The Mutographs biorepository: A unique genomic resource to study cancer around the world

Large-scale biorepositories and databases are essential to generate equitable, effective, and sustainable advances in cancer prevention, early detection, cancer therapy, cancer care, and surveillance. The Mutographs project has created a large genomic dataset and biorepository of over 7,800 cancer cases from 30 countries across five continents with extensive demographic, lifestyle, environmental, and clinical information. Whole-genome sequencing is being finalized for over 4,000 cases, with the primary goal of understanding the causes of cancer at eight anatomic sites. Genomic, exposure, and clinical data will be publicly available through the International Cancer Genome Consortium Accelerating Research in Genomic Oncology platform. The Mutographs sample and metadata biorepository constitutes a legacy resource for new projects and collaborations aiming to increase our current research efforts in cancer genomic epidemiology globally.

The contribution of smoking and smokeless tobacco to oesophageal squamous cell carcinoma risk in the African oesophageal cancer corridor: Results from the ESCCAPE multicentre case-control studies

Tobacco use is a well-established risk factor for oesophageal squamous cell carcinoma (ESCC) but the extent of its contribution to the disease burden in the African oesophageal cancer corridor has not been comprehensively elucidated, including by type of tobacco use. We investigated the contribution of tobacco use (smoking and smokeless) to ESCC in Tanzania, Malawi and Kenya. Hospital-based ESCC case-control studies were conducted in the three countries. Incident cases and controls were interviewed using a comprehensive questionnaire which included questions on tobacco smoking and smokeless tobacco use. Logistic regression models were used to estimate odds ratios (OR) and their 95% confidence intervals (CI) of ESCC associated with tobacco, adjusted for age, sex, alcohol use, religion, education and area of residence. One thousand two hundred seventy-nine cases and 1345 controls were recruited between August 5, 2013, and May 24, 2020. Ever-tobacco use was associated with increased ESCC risk in all countries: Tanzania (OR 3.09, 95%CI 1.83-5.23), and in Malawi (OR 2.45, 95%CI 1.80-3.33) and lesser in Kenya (OR 1.37, 95%CI 0.94-2.00). Exclusive smokeless tobacco use was positively associated with ESCC risk, in Tanzania, Malawi and Kenya combined (OR 1.92, 95%CI 1.26-2.92). ESCC risk increased with tobacco smoking intensity and duration of smoking. Tobacco use is an important risk factor of ESCC in Tanzania, Malawi and Kenya. Our study provides evidence that smoking and smokeless tobacco cessation are imperative in reducing ESCC risk.

Alcohol consumption and oesophageal squamous cell cancer risk in east Africa: findings from the large multicentre ESCCAPE case-control study in Kenya, Tanzania, and Malawi

BACKGROUND

The contribution of alcohol to the large burden of oesophageal squamous cell carcinoma (ESCC) in east Africa remains uncertain and difficult to assess owing to complex consumption patterns of traditional and commercial drinks. We aimed to assess whether alcohol drinking, overall and at specific intake levels, contributes to ESCC risk in east Africa.

METHODS

We did a hospital-based case-control study in Kenya, Tanzania, and Malawi, which included comprehensive assessment of a variety of locally consumed alcohol that we used to classify drinkers as exclusively low alcohol-by-volume (ABV; <30% ABV) drinkers or drinkers of some high-ABV drinks, as well as the number of drinks consumed, average weekly ethanol intake, and the contribution of each drink type to overall ethanol consumption. Cases were patients aged 18 years and older with incident primary ESCC, confirmed histologically for the majority of cases, and a clinical diagnosis for the remainder. Controls were frequency-matched on age and sex in a 1:1 ratio with cases. The controls were recruited from the same hospitals as cases and included outpatients, inpatients, and hospital visitors who did not have cancer or any other digestive disease. Consenting participants took part in face-to-face interviews in which they were asked whether they had ever consumed alcohol (the primary exposure variable); those who had were asked follow-up questions about their consumption habits for different alcoholic drinks.

FINDINGS

1279 cases and 1346 controls were recruited between Aug 5, 2013, and May 24, 2020, including 430 cases and 440 controls from Kenya, 310 cases and 313 controls from Tanzania, and 539 cases and 593 controls from Malawi. 65 (4·8%) of 1344 cases were excluded. Consistent positive associations with ESCC risk were found for ever having consumed alcohol in Kenyan men and Tanzanian men, and for daily number of drinks and estimated ethanol intake in Kenya, Tanzania (both sexes) and Malawian women. Corresponding population-attributable fractions of ESCC for those reporting ever drinking alcohol (vs never drinking) were 65% (95% CI 52-78) in Kenyan men and 23% (<1-45) in Kenyan women, and 56% (95% CI 36-76) in Tanzanian men and 5% (0-42) in Tanzanian women. Increased risk and population-attributable fractions were almost entirely due to risks in high-ABV drinkers.

INTERPRETATION

Alcohol appears to be a substantial contributor to ESCC risk in east Africa, particularly among men, and a large fraction of ESCC could be prevented by cessation or reduction of alcohol consumption. Future studies should consider independent ascertainment of alcohol intake to assess the potential of under-reporting in Malawi.

FUNDING

US National Cancer Institute, Wereld Kanker Onderzoek Fonds, and the IARC Environment and Lifestyle Epidemiology Branch.

TRANSLATIONS

For the Swahili and Chichewa translations of the abstract see Supplementary Materials section.

Mutational signatures in esophageal squamous cell carcinoma from eight countries with varying incidence

Esophageal squamous cell carcinoma (ESCC) shows remarkable variation in incidence that is not fully explained by known lifestyle and environmental risk factors. It has been speculated that an unknown exogenous exposure(s) could be responsible. Here we combine the fields of mutational signature analysis with cancer epidemiology to study 552 ESCC genomes from eight countries with varying incidence rates. Mutational profiles were similar across all countries studied. Associations between specific mutational signatures and ESCC risk factors were identified for tobacco, alcohol, opium and germline variants, with modest impacts on mutation burden. We find no evidence of a mutational signature indicative of an exogenous exposure capable of explaining differences in ESCC incidence. Apolipoprotein B mRNA-editing enzyme, catalytic polypeptide-like (APOBEC)-associated mutational signatures single-base substitution (SBS)2 and SBS13 were present in 88% and 91% of cases, respectively, and accounted for 25% of the mutation burden on average, indicating that APOBEC activation is a crucial step in ESCC tumor development.

Distribution of variations in anatomy of the circle of Willis: results of a cadaveric study of the Malawian population and review of literature

Introduction

the circle of Willis is an anatomical structure of clinical importance particularly in the evaluation of neurovascular diseases. Individuals show considerable variations in the anatomical configuration of the circle of Willis. A cross-sectional study was conducted to determine the distribution of morphological variations of the circle of Willis in Malawians and compare with other ethnic groups.

Methods

brains were collected from twenty-four recently deceased black Malawians during autopsy at Queen Elizabeth Central Hospital, a referral teaching hospital in Blantyre, Malawi and fixed in 10% buffered formalin. Digital images of the interpeduncular region (exposing the circle of Willis) were taken with an 18.4 megapixels camera from the base of the brain. Whole-circle and segmental parameters of the circle of Willis were assessed using the Osiris computer programme and classified based on a 22-type classification scheme.

Results

the following morphological variations were observed: hypoplasia, aplasia, asymmetry and accessory vessels. Typical circle of Willis was seen in 26% of the cases. Only six of the original twenty-two types were observed. Consistent with most previous studies, types 1, 3, 4, 6, 8 and 9 were common while types 10-22 were rare. Three variants not previously described in the original scheme (unilateral PcoA aplasia, AcoA duplication, and PcoA aplasia with contralateral PcoA hypoplasia) were observed in this study.

Conclusion

anatomical variations of the circle of Willis in Malawians seem to be distributed in similar frequencies and patterns as in other more-diverse populations. Circle of Willis variants with potential predilection for atherogenesis and aneurysm formation exist in the Malawian population. These should be considered in clinical practice.

Anatomical variations and morphometric properties of the circulus arteriosus cerebri in a cadaveric Malawian population

BACKGROUND

Knowledge of the anatomy of the circulus arteriosus cerebri (CAC) is important in understanding its role as an arterial anastomotic structure involved in collateral perfusion and equalisation of pressure, and may explain observed variations in neurovascular disease prevalences across populations. This study was aimed at understanding the anatomical configuration and morphometric properties of the CAC in Malawian population.

MATERIALS AND METHODS

Brains were collected from 24 recently-deceased black Malawian human cadavers during medico-legal autopsies. Photographs of the CACs were taken using a camera placed at a 30 cm height from the base of the brain. Whole-circle properties and segmental vessel parameters were analysed using the OSIRIS computer programme, paying attention to completeness, typicality, symmetry, and segmental vessel diameters and lengths.

RESULTS

The complete-circle configuration was found in 69.57% of the CACs. Of these, 37.5% were typical, representing an overall typicality prevalence of 26.09%. Vessel asymmetry was observed in 30.43% of cases. There were 7 cases of vessel aplasia and 12 cases of vessel hypoplasia. The posterior communicating artery (PcoA) was the most variable (with 12 variations), widest (7.67 mm) and longest (27.7 mm) vessel while the anterior communicating artery (AcoA) was the shortest (0.78 mm). Both the AcoA and the PcoA were the narrowest vessels (0.67 mm) in this study. CAC variations in Malawian populations appeared to be similar to those observed in diverse populations.

CONCLUSIONS

Anatomical variations of the CAC exist in Malawian population and should be taken into consideration in clinical practice.

Breast cancer pathology services in sub-Saharan Africa: a survey within population-based cancer registries

BACKGROUND

Pathologists face major challenges in breast cancer diagnostics in sub-Saharan Africa (SSA). The major problems identified as impairing the quality of pathology reports are shortcomings of equipment, organization and insufficiently qualified personnel. In addition, in the context of breast cancer, immunohistochemistry (IHC) needs to be available for the evaluation of biomarkers. In the study presented, we aim to describe the current state of breast cancer pathology in order to highlight the unmet needs.

METHODS

We obtained information on breast cancer pathology services within population-based cancer registries in SSA. A survey of 20 participating pathology centres was carried out. These centres represent large, rather well-equipped pathologies. The data obtained were related to the known population and breast cancer incidence of the registry areas.

RESULTS

The responding pathologists served populations of between 30,000 and 1.8 million and the centres surveyed dealt with 10-386 breast cancer cases per year. Time to fixation and formalin fixation time varied from overnight to more than 72 h. Only five centres processed core needle biopsies as a daily routine. Technical problems were common, with 14 centres reporting temporary power outages and 18 centres claiming to own faulty equipment with no access to technical support. Only half of the centres carried out IHC in their own laboratory. For three centres, IHC was only accessible outside of the country and one centre could not obtain any IHC results. A tumour board was established in 13 centres.

CONCLUSIONS

We conclude that breast cancer pathology services ensuring state-of-the-art therapy are only available in a small fraction of centres in SSA. To overcome these limitations, many of the centres require larger numbers of experienced pathologists and technical staff. Furthermore, equipment maintenance, standardization of processing guidelines and establishment of an IHC service are needed to comply with international standards of breast cancer pathology.

Frequent HIV and Young Age Among Individuals With Diverse Cancers at a National Teaching Hospital in Malawi

Purpose

Cancer surveillance provides a critical evidence base to guide cancer control efforts, yet population-based coverage in Africa is sparse. Hospital-based registries may help fill this need by providing local epidemiologic data to guide policy and forecast local health care needs. We report the epidemiology of patients with cancer recorded by a de novo hospital-based cancer registry at Kamuzu Central Hospital, Malawi, the sole provider of comprehensive oncology services for half the country and location of a high-volume pathology laboratory.

Methods

We conducted active case finding across all hospital departments and the pathology laboratory from June 2014 to March 2016. Patient demographics, tumor characteristics, treatment, and HIV status were collected. We describe epidemiology of the cancer caseload, registry design, and costs associated with registry operations.

Results

Among 1,446 registered patients, Kaposi sarcoma and cervical cancer were the most common cancers among men and women, respectively. Burkitt lymphoma was most common cancer among children. The current rate of pathology confirmation is 65%, a vast improvement in the diagnostic capacity for cancer through the hospital’s pathology laboratory. Among leading cancer types, an alarming proportion occurred at young ages; 50% of Kaposi sarcoma and 25% of esophageal, breast, and cervical cancers were diagnosed among those younger than 40 years of age. A systematic, cross-sectional assessment of HIV status reveals a prevalence of 58% among adults and 18% among children.

Conclusion

We report a high caseload among typically young patients and a significant burden of HIV infection among patients with cancer. In low- and middle-income countries with intermittent, sparse, or nonexistent cancer surveillance, hospital-based cancer registries can provide important local epidemiologic data while efforts to expand population-based registration continue.

High Cancer Burden Among Antiretroviral Therapy Users in Malawi: A Record Linkage Study of Observational Human Immunodeficiency Virus Cohorts and Cancer Registry Data

BACKGROUND

With antiretroviral therapy (ART), AIDS-defining cancer incidence has declined and non-AIDS-defining cancers (NADCs) are now more frequent among human immunodeficiency virus (HIV)-infected populations in high-income countries. In sub-Saharan Africa, limited epidemiological data describe cancer burden among ART users.

METHODS

We used probabilistic algorithms to link cases from the population-based cancer registry with electronic medical records supporting ART delivery in Malawi's 2 largest HIV cohorts from 2000-2010. Age-adjusted cancer incidence rates (IRs) and 95% confidence intervals were estimated by cancer site, early vs late incidence periods (4-24 and >24 months after ART start), and World Health Organization (WHO) stage among naive ART initiators enrolled for at least 90 days.

RESULTS

We identified 4346 cancers among 28 576 persons. Most people initiated ART at advanced WHO stages 3 or 4 (60%); 12% of patients had prevalent malignancies at ART initiation, which were predominantly AIDS-defining eligibility criteria for initiating ART. Kaposi sarcoma (KS) had the highest IR (634.7 per 100 000 person-years) followed by cervical cancer (36.6). KS incidence was highest during the early period 4-24 months after ART initiation. NADCs accounted for 6% of new cancers.

CONCLUSIONS

Under historical ART guidelines, NADCs were observed at low rates and were eclipsed by high KS and cervical cancer burden. Cancer burden among Malawian ART users does not yet mirror that in high-income countries. Integrated cancer screening and management in HIV clinics, especially for KS and cervical cancer, remain important priorities in the current Malawi context.

The African Esophageal Cancer Consortium: A Call to Action

Esophageal cancer is the eighth most common cancer worldwide and the sixth most common cause of cancer-related death; however, worldwide incidence and mortality rates do not reflect the geographic variations in the occurrence of this disease. In recent years, increased attention has been focused on the high incidence of esophageal squamous cell carcinoma (ESCC) throughout the eastern corridor of Africa, extending from Ethiopia to South Africa. Nascent investigations are underway at a number of sites throughout the region in an effort to improve our understanding of the etiology behind the high incidence of ESCC in this region. In 2017, these sites established the African Esophageal Cancer Consortium. Here, we summarize the priorities of this newly established consortium: to implement coordinated multisite investigations into etiology and identify targets for primary prevention; to address the impact of the clinical burden of ESCC via capacity building and shared resources in treatment and palliative care; and to heighten awareness of ESCC among physicians, at-risk populations, policy makers, and funding agencies.

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

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

Characterising cancer burden and quality of care at two palliative care clinics in Malawi

BACKGROUND

This paper describes cancer burden and compares characteristics of cancer patients enrolled at 2 palliative care facilities of contrasting resources and geographical locations in Malawi. It also assesses the extent of differences in service delivery and the impact these might have on outcomes.

METHODS

Data on all cancer patients registered between October 2010 and October 2015 at Tiyanjane Clinic (at Queen Elizabeth Central Hospital, Blantyre) and Mzuzu Central Hospital (MCH) palliative care clinics were extracted and analysed. Key informant in-depth interviews were carried out at both sites. Thematic analysis was used for qualitative data and Excel 2010 and Stata 12 were used for analysis of quantitative data.

RESULTS

Quantitative: There were 1362 and 633 cancer patients at Tiyanjane and MCH, respectively. Overall, females predominated over males (55.8% vs 42.8%); however, Tiyanjane had more males (52.2% vs 45.8%), which was contrary to Mzuzu (77.4% females vs 22.6% males). The 35- to 54-year age group was predominant at both Tiyanjane (43.1%) and Mzuzu (40.1%).Overall, the most common cancers were Kaposi's sarcoma (26.9%), cervical cancer (26.8%), oesophageal cancer (14.2%), hepatocellular carcinoma (4.9%), and bladder cancer (3.0%). Histologically confirmed diagnoses accounted for 13% of cases at Tiyanjane, whereas all patients from MCH were diagnosed clinically. Qualitative: Palliative care services were free of charge at both facilities, and owing to the expansion of services to district hospitals, the workload at central hospitals had been reduced. Between the 2 sites, there were differences in follow-up procedures, drug availabilities, as well as human resource capacity, with Mzuzu palliative care facility facing more extensive challenges.

CONCLUSIONS

The characteristics of patients seen at each site varied according to services available. Quality of care was assessed as superior at Tiyanjane, demonstrating the importance of multiple stakeholder involvement in the delivery of palliative care services.

Leveraging HIV Research and Implementation for Cancer and Noncommunicable Diseases in Malawi

Abstract 33

Background:

Enabled by collaboration and political stability, Malawi is a global leader for HIV research and implementation. We undertook this work to identify ways to leverage successes in HIV treatment and research for cancer and noncommunicable diseases (NCDs).

Methods:

Over more than two decades, investment from the National Institutes of Health (NIH) and other funders has allowed Malawi participation in international HIV networks. As these sought to address HIV-positive cancer, investment occurred to increase pathology, improve cancer registration, scale up cervical cancer screening, and improve nursing and pharmacy skills for chemotherapy administration. This allowed Malawi to participate in multinational clinical trials for HIV-positive Kaposi sarcoma treatment and cervical cancer prevention. Building on this, Malawi was one of six countries in 2014 to receive an NIH U54 consortium award for HIV-positive malignancies and was one of six countries added to the National Cancer Institute (NCI) AIDS Malignancy Consortium. In 2016, expanding beyond HIV-positive cancer, Malawi was one of three countries invited to join a new NCI–International Agency for Research on Cancer esophageal cancer consortium, one of five recipients of a new NCI Burkitt lymphoma award, and one of six recipients of a new NCI P20 grant for a regional center of research excellence for NCDs. Malawi is also one of 11 countries to convene a Lancet noncommunicable diseases and injury poverty commission for NCDs and injury. Finally, partners have improved surveillance and treatment for hypertension, diabetes, injury, and sickle cell anemia, in part, through a national Knowledge Translation Platform for HIV-NCD integration. With this support and funding, career development opportunities are embedded for Malawian NCD researchers.

Results:

Building on successes in HIV treatment and research, Malawi has become a global leader for cancer and NCD research and implementation.

Conclusion:

Continue developing a multilateral national platform for NCD research and implementation that is globally impactful and can lead to measurable outputs for individual cancer and NCD focus areas. Funding: National Institutes of Health.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.

Historical Evolution of the Malawi National Cancer Registry: A Collaborative Effort to Develop and Sustain an Impactful Cancer Control Resource in a Low-Income Country

Abstract 26

Background:

Population-based cancer registration is essential to inform cancer control, yet high-quality cancer registration is absent in much of Africa. We undertook this work to initiate and sustain the Malawi National Cancer Registry (MNCR) to: collect high-quality, population-based cancer data to describe the national burden; inform national cancer control programs and policies; provide a rich national resource for epidemiologic cancer research; and develop collaborations with other partners to increase MNCR impact.

Methods:

MNCR began in 1989 as a hospital-based pathology registry in Blantyre, Malawi. A population-based component was introduced in 1993 that initially covered the Blantyre district with active case finding. By using this platform, regular national surveys were initiated in 2005 and are carried out every 5 years. Building on this surveillance program, MNCR has pursued collaborations with the Malawi HIV unit to conduct a national HIV-Cancer Match Study to assess the evolving cancer burden in the antiretroviral scale-up era. MNCR has also collaborated with other regional registries through the African Cancer Registry Network.

Results:

MNCR has published descriptions of the cancer burden in Malawi and is one of few African data sources to contribute to the WHO’s Cancer Incidence in Five Continents. Kaposi sarcoma and cervical cancer are the most common cancers in men and women, respectively. Approximately 93,000 records from MNCR and the two largest HIV cohorts in Malawi have been linked, with preliminary data demonstrating 3,499 cancers among 15,920 antiretroviral initiators in Lilongwe. MNCR has also contributed to regional studies that have described the high incidence and young age for esophageal cancer in Africa.

Conclusion:

We must continue to improve the quality and coverage of population-based cancer registration throughout Malawi, update the HIV-cancer record linkage at regular intervals, and pursue further opportunities for collaboration.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.

Informing etiologic research priorities for squamous cell esophageal cancer in Africa: A review of setting-specific exposures to known and putative risk factors

Esophageal squamous cell carcinoma (ESCC) is one of the most common cancers in most Eastern and Southern African countries, but its etiology has been understudied to date. To inform its research agenda, we undertook a review to identify, of the ESCC risk factors which have been established or strongly suggested worldwide, those with a high prevalence or high exposure levels in any ESCC-affected African setting and the sources thereof. We found that for almost all ESCC risk factors known to date, including tobacco, alcohol, hot beverage consumption, nitrosamines and both inhaled and ingested PAHs, there is evidence of population groups with raised exposures, the sources of which vary greatly between cultures across the ESCC corridor. Research encompassing these risk factors is warranted and is likely to identify primary prevention strategies.

The dynamics of adult neurogenesis in human hippocampus

The phenomenon of adult neurogenesis is now an accepted occurrence in mammals and also in humans. At least two discrete places house stem cells for generation of neurons in adult brain. These are olfactory system and the hippocampus. In animals, newly generated neurons have been directly or indirectly demonstrated to generate a significant amount of new neurons to have a functional role. However, the data in humans on the extent of this process is still scanty and such as difficult to comprehend its functional role in humans. This paper explores the available data on as extent of adult hippocampal neurogenesis in humans and makes comparison to animal data.

The Malawi Cancer Consortium – Catalyzing Cancer Care and Research in Southern Africa

Abstract 68

Background:

Cancer burden is increasing in Malawi, particularly for HIV-associated malignancies.

Methods:

With support from the National Cancer Institute, the Malawi Cancer Consortium (MCC) was initiated in September 2014. Partners include the UNC Lineberger Comprehensive Cancer Center, Malawi Ministry of Health, University of Malawi College of Medicine, and Lighthouse Trust. Spanning Malawi’s two major cities, Lilongwe and Blantyre, MCC includes three support cores (administration, analysis, mentoring) and three multi-institution research projects: (1) a national HIV-cancer match study to assess cancer incidence in the ART era; (2) a longitudinal cohort to identify clinical and molecular correlates of KS chemotherapy response; and (3) a longitudinal cohort to elucidate lymphoma biology and develop better treatments for HIV-associated lymphoma.

Results:

For project 1, 65,500 records from the Malawi National Cancer Registry and Malawi HIV cohorts have been abstracted, and initial data harmonization completed. Record linkage is planned for February 2016, will be updated at regular intervals, and will contribute to regional analyses through the IeDEA- Southern Africa network. For project 2, KS studies through MCC have led to descriptions of KS biologic subtypes defined by viral gene expression profiling, and detailed characterization of multicentric Castleman disease. Malawi has also led enrollment into multinational phase III KS clinical trials implemented by the AIDS Clinical Trials Group and AIDS Malignancy Consortium. For project 3, more than 300 adults and children with lymphoma have been enrolled since June 2014, with approximately 2/3 of adults being HIV-infected. Patients receive standardized treatment and supportive care, and standardized clinical and laboratory evaluations. Specimen-based correlative studies (virologic, genomic, biomarker studies) are ongoing. Finally, the consortium provides a platform for pilot studies in breast and esophageal cancer, and facilitates career development for Malawian cancer investigators.

Conclusions:

MCC has initiated a national coalition to address cancer in Malawi, and continued progress is anticipated.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST:

Sam Phiri No relationship to disclose Joe Gumulira No relationship to disclose Hannock Tweya No relationship to disclose Lameck Chinula No relationship to disclose Agnes Moses No relationship to disclose Bongani Kaimila No relationship to disclose Christopher Stanley No relationship to disclose Edwards Kasonkanji No relationship to disclose Steady Chasimpha No relationship to disclose Richard Nyasosela No relationship to disclose Leo Masamba No relationship to disclose Tamiwe Tomoka No relationship to disclose Steve Kamiza No relationship to disclose Mina Hosseinipour No relationship to disclose Nora Rosenberg Research Funding: NIH/NCI Ron Mataya No relationship to disclose Charles Dzamalala No relationship to disclose George Liomba No relationship to disclose Irving Hoffman No relationship to disclose Dirk Dittmer No relationship to disclose Yuri Fedoriw Honoraria: Alexion Pharmaceuticals Blossom Damania No relationship to disclose Satish Gopal No relationship to disclose

Quantitative Assessment of Multiorgan Sequestration of Parasites in Fatal Pediatric Cerebral Malaria

Children in sub-Saharan Africa continue to acquire and die from cerebral malaria, despite efforts to control or eliminate the causative agent, Plasmodium falciparum. We present a quantitative histopathological assessment of the sequestration of parasitized erythrocytes in multiple organs obtained during a prospective series of 103 autopsies performed between 1996 and 2010 in Blantyre, Malawi, on pediatric patients who died from cerebral malaria and controls. After the brain, sequestration of parasites was most intense in the gastrointestinal tract, both in patients with cerebral malaria and those with parasitemia in other organs. Within cases of histologically defined cerebral malaria, which includes phenotypes termed "sequestration only" (CM1) and "sequestration with extravascular pathology" (CM2), CM1 was associated with large parasite numbers in the spleen and CM2 with intense parasite sequestration in the skin. A striking histological finding overall was the marked sequestration of parasitized erythrocytes across most organs in patients with fatal cerebral malaria, supporting the hypothesis that the disease is, in part, a result of a high level of total-body parasite sequestration.

The systemic pathology of cerebral malaria in African children

Pediatric cerebral malaria carries a high mortality rate in sub-Saharan Africa. We present our systematic analysis of the descriptive and quantitative histopathology of all organs sampled from a series of 103 autopsies performed between 1996 and 2010 in Blantyre, Malawi on pediatric cerebral malaria patients and control patients (without coma, or without malaria infection) who were clinically well characterized prior to death. We found brain swelling in all cerebral malaria patients and the majority of controls. The histopathology in patients with sequestration of parasites in the brain demonstrated two patterns: (a) the “classic” appearance (i.e., ring hemorrhages, dense sequestration, and extra-erythrocytic pigment) which was associated with evidence of systemic activation of coagulation and (b) the “sequestration only” appearance associated with shorter duration of illness and higher total burden of parasites in all organs including the spleen. Sequestration of parasites was most intense in the gastrointestinal tract in all parasitemic patients (those with cerebral malarial and those without).

Burden of cancer in Malawi; common types, incidence and trends: national population-based cancer registry

Background

Cancer is a leading cause of morbidity and mortality worldwide with a majority of cases and deaths occurring in developing countries. While cancer of the lung, breast, colorectum, stomach and prostate are the most common types of cancer globally, in east and southern Africa these are less common and comprehensive data to inform policies are lacking.

Methods

Nationwide cancer registry was conducted between September and October 2010 in Malawi. New cancer cases registered from 2007 to 2010 were identified from hospital and clinic registers of 81 out of 84 health facilities providing cancer diagnosis, treatment or palliative care services. Demographic and cancer data were extracted from registers and case notes using a standard form.

Results

A total of 18,946 new cases of cancer were registered in Malawi from 2007-2010. Of these 55.9% were females, 7.2% were children aged less than 15 years, 76.5% were adults aged 15-59 years and 16.4% were elderly aged 60 years or more. Only 17.9% of the cases had histologically verified diagnosis, 33.2% were diagnosed clinically and 49.6% based on clinical and some investigations. Amongst females, cancer of the cervix was the commonest accounting for 45.4% of all cases followed by Kaposi sarcoma (21.1%), cancer of the oesophagus (8.2%), breast (4.6%) and non-Hodgkin lymphoma (4.1%). In males, Kaposi sarcoma was the most frequent (50.7%) then cancer of oesophagus (16.9%), non-Hodgkin lymphoma (7.8), prostate (4.0%) and urinary bladder (3.7%). Age-standardised incidence rate per 100,000 population for all types of cancer in males increased from 31 in 1999-2002 to 56 in 2007-2010. In females it increased from 29 to 69. Kaposi sarcoma and cancer of the oesophagus, cervical cancer and Kaposi sarcoma were the main causes for the increased incidence in males and females respectively. It was estimated that, annually at least 8,151 new cases of cancer (all types) occur in Malawi.

Conclusions

This study provided data on common types and trends of cancer that could be used to focus prevention, treatment and control interventions in the context of limited resources. The problem of under-reporting and misdiagnosis of cancer cases has been highlighted.

Oesophageal cancer and Kaposi's sarcoma in Malawi: a comparative analysis

Given that oesophageal cancer (OC) is common in Malawi and its outcome is so dismal, would it be pragmatic to promptly mitigate the effects of smoking, alcohol and aflatoxins rather than seek a higher degree of local evidence for their role in OC? We retrospectively analysed a total of 13,217 OC and Kaposi's sarcoma (KS) cases as recorded in the Malawi National Cancer Registry from 1985 to February, 2006. We found no OC clustering to suggest a role for culturally variable habits like smoking, alcohol, maize use and maize storage in the country. It may be that drinking and eating hot foods physically damages the oesophageal mucosa, this is in line with work recently reported from Asia. We also found that OC numbers have risen in line with KS (and HIV) suggesting a link between these conditions.

The need for a national cancer policy in Malawi

Cancer is causing a lot of suffering and death in Africa but is not considered a major health problem in Africa. This needs to change. Cancer should be given equal emphasis to HIV/AIDS, tuberculosis (TB) and Malaria. A national cancer policy is required in Malawi to develop and improve evidence-based cancer prevention, early diagnosis, curative and palliative therapy. A national cancer policy is crucial to ensure a priotised, clear, coordinated and sustained fight against cancer. When no policy exists, events are likely to be random, stakeholders and practitioners in the fight against cancer may not agree on how to proceed, may duplicate efforts or may neglect areas that would have greater nationwide impact resulting in poor quality activities and haphazard development.

ABO blood group phenotypes influence parity specific immunity to Plasmodium falciparum malaria in Malawian women

Background

Blood group O has been significantly associated with increased placental malaria infection in primiparae and reduced risk of infection in multiparae in the Gambia, an area with markedly seasonal malaria transmission. This study analyses the association between ABO blood group phenotypes in relation to placental malaria pathology and birth outcomes in southern Malawi, an area with perennial malaria transmission.

Methods

A cross-sectional study of 647 mother/child pairs delivering in Montfort Hospital, Chikwawa District between February-June 2004 and January-July 2005 was undertaken. Maternal peripheral and cord blood samples were obtained at delivery. Placental tissue was obtained and malaria histology classified as active, past or no malaria infection. Birth anthropometry was recorded. ABO blood group was measured by agglutination.

Results

In primiparae, blood group O was significantly associated with increased risk of active placental infection (OR 2.18, 95% CI 1.15–4.6, p = 0.02) and an increased foetal-placental weight ratio compared to non-O phenotypes (5.68 versus 5.45, p = 0.03) In multiparae blood group O was significantly associated with less frequent active placental infection (OR 0.59, 95% CI 0.36–0.98, p = 0.04), and a higher newborn ponderal index compared to non-O phenotypes (2.65 versus 2.55, p = 0.007). In multivariate regression parity was independently associated with increased risk of placental malaria (active andpast infection) in primiparae with blood group O (p = 0.034) and reduced risk in multiparae with the same phenotype (p = 0.015).

Conclusion

Parity related susceptibility to placental malaria is associated with the mothers ABO phenotype. This interaction influences foetal and placental growth and could be an important modifying factor for pregnancy outcomes. The biological explanation could relate to sialic acid dependent placental membrane differences which vary with ABO blood group.

Etiology and incidence of chronic ulcers in Blantyre, Malawi

BACKGROUND

Little information is available on the incidence and etiology of chronic ulcers in the tropics. Therefore, the incidence and etiology of chronic skin ulcers were assessed in out-patients at the Department of Dermatology and in in-patients at the Departments of Dermatology, Surgery, Medicine, and Pediatrics, Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi.

METHOD

In a 10-week study period, 44 patients (31 males, 70%) with chronic skin ulcers were diagnosed from 6292 patients seen by the departments involved.

RESULTS

The mean age of patients with ulcers was 38 years (range, 9 months to 82 years). The most frequent cause of ulcers was bacterial infection (n=22), followed by malignancy (n=11) and trauma (n=7).

CONCLUSION

In contrast with developed countries, venous and diabetic ulcers were uncommon. In addition to bacterial infections, a surprisingly large number of malignancies were found in this study. We speculate that human immunodeficiency virus (HIV) infection, which is seen with a high prevalence at QECH, is a contributing factor. Because of the large number of malignancies, we recommend early histopathologic investigation of chronic ulcers in this part of Africa.