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No Patients to Resect or Transplant: An Analysis of Patients with Hepatocellular Carcinoma Admitted to a Major African Referral Hospital
Abstract
Background:
This study aimed to describe the characteristics of patients diagnosed with hepatocellular carcinoma (HCC) at the Komfo Anokye Teaching Hospital (KATH) in Ghana and to determine their treatment options per the Barcelona Clinic Liver Cancer (BCLC) algorithm.
Methods:
We reviewed the medical records of patients diagnosed with HCC at KATH in the period 2007-2013. Patient demographics, medical history, investigations, management, and outcome were extracted. BCLC staging was applied to determine their treatment options. Results were expressed as descriptive statistics.
Results:
The charts for 206/465 patients were available for review. The male:female ratio was 2:1 and mean age was 44.0 ± 14.5 years. Common presenting complaints were abdominal distension, abdominal pain, and jaundice. hepatitis B virus (HBV) positivity was 52 %. Almost all patients received only supportive treatment. None underwent surgery, ablation, or transarterial chemoembolization. BCLC staging could be completed for 118 patients. Using predicted INR values in cases without the result, < 8 % of patients were eligible for resection, transplantation, or ablation; 25-53 % were eligible for embolization or sorafenib therapy. Up to 72 % were eligible only for supportive care. Seventy-six percent of patients reviewed were discharged alive; 71 % of patients whose charts were not available died during an admission. Thus, of the 465-patient cohort, 50 % died in the hospital.
Conclusions:
The majority of HCC in our population is caused by HBV. Up to 61 % of patients may be eligible for curative treatment, transarterial chemoembolization, or sorafenib treatment. This percentage may be increased with a robust surveillance program for patients at increased risk for HCC. Hepatitis B vaccination must also be a public health priority.
... When HBV testing was performed, the positivity rate peaked at 80%. 21,23,25-29,31-42, 46,48,51,52,54-57,59 In 26 studies, five to 80% of HCCs occurred in non-cirrhotic livers. [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]37,42,[47][48][49][50]54,[56][57][58][59] In nine studies, five to 41% of the patients had PVTT. [25][26][27]29,31,39,42,51,57 The presence of extrahepatic metastases was documented in two to 59% of patients; the lungs were the most frequent site of spread. ...
... 21,23,24,30,31,34,37,39,41,[45][46][47][48][49][50][51][52]54,55,58,59 In 21 papers, best supportive care (BSC) was the sole treatment in 90% of the patients. [21][22][23][28][29][30][31][33][34][35][36][37][38][39]41,42,[50][51][52]56,57 No publication reported on all available treatment modalities. Notably, 12 studies reported on 1142 patients (29%) treated before 1990. ...
... Notably, 12 studies reported on 1142 patients (29%) treated before 1990. [20][21][22]28,[30][31][32]41,[52][53][54][55] Many of these treatments are now obsolete and of historical value only. ...
... Data are scarce, but studies consistently report curative-intended treatment being pursued in less than 1% of patients who present with hepatocellular carcinoma. 5,8,9 The importance of primary prevention through the eradication and reduction of risk factors cannot be overemphasised and should be the main focus of hepatocellular carcinoma prevention. Nonetheless, the roll-out of birth-dose vaccination to prevent hepatitis B (HBV) virus infections in sub-Saharan Africa is still suboptimal due to logistical challenges. ...
... The major reason is the inability to reproduce improved stage migration, as is seen with screening and surveillance reported from high-income countries. 24 Few patients in sub-Saharan Africa are thus diagnosed at a stage at which they are eligible for curative-intended treatment, 9,25 as shown in a retrospective observational cohort study, which included data from 1315 patients from sub-Saharan Africa countries. 5 In the 545 patients in whom the BCLC stage was known, only 27 (5%) were diagnosed with BCLC stage A or B. Extrapolated to the whole group, 66 patients would have qualified for curativeintended treatment or TACE. ...
... Although most patients present with advanced stage disease where systemic therapy could be beneficial, case series report either no or extremely low percentages of patients receiving systemic therapies. 5,9,25 Regarding transarterial therapies, TACE is the most frequently used and investigated transarterial treatment method, and is included as a palliative interventional method in all guidelines, for BCLC intermediate stage (B) patients. Despite a lack of compelling evidence that TACE is better than bland TAE, bland TAE is seldom done. ...
Most patients who develop hepatocellular carcinoma reside in resource-poor countries, a category that includes most countries in sub-Saharan Africa. Age-standardised incidence rates of hepatocellular carcinoma in western, central, eastern, and southern Africa is 6·53 per 100 000 inhabitants to 11·1 per 100 000 inhabitants. In high-income countries, around 40% of patients are diagnosed at an early stage, in which interventions with curative intent or palliative interventions are possible. By contrast, 95% of patients with hepatocellular carcinoma in sub-Saharan Africa present with advanced or terminal disease. In high-income countries, targets of 30-40% that have been set for intervention with curative intent are regularly met, with expected 5-year overall survival rates in the region of 70%. These outcomes are in sharp contrast with the very small proportion of patients in sub-Saharan Africa who are treated with curative intent. Primary prevention through the eradication and reduction of risk factors is still suboptimal because of logistical challenges. The challenges facing primary prevention, in combination with difficult-to-manage historic and emerging risk factors, such as ethanol overconsumption and metabolic dysfunction-associated liver disease, mandates secondary prevention for populations at risk through screening and surveillance. Although the increased treatment needs yielded by screening and surveillance in high-income countries are manageable by the incremental expansion of existinginterventional resources, the lack of resources in sub-Saharan Africa will undermine the possible benefits of secondary prevention. An estimate of the projected effect of the introduction and expansion of screening and surveillance, resulting in stage migration and possibilities for active interventions for hepatocellular carcinoma, would facilitate optimal planning and development of resources.
... Data are scarce, but studies consistently report curative-intended treatment being pursued in less than 1% of patients who present with hepatocellular carcinoma. 5,8,9 The importance of primary prevention through the eradication and reduction of risk factors cannot be overemphasised and should be the main focus of hepatocellular carcinoma prevention. Nonetheless, the roll-out of birth-dose vaccination to prevent hepatitis B (HBV) virus infections in sub-Saharan Africa is still suboptimal due to logistical challenges. ...
... The major reason is the inability to reproduce improved stage migration, as is seen with screening and surveillance reported from high-income countries. 24 Few patients in sub-Saharan Africa are thus diagnosed at a stage at which they are eligible for curative-intended treatment, 9,25 as shown in a retrospective observational cohort study, which included data from 1315 patients from sub-Saharan Africa countries. 5 In the 545 patients in whom the BCLC stage was known, only 27 (5%) were diagnosed with BCLC stage A or B. Extrapolated to the whole group, 66 patients would have qualified for curativeintended treatment or TACE. ...
... Although most patients present with advanced stage disease where systemic therapy could be beneficial, case series report either no or extremely low percentages of patients receiving systemic therapies. 5,9,25 Regarding transarterial therapies, TACE is the most frequently used and investigated transarterial treatment method, and is included as a palliative interventional method in all guidelines, for BCLC intermediate stage (B) patients. Despite a lack of compelling evidence that TACE is better than bland TAE, bland TAE is seldom done. ...
... Data are scarce, but studies consistently report curative-intended treatment being pursued in less than 1% of patients who present with hepatocellular carcinoma. 5,8,9 The importance of primary prevention through the eradication and reduction of risk factors cannot be overemphasised and should be the main focus of hepatocellular carcinoma prevention. Nonetheless, the roll-out of birth-dose vaccination to prevent hepatitis B (HBV) virus infections in sub-Saharan Africa is still suboptimal due to logistical challenges. ...
... The major reason is the inability to reproduce improved stage migration, as is seen with screening and surveillance reported from high-income countries. 24 Few patients in sub-Saharan Africa are thus diagnosed at a stage at which they are eligible for curative-intended treatment, 9,25 as shown in a retrospective observational cohort study, which included data from 1315 patients from sub-Saharan Africa countries. 5 In the 545 patients in whom the BCLC stage was known, only 27 (5%) were diagnosed with BCLC stage A or B. Extrapolated to the whole group, 66 patients would have qualified for curativeintended treatment or TACE. ...
... Although most patients present with advanced stage disease where systemic therapy could be beneficial, case series report either no or extremely low percentages of patients receiving systemic therapies. 5,9,25 Regarding transarterial therapies, TACE is the most frequently used and investigated transarterial treatment method, and is included as a palliative interventional method in all guidelines, for BCLC intermediate stage (B) patients. Despite a lack of compelling evidence that TACE is better than bland TAE, bland TAE is seldom done. ...
Most patients who develop hepatocellular carcinoma reside in resource-poor countries, a category that includes most countries in sub-Saharan Africa. Age-standardised incidence rates of hepatocellular carcinoma in western, central, eastern, and southern Africa is 6·53 per 100 000 inhabitants to 11·1 per 100 000 inhabitants. In high-income countries, around 40% of patients are diagnosed at an early stage, in which interventions with curative intent or palliative interventions are possible. By contrast, 95% of patients with hepatocellular carcinoma in sub-Saharan Africa present with advanced or terminal disease. In high-income countries, targets of 30–40% that have been set for intervention with curative intent are regularly met, with expected 5-year overall survival rates in the region of 70%. These outcomes are in sharp contrast with the very small proportion of patients in sub-Saharan Africa who are treated with curative intent. Primary prevention through the eradication and reduction of risk factors is still suboptimal because of logistical challenges. The challenges facing primary prevention, in combination with difficult-to-manage historic and emerging risk factors, such as ethanol overconsumption and metabolic dysfunction-associated liver disease, mandates secondary prevention for populations at risk through screening and surveillance. Although the increased treatment needs yielded by screening and surveillance in high-income countries are manageable by the incremental expansion of existing interventional resources, the lack of resources in sub-Saharan Africa will undermine the possible benefits of secondary prevention. An estimate of the projected effect of the introduction and expansion of screening and surveillance, resulting in stage migration and possibilities for active interventions for hepatocellular carcinoma, would facilitate optimal planning and development of resources.
... The demographic characteristics of HCC cases at KBTH appear to confirm previously known trends about the disease in Ghana and the West African Region. The male predominance seen in this report has been previously reported in Ghana, West Africa and globally [10][11][12]. This has previously been attributed to the higher prevalence of risk factors including chronic viral hepatitis, environmental carcinogens like alcohol and smoking, higher testosterone levels and lower levels of IL-6 production in males [13,14]. ...
... This study confirms the important contribution of HBV to HCC in Ghana as in many other SSA countries [2,12]. HBsAg positivity of 71.7% is higher than 52% previously reported in 2015 from Kumasi in Ghana and 60% from The Gambia and 48% from Ethiopia, both of which also have very high population prevalence of HBV [9,11,15]. ...
... The proportion of patients in many African countries receiving specific HCC treatment has been disappointingly low compared to the trend in Asia, Europe and North America [12,31]. Gyedu et al. have also previously reported that HCC patients in Ghana were not eligible for surgical resection [11]. This study similarly finds low utilization of potentially curative therapies of HCC like resection, radiofrequency ablation and percutaneous ethanol injection. ...
Introduction:
Hepatocellular carcinoma (HCC) is a cancer of global public health concern because of its high incidence and mortality. The impact is greatest in areas with high prevalence of its major risk factors including chronic hepatitis B virus (HBV). HBV is endemic in Ghana but a comprehensive data on HCC is lacking. The aim of this study was to describe the clinical, laboratory and radiological features of HCC at the Korle Bu Teaching Hospital in Ghana.
Methods:
The medical records of 194 HCC cases attended to at the Gastrointestinal Clinic of the Korle Bu Teaching Hospital between January 2015 and December 2018 were retrospectively analyzed for demographic, clinical, laboratory and radiological data.
Results:
The male: female ratio was 2:1 and mean age was 45.2 years. Weight loss and abdominal pain were the major presenting symptoms. No patients were identified through surveillance. HBsAg was positive in 109/145 (75.2%) of cases tested. Sixty-five (59.6%) of 109 HBsAg positives were aware of their HBsAg status but only 3 were receiving medical follow ups prior to the diagnosis of HCC. Raised alpha-fetoprotein level >165.2 IU/ML was found in 53.9%. One hundred and forty-four patients were eligible for only analgesia.
Conclusion:
HBV infection is the leading aetiologial risk factor associated with HCC. Majority of HBV carriers are aware of their status but do not receive care prior to HCC diagnosis. Majority present late and are eligible for only palliative treatment. Improvement in the health seeking behavior of HBV carriers can aid early detection of HCC.
... Hepatocellular carcinoma (HCC), principal histological form of primary liver cancer, and overwhelming histo-type (90-95% of cases) in sub-Saharan Africa represents a serious public health problem in West Africa [2][3][4]. In sub-Saharan Africa, HCC is associated with a very high lethality, due to the presentation at later stages of the disease and to the local intrinsic difficulties to practice liver surgery [5]. Primary prevention measures targeting chronic liver diseases appear, therefore, as the only realistic and urgent measures of protection for local populations [6]. ...
... We present in a flow chart the outcome inclusion and exclusion process. As already underlined in similar studies conducted in sub-Saharan Africa, the major limitation of our analysis is related to the missing data in medical records [5]. Due to their costs and to the average low economic status of the patients in a country without universal social insurance, laboratory tests were particularly affected by the lack of data. ...
... In Côte d'Ivoire, age at diagnosis seems to be currently slightly older than the value reported in a recent multicenter study performed in 7 countries from Eastern and Western Africa (median 43 years) [18]. Other surveys conducted in sub-Saharan Africa suggest that, in Côte d'Ivoire, liver cancer tends to be diagnosed later than in many countries (Burkina Faso, Congo, Ghana, North Eastern Nigeria, Uganda) but in a range similar to what is observed in close or distant locations such as South Africa, Gambia, South-Western Nigeria, Niger, Congo or Central African Republic [3,5,[19][20][21][22][23]. The causes of these variations are partly to be found in nutrition factors that might accelerate tumorigenesis either directly as aflatoxin B1 or indirectly as vitamin or nutrients deficiencies that decrease the strength of anticancer immune response [24]. ...
... Hepatocellular carcinoma (HCC), principal histological form of primary liver cancer, and overwhelming histo-type (90-95% of cases) in sub-Saharan Africa represents a serious public health problem in West Africa [2][3][4]. In sub-Saharan Africa, HCC is associated with a very high lethality, due to the presentation at later stages of the disease and to the local intrinsic difficulties to practice liver surgery [5]. Primary prevention measures targeting chronic liver diseases appear, therefore, as the only realistic and urgent measures of protection for local populations [6]. ...
... We present in a flow chart the outcome inclusion and exclusion process. As already underlined in similar studies conducted in sub-Saharan Africa, the major limitation of our analysis is related to the missing data in medical records [5]. Due to their costs and to the average low economic status of the patients in a country without universal social insurance, laboratory tests were particularly affected by the lack of data. ...
... In Côte d'Ivoire, age at diagnosis seems to be currently slightly older than the value reported in a recent multicenter study performed in 7 countries from Eastern and Western Africa (median 43 years) [18]. Other surveys conducted in sub-Saharan Africa suggest that, in Côte d'Ivoire, liver cancer tends to be diagnosed later than in many countries (Burkina Faso, Congo, Ghana, North Eastern Nigeria, Uganda) but in a range similar to what is observed in close or distant locations such as South Africa, Gambia, South-Western Nigeria, Niger, Congo or Central African Republic [3,5,[19][20][21][22][23]. The causes of these variations are partly to be found in nutrition factors that might accelerate tumorigenesis either directly as aflatoxin B1 or indirectly as vitamin or nutrients deficiencies that decrease the strength of anticancer immune response [24]. ...
Introduction:
Hepatocellular carcinoma is a major concern for Public health in West Africa. In Côte d'Ivoire, the bulk of our knowledge stems from studies conducted decades ago. Our aim was, thus, to assess whether the epidemiological features of this tumor changed recently.
Methods:
Records from 863 patients diagnosed between 2007 and 2014 were analyzed.
Results:
We observed major drifts concerning hepatocellular carcinoma with regards to the 1970-1980 period. Age at presentation is substantially delayed (49.4±14.1 years) whereas sex ratio decreased substantially (M:F=2.6). Patients seropositive for hepatitis B surface antigen and anti-hepatitis C virus represented 65% and 25% of cases whereas alcohol intake was reported in 36%. AFP level was above 400ng/mL in 36% of cases and tumors were already multinodular and/or metastatic at diagnosis in 77% and 26% of patients. Geographical and anthropological variations were observed with excesses of female cases affecting regions (Lagunes) or linguisitic groups (Kru). North-Mande speakers were more often identified as nonBnonC than others.
Discussion:
Ivorian epidemiology of hepatocellular carcinoma was reshaped during the last decades. These changes, most likely due to the spread of hepatitis C virus, resulted in an older and feminized population of patients. We fear that the current and future prevalence of anti-HCV cases might thwart the expected benefits of anti-hepatitis B immunization. Appropriate measures should be taken to prevent further transmission of hepatitis C in the country.
... Previous studies on the characteristics and clinical pro le of ESLD patients in sub-Saharan Africa have primarily focused on liver cancer and have recognized limitations in data collection due to challenges in retrieval of records, compounded by the fact that they have been retrospective in design (9,10). ...
... This is not an uncommon nding in sub-Saharan African countries.Yang et al. in 2017 reported that 84% of liver cancer cases presented with multinodular disease(9). In Ghana, Gyedu et al. found that only 8% of persons with HCC seen at the Komfo Anokye Teaching Hospital in Accra between 2007-2013 were eligible for curative treatment(10). In our study, the AFP performed well as a diagnostic test in the detection in HCC. ...
Background: End-stage liver disease (ESLD) is a major burden on public health, particularly in sub-Saharan Africa, where hepatitis B virus (HBV) is an important risk factor. We aimed to describe clinical characteristics of ESLD from cirrhosis or hepatocellular carcinoma (HCC) and the performance of aspartate aminotransferase (AST) - platelet ratio index (APRI) and alpha fetoprotein (AFP) in Ghana.
Methods: We performed an observational cross-sectional study in outpatient hepatology clinics at three teaching hospitals in Ghana, West Africa. One hundred and forty-one HCC, 216 cirrhosis and 218 chronic HBV patients were recruited by convenience sampling. Sociodemographic, history and examination, laboratory, and disease staging information were shown using descriptive statistics. Performance of the APRI score in diagnosis of cirrhosis and AFP in the diagnosis of HCC was determined using AUROC analysis.
Results: Median age at presentation was 44 years for HCC and 46 years for cirrhosis. HBV was found in 69.5% of HCC and 47.2% of cirrhosis cases, and HCV in 6.4% and 3.7% respectively. APRI cut-off of 2 had sensitivity of 45.4% and specificity of 95% in diagnosis of cirrhosis, and cut-off of 1 had sensitivity of 75.9% and specificity of 89%. AUC of AFP was 0.88 (95% CI 0.81-0.94) in diagnosis of HCC. Low monthly income was associated with lower odds of undertaking AFP. Thirty one percent of cirrhotic persons were Child-Pugh C, and 67.9% of HCC patients had advanced or terminal disease at presentation.
Conclusions: Our findings emphasize the young age of ESLD patients in Ghana and the advanced nature at presentation. It highlights shortcomings in surveillance and the need for policies to address the burden and improve outcomes in Ghana.
... Previous studies on the characteristics and clinical profile of ESLD patients in sub-Saharan Africa have primarily focused on liver cancer and have recognized limitations in data collection due to challenges in retrieval of records, compounded by the fact that they have been retrospective in design [9,10]. Furthermore, in Ghana, there are few studies on the characteristics and clinical profile of patients presenting with ESLD. ...
... Yang et al. [9] in 2017 reported that 84% of liver cancer cases presented with multinodular disease. In Ghana, Gyedu et al. [10] found that only 8% of persons with HCC seen at the Komfo Anokye Teaching Hospital in Accra between 2007 and 2013 were eligible for curative treatment. In our study, the AFP performed well as a diagnostic test in the detection in HCC. ...
Background
End-stage liver disease (ESLD) is a major burden on public health, particularly in sub-Saharan Africa, where hepatitis B virus (HBV) is an important risk factor. We aimed to describe clinical characteristics of ESLD from cirrhosis or hepatocellular carcinoma (HCC) and the performance of aspartate aminotransferase (AST)—platelet ratio index (APRI) and alpha fetoprotein (AFP) in Ghana.
Methods
We performed an observational cross-sectional study in outpatient hepatology clinics at three teaching hospitals in Ghana, West Africa. One hundred and forty-one HCC, 216 cirrhosis and 218 chronic HBV patients were recruited by convenience sampling. Sociodemographic, history and examination, laboratory, and disease staging information were shown using descriptive statistics. Performance of the APRI score in diagnosis of cirrhosis and AFP in the diagnosis of HCC was determined using AUROC analysis.
Results
Median age at presentation was 44 years for HCC and 46 years for cirrhosis. HBV was found in 69.5% of HCC and 47.2% of cirrhosis cases, and HCV in 6.4% and 3.7% respectively. APRI cut-off of 2 had sensitivity of 45.4% and specificity of 95% in diagnosis of cirrhosis, and cut-off of 1 had sensitivity of 75.9% and specificity of 89%. AUC of AFP was 0.88 (95% CI 0.81–0.94) in diagnosis of HCC. Low monthly income was associated with lower odds of undertaking AFP. Thirty one percent of cirrhotic persons were Child–Pugh C, and 67.9% of HCC patients had advanced or terminal disease at presentation.
Conclusions
Our findings emphasize the young age of ESLD patients in Ghana and the advanced nature at presentation. It highlights shortcomings in surveillance and the need for policies to address the burden and improve outcomes in Ghana.
... Previous studies on the characteristics and clinical pro le of ESLD patients in sub-Saharan Africa have primarily focused on liver cancer and have recognized limitations in data collection due to challenges in retrieval of records, compounded by the fact that they have been retrospective in design (9,10). ...
... Yang et al. in 2017 reported that 84% of liver cancer cases presented with multinodular disease (9). In Ghana, Gyedu et al. found that only 8% of persons with HCC seen at the Komfo Anokye Teaching Hospital in Accra between 2007-2013 were eligible for curative treatment (10). In our study, the AFP performed well as a diagnostic test in the detection in HCC. ...
Background: End-stage liver disease (ESLD) is a major burden on public health, particularly in sub-Saharan Africa, where hepatitis B virus (HBV) is an important risk factor. We aimed to describe clinical characteristics of ESLD from cirrhosis or hepatocellular carcinoma (HCC) and the performance of aspartate aminotransferase (AST) - platelet ratio index (APRI) and alpha fetoprotein (AFP) in Ghana.
Methods: We performed an observational cross-sectional study in outpatient hepatology clinics at three teaching hospitals in Ghana, West Africa. One hundred and forty-one HCC, 216 cirrhosis and 218 chronic HBV patients were recruited by convenience sampling. Sociodemographic, history and examination, laboratory, and disease staging information were shown using descriptive statistics. Performance of the APRI score in diagnosis of cirrhosis and AFP in the diagnosis of HCC was determined using AUROC analysis.
Results: Median age at presentation was 44 years for HCC and 46 years for cirrhosis. HBV was found in 69.5% of HCC and 47.2% of cirrhosis cases, and HCV in 6.4% and 3.7% respectively. APRI cut-off of 2 had sensitivity of 45.4% and specificity of 95% in diagnosis of cirrhosis, and cut-off of 1 had sensitivity of 75.9% and specificity of 89%. AUC of AFP was 0.88 (95% CI 0.81-0.94) in diagnosis of HCC. Low monthly income was associated with lower odds of undertaking AFP. Thirty one percent of cirrhotic persons were Child-Pugh C, and 67.9% of HCC patients had advanced or terminal disease at presentation.
Conclusions: Our findings emphasize the young age of ESLD patients in Ghana and the advanced nature at presentation. It highlights shortcomings in surveillance and the need for policies to address the burden and improve outcomes in Ghana.
... In Chad, the distribution of risk factors of HCC presents some peculiarities that bring it close to Sudan, its Eastern neighbor. The prevalence of HBsAg in patients with HCC (52.2%) is in keeping with the rate reported by Yang and coworkers in a multicentric study (50%) or in single center description made in Ghana or South West Nigeria [2] [27] [28]. This rate is, however, much lower than in immediately neighboring countries such as Cameroon (68%), Niger (71%) or North Eastern Nigeria (Maiduguri, 86%) and similar or slightly higher than in Sudan (49%) or Central African Republic (41%) [22] [29] [30] [31] [32]. ...
... In patients with liver disease, by the time they see a hepatologists, there are multiple delay points that will make them ineligible for liver transplantation. This was also a problem observed by Gyedu et al when analyzing patients presenting with hepatocellular carcinoma in sub-Saharan Africa [22]. ...
... Previous studies on the characteristics and clinical profile of ESLD patients in sub-Saharan Africa have primarily focused on liver cancer and have recognized limitations in data collection due to challenges in retrieval of records, compounded by the fact that they have been retrospective in design (9,10). ...
Background: End-stage liver disease (ESLD) is a major burden on public health, particularly in sub-Saharan Africa, where hepatitis B virus (HBV) is an important risk factor. We aimed to describe clinical characteristics of ESLD from cirrhosis or hepatocellular carcinoma (HCC) and the performance of aspartate aminotransferase (AST) - platelet ratio index (APRI) and alpha fetoprotein (AFP) in Ghana.
Methods: We performed an observational cross-sectional study in outpatient hepatology clinics at three teaching hospitals in Ghana, West Africa. One hundred and forty-one HCC, 216 cirrhosis and 218 chronic HBV patients were recruited by convenience sampling. Sociodemographic, history and examination, laboratory, and disease staging information were shown using descriptive statistics. Performance of the APRI score in diagnosis of cirrhosis and Alpha fetoprotein in the diagnosis of HCC was determined using AUROC analysis.
Results: Median age at presentation was 44 years for HCC and 46 years for cirrhosis. HBV was found in 69.5% of HCC and 47.2% of cirrhosis cases, and HCV in 6.4% and 3.7% respectively. APRI cut-off of 2 had sensitivity of 45.4% and specificity of 95% in diagnosis of cirrhosis, and cut-off of 1 had sensitivity of 75.9% and specificity of 89%. AUC of AFP was 0.88 (95% CI 0.81-0.94) in diagnosis of HCC. Low monthly income was associated with lower odds of undertaking AFP. Thirty one percent of cirrhotic persons were Child-Pugh C, and 67.9% of HCC patients had advanced or terminal disease at presentation.
Conclusions: Our findings emphasize the young age of ESLD patients in Ghana and the advanced nature at presentation. It highlights shortcomings in surveillance and the need for policies to address the burden and improve outcomes in Ghana.
... 3 In a HCC cohort of 206 patients presenting to a major referral hospital in Ghana, less than 8% were assessed as candidates for treatment with curative intent, none of whom were treated. 6 Due to the wide disparity in available resources in SSA between as well as within countries, developing HCC management strategies will be best served by applying resource-sensitive guidelines that propose escalating levels of preventative measures tailored to available treatment options. 7 Screening and surveillance are only indicated in medium and high resource environments where early lesions that are detected can be treated appropriately. ...
... We were unable to consider tumour vascularity as we did not have access to Doppler ultrasound, but were able to estimate tumour volume as spheroids from twodimensional ultrasound measurements, and over a wide range of volumes there was no association with ULBP1 concentration. This may be because HCC presents late, with advanced disease in Africa (Gyedu et al. 2014). As a result patients with very large tumours often have large, single, slow growing lesions that may be less aggressive. ...
Natural killer (NK) cells are implicated in tumour surveillance and control in a number of settings. The liver contains large numbers of NK cells and hepatocellular carcinoma (HCC) has been shown to express various ligands that permit interactions with NK cells, some of which have been shown to have prognostic significance. Similar prognostic associations have been shown for colorectal cancer, a tumour which commonly metastasizes to the liver. However the mechanistic underpinning of these effects is unclear. This thesis describes a survey of soluble NKG2D ligand expression in patients with HCC caused by chronic hepatitis B (CHB), patients with CHB without cancer, and healthy controls. ULBP1 was found to be raised in HCC patients; where it was associated with poor survival, and in active CHB; where it was associated with hepatitis B viral load. ULBP1 was not seen in secondary liver tumours, suggesting that this protein may be useful as a biomarker of severe disease or to monitor treatment response. The other NKG2D ligands MICA, MICB, ULBP2 and ULBP3 were not found to be elevated in patient serum. Soluble NKG2D ligands did not affect NKG2D expression by circulating NK cells. Tumour infiltrating NK cells have the potential to be important effector cells, but are functionally defective. This work builds on recent advances in the understanding of liver-resident NK cells to characterise the functional defect in primary and secondary liver cancers, using human ex vivo intrahepatic and tumour-infiltrating NK cells. Using an in vitro model of HCC we have investigated the mechanisms for this defect and examine the potential for IL- 15 to restore NK cell cytotoxicity and cytokine production. Ex-vivo tumourinfiltrating NK cells had reduced NKG2D expression, IFNγ production and degranulation potential compared with paired intrahepatic NK cells, but maintained expression of NKp46. We were able to recapitulate this phenotype by co-culture with an HCC cell line, but were not able to protect NK cells from NKG2D downregulation and functional inhibition by NKG2D blockade. However, IL-15 was able to restore function after HCC exposure. This model may serve as an in-vitro assay for future therapeutics targeting tumour-infiltrating NK cells.
... In a series reported form Nigeria, over 96% of patients were offered symptomatic treatment only (Ndububa et al. 2001). In a review of 465 patients with liver cancer in Ghana, only 8% of patients were judged curative using the Barcelona Clinic Liver Cancer (BCLC) algorithm (Gyedu et al. 2015). However, none of these patients had surgery, ablation or embolization. ...
The greatest burden of disease in Sub-Saharan Africa (SSA) is from infectious diseases. The incidence of all cancers is however rising. A complex web of poverty, ignorance, inadequate diagnostic and treatment facilities has made cancer outcomes worse in SSA in comparison with other world regions. This chapter provides an overview of cancer burden in SSA using data from cancer epidemiology databases and peer-reviewed publications. Age-standardized Cancer Incidences in SSA were obtained from the International Agency for Research in Cancer (IARC) publication – ‘Cancer incidences in five continents’. Recent cancer estimates were from GLOBOCAN 2008 (Ferlay et al. 2010) and GLOBOCAN 2012 (Ferlay et al. 2013). Cancer mortality was from WHO Mortality Database. The five commonest cancers in males in SSA in (Ferlay et al. 2013) (age-standardised incidence rate per 100,000 population) were: prostate cancer (27.9), liver cancer (10.2), Kaposi sarcoma (7.2), oesophageal cancer (6.8) and colorectal cancer (6.4). In females, ASIR per 100,000 for the commonest cancers were: cervix uteri cancer (34.8), breast cancer (33.8), liver cancer (5.4), colorectal cancer (5.4), ovarian (4.6). There were regional variations observed in cancer incidence in SSA. Tragically, survival from cancer in SSA was significantly worse than the rest of the world regions. Sub-Saharan Africa had disproportionately higher mortality rates from cancers compared to other world regions. The changes in population dynamics, lifestyles and diet across Africa, and the increasing role of viruses have coincided with the increasing cancer incidence. There is an urgent need for investment in cancer diagnosis and treatment to stem the current tide.
... In a series reported form Nigeria, over 96% of patients were offered symptomatic treatment only (Ndububa et al. 2001). In a review of 465 patients with liver cancer in Ghana, only 8% of patients were judged curative using the Barcelona Clinic Liver Cancer (BCLC) algorithm (Gyedu et al. 2015). However, none of these patients had surgery, ablation or embolization. ...
Surgery is the mainstay of achieving cure in gastrointestinal cancers. While health expenditure per capita (HEpC) has increased from 41 US in sub-Saharan Africa (SSA) in 2014, it remains well below the world HEpC of 1061 US in 2014. Cancer appears to be a low public health priority in SSA, and this may in part be attributable to the burden of communicable disease such as Human Immunodeficiency Virus, malaria and tuberculosis. However, by 2030, the incidence of gastrointestinal cancers is set to increase by 73% in SSA compared to 59% worldwide. Over 90% of all GI cancers in SSA present late and the peak incidences occur about a decade earlier than in the West. The younger age at presentation could be the result of yet undefined molecular and biological differences, and environmental factors. For the few who present early, lack of infrastructure and expertise lead to poor therapeutic options and inevitable poorer outcomes. This chapter will give an overview of oesophageal, liver, gastric, and colorectal cancers pathways in sub-Saharan Africa.
Hepatocellular carcinoma (HCC) is a major public health problem in Senegal, and the third most common cancer in terms of incidence. However, there are no recent data on the characteristics of this pathology in our country. The aim was to describe the epidemiological, clinical, aetiological and therapeutic aspects of HCC at Hôpital Principal de Dakar, Senegal. We did a descriptive retrospective study, including patients hospitalized from January 2012 to December 2017. We included 229 patients. The mean age was 47.4 years (21 - 88 years), and 77 patients (33.6%) were under 40 years of age. The sex ratio was 6.6. Twelve patients (5.2%) had a family history of 1st degree cirrhosis or HCC. Ten patients (4.4%) were previously treated with nucleotide analogues. The most common clinical sign at diagnosis was abdominal pain (91.7%). Alpha-fetoprotein level was normal in 12.2% of patients, and greater than 400 ng/ml in 68.1% of cases. Abdominal ultrasound found nodular HCC in 122 patients (68.2%), infiltrative HCC in 19 patients (10.6%), and was normal in 38 cases (21.2%). Subjacent cirrhosis was detected in 71.3% of cases. Abdominal computed tomography (CT) scan showed compatible HCC lesions in 88.8% of cases. A histological diagnosis was obtained in 2 patients (0.9%). The most common etiological factor was hepatitis B virus (69.4%), characterized mostly by a younger age (p = 0.001). In 20.9% of cases, no aetiology was found. An advanced or terminal stage (BCLC C/D) was found in 217 cases (94.8%). The treatment was curative in 12 patients (5.2%), and palliative in 7 cases (3.1%). The evolution at one year was favourable in 6 patients (2.6%). Hepatocellular carcinoma (HCC) is a disease that mainly affects young male adults in Senegal. The main aetiological factor remains HBV infection. The diagnosis is made at an advanced stage and the prognosis very bad.
Background and Objectives
Outcome data after surgery for cancer in Sub‐Saharan Africa are insufficient. We aimed to describe the presentation and outcomes of patients with solid cancers managed at a tertiary hospital in Ghana.
Methods
Records of cancer patients admitted to Komfo Anokye Teaching Hospital general surgery wards from 2013 to 2016 were reviewed for data on presentation, staging, management, and mortality. Patients discharged alive were followed‐up by biannual telephone calls to establish their postdischarge status. Survival analysis was performed for patients with pathologic or radiologic confirmation of cancer and adequate staging.
Results
A total of 343 patients were included. Of these, 76% were female. The most common diagnoses were breast 136 (40%), foregut 70 (20%), and colorectal 63 (18%) cancers. Cancer diagnosis was confirmed by pathology or radiology in 281 (82%) patients, but only 112 (40%) had adequate staging. Seventy‐four (66%) patients were stage IV. Two‐year overall survival for all 343 patients was 22% to 69%, depending on cancer site. Among those with adequate staging who were alive after postoperative 90 days, 3‐year survival was similar for curative compared with palliative operations (P = 0.64).
Conclusions
Improved capacity for both therapeutic and palliative cancer care is needed to achieve better outcomes by more appropriate allocation of surgery with respect to the goal of treatment.
Surgery is a key component of all aspects of cancer care, ranging from diagnostic biopsies to therapeutic or palliative procedures. However, surgery is often overlooked in public health efforts to address cancer due to surgeon under-representation in the public health community.
In the previous guideline, groups were specified for which surveillance was likely to be cost-effective because the hepatocellular carcinoma (HCC) incidence was high enough. New data on defining HCC risk have emerged for hepatitis B virus,1, 2 hepatitis C virus,3 and autoimmune hepatitis.4 Surveillance is deemed cost-effective if the expected HCC risk exceeds 1.5% per year in patients with hepatitis C and 0.2% per year in patients with hepatitis B. Analysis of recent studies show that alpha-fetoprotein determination lacks adequate sensitivity and specificity for effective surveillance (and for diagnosis).5, 6 Thus, surveillance has to be based on ultrasound examination. The recommended screening interval is 6 months. Diagnosis of HCC should be based on imaging techniques and/or biopsy.The 2005 diagnostic algorithm has been validated and the diagnostic accuracy of a single dynamic technique showing intense arterial uptake followed by “washout” of contrast in the venous-delayed phases has been demonstrated.7-9 Contrast-enhanced US may offer false positive HCC diagnosis in patients with cholangiocarcinoma and thus, has been dropped from the diagnostic techniques. The diagnostic algorithm is shown in Fig. 1. The application of dynamic imaging criteria should be applied only to patients with cirrhosis of any etiology and to patients with chronic hepatitis B who may not have fully developed cirrhosis or have regressed cirrhosis. Interpretation of biopsies and distinction between high-grade dysplatic nodules and HCC is challenging. Expert pathology diagnosis is reinforced by staining for glypican 3, heat shock protein 70, and glutamine synthetase, because positivity for two of these three stains confirms HCC.10
This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of sorafenib according to its licensed indication for advanced hepatocellular carcinoma (HCC). The ERG report was based on the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The licensed indication for sorafenib specifies advanced HCC patients for whom locoregional intervention and surgery are unsuitable or had been unsuccessful. The clinical evidence came from a multicentre randomised controlled trial (Sorafenib HCC Assessment Randomized Protocol; SHARP) of sorafenib plus best supportive care versus placebo plus best supportive care, with 602 participants of a predominantly European ethnicity broadly comparable to the UK population. The submitted evidence indicated that for advanced HCC patients with Child-Pugh grade A liver function and relatively good Eastern Cooperative Oncology Group performance status, sorafenib on average improves overall survival by 83 days relative to placebo, and also increases time-to-radiological disease progression. Sorafenib therapy had little or no effect on time-to-symptom progression or on quality of life as measured using a disease-specific questionnaire. Sorafenib treatment was associated with increased incidence of hypertension and of gastrointestinal and dermatological problems. However, the therapy was reasonably well tolerated and, in SHARP, withdrawals from treatment due to adverse events were similar in the sorafenib and placebo arms, although more temporary reductions in dose were required in the sorafenib than in the placebo group. In the base case, the manufacturer's submitted economic analysis generated a deterministic incremental cost-effectiveness ratio (ICER) of 64,754 pounds per quality-adjusted life-year (QALY). The ERG extracted individual patient data for overall survival and disease progression, reran the economic model to check the submitted cost-effectiveness results, and performed new analyses which the ERG considered relevant to the decision problem; these analyses delivered ICERs between 76,000 pounds/QALY and 86,000 pounds/QALY. The guidance issued by NICE (7 May 2009) stated that sorafenib, within its licensed indication, is not recommended for the treatment of advanced (Barcelona-Clínic Liver Cancer stage C) HCC patients for whom surgical or locoregional therapies have failed or are not suitable, and people currently receiving sorafenib for the treatment of HCC should have the option to continue treatment until they and their clinician consider it appropriate to stop. Subsequently the manufacturer submitted a patient access scheme to the Department of Health. The base-case ICER submitted by the manufacturer for this scheme was 51,899 pounds/QALY. When the ERG reran the model with inputs considered relevant to the decision problem the ICER estimates ranged between 53,000 pounds to 58,000 pounds/QALY and substantially higher values depending on the nature of the sensitivity analyses. NICE considered the impact of the patient access scheme and determined that it was not sufficient to alter the guidance.
Hepatic cirrhosis is the commonest liver disease causing death in Accra, Ghana. The roles of hepatitis B (HBV) and C (HCV) virus infections in cirrhosis have not been well documented in Ghana. A nested case-control study was carried out to determine this and the role of blood transfusion in transmission of the two viruses. A total of 70 patients with cirrhosis diagnosed on combined clinical and ultrasonographic evidence and 280 controls with non-hepatic diseases were recruited for the study. HBsAg was detected in 30 out of the 70 cases, giving a prevalence rate of 42.9% compared to the rate of 7.5% (21 out of 280) among the controls. HBV infection was significantly associated with cirrhosis (χ2 = 75.622, P = 0.000, C.I. = 28.6 – 42.156.08; OR=8.07, 95% CI=4.62 – 15.20). The risk of developing cirrhosis is 8-fold increased in patients with HBV infections than those without. The sero-prevalence of antibodies to HCV of 7.1% (5 out of 70) among cases was higher compared to the 3.6% (10 out of 280) in controls but there was no statistically significant difference between the two rates (χ2 = 0.962, P = 0.327, C.I. = -1.42 – 5.70). Our results show that HBV infection and not HCV infection is a major risk factor for developing liver cirrhosis in Accra. There was statistically significant association between blood transfusion and HBV but not HCV infection.
Primary hepatocellular carcinoma is the commonest cancer in The Gambia. The Gambia Hepatitis Intervention Study (GHIS) was established in 1986 to evaluate the protective effectiveness of infant hepatitis B immunization in the prevention of chronic liver disease, particularly, hepatocellular carcinoma and cirrhosis later in adult life. This program was designed based on a series of assumptions. Here, we used data from observational and epidemiologic studies developed since 1986 to examine the validity of these assumptions. We found that (a) hepatitis B vaccine coverage was 15% more than originally assumed, (b) protection against hepatitis B virus (HBV) infection was not dependent on the number of vaccine doses received, (c) perinatal infection with HBV was of negligible importance, and (d) the HBV attributable risk of hepatocellular carcinoma at age < 50 was 70% to 80%, lower than initially assumed. Based on these data, the final outcome of the GHIS should be measurable from 2017, sooner than originally assumed. The GHIS strategy takes into account-specific patterns of virus epidemiology and natural history of hepatocellular carcinoma in Africa and provides a model for integrating and evaluating new vaccines into the Expanded Programme of Immunization of sub-Saharan African countries.
The ECOG Scale of Performance Status (PS) is widely used to quantify the functional status of cancer patients, and is an important factor determining prognosis in a number of malignant conditions. The PS describes the status of symptoms and functions with respect to ambulatory status and need for care. PS 0 means normal activity, PS 1 means some symptoms, but still near fully ambulatory, PS 2 means less than 50%, and PS 3 means more than 50% of daytime in bed, while PS 4 means completely bedridden. An inter-observer variability study of PS assessment has been carried out to evaluate the non-chance agreement among three oncologists rating 100 consecutive cancer patients. Total unanimity was observed in 40 cases, unanimity between two observers in 53 cases, and total disagreement in seven cases. Kappa statistics reveal the ability of the observers compared to change alone and were used to evaluate non-chance agreement. Overall Kappa was 0.44, (95% confidence limits 0.38-0.51). The Kappa for PS 0 was 0.55 (0.44-0.67), while those for PS 1, 2, 3 and four were 0.48 (0.37-0.60), 0.31 (0.19-0.42), 0.43 (0.32-0.55), and 0.33 (0.33-0.45), respectively. If one observer allocated patients to PS 0-2, then another randomly selected observed placed the patients in the same category with a probability of 0.92. For patients with PS 3-4 the probability that the same category would be chosen was 0.82. Overall, the non-chance agreement between observers was only moderate, when all ECOG Performance Status groups were considered. However, agreement with regard to allocation of patients to PS 0-2 versus 3-4 was high. This is of interest because this cut-off is often used in clinical studies.
Cancer mortality pattern in Ghana has not been reviewed since 1953, and there are no population-based data available for cancer morbidity and mortality patterns in Ghana due to the absence of a population-based cancer registry anywhere in the country.
A retrospective review of autopsy records of Department of Pathology, and medical certificate of cause of death books from all the wards of the Korle-Bu Teaching Hospital (KBTH), Accra, Ghana during the 10-year period 1991-2000 was done.
The present study reviews 3659 cancer deaths at the KBTH over the 10-year period. The male-to-female ratio was 1.2:1. The mean age for females was 46.5 [Standard Deviation (SD), 20.8] years, whilst that of males was 47.8 (SD, 22.2) years. The median age was 48 years for females and 50 years for males. Both sexes showed a first peak in childhood, a drop in adolescence and young adulthood, and a second peak in the middle ages followed by a fall in the elderly, with the second peak occurring a decade earlier in females than in males. The commonest cause of cancer death in females was malignancies of the breast [Age-Standardized Cancer Ratio (ASCAR), 17.24%], followed closely by haematopoietic organs (14.69%), liver (10.97%) and cervix (8.47%). Whilst in males, the highest mortality was from the liver (21.15%), followed by prostate (17.35%), haematopoietic organs (15.57%), and stomach (7.26%).
Considering the little information available on cancer patterns in Ghana, this combined autopsy and death certification data from the largest tertiary hospital is of considerable value in providing reliable information on the cancer patterns in Ghana.
This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of sorafenib according to its licensed indication for advanced hepatocellular carcinoma (HCC). The ERG report was based on the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The licensed indication for sorafenib specifies advanced HCC patients for whom locoregional intervention and surgery are unsuitable or had been unsuccessful. The clinical evidence came from a multicentre randomised controlled trial (Study of Heart and Renal Protection; SHARP) of sorafenib plus best supportive care versus placebo plus best supportive care, with 602 participants of a predominantly European ethnicity broadly comparable to the UK population. The submitted evidence indicated that for advanced HCC patients with Child–Pugh grade A liver function and relatively good Eastern Cooperative Oncology Group performance status, sorafenib on average improves overall survival by 83 days relative to placebo, and also increases time-to-radiological disease progression. Sorafenib therapy had little or no effect on time-to-symptom progression or on quality of life as measured using a disease-specific questionnaire. Sorafenib treatment was associated with increased incidence of hypertension and of gastrointestinal and dermatological problems. However, the therapy was reasonably well tolerated and, in SHARP, withdrawals from treatment due to adverse events were similar in the sorafenib and placebo arms, although more temporary reductions in dose were required in the sorafenib than in the placebo group. In the base case, the manufacturer’s submitted economic analysis generated a deterministic incremental cost-effectiveness ratio (ICER) of £64,754 per quality-adjusted life-year (QALY). The ERG extracted individual patient data for overall survival and disease progression, reran the economic model to check the submitted cost-effectiveness results, and performed new analyses which the ERG considered relevant to the decision problem; these analyses delivered ICERs between £76,000/QALY and £86,000/QALY. The guidance issued by NICE (7 May 2009) stated that sorafenib, within its licensed indication, is not recommended for the treatment of advanced (Barcelona-Clínic Liver Cancer stage C) HCC patients for whom surgical or locoregional therapies have failed or are not suitable, and people currently receiving sorafenib for the treatment of HCC should have the option to continue treatment until they and their clinician consider it appropriate to stop. Subsequently the manufacturer submitted a patient access scheme to the Department of Health. The base-case ICER submitted by the manufacturer for this scheme was £51,899/QALY. When the ERG reran the model with inputs considered relevant to the decision problem the ICER estimates ranged between £53,000 to £58,000/QALY and substantially higher values depending on the nature of the sensitivity analyses. NICE considered the impact of the patient access scheme and determined that it was not sufficient to alter the guidance.
Hepatocellular carcinoma and cirrhosis frequently coexist. In populations with a low incidence of hepatocellular carcinoma, the tumor often arises as a complication of long-standing symptomatic cirrhosis, which may be micronodular or macronodular and which is usually alcoholic in origin, and cirrhosis per se is the major etiologic association of the tumor. The relation between these two pathologic conditions in populations with a high incidence of hepatocellular carcinoma has not hitherto been analyzed. In this study the association was examined in 463 southern African black men with hepatocellular carcinoma. Cirrhosis, almost always macronodular and rarely showing features of alcoholic toxicity, was present in 63.1% of the patients. No differences were found in the age structure, clinical features, hepatic function, serum α-fetoprotein concentrations, or hepatitis B virus status between patients with hepatocellular carcinoma with and without cirrhosis. Patients with cirrhosis survived slightly longer, but the difference was not biologically significant. It is concluded that the relation between hepatocellular carcinoma and cirrhosis in southern African blacks differs substantially from that in low incidence regions of the tumor.
Most cases of hepatocellular carcinoma (HCC) are associated with cirrhosis related to chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. Changes in the time trends of HCC and most variations in its age-, sex-, and race-specific rates among different regions are likely to be related to differences in hepatitis viruses that are most prevalent in a population, the timing of their spread, and the ages of the individuals the viruses infect. Environmental, host genetic, and viral factors can affect the risk of HCC in individuals with HBV or HCV infection. This review summarizes the risk factors for HCC among HBV- or HCV-infected individuals, based on findings from epidemiologic studies and meta-analyses, as well as determinants of patient outcome and the HCC disease burden, globally and in the United States.
Estimates of the worldwide incidence and mortality from 27 cancers in 2008 have been prepared for 182 countries as part of the GLOBOCAN series published by the International Agency for Research on Cancer. In this article, we present the results for 20 world regions, summarizing the global patterns for the eight most common cancers. Overall, an estimated 12.7 million new cancer cases and 7.6 million cancer deaths occur in 2008, with 56% of new cancer cases and 63% of the cancer deaths occurring in the less developed regions of the world. The most commonly diagnosed cancers worldwide are lung (1.61 million, 12.7% of the total), breast (1.38 million, 10.9%) and colorectal cancers (1.23 million, 9.7%). The most common causes of cancer death are lung cancer (1.38 million, 18.2% of the total), stomach cancer (738,000 deaths, 9.7%) and liver cancer (696,000 deaths, 9.2%). Cancer is neither rare anywhere in the world, nor mainly confined to high-resource countries. Striking differences in the patterns of cancer from region to region are observed.
In Egypt, few data are available on the outcome of colonoscopy. Epidemiologic studies have shown that inflammatory bowel disease (IBD) tends to increase. Endoscopists have reported an increasing incidence of IBD and colorectal cancer (CRC). This may be explained by an increasing index of suspicion and the availability of endoscopy. Population-based studies are lacking.
The aim of our study was to retrospectively evaluate the patient characteristics and final diagnosis in patients subjected to colonoscopy in Tanta University Hospital and affiliated hospitals at the middle of Nile delta of Egypt, which is one of the most densely populated regions in the country.
This study was done at the endoscopy units of Tanta University Hospital and affiliated hospitals (all units of colonoscopy at Gharbia governorate) from June 2008 to June 2009. A total of 864 patients presented with different indications for colonoscopy. All findings were recorded, analyzed, and discussed.
Colonoscopy revealed a diagnosis of ulcerative colitis (UC) in 22%, hemorrhoids in 18%, CRC in 15%, benign colorectal polyps in 9%, Crohn's disease (CD) in 3%, diverticulosis in 2%, and anal fissures in 2% of patients. No organic colonic disease was found in 28% of patients. Complications occurred in less than 1% of the cases.
In Egyptian patients subjected to colonoscopy, the most frequent diagnoses were UC, followed by hemorrhoids, CRC, benign polyps, and CD. This may represent an increasing incidence of UC and CRC. Colonoscopy was safe and few complications were recorded. Prospective population-based studies are needed in order to measure the incidence, prevalence, and risk factors of various diseases of the colon in Egypt.
Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, with a high burden in West Africa. Data evaluating aetiological differences in HCC presentation from this region are limited.
The aim of this study was to describe the demographical, clinical and pathological characteristics of HCC by aetiology (hepatitis B or C infection, aflatoxin associated).
One hundred and ninty-three cases of HCC diagnosed between 1997 and 2001 in The Gambia were analysed. Characteristics were compared by aetiology using χ(2)-tests, student t-test and Wilcoxon's rank sum tests as appropriate.
The prevalence of hepatitis B surface antigen, hepatitis C antibody and aflatoxin-associated 249(ser) TP53 mutations among HCC patients was 60, 20 and 38% respectively. The typical HCC patient was a 49-year-old male positive for hepatitis B surface antigen presenting with hepatomegaly (93%), abdominal pain (94%) and weight loss (95%) 8 weeks after symptom onset. Most patients had multifocal lesions with background cirrhosis. The median largest tumour was 10.3 cm and the median α-fetoprotein level was 500 ng/ml. Eighty-four per cent of patients had advanced HCC (patients not meeting the Milan criteria) at presentation.
Irrespective of aetiological agent, HCC among West Africans presents at very advanced stages. Few clinical or pathological differences exist by aetiology. More studies are needed to understand the mechanisms of hepatocarcinogenesis among these patients as well as identify high-risk populations in which early detection through screening will be beneficial.
To study the profile and outcome of therapy for hepatocellular carcinoma (HCC) in India.
Data analysis of HCC patients enrolled in liver clinic between 1990 and 2005.
We registered 324 HCC patients [males 284 (88%), mean age 52.4 +/- 13.1 years]. The etiology of HCC was: hepatitis B virus 165 (51%), hepatitis C virus 38 (12%), alcohol 20 (6%), combined 31 (10%) and unknown 70 (21%). Serum alpha-fetoprotein was >400 ng in 36%, portal vein invasion was seen in 40% and distant metastases in 13%. Therapy was offered to 141 (43.5%) patients, but survival data was available in only 130 (93%) of them. Treatment given and median survival time was as follows: surgical resection, 19 months (n = 14); transarterial chemoembolization, 11 months (n = 23); transarterial rhenium therapy, 26 months (n = 7); radiofrequency ablation, 24 months (n = 4); acetic acid ablation, 13 months (n = 17); oral chemotherapy, 26 months (n = 33), and combination therapy, 26 months (n = 32). Vascular invasion, Okuda staging and therapy were independent factors associated with survival. Treated patients had longer median survival compared to untreated ones (16 months vs. 7 months, p < 0.05).
Hepatitis B infection is the predominant cause of HCC in India. Serum alpha-fetoprotein was diagnostic in only one third of our patients. Most patients present late, when curative therapies are not possible. Treated patients had better survival than untreated ones.
Hepatocellular carcinoma and cirrhosis frequently coexist. In populations with a low incidence of hepatocellular carcinoma, the tumor often arises as a complication of long-standing symptomatic cirrhosis, which may be micronodular or macronodular and which is usually alcoholic in origin, and cirrhosis per se is the major etiologic association of the tumor. The relation between these two pathologic conditions in populations with a high incidence of hepatocellular carcinoma has not hitherto been analyzed. In this study the association was examined in 463 southern African black men with hepatocellular carcinoma. Cirrhosis, almost always macronodular and rarely showing features of alcholic toxicity, was present in 63.1% of the patients. No differences were found in the age structure, clinical features, hepatic function, serum alpha-fetoprotein concentrations, or hepatitis B virus status between patients with hepatocellular carcinoma with and without cirrhosis. Patients with cirrhosis survived slightly longer, but the difference was not biologically significant. It is concluded that the relation between hepatocellular carcinoma and cirrhosis in southern African blacks differs substantially from that in low incidence regions of the tumor.
In a series of 282 cases of primary carcinoma of the liver in Uganda Africans particular attention was paid to the histology of liver cell and bile duct carcinomas, to differences in their natural history and to results of serological testing for alpha fetoprotein (AFP). Liver cell carcinoma was a tumor of younger males and was commonly associated with cirrhosis. Four main histologic types were distinguished: the hepatic type showed a plate like pattern of growth with a scanty stroma of thin walled sinusoids and cellular characteristics that were often strongly reminiscent of the normal liver; bile secretion was rare, but finely granular glycogen was sometimes seen in the cytoplasm of the tumor cells; the pleomorphic type tended to grow in a solid fashion and was composed of bizarre and multinucleate cells; the adenoid type had a seemingly glandular pattern of ducts and cysts that was due, in most instances, to central breakdown in an otherwise solid growth; the rare clear cell type was heavily laden with glycogen. In nearly half of these tumors there were no metastases present at death, which was often the result of rupture of the liver with massive intraperitoneal hemorrhage. By contrast intrahepatic bile duct carcinoma was a tumor of older people of both sexes and showed no association with cirrhosis. Most cases were well to moderately differentiated mucus secreting adenocarcinomas. Widespread dissemination to many organs was common and death was usually due to carcinomatosis. AFP was detected in 53 of 72 (73.6%) of liver cell carcinomas of all types, but in none of 7 bile duct carcinomas. A plea is made for discarding elaborate histogenetic classifications that do not distinguish clearly between liver cell and bile duct carcinomas. The importance of recognizing the 2 main forms of primary liver cancer in diagnosis, epidemiology and research is emphasized.
The proceedings of the UICC 17th International Cancer Congress, held in Rio de Janeiro in August, are now available on videotape. The following videos are available: Highlights of the Congress, Interviews with the Panels, Prostate Diseases (ICUD/UICC/WHO), Global Cancer Facts and Figures (Dr. Max Parkin), The Fatal Combination in Cancer Development: Self-Stimulation and Self-Renewal (Dr. Donald Metcalf), Viral Oncology: The HPV Story (Dr. Harald zur Hausen), Nature and Nurture (Sir Richard Doll), Metastases (Dr. Max Burger), Pain Management in Cancer (Dr. Charles Cleeland), Behavioral Science (Dr. David Hill), Eurotrial 40 (Dr. Marco Rosselli del Turco), History and Development of Intravenous Feeding and Use in Cancer Therapy (Dr. Jonathan Rhoads), Cytopathology (Dr. William Frable), Laparoscopic Surgery (Dr. Bruce Ramshaw), Radiology for the Year 2000 (Dr. Carl d'Orsi), Breast Cancer (Dr. Kirby Bland), Rectal Cancer (Dr. Glen Steele), Prostate Cancer (Dr. Michael Brawer), Cervical Cancer (Dr. Hervy Averette), Lymphoma (Dr. Charles Coltman), Chronic Leukemias (Dr. Heinz Ludwig), and Soft Tissue Sarcoma (Dr. Murray Brennan).
Estimates from the year 2000 indicate that liver cancer remains the fifth most common malignancy in men and the eighth in women worldwide. The number of new cases is estimated to be 564,000 per year, including 398,000 in men and 166,000 in women. In high-risk countries, liver cancer can arise before the age of 20 years, whereas, in countries at low risk, liver cancer is rare before the age of 50 years. Rates of liver cancer in men are typically 2 to 4 times higher than in women. The incidence of primary liver cancer is increasing in several developed countries, including the United States, and the increase will likely continue for some decades. The trend is a result of a cohort effect related to infection with hepatitis B and C viruses, the incidence of which peaked in the 1950s to 1980s. In selected areas of some developing countries, the incidence of primary liver cancer has decreased, possibly as a result of the introduction of hepatitis B virus vaccine. The geographic variability in incidence of primary liver cancer is largely explained by the distribution and the natural history of the hepatitis B and C viruses. The attributable risk estimates for the combined effects of these infections account for well over 80% of liver cancer cases worldwide. Primary liver cancer is the first human cancer largely amenable to prevention using hepatitis B virus vaccines and screening of blood and blood products for hepatitis B and C viruses.
Estimates of the worldwide incidence, mortality and prevalence of 26 cancers in the year 2002 are now available in the GLOBOCAN series of the International Agency for Research on Cancer. The results are presented here in summary form, including the geographic variation between 20 large "areas" of the world. Overall, there were 10.9 million new cases, 6.7 million deaths, and 24.6 million persons alive with cancer (within three years of diagnosis). The most commonly diagnosed cancers are lung (1.35 million), breast (1.15 million), and colorectal (1 million); the most common causes of cancer death are lung cancer (1.18 million deaths), stomach cancer (700,000 deaths), and liver cancer (598,000 deaths). The most prevalent cancer in the world is breast cancer (4.4 million survivors up to 5 years following diagnosis). There are striking variations in the risk of different cancers by geographic area. Most of the international variation is due to exposure to known or suspected risk factors related to lifestyle or environment, and provides a clear challenge to prevention.
Hepatocellular carcinoma (HCC) is a complication of liver cirrhosis caused by hepatitis B viral infection, fungal infection and genetic factors. This disease though having a silent course is associated with variable morbidity and mortality in this environment.
Previously prepared histologic slides were retrieved and re-evaluated to confirm the diagnosis. Clinical data such as the age, sex, clinical presentations, histologic grading and cause of death were extracted from the case notes, histology request forms and autopsy protocol forms.
Seventy five cases were used for the study during the period under review. The youngest was a 14 year old male while the oldest was a 66 years old male. Male to female ratio was 2:1. Majority (28%) occurred in the age group 40-49 years. Upper abdominal mass was the most common clinical presentation (30.7%) and well differentiated hepatocellular carcinoma was the most common (64.0%) histologic grade. Trabecular inusoidal pattern (49.3%) was the most common histologic type (pattern) while upper gastro-intestinal bleeding (38.7%) was the most common cause of death at autopsy.
Hepatocellular carcinoma is a notable malignancy of the liver associated with variable morbidities and mortality as it has an insidious onset and very aggressive course.
Cancer is an under-emphasised issue in Africa, partly because of the overwhelming burden of communicable diseases. However cancer is a common disease in Africa with 650 000 people, of a population of 965 million, diagnosed annually. Furthermore, the lifetime risk in females (between 0 and 64 years) of cancer is about 10%, which is only about 30% lower than the risk in developed countries. In females, the lifetime risk of dying from cancer in Africa is almost double the risk in developed countries. This Review is the first of two papers and focuses on the current knowledge of the distribution and trends of the most common cancers in Africa. The cancers with the highest incidence are cervical, breast, and now HIV-associated Kaposi's sarcoma. The top five cancers in males--Kaposi's sarcoma (constituting 12.9% of all cancers in males) and cancer of the liver (14.8%), prostate (9.5%), bladder (6.1%), and non-Hodgkin lymphoma (5.7%)--and in females--cancer of the cervix (constituting 23.3% of all cancers in females) and breast (19.2%), Kaposi's sarcoma (5.1%), cancer of the liver (5.0%), and non-Hodgkin lymphoma (3.7%)--are discussed in detail. The second paper will focus on the causes and control of cancer in Africa. The cancer burden in Africa is likely to increase as a result of increases in HIV-associated cancers, changes in lifestyles associated with economic development, and the increasing age of the population (despite AIDS). Although the knowledge of cancer in this region is improving, better surveillance of cancer incidence, mortality, and prevalence of risk factors is urgently needed to monitor the development of the cancer epidemic, formulate appropriate cancer-control strategies, and assess the outcomes of these strategies.
Performance status assessment in cancer patients. an inter-observer variability study
- J B Sorensen
- M Klee
- T Palshof
- JB Sorensen
Primary liver cancer: worldwide incidence and trends
- F X Bosch
- J Ribes
- M Diaz
- FX Bosch