondary hospitals between 2014 and 2019.

PATIENTS AND METHODS

All clinically or pathologically confirmed cancer cases that were diagnosed between 1 May 2014 and 29 April 2019 were included. A structured data extraction tool was used to retrospectively review patients' charts and descriptive analysis was done.

RESULTS

A total of 1298 cancer cases were identified, of which three-fourths were females with a median age of 42 years. Breast (38%) and cervical (29%) cancers were the most common among females, while prostate (19%) and oesophageal cancers (16%) were the most common among males. Only 39% of tumors were pathologically confirmed. Nearly two-thirds of the cases were diagnosed at an advanced stage. Surgery was the only accessible treatment option for more than half of the cancer patients, and systemic treatment (except endocrine) was rarely available. One in 5 patients did not receive the recommended surgical procedure, half due to patient refusal or lack of the patient returning to the hospital.

CONCLUSION

The pattern of cancer diagnoses in rural hospitals shows an exceptionally high burden in women in their middle-ages due to breast and cervical cancers. Advanced stage presentation, lack of pathology services, and unavailability of most systemic treatment options were common. The surgery was offered to nearly 60% of the patients, showing the significant efforts of health workers to reduce sufferings.

Treatment guideline concordance, initiation, and abandonment in patients with non-metastatic breast cancer from the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort in sub-Saharan Africa: a prospective cohort study

BACKGROUND

Comprehensive breast cancer management is essential to achieve high breast cancer survival; however, detailed reports of the treatment regimens received by patients are scarce in sub-Saharan Africa where survival is low. We aimed to examine treatment initiation, guideline concordance, and abandonment in patients with non-metastatic breast cancer in sub-Saharan Africa from the African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort.

METHODS

The ABC-DO prospective cohort study recruited women (aged ≥18 years) with newly diagnosed invasive breast cancer in eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, Uganda, South Africa, and Zambia). We analysed treatments received by women who were classified as non-metastatic (M0) at the initial presentation. Data on surgery, radiotherapy, and systemic therapies were obtained from medical records and a self-reported follow-up questionnaire at 6 months after the diagnosis, follow-up calls every 3 months, and a baseline questionnaire. Initiation, completion, and abandonment of treatment modalities and combined therapy regimens were examined overall, by country-specific groups, and by clinical factors relevant for guideline-based treatment.

FINDINGS

Of 2313 women recruited into the ABC-DO study between Sept 10, 2014, and Dec 31, 2017, 2226 had histologically or clinically confirmed breast cancer. Of these 2226 women, 510 were excluded from the present analysis because 378 had metastatic disease, 37 were prevalent cases (defined as those previously diagnosed with breast cancer >2 years before baseline), 82 had unknown TNM stage, and 13 were White or Asian women in South Africa (number was too small for analysis). After a median follow-up of 5·2 years (IQR 4·6-5·9), 1163 (68%) of 1716 women underwent breast cancer surgery. Surgery and systemic therapy (ie, multimodality treatment) with radiotherapy was initiated in 370 (36%) of 1028 women with localised tumours versus 156 (23%) of 688 women with locally advanced tumours, whereas multimodality treatment without radiotherapy was initiated in 386 (38%) versus 167 (24%) women, respectively. Of 1530 patients requiring chemotherapy (which excludes 105 who died within 6 months after baseline), 1013 (66%) initiated treatment of neoadjuvant chemotherapy or surgery within 3 months after baseline, which was adequately completed by 359 (35%) of 1013 women, marginally completed by 284 (28%), abandoned by 200 (20%), and unknown in 151 (15%). 19 (2%) women died within 6 months after chemotherapy initiation. Of 1375 women in whom endocrine therapy was indicated, this treatment was initiated in 920, and lasted at least 3 years in 367 (40%) women. Treatment disparities between country-specific groups were substantial for all therapy regimens.

INTERPRETATION

A high proportion of patients with non-metastatic breast cancer did not initiate, did not fully complete, or abandoned treatment with surgery, systemic therapy, radiotherapy, or an appropriate combination of these, highlighting the need for improved treatment access and completion in sub-Saharan Africa to potentially prevent premature breast cancer deaths.

FUNDING

National Institutes of Health (National Cancer Institute), Susan G Komen, and the International Agency for Research on Cancer.

OUP accepted manuscript

Introduction

Many women in rural Ethiopia do not receive adjuvant therapy following breast cancer surgery despite the majority being diagnosed with estrogen-receptor-positive breast cancer and tamoxifen being available in the country. We aimed to compare a breast nurse intervention to improve adherence to tamoxifen therapy for breast cancer patients.

Methods and Materials

The 8 hospitals were randomized to intervention and control sites. Between February 2018 and December 2019, patients with breast cancer were recruited after their initial surgery. The primary outcome of the study was adherence to tamoxifen therapy by evaluating 12-month medication-refill data with medication possession ratio (MPR) and using a simplified medication adherence scale (SMAQ) in a subjective assessment.

Results

A total of 162 patients were recruited (87 intervention and 75 control). Trained nurses delivered education and provided literacy material, gave additional empathetic counselling, phone call reminders, and monitoring of medication refill at the intervention hospitals. Adherence according to MPR at 12 months was high in both the intervention (90%) and control sites (79.3%) (P = .302). The SMAQ revealed that adherence at intervention sites was 70% compared with 44.8% in the control sites (P = .036) at 12 months. Persistence to therapy was found to be 91.2% in the intervention and 77.8% in the control sites during the one-year period (P = .010).

Conclusion

Breast nurses can improve cost-effective endocrine therapy adherence at peripheral hospitals in low-resource settings. We recommend such task sharing to overcome the shortage of oncologists and distances to central cancer centers.

Prostate cancer survival in sub-Saharan Africa by age, stage at diagnosis, and human development index: a population-based registry study

OBJECTIVES

To estimate observed and relative survival of prostate cancer patients in sub-Saharan Africa (SSA) and to examine the influence of age, stage at diagnosis and the Human Development Index (HDI).

PATIENTS AND METHODS

In this comparative registry study, we selected a random sample of 1752 incident cases of malign prostatic neoplasm from 12 population-based cancer registries from 10 SSA countries, registered between 2005 and 2015. We analyzed the data using Kaplan-Meier and Ederer II methods to obtain outcome estimates and flexible Poisson regression modeling to calculate the excess hazards of death RESULTS: For the 1406 patients included in the survival analyses, 763 deaths occurred during 3614 person-years of observation. Of patients with known stage, 45.2% had stage IV disease, 31.2% stage III and only 23.6% stage I and II. The 1 and 5-year relative survival for the entire cohort was 78.0% (75.4-80.7) and 60.0% (55.7-64.6), while varying between the registries. Late presentation was associated with increased excess hazards and a 0.1 increase in the HDI was associated with a 20% lower excess hazard of death, while for age at diagnosis no association was found.

CONCLUSIONS

We found poor survival of SSA prostatic tumor patients, as well as high proportions of late stage presentation, which are associated with inferior outcome. This calls for investment in health-care systems and action regarding projects to raise awareness among the population to achieve earlier diagnosis and improve survival.

Breast Awareness, Self-Reported Abnormalities, and Breast Cancer in Rural Ethiopia: A Survey of 7,573 Women and Predictions of the National Burden

Background

Breast cancer (BC) is the most frequently diagnosed cancer and leading cause of cancer deaths among women in low‐income countries. Ethiopia does not have a national BC screening program, and over 80% of patients are diagnosed with advanced stage disease. The aim of this study was to assess how many women self‐report a breast abnormality and to determine their diagnoses in rural Ethiopia.

Methods

A community‐based cross‐sectional study was conducted among 7,573 adult women. Women were interviewed and educated about breast awareness, and those who reported breast abnormalities underwent clinical examination by experienced surgeons. Ultrasound‐guided fine needle aspiration cytology (FNAC) was obtained, and cytological analysis was performed. The findings were projected to the female population of Ethiopia to estimate current and future burden of diseases.

Findings

Of the 7,573 women surveyed, 258 (3.4%) reported a breast abnormality, 246 (3.2%) received a physical examination, and 49 (0.6%) were found to be eligible for ultrasound‐guided FNAC or nipple discharge evaluation. Of all the cases, five (10.2%) breast malignancies were diagnosed. We projected for Ethiopia that, approximately, 1 million women could self‐report a breast abnormality, 200,000 women could have a palpable breast mass, and 28,000 women could have BC in the country.

Conclusion

The health care system needs to build capacity to assess and diagnose breast diseases in rural areas of Ethiopia. These data can be used for resource allocation to meet immediate health care needs and to promote detecting and treating BC at earlier stages of disease.

Implications for Practice

Routine mammography screening in a resource‐limited country with a young population is neither sensitive nor affordable. Clinical breast examination with consecutive ultrasound‐guided fine needle aspiration cytology may ensure early diagnosis, downstage disease, and reduce breast cancer mortality. This study had the unique opportunity to educate over 7,573 rural women about breast abnormalities and offer clinical and cytological diagnosis for reported breast abnormalities. The findings were extrapolated to show the nationwide burden of breast abnormalities and unmet diagnostic needs. These data will serve as policy guide to improve adequate referral mechanisms and breast diagnostic and treatment facilities.

Developing tailored interventions for the prevention of breast cancer in Ethiopia is a major challenge in this resource‐limited country. This article reports on the proportion of adult women with self‐reported breast abnormalities in a rural region of Ethiopia, assessing the diagnosis of these abnormalities and extrapolating the disease burden for the entire Ethiopian female population.

Cervical Cancer in Sub-Saharan Africa: A Multinational Population-Based Cohort Study of Care and Guideline Adherence

BACKGROUND

Cervical cancer (CC) is the most common female cancer in many countries of sub-Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS).

METHODS

Our observational study covered nine population-based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44-125 patients diagnosed from 2010 to 2016 were selected in each. Cancer-directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (U.S.) Guidelines.

RESULTS

Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline-adherent, 2.4% with minor deviations, and 8.2% with major deviations. CDT was not documented or was without curative potential in 22%; 15.7% were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease. Adherence was not assessed in 46.9% (no stage or follow-up documented, 11.9%, or records not traced, 35.1%). The largest share of guideline-adherent CDT was observed in Nairobi (49%) and the smallest in Maputo (4%). In patients with FIGO stage I-III disease (n = 190), minor and major guideline deviations were associated with impaired OS (hazard rate ratio [HRR], 1.73; 95% confidence interval [CI], 0.36-8.37; HRR, 1.97; CI, 0.59-6.56, respectively). CDT without curative potential (HRR, 3.88; CI, 1.19-12.71) and no CDT (HRR, 9.43; CI, 3.03-29.33) showed substantially worse survival.

CONCLUSION

We found that only one in six patients with cervical cancer in SSA received CDT with curative potential. At least one-fifth and possibly up to two-thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of many patients.

IMPLICATIONS FOR PRACTICE

Despite evidence-based interventions including guideline-adherent treatment for cervical cancer (CC), there is huge disparity in survival across the globe. This comprehensive multinational population-based registry study aimed to assess the status quo of presentation, treatment guideline adherence, and survival in eight countries. Patients across sub-Saharan Africa present in late stages, and treatment guideline adherence is remarkably low. Both factors were associated with unfavorable survival. This report warns about the inability of most women with cervical cancer in sub-Saharan Africa to access timely and high-quality diagnostic and treatment services, serving as guidance to institutions and policy makers. With regard to clinical practice, there might be cancer-directed treatment options that, although not fully guideline adherent, have relevant survival benefit. Others should perhaps not be chosen even under resource-constrained circumstances.

Rising Prostate Cancer Incidence in Sub-Saharan Africa: A Trend Analysis of Data from the African Cancer Registry Network

BACKGROUND

Prostate cancer is the leading cancer in men in sub-Saharan Africa (SSA) regarding incidence and mortality. Published data from a few registries in SSA suggest that the rates are still rising, but there is little comprehensive information on the time trends of prostate cancer incidence.

METHODS

We analyzed registry data on 13,170 incident prostate cancer cases in men aged 40 years or above, from 12 population-based cancer registries in 11 SSA countries, with at least a 10-year time span of comparable data.

RESULTS

We observed an increase in cumulative risks (CR) and age-standardized incidence rates (ASR) over time in all registries (statistically significant in all but one). The highest values of CR were found in Seychelles and Harare (Zimbabwe). The highest annual increase in the ASRs was seen in Seychelles and Eastern Cape (South Africa), whereas the lowest was seen in Mauritius. We mainly found a steady increase in incidence with age and during successive periods.

CONCLUSIONS

This analysis reveals that prostate cancer incidence rates are rising in many populations in SSA-often very rapidly-which is in contrast to recent observations worldwide. We acknowledge that the reasons are multifactorial and largely remain unclear, but believe that they are primarily associated with improvements in health care systems, for example, a broader use of prostate-specific antigen testing.

IMPACT

This study is the first to compare population-level data on time trends of prostate cancer incidence between multiple countries of SSA, presenting the different rates of increase in 11 of them.

Comparison of six breast cancer classifiers using qPCR

MOTIVATION

Several gene expression-based risk scores and subtype classifiers for breast cancer were developed to distinguish high- and low-risk patients. Evaluating the performance of these classifiers helps to decide which classifiers should be used in clinical practice for personal therapeutic recommendations. So far, studies that compared multiple classifiers in large independent patient cohorts mostly used microarray measurements. qPCR-based classifiers were not included in the comparison or had to be adapted to the different experimental platforms.

RESULTS

We used a prospective study of 726 early breast cancer patients from seven certified German breast cancer centers. Patients were treated according to national guidelines and the expressions of 94 selected genes were measured by the mid-throughput qPCR platform Fluidigm. Clinical and pathological data including outcome over five years is available. Using these data, we could compare the performance of six classifiers (scmgene and research versions of PAM50, ROR-S, recurrence score, EndoPredict and GGI). Similar to other studies, we found a similar or even higher concordance between most of the classifiers and most were also able to differentiate high- and low-risk patients. The classifiers that were originally developed for microarray data still performed similarly using the Fluidigm data. Therefore, Fluidigm can be used to measure the gene expressions needed by several classifiers for a large cohort with little effort. In addition, we provide an interactive report of the results, which enables a transparent, in-depth comparison of classifiers and their prediction of individual patients.

AVAILABILITY AND IMPLEMENTATION

https://services.bio.ifi.lmu.de/pia/.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Abstract C031: NanoString nCounter-based gene expression assay for evaluation of breast cancer molecular subtypes in Ethiopian patients

Introduction: The burden of breast cancer is escalating across the globe and becoming a major public health problem in Ethiopia. Considering the fact that breast cancer is a heterogeneous disease in its nature, it demands a coordinated multimeric approach for diagnosis, treatment and management. Therefore, NanoString nCounter-based gene expression analysis might be employed for breast cancer intrinsic molecular subtyping, since it is a robust, highly reproducible tool and allows to simultaneously explore the expression of hundreds of genes in a single reaction tube. The aim of the study was to determine the intrinsic molecular subtypes of breast cancer samples from Ethiopian patients using a tailored NanoString nCounter gene expression assay for formalin-fixed, paraffin-embedded (FFPE) material.

Methods: The present study was carried out to determine the molecular subtypes of breast cancer in Ethiopian patients. Archived FFPE tumor samples from public hospitals in Ethiopia were retrieved and blocks with clinical and pathologic data were used. From each sample total RNA was extracted by miRNeasy kit, then total RNA concentration and quality were determined and high-quality RNA was subjected to NanoString-based nCounter gene expression analysis using a tailored assay consisting of molecular and immunologic markers. For each gene, gene-fold change expression is given when compared to the reference cut-off value. The study focused on the analyses of estrogen receptor 1(ESR1), progestrone receptor (PGR), erythroblastic oncogene B (ERBB2) genes expression and the intrinsic molecular subtypes done using PAM 50 assay. Statistical analysis was carried out using SPSS software.

Results: A total of 164 FFPE breast cancer blocks were analyzed for protein (ER, PR and Her2) expression status and mRNA expression levels. 86/164 (52.4%) breast cancer patients were tumor grade 3. More than 50% of tumor samples were ER and PR positive. In contrast to hormone receptors, only 20 (12.2%) breast tumor samples were found to be positive for HER-2. With regard to the mRNA expression levels of the respective genes, 106 (64.6%), 43 (26.2%) and 143 (87.2%) of breast cancer lesions analyzed showed an upregulation of ESR-1, PGR and ERBB2 genes, respectively. The samples with ER and PR positive results demonstrated by immunohistochemistry (IHC) showed nCounter levels from -60 to 124 (median=7) and -379 to 9 (median= -2), respectively. Samples with HER-2 positive results by IHC showed nCounter levels from -1 to 60 (median=17.5). Using PAM50 algorithm, we found 32 (19.5%) luminal A, 33 (20.1%) luminal B, 24 (14.6%) HER-2 enriched, 29 (17.7%) basal and 17 (10.4%) normal type breast cancer.

Conclusion: According to the RNA expression assay, the majority of breast cancer subtypes were luminal A and luminal B and the lowest was normal type. In addition, the large majority of the cases analyzed were hormone receptor positive. Thus, hormonal therapy is of high importance for breast cancer care in Ethiopia.

Citation Format: Zelalem Desalegn Woldesonbet, Martina Vetter, Meron Yohannes Nigussie, Tamrat Abebe Zeleke, Yonas Bekuretsion, Mahlet Arayselassie, Mathewos Assefa, Abebe Bekele, Endale Anberber, Claudia Wickenhauser, Eva J. Kantelhardt, Jürgen Bukur, Barbara Seliger. NanoString nCounter-based gene expression assay for evaluation of breast cancer molecular subtypes in Ethiopian patients [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C031.

Abstract A118: Optimization of end point PCR for the determination of ESR1, PGR, and ERBB2 expression level in resource-limited settings: Ethiopian context

Background: Breast cancer is becoming a major public health problem in developing countries. Accumulated evidence noted that the majority of breast cancer patients are in a younger age group. Moreover, most breast cancer patients appear in health institutions at late stages of the disease, which compromises the clinical outcome and disease management. With regard breast cancer, it solely depends on pathologic and clinical diagnoses. The characterization of hormone receptors and HER-2 status using immunohistochemistry (IHC) has been introduced in Ethiopia; however, there is critical problem with the provision of requirements for the test. As a result, the development and establishment of a rapid, reproducible, and alternative diagnostic method in resource limited setting is essential. The current research work aims to optimize endpoint PCR as a tool for determination of ESR1, PGR, and ERBB2 expression level using breast cancer specimen in Ethiopian patients. Furthermore, the project work will be extended to implement the method into clinical practice in the Ethiopian settings.

Methods: The experiments were started with known ESR1, PGR, and ERBB2 RNA expression in different breast cancer cell lines such as MCF-7, MDA-MB-231, BT-20, and SKBR-3 .cDNA from the breast cancer cell lines and FFPE derived-RNAof BC lesions was synthesized using BiozymcDNA synthesis kit. Variable concentrations (25ng, 50ng, and 100ng) of breast cancer cell lines and FFPE-derived total RNA were used for ESR1, PGR, and ERBB2 mRNA transcript detection using the corresponding primer pairs of each gene. GAPDH served as a reference gene. The following PCR program was applied: denaturation 950c (1min), 620c annealing temperature (20sec), 720c synthesis/extension temperature (20sec) for 35 cycles. The experiments were performed by including non-template controls in each PCR run. The PCR products were subjected to gel electrophoresis using SERVA agarose standard electro endosmosis (EEO)followed by documentation with the Image QuantTM LAS4000.

Results: Multiple PCR experiments were carried out with different counts of PCR cycles, with and without extension, with various RNA concentrations and using breast cancer cell lines and FFPE-derived RNA. With the PCR conditions, testing of ESR1, PGR, and ERBB2 expression was possible. In particular, the MCF-7, MDA-MB-231 cell lines PCR run produced concordant data with IHC. However, some BC cell lines (BT-20 and SKBR-3) known as negative for the respective hormone receptor showed discordant results.

Conclusion: In summary, the determination of the expression of ESR1, PGR and ERBB2 level in BC was successful. However, it requires further tests using different PCR conditions and a large set of known human breast tissues. From the experiment, we have learnt that endpoint PCR based ESR1, PGR, and ERBB2 detection can be used as an alternative method for better BC receptor diagnosis, treatment plan, and management in resource-limited countries.

Citation Format: Zelalem Desalegn Woldesonbet, Martina Vetter, Meron Yohannes Nigussie, Tamrat Abebe Zeleke, Yonas Bekuretsion, Mahlet Arayselassie, Mathewos Assefa, Abebe Bekele, Endale Anberber1, Claudia Wickenhauser, Eva J Kantelhardt, Jürgen Bukur, Seliger Barbara. Optimization of end point PCR for the determination of ESR1, PGR, and ERBB2 expression level in resource-limited settings: Ethiopian context [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A118.

Abstract B034: Assessment of the prevalence and diagnosis of breast abnormalities among adult women in rural Ethiopia

Background: Breast cancer (BC) is the most frequently diagnosed cancer and the leading cause of cancer death among females in Ethiopia. BC screening programs are lacking and above 80% breast cancer are diagnosed at advanced stages. Ultrasound-guided fine needle aspiration (FNA) is a simple and effective approach to evaluate breast mass in resource limited countries. The aim of this study was to assess the prevalence and diagnosis of breast abnormalities among adult women in rural Ethiopia.

Methods: Community based cross-sectional study was conducted among 7,573 adult women, age 15 years and older from March to April 2018 in Butajira Health and Demographic Surveillance Site, South Central Ethiopia. A two stage-stratified cluster sampling method was used to select the population-based study participants. Data were collected using a pretested interviewer-administered questionnaire to inquire about breast abnormalities from eligible respondents. Further clinical assessment with history and physical examination of those reporting breast abnormalities (e.g., lump or breast pain) were assessed by experienced surgeons. If indicated, surgeons ordered the ultrasound-guided FNA performed by pathologist and cytologic analysis was done by an experienced pathologist. Women with BC were referred to Butajira Hospital for oncologic care. Data were analyzed using EPI- Info and SPSS V20. Descriptive statistics were used to summarize clinical and pathology result.

Result: Out of 7,573 women surveyed, 258 (3.4%) women with breast abnormality were identified and referred to the Butajira Health Center. Only two women had visited a health facility to seek medical care before the survey was administered. Of those who reported breast abnormalities, 246 (95.3%) women had physical examinations. Forty-nine women had findings requiring ultrasound-guided FNAs. The median age of women was 30 years old with interquartile range of 25-40 years. Of the FNAs performed, 13 (26.5%) were benign lesions, 8 (16.3%) were fibroadenomas, 9 (18.4%) were reactive lymphoid hyperplasia, and 14 (28.6%) were other noncarcinoma cases. One (2%) was suspicious of BC and required excisional biopsy for diagnosis, and 4 (8.2%) ascertained non-special type carcinoma of the breast. Of BC patients, 2 patients presented with ulcerated and fungating lesion with tumor size greater than 5cm, one patient presented with ulcerating tumor measuring 3 cm, and two patients presented with a breast mass measuring 4 cm.

Conclusion: A few women with self-reported breast abnormalities in a rural region of Ethiopia sought medical attention for their problem prior to our survey. We found the prevalence of women with breast abnormalities in our population-based study was similar to reports from Liberia and Rwanda. Raising awareness of health care services available to women in rural regions of Ethiopia could increase earlier detection of breast cancer and improve quality of life.

Citation Format: Wondimu Ayele Manamo, Adamu Addissie Nuramo, Ahmedin Jemal, Lesley Taylor, Eva J. Kantelhardt. Assessment of the prevalence and diagnosis of breast abnormalities among adult women in rural Ethiopia [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B034.

Abstract B033: Breast cancer and other cause of death among adult women in rural Ethiopia: Presentation and duration of suffering using the direct sisterhood method

Background: In Ethiopia, breast cancer is the leading cause of cancer morbidity and mortality among women. Studies on breast cancer death are very scarce in Ethiopia. Moreover, little is known about breast cancer compared to other causes of death in Ethiopia, particularly in a rural setting, where there is no registration about the cause of death. Hence, the present study assessed breast cancer and other deaths with a special focus on the duration of suffering in a rural setting using the direct sisterhood method.

Methods: We determined the pattern of causes of death among randomly selected adult women in rural Ethiopia. A modified standard verbal autopsy (VA) questionnaire was filled and reviewed by two independent local physicians to assign causes of death; contradicting diagnoses were reviewed by a third physician. Descriptive statistics with relative frequencies and their 95% confidence intervals (CI) on the basis of the binomial distribution were used. Duration of suffering was taken from the standard verbal autopsy questionnaire.

Result: The median age of breast cancer death was 37 years, younger than the other cause of death. Breast cancer deaths were the second leading neoplasm responsible for 2.7% of all deaths (95% CI 1.5%-3.7%) and among top five noncommunicable diseases death. The median duration of illness for breast cancer deaths, which accounted for only 2.7% of the total cause of death, was above one year. Reproductive neoplasms, breast cancer, and epilepsy were those three causes of deaths with the largest proportion of women (more than 70%) suffering for more than six months compared to all other causes of death.

Conclusion and Recommendation: Breast cancer deaths occurred in younger age groups than other causes of death. This age is considered a young age group as compared to the country overall lifespan. The very long duration of illness for a considerable number of women has practical implications to introduce palliatives care for a cancer patient. Substantial efforts need to be made to improve the prevention and control of breast cancer in order to reduce premature death of women.

Citation Format: Wondimu Ayele Manamo, Adamu Addissie Nuramo, Wienke Andreas, Fikre Enquselassi Gash, Eva J. Kantelhardt. Breast cancer and other cause of death among adult women in rural Ethiopia: Presentation and duration of suffering using the direct sisterhood method [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B033.

Abstract B020: Antiproliferative efficacy of different targeted drugs on breast cancer cell lines of distinct subtypes

Background: Breast cancer is the most common cancer overall, with an estimated 2.4 million incident cases in 2015. Current treatment of breast cancer is mainly surgery, chemotherapy, radiotherapy, and hormonal therapy. Although these approaches appear to be effective, they have failed to result in long-term cure, especially for aggressive HER2-positive and triple-negative breast cancer. This particularly holds for sub-Saharan Africa with a dominance of aggressive breast cancer subtypes with very limited treatment options and almost no research activities in place. As a result, continuous exploration of alternative treatment strategies is urgently required. Consequently, a collaborative research program has been established between Addis Ababa University, Ethiopia, and Martin-Luther-University, Germany, to enhance breast cancer research in Ethiopia. As a pilot study in Germany, we have assessed the in vitro potency of the three inhibitors romidepsin, trametinib, and lapatinib targeting HDAC, MEK and HER2/EGFR, respectively, in different breast cancer cell lines.

Methods: Seven distinct breast cancer cell lines (MCF7, SKBR3, T47D, BT474, BT20, HCC1806 and HCC1937) of known HER-2 and hormone status were used to evaluate the antiproliferative effect of romidepsin, lapatinib, and trametinib. Cells cultivated in complete RPMI media were seeded in to 96 well plates (3,000 cells/well) and incubated at 370C and 5% CO2 for 24hrs. The cells were then treated for 24, 48, and 72 hours with different concentrations of the drugs. Cells exposed to solvent alone served as controls. XTT cell viability assay was used to determine proliferation of cells following manufacturers' instruction. IC50 value was calculated (Compusyn software) for each drug against the different cell lines to determine the antiproliferative effect.

Results: Romidepsin exhibited a strong antiproliferative effect against all breast cancer cell lines tested, resulting in a marked decrease in cell viability with increasing concentrations, which highly varied between the breast cancer cell lines analyzed. The calculated IC50 values 48 hrs after the onset of treatment ranged between 2.2 and 52 nM; T47D was the most sensitive. Lapatinib treatment of the EGFR/HER-2 expressing BT20, SKBR3 and BT474 caused dose-dependent suppression of cell viability against SKBR3 and BT474 with an IC50 value of 450 and 77 nM, respectively. In contrast, BT20 cells were resistant to this treatment and were the only breast cancer cell line with an enhanced sensitivity to increasing concentrations of trametinib (IC50 =2.79 μM).

Conclusion: In sum, romidepsin might improve the treatment efficacy of breast cancer though it needs to be further explored in vitro as well as in vivo alone and in combination with other therapies. Although trametinib has been suggested to be insufficient for monotherapy of breast cancer in general, it might be still a candidate for the treatment of basal-like breast cancers due to the sensitivity of BT20 cells.

Citation Format: Meron Yohannes Nigussie, Jürgen Bukur, Zelalem Desalegn Woldesonbet, Tamrat Abebe Zeleke, Yonas Bekuretsion, Mahlet Arayselassie, Mathewos Assefa, Abebe Bekele, Endale Anberber, Martina Vetter, Claudia Wickenhauser, Eva J Kantelhardt, Barbara Seliger. Antiproliferative efficacy of different targeted drugs on breast cancer cell lines of distinct subtypes [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B020.

Cancer in Africa 2018: The role of infections

We estimate the fractions of cancer attributed to infections in Africa in 2018. The number of new cancer cases occurring was taken from Globocan2018 with some additional estimations based on data from African population-based registries. Population attributable fractions were calculated using prevalence of infection and relative risk in exposed vs. nonexposed. The greatest share of infection-associated cancers is due to the human papillomaviruses (12.1% of all cancers in Africa and 15.4% in sub-Saharan Africa [SSA]); of these, cervical cancer is by far the most common. Kaposi sarcoma-associated herpesvirus is responsible for 3.1% of all cancers in Africa, the hepatitis viruses (B and C) for 2.9% and Helicobacter pylori for 2.7% (non-Cardia Gastric cancer and primary gastric lymphomas). Two percent of cancers are attributable to the Epstein-Barr virus, Schistosoma haematobium increases the risk of bladder cancer resulting in 1.0% of all cancers. HIV-related NHL and squamous cell carcinoma of the conjunctiva account for 0.6% of cancers. Altogether 24.5% of cancers in Africa and 28.7% in SSA are due to infectious agents. Infections are by far the most common cancer risk factor for cancer in Africa-the traditional risk factors (smoking, alcohol and unhealthy diet) probably cause only one in eight cancers in Africa. Prevention should focus on those infectious diseases preventable through vaccination (HPV and hepatitis B) which could reduce two-thirds of the burden. Helicobacter pylori and schistosomiasis are treatable with antibiotics and praziquantel, with a potential reduction of one in eight infection-associated cancers.

Clinical presentation and diagnosis of adult patients with non-Hodgkin lymphoma in Sub-Saharan Africa

Non-Hodgkin lymphoma (NHL) is the sixth most common cancer in Sub-Saharan Africa (SSA). Comprehensive diagnostics of NHL are essential for effective treatment. Our objective was to assess the frequency of NHL subtypes, disease stage and further diagnostic aspects. Eleven population-based cancer registries in 10 countries participated in our observational study. A random sample of 516 patients was included. Histological confirmation of NHL was available for 76.2% and cytological confirmation for another 17.3%. NHL subclassification was determined in 42.1%. Of these, diffuse large B cell lymphoma, chronic lymphocytic leukaemia and Burkitt lymphoma were the most common subtypes identified (48.8%, 18.4% and 6.0%, respectively). We traced 293 patients, for whom recorded data were amended using clinical records. For these, information on stage, human immunodeficiency virus (HIV) status and Eastern Cooperative Oncology Group Performance Status (ECOG PS) was available for 60.8%, 52.6% and 45.1%, respectively. Stage at diagnosis was advanced for 130 of 178 (73.0%) patients, HIV status was positive for 97 of 154 (63.0%) and ECOG PS was ≥2 for 81 of 132 (61.4%). Knowledge about NHL subclassification and baseline clinical characteristics is crucial for guideline-recommended treatment. Hence, regionally adapted investments in pathological capacity, as well as standardised clinical diagnostics, will significantly improve the therapeutic precision for NHL in SSA.

Perceived barriers to early diagnosis of breast Cancer in south and southwestern Ethiopia: a qualitative study

Background

Early diagnosis is a key determinant of breast cancer prognosis and survival. More than half of breast cancer cases are diagnosed at an advanced stage in Ethiopia, and the barriers to early diagnosis in this country are not well understood. We aimed to identify the perceived barriers to early diagnosis of breast cancer from the perspective of patients and health care providers in south and southwestern Ethiopia.

Methods

A qualitative study was conducted from March to April 2018 using in-depth interviews of breast cancer patients and breast cancer health care providers from six public hospitals located in urban and rural areas of south and southwestern Ethiopia. All participants provided verbal consent before participating. A thematic analysis was performed using Open Code 4.02.

Results

Twelve breast cancer patients and thirteen health care providers were included in the study. Patient and health-system related barriers to early diagnosis of breast cancer were identified. Patient-related barriers were lack of knowledge and awareness of breast cancer, belief in traditional medicine and religious practices for treatment, and lack of social and financial support to seek care at a medical facility. Health-system related barriers were misdiagnosis of breast cancer, long distance to referral facilities, high cost of diagnostic services, long waiting time for diagnostic tests, and lack of screening and diagnostic tests in local facilities.

Conclusions

Early diagnosis of breast cancer is affected by multiple barriers in south and southwestern Ethiopia. Awareness campaigns and education about the disease, prevention, and early detection are needed to increase early diagnosis of breast cancer. Opportunities exist to improve early diagnosis and timely treatment in rural areas.

Cervical cancer screening knowledge and barriers among women in Addis Ababa, Ethiopia

INTRODUCTION

Routine cervical screening has been shown to greatly reduce both the number of new cervical cancers diagnosed each year and the number of deaths resulting from the disease. Nevertheless, cervical screening knowledge and screening uptake is very low in developing countries. In Ethiopia, the coverage of cervical cancer screening is only 1%. In this study, we aimed to assess cervical cancer screening knowledge and barriers for screening uptake among women in Addis Ababa Ethiopia.

METHODS

A facility-based cross-sectional study was conducted from February to March 2015 in Addis Ababa, Ethiopia. A total of 520 women were selected by a multi-stage sampling procedure. Interview based questioner was used to collect the data. Descriptive statistics was used to describe the socio-demographic and clinical profiles of the women. Multivariate logistic regression using adjusted odds ratio (AOR) and 95% confidence interval (CI) was used to identify independent predictors for cervical screening knowledge. A p-value of <0.05 was set to determine level of statistical significance.

RESULTS

Among all women, 42.7% had heard of cervical cancer screening and 144 (27.7%) women had adequate knowledge of cervical cancer screening. The mean (±SD) age of women was 27.7 (±5.49) years. In total, a quarter (25%) of eligible women had experience of cervical cancer screening. Not being married (adjusted odds ratio (AOR) = 1.8, 1.1-3.3), having an awareness of cervical cancer (AOR = 5.0, 2.7-9.1) and receiving information from health professionals (AOR = 1.9, 1.1-3.2) were the predictors for good cervical cancer screening knowledge. An absence of symptoms (57%), a lack of knowledge about screening (56.3%) and the lack of a screening service in their living area (42.2%) were the perceived barriers for screening uptake.

CONCLUSIONS

Cervical screening knowledge was low among women and less than half had heard of screening. Women also had low experience of screening. The lack of a screening service, the absence of symptoms and not knowing about screening were the perceived reasons for the low uptake. Hence, awareness campaigns and education should be undertaken by health professionals. Access and availability of screening service is also essential to improve screening uptake.

Abstract P6-09-03: Association of Caspase 8 polymorphisms with TILs and disease-free survival in primary breast cancer patients

BACKGROUND: The minor allele of two caspase-8 polymorphisms, namely CASP8 -652 6N InsDel and CASP8 Asp302His, were shown to promote survival of T-lymphocytes and were repeatedly associated with reduced breast cancer susceptibility. However, besides some preliminary findings, clinical relevance of these polymorphisms in patients with already existing primary breast cancer has not yet been established. Considering an immunomodulatory and potentially tumor-protective role of these caspase-8 variants, we genotyped 785 primary breast cancer patients and correlated caspase-8 variants with i) disease-free survival (DFS) and ii) the presence of tumor infiltrating lymphocytes (TILs).

METHODS: Primary breast cancer samples were collected at the Martin-Luther University, Halle-Wittenberg between 2009 and 2011 as part of the multicenter prospective PiA trial (NCT 01592825). The majority of patients had luminal-like tumors (75.9%), followed by triple negative (10.1%), luminal-Her2-like (9.6%) and Her2-enriched tumors (4.5%). Genotyping was performed by pyrosequencing, TILs status was assessed by hematoxylin and eosin staining.

RESULTS: The CASP8 -652 deletion was significantly associated with improved DFS in an allele-dose dependent manner (p=0.027). Homozygosity for the -652 6N Del variant was an independent predictor for improved DFS (p=0.005). In patients with a 302His/His genotype, there was no event of recurrence during the entire observation time. Combined analysis of diplotypes revealed that both polymorphisms had an influence on DFS (p=0.029). Interestingly, patients with the 302His/His variant among the unstratified patient cohort and among the luminal-like subtype alone had tumors with very low lymphocyte infiltration (0-10% TILs in 65% of cases compared to 31% of cases for other genotypes, p=0.025).

CONCLUSION: In line with previous epidemiological findings, we propose a prognostically favorable role of the CASP8 -652 6N Del and the Asp302His variant in primary breast cancer patients. Moreover, we suggest for the first time a role of the Asp302His variant in immunosurveillance and lymphocyte infiltration of breast cancer. Our findings strongly encourage further analyze of these genetic variants as a biomarker for prognostic and immunotherapeutic considerations.

Citation Format: Wimberger P, Bachmann HS, Kuhlmann JD, Link T, Kröber E, Thomssen C, Malle B, Vetter M, Kantelhardt EJ. Association of Caspase 8 polymorphisms with TILs and disease-free survival in primary breast cancer patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-09-03.

Improving Access and Adherence to Endocrine Therapy With Nurse-Based Intervention

Purpose

The majority of women with breast cancer from low-income countries, including Ethiopia, present with advanced clinical stage disease, which results in limited and difficult therapeutic options and high mortality rates. In Ethiopia, breast cancer is the most common cancer. We found that 70% of breast cancer cases in Ethiopia are hormone receptor positive. Endocrine therapy is one of the treatment options recommended for breast cancer but that is highly underutilized in the country. Recommendations on interventions to improve uptake and adherence to therapy exist, but studies that have assessed the feasibility of implementing these are limited. Our study (n = 107) in rural Ethiopia revealed an estimated 53% 2-year survival rate in patients who underwent surgery only. In our pilot study, of 51 eligible patients 26 initiated therapy and one half of those adhered after 1 year. Our study aims to evaluate the effectiveness of using a trained breast nurse navigator to improve patient adherence to tamoxifen therapy among patients with breast cancer in rural Ethiopia.

Methods

A cluster randomized intervention trial is being carried out in rural hospitals in southwestern Ethiopia from February 2018 to June 2019. We use hospitals in clusters as the units of randomization. The sample size includes four per intervention arm and control arm, with each cluster comprised of approximately 15 patients. Before intervention, all patients in the hospitals will receive tamoxifen therapy free of charge. Hormone receptor status of the breast cancer specimen will be determined before the initiation of therapy or throughout the course of therapy. The primary outcome of this trial is adherence to endocrine therapy on the basis of objective and subjective measures. Data will be collected with a prospective repeated measures approach. Analysis will be based on an intention-to-treat principle.

Results

The trial aims to provide evidence on the effectiveness of the breast nurse intervention to improve adherence to long-term endocrine therapy and answer the following research question: does the nursing intervention improve long-term treatment adherence by patients to endocrine therapy compared with those who receive usual care services?

Conclusion

These data are essential to maximize the impact of trained nurse-based interventions on adherence to endocrine (tamoxifen) therapy among patients with breast cancer on follow-up.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Eva J. Kantelhardt Travel, Accommodations, Expenses: Daiichi Sankyo Oncology Europe

Cervical Cancer in Ethiopia: The Effect of Adherence to Radiotherapy on Survival

BACKGROUND

Discontinuation of radiotherapy (RT) for cervical cancer (CC) in sub-Saharan Africa is common because of patient- and health service-related reasons. This analysis describes toxicities and the effect of adherence on survival.

MATERIALS AND METHODS

A total of 788 patients with CC (2008-2012) who received RT at Addis Ababa University Hospital were included. External beam RT without brachytherapy was performed according to local guidelines. We previously described survival and prognostic factors. Now we analyzed adherence and survival according to total doses received. Adjustment via multivariate cox regression analysis was done.

RESULTS

One-year overall survival (OS) after radical RT (n = 180) for International Federation of Gynecology and Obstetrics (FIGO) stages IIA-IIIA was 89% for discontinuation (<72 Gy) and 96% for adherence (≥72 Gy; hazard ratio [HR], 1.3; 95% confidence interval [CI], 0.5-3.3). One-year OS after nonradical RT (n = 389) for FIGO stages IIIB-IVA was 71% for discontinuation (<40 Gy) and 87% for adherence (44-50 Gy; HR, 3.1; 95% CI, 1.4-6.9). One-year OS for FIGO stages IIIB-IVB (n = 219) after one compared with two or more palliative single fractions of 10 Gy were 14% and 73% respectively (HR, 7.3; 95% CI, 3.3-16). Reasons for discontinuation were toxicities, economic background, and RT machine breakdown. Grade 1-2 late toxicities were common (e.g., 30% proctitis, 22% incontinence). Grade 3 early and late toxicities were seen in 5% and 10% respectively; no grade 4 toxicities occurred.

CONCLUSION

Patients who adhered to guideline-conforming RT had optimum survival. Better supportive care, brachytherapy to reduce toxicities, socioeconomic support, and additional radiation capacities could contribute to better adherence and survival.

IMPLICATIONS FOR PRACTICE

This study presents the effect of adherence on survival of 788 patients with cervical cancer receiving external beam radiotherapy without brachytherapy in Ethiopia. Discontinuation of planned radiotherapy according to local guidelines considerably reduced survival for all International Federation of Gynecology and Obstetrics (FIGO) stages treated (hazard ratios were 1.3, 3.1, and 7.3 for FIGO stages IIA-IIIA and IIIB-IVA and the palliative approach, respectively). Early toxicity (5% grade 3) should be treated to improve adherence. Economic difficulties and machine breakdown should also be addressed to reduce discontinuation and improve survival.

Knowledge about cervical cancer and barriers toward cervical cancer screening among HIV-positive women attending public health centers in Addis Ababa city, Ethiopia

Screening rate for cervical cancer among HIV‐infected women and among women overall is low in Ethiopia despite the high burden of the disease and HIV infection, which increases cervical cancer risk. In this paper, we assessed knowledge about cervical cancer symptoms, prevention, early detection, and treatment and barriers to screening among HIV‐positive women attending community health centers for HIV‐infection management in Addis Ababa. A cross‐sectional survey of 581 HIV‐positive women aged 21–64 years old attending 14 randomly selected community health centers without cervical cancer screening service in Addis Ababa. We used univariate analysis to calculate summary statistics for each variable considered in the analysis, binary logistic regression analysis to measure the degree of association between dependent and independent variables, and multiple regressions for covariate adjusted associations. Statistical significance for all tests was set at P < 0.05. We used thematic analysis to describe the qualitative data. Of the 581 women enrolled in the study with mean age 34.9 ± 7.7 years, 57.8% of participants had heard of cervical cancer and 23.4% were knowledgeable about the symptoms, prevention, early detection, and treatment of the disease. In multivariate analysis, higher educational attainment and employment were significantly associated with good knowledge about cervical cancer. In addition, only 10.8% of the participants ever had screening and 17% ever received recommendation for it. However, 86.2% of them were willing to be screened if free of cost. Knowledge about cervical cancer is poor and cervical cancer screening rate and provider recommendation are low among HIV‐positive women attending community health centers for management and follow‐up of their disease in Addis Ababa. These findings underscore the need to scale up health education about cervical cancer prevention and early detection among HIV‐positive women as well as among primary healthcare providers in the city.

The long-term effects of adolescent pregnancies in a community in Northern Ghana on subsequent pregnancies and births of the young mothers

Background

In Ghana, adolescents represent 22% of the total population. The rates of adolescent pregnancies are high. Of all births registered in the country in 2014, 30% were by adolescents, and 14% of adolescents aged between 15 and 19 years had begun childbearing. Pregnancies and deliveries of adolescents are accompanied by more risks as compared to older women. The aim of the study was to explore the long-term effects of adolescent pregnancies on subsequent pregnancies and births and on the socioeconomic status of the women.

Method

A cross-sectional interviewer-performed survey of a purposive sample of 400 women in one community of Northern Ghana was conducted. Relationships between the age at first pregnancy and complications such as cesarean section, preterm or stillbirth and others were explored in 143 patients using the statistical program SPSS (Statistical Package for the Social Sciences).

Result

Results show that adolescent women (<19 years at their first pregnancy) have an 80% higher risk for a cesarean section for the first and subsequent births as compared to older women (≥ 19 years). Furthermore, younger mothers have a 45% higher risk of stillbirths and a 30% increased risk of losing their baby within the first 6 weeks after birth. There was no difference in the socioeconomic status between the two age groups.

Conclusion

Adolescent pregnancies are risk factors for the outcome of subsequent pregnancies of these mothers. This study, for the first time, shows that not only the first pregnancy and birth of very young women are negatively influenced by the early pregnancy but also subsequent pregnancies and births. While this study is of a purposive sample of women in one community, the clinical relevance of this study should not only be interesting for healthcare practitioners in Northern Ghana and other African regions but also for prevention campaigns in these regions.

Abstract P2-05-12: The ASCO-recommended prognostic factors uPA/PAI-1 in a multicenter cohort study (PiA)

Introduction

The PiA-study (Prognostic assessment in routine Application, NCT 01592825) was designed as a representative cohort of breast cancer patients to estimate the proportions of traditional and modern prognostic factors. The ASCO-recommended biomarkers uPA (urokinase-type plasminogen activator) and its inhibitor PAI-1 were used for biological risk assessment particularly for intermediate risk breast cancer patients and disease-free survival of the patients after 5 yrs of follow-up (F/U) was calculated.

Material & Methods

Between 2009 and 2011, 1,074 non-metastasized, primarily operated breast cancer patients from six centers in Germany were included. From 815 patients, fresh frozen tissue was obtained and processed for central testing uPA/PAI-1 by ELISA (FEMTELLE®, Sekisui Diagnostics GmbH). Low uPA/PAI-1 status is defined by uPA and PAI-1 concentrations below the published cut-offs, high status means one or both were higher than the corresponding cut-offs. Tumor characteristics were based on local pathology. The centers had to follow the national guidelines. In low-risk patients, adjuvant chemotherapy was spared. The median F/U is 56 months (range 0-78).

Results

In the total cohort of 1,074 patients, 166 had G1- and 237 had G3-tumors. Of the 671 patients with a G2-tumor, the following were allocated to the high-risk group: node-positive (n=371), younger than 35 yrs (n=17), and triple-negative (TN) or HER2-positive (n=118). For 253 tumors of the remaining 355 patients with an intermediate risk of recurrence (pN0, G2, HR positive, HER2-negative, ≥35 yrs), uPA/PAI-1 status was available. 126 (49.8%) were allocated to the low-risk group, one patient had a recurrence. At 5 yrs, in the total cohort 90.6% (95% CI, 89.5-91.7) of the patients were free of invasive disease. Of 114 HER2-positive tumors, 94 (82.4 %) had a high uPA/PAI-1 status, only one of the 38 HR negative/HER2 positive tumors had a low uPA/PAI-1 status. In the TN group, the majority of tumors had a high uPA/PAI-1 status (66 of 81; 81.5 %). In 30 patients lymph nodes were involved, 18.5% (n=15) had a low uPA/PAI-1 status, one event was detected. In N pos. patients with an high uPA/PAI-1 6 events were observed.

Conclusion

Testing for uPA/PAI-1 in the daily routine is feasible, fresh frozen tissue has been prepared from 76% of the tumors of the recruited patients, 37% of them had a low risk status. Using uPA/PAI-1, about half of the node-negative patients with an intermediate risk of recurrence were allocated to a group with an extremely low risk of recurrence and thus chemotherapy could be spared. Also in node-positive disease, uPA/PAI-1 has a prognostic impact.

Tab 1: Proportion of the subgroups according to IHC, grading and uPA/PAI-1-statusTumor typetotallow uPA/PAI-1 statushigh uPA/PAI-1 statusn=815 (100%)n=304 (37%)n=511 (63%)Luminal A-like tumors:HRpos., HER2neg., G1, G2515 (63.2%)240 (78.9%)275 (53.9%)Luminal B/HER2-negative-like tumors:HRpos., HER2neg., G3104 (12.8%)29 (9.5%)75 (14.7%)Luminal B/HER2-positive-like tumors:HR pos., HER2 pos., all grades77 (9.4%)19 (6.2%)58 (11.4%)HER2-positive (nonluminal) - like tumors:HRneg., HER2pos., all grades38 (4.7%)1 (0.3%)37 (7.3%)TN tumors:HRneg., HER2neg., all grades81 (9.9%)15 (4.9%)66 (12.9%)

Citation Format: Vetter M, Hartung C, Hanf V, Lantzsch T, Uleer C, Peschel S, John J, Buchmann J, Bürrig K-F, Weigert E, Thomssen C, Kantelhardt EJ. The ASCO-recommended prognostic factors uPA/PAI-1 in a multicenter cohort study (PiA) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-12.

Mutant p53 promotes tumor progression and metastasis by the endoplasmic reticulum UDPase ENTPD5

Mutations in the p53 tumor suppressor gene are the most frequent genetic alteration in cancer and are often associated with progression from benign to invasive stages with metastatic potential. Mutations inactivate tumor suppression by p53, and some endow the protein with novel gain of function (GOF) properties that actively promote tumor progression and metastasis. By comparative gene expression profiling of p53-mutated and p53-depleted cancer cells, we identified ectonucleoside triphosphate diphosphohydrolase 5 (ENTPD5) as a mutant p53 target gene, which functions as a uridine 5'-diphosphatase (UDPase) in the endoplasmic reticulum (ER) to promote the folding of N-glycosylated membrane proteins. A comprehensive pan-cancer analysis revealed a highly significant correlation between p53 GOF mutations and ENTPD5 expression. Mechanistically, mutp53 is recruited by Sp1 to the ENTPD5 core promoter to induce its expression. We show ENTPD5 to be a mediator of mutant p53 GOF activity in clonogenic growth, architectural tissue remodeling, migration, invasion, and lung colonization in an experimental metastasis mouse model. Our study reveals folding of N-glycosylated membrane proteins in the ER as a mechanism underlying the metastatic progression of tumors with mutp53 that could provide new possibilities for cancer treatment.

A Review on Breast Cancer Care in Africa

BACKGROUND

The global incidence of breast cancer (BC) is rising, especially in low- and middle-income countries. The purpose of this review is to summarize existing publications on BC care in Africa.

PATIENTS AND METHODS

A systematic search in MEDLINE and smaller databases was carried out to identify African studies on BC treatment, and an additional PubMed search was performed for relevant topics on BC care.

RESULTS

A total of 219 publications, mainly from North and West Africa, were found by systematic search. We also selected articles on BC epidemiology, risk factors, clinical presentation, and cancer control in Africa.

CONCLUSIONS

Publications on BC treatment are mostly from hospital case series. Evidence on treatment from prospective randomized trials that address the specific characteristics of African patients is lacking. The epidemiologic data shows rising incidences in Africa. The prevalence of risk factors is changing by age group, geographic region, and over time. The clinical picture of BC differs from that of Western countries due to the high proportion of young patients (on account of the African population with a high proportion of young people) and late presentation. Global collaborative efforts are needed to address the rising need for improved BC care in Africa.