Most cancers occur in developing countries, and therefore, a discussion about cancer care would be incomplete without providing a developing world perspective. This chapter focuses on challenges and practices relating to hypopharyngeal cancer in limited-resource public healthcare systems in developing countries and specifically in Sub-Saharan Africa, India and South America and by extension, most patients in the developing world. Management of hypopharyngeal cancer must be adapted to the availability of specialised diagnostic and therapeutic services, radiotherapy and surgical expertise, and tailored to patient factors such as reliability of follow-up and social support. A particular challenge for physicians is to decide who can be denied the opportunity to be cured when the burden of cancer cases exceeds available resources. Public education campaigns about reducing risk factors for hypopharyngeal cancer are an important aspect of reducing the burden of cancer.

PURPOSE: To determine the feasibility, safety, and tolerability of concomitant chemoradiotherapy administered at standard doses in HIV-infected women with locally-advanced cervical cancer (LACC) receiving antiretroviral therapy (ART).
PATIENTS AND METHODS: Eligible participants had HIV infection and untreated, histologically-confirmed, invasive carcinoma of the uterine cervix, FIGO stages IB2, IIA (if tumor >4 cm), IIB, IIIA, IIIB, or IVA and met standard eligibility criteria. Subjects were prescribed 41.4-45 Gy external beam radiation therapy followed by high dose rate brachytherapy concomitant with up to six weekly doses of cisplatin 40 mg/m2 and were followed for 12 months.
RESULTS: Sixty-four women were screened at two sites in sub-Saharan Africa, of whom 40 eligible participants were enrolled, for a screening ratio of 1.60. Of the 38 eligible participants who initiated study treatment, 31 (82%) completed treatment. By the 12-month follow-up visit, 7 women had died of disease and 29 of 31 (94%) returned for follow-up. One-year progression-free survival was 76.3% (95% CI, 59.4-86.9%), and did not significantly differ according to stage at entry (p = 0.581). Participant-reported adherence to ART was high; by 12 months, 93% of participants had an undetectable viral load. The most common grade 3 or 4 adverse event was decreased lymphocyte count that affected all treated participants. Non-hematologic serious adverse events were similar to those observed in women with LACC without HIV infection.
CONCLUSIONS: The majority of HIV-infected women with LACC can complete concomitant chemoradiotherapy with the same cisplatin dose used in HIV-uninfected women with comparable tolerability and high ART adherence while on treatment.

Introduction: Colon cancer is preventable. There is a plethora of data regarding epidemiology and screening guidelines, however this data is sparse from the African continent. Objective: we aim to evaluate the trends of colorectal cancer (CRC) in a native African population based on age at diagnosis, gender and stage at diagnosis.
Methods: We conducted a retrospective analysis of the Cancer Disease Hospital (CDH) registry in Zambia, Southern Africa.
Results: 377 charts were identified in the CDH registry between 2007 and 2015, of which 234 were included in the final analysis. The mean age at diagnosis was 48.6 years and 62% are males. Using descriptive analysis for patterns: mode of diagnosis was surgical in 195 subjects (84%), histology adenocarcinoma in 225 (96.5%), most common location is rectum 124 (53%) followed by sigmoid 31 (13.4%), and cecum 26 (11%). 122 subjects (54%) were stage 4 at diagnosis. Using the Spearman rank correlation, we see no association between year and stage at diagnosis (p = 0.30) or year and age at diagnosis (p = 0.92).
Conclusion: Colorectal cancer was diagnosed at a young age and late stage in the Zambian patients.

BACKGROUND AND METHODS: The prevention and control of breast cancer in sub-Saharan Africa (SSA) is an increasingly critical public health issue. Breast cancer is the most frequent female cancer in SSA and mortality rates from this disease are the highest globally. Breast cancer has traditionally been considered a disease of high-income countries, and programs for early detection have been developed and implemented in these settings. However, screening programs for breast cancer in SSA have been less effective than in high-income countries. This article reviews the literature on breast cancer in SSA, focusing on early detection practices. It then examines the case for and against mammography and other early detection approaches for breast cancer in SSA.
RESULTS: Women with breast cancer in SSA are younger compared with high-income countries. Most women present with advanced disease and because treatment options are limited, have poor prognoses. Delay between symptom onset and healthcare seeking is common. Engagement with early detection practices such as mammography and breast examination is low and contributes to late stage at diagnosis.
DISCUSSION: While early detection of breast cancer through screening has contributed to important reductions in mortality in many high-income countries, most countries in SSA have not been able to implement and sustain screening programs due to financial, logistical and sociocultural constraints. Mammography is widely used in high-income countries but has several limitations in SSA and is likely to have a higher harm-to-benefit ratio. Breast self-examination and clinical breast examination are alternative early detection methods which are more widely used by women in SSA compared with mammography, and are less resource intensive. An alternative approach to breast cancer screening programs for SSA is clinical downstaging, where the focus is on detecting breast cancer earlier in symptomatic women. Evidence demonstrates effectiveness of clinical downstaging among women presenting with late stage disease.
CONCLUSIONS: Approaches for early detection of breast cancer in SSA need to be context-specific. While screening programs with mammography have been effective in high-income countries, evidence suggests that other strategies might be equally important in reducing mortality from breast cancer, particularly in low-resource settings. There is a strong argument for further research into the feasability and acceptability of clinical downstaging for the control of breast cancer in SSA.

The fields of cell and gene therapy are moving rapidly towards providing innovative cures for incurable diseases. A current and highly topical example is immunotherapies involving T-cells that express chimeric antigen receptors (CAR T-cells), which have shown promise in the treatment of leukaemia and lymphoma. These new medicines are indicative of the changes we can anticipate in the practice of medicine in the near future. Despite their promise, they pose challenges for introduction into the healthcare sector in South Africa (SA), including: (i) that they are technologically demanding and their manufacture is resource intensive; (ii) that the regulatory system is underdeveloped and likely to be challenged by ethical, legal and social requirements that accompany these new therapies; and (iii) that costs are likely to be prohibitive, at least initially, and before economies of scale take effect. Investment should be made into finding novel and innovative ways to introduce these therapies into SA sooner rather than later to ensure that SA patients are not excluded from these exciting new opportunities.

Cervical cancer is responsible for one-quarter of a million deaths per year worldwide. In South Africa (SA), cervical cancer is the leading cause of cancer deaths among women aged 15 - 44 years. Human papillomavirus (HPV) vaccines provide a safe and highly effective means to reduce the burden of cervical cancer. The World Health Organization initiated a plan for the elimination of cervical cancer; the programme's success relies on the introduction and high uptake of HPV vaccines globally. SA introduced a school-based HPV vaccination programme in 2014, but uptake is not as high as expected. Suboptimal HPV vaccination coverage may result from various factors, including vaccine hesitancy. Vaccine-hesitant parents may delay or refuse HPV vaccination for their daughters. Tailored interventions are needed to address this. However, knowledge regarding vaccine hesitancy and policies to address this hesitancy in SA are currently limited. While SA has taken commendable steps in cervical cancer prevention by implementing and financing the HPV vaccination programme, it is imperative that there are clear policies in place to help strengthen the programme. These policies need to clarify areas of uncertainty that may lead to mistrust, and pre-empt factors that will cause hesitancy. Equally important is that local research should be conducted to better understand HPV vaccination hesitancy and other determinants of uptake to further inform and shape national policies.

PURPOSE: Breast cancer is the most frequently diagnosed cancer and leading cause of cancer death among women, representing a considerable public health burden in South Africa and other low-middle income countries. Short- and long-term complications of these treatments include shoulder morbidities such as pain, decreased range of motion, tightness, weakness, pain, numbness and lymphoedema and may be present for up to 6 years post-treatment. An understanding of baseline demographic and clinical risk factors can guide rehabilitation and management strategies for high-risk patients. The aims of this study were to quantify the burden of shoulder pain and disability in a tertiary academic hospital in Cape Town, South Africa, and identify potential risk factors for the development of shoulder morbidity.
METHODS: This study was a cross-sectional analysis of the prevalence of shoulder pain and dysfunction in women attending their post-treatment annual follow-up visit for unilateral breast carcinoma.
RESULTS: Three in four patients reported a presence of any pain or disability while only 9% experienced severe pain and disability. Multivariable ordinal logistic regression analysis identified race, side, axillary surgery, chemotherapy and age as significant predictors of pain and chemotherapy a significant predictor of disability.
CONCLUSION: The substantial burden of shoulder morbidity in this population represents a significant public health burden. The use of identified clinical and demographic characteristics may guide in the development of survivorship programmes incorporating surveillance and management of these high-risk patients.

Human immunodeficiency virus (HIV) is associated with an increased risk of developing Hodgkin lymphoma (HL). South Africa (SA) has the highest HIV prevalence rate in the world. There is currently no outcome-based data for HIV-associated HL from SA. A bone marrow database was compiled of all bone marrow biopsies (BMB) reported at National Health Laboratory Service (NHLS) Groote Schuur Hospital (GSH) between January 2005 and December 2012. Patients who had a BMB performed for staging of HL or where HL was diagnosed on the BMB were included for further analysis. Clinical and laboratory data was extracted from medical and laboratory records. Primary outcome measures included histological subtype, bone marrow infiltration (BMI) by HL, CD4 count, HIV-viral load (HIV-VL), tuberculosis (TB) data, treatment with chemotherapy and 5-year overall survival (OS). The database included 6569 BMB and 219 patients of these had HL and were included for analysis. The median age at presentation (32 years) was similar in the HIV+ and HIV- populations. While males predominated in the HIV- group, females predominated in the HIV+ group (male:female ratio of 1.5:1 vs 0.7:1, respectively). The majority of patients (71%) were HIV negative (HIV-) and 29% were HIV positive (HIV+). The diagnosis of HL was made on BMB in 17% of cases. BMI was seen in 37% (82/219) overall, and was found in more HIV+ patients (61%; 39/64) than HIV- patients (28%; 43/155; p = 0.03). The histological subtype varied according to HIV status with nodular sclerosis classical Hodgkin lymphoma (NSCHL) being most frequent in the HIV- group and classical Hodgkin lymphoma (CHL)-unclassifiable the most frequent in the HIV+ group. HIV+ patients had a median CD4 count of 149 × 10

Human papillomavirus (HPV) is the most common sexually transmitted viral infection. HPV can cause cervical cancer and other cancers of the genitals, neck and throat. Two HPV vaccines are available, Cervarix and Gardasil, which are the first vaccines directed at the prevention of cervical cancer. The purpose of the study was to assess the knowledge of human papilloma virus and HPV vaccine among rural women in Vhembe district in Limpopo Province. A quantitative descriptive approach was adopted. The quantitative design enabled the discovery of more information by means of direct questioning of a sample of women 30years and older. A convenience sampling was used to select 1546 respondents. Data was analysed using the Statistical Package for Social Sciences. The findings revealed that (97.8%) of women lacked knowledge about Human Papilloma Virus and HPV vaccine and were also not aware of the transmission methods of HPV virus. Furthermore (94.3%) were not aware who was eligible for HPV vaccine and the age range for vaccination and (92.1%) displayed negative attitudes to the use of vaccines if given a pamphlet to let their daughters be immunized. The awareness on human papilloma virus and HPV vaccine among women in Vhembe district is limited. There is a need to educate and promote awareness on cervical cancer screening methods among women to reduce the burden of morbidity and mortality.

OBJECTIVES: To quantify the epidemiology of bladder cancer in Africa to guide a targeted public health response and support research initiatives.
METHODS: We systematically searched publicly available sources for population-based registry studies reporting the incidence of bladder cancer in Africa between January 1980 and June 2017. Crude incidence rates of bladder cancer were extracted. A Bayesian network meta-analysis model was used to estimate incidence rates.
RESULTS: The search returned 1328 studies. A total of 22 studies carried out across 15 African countries met our pre-defined selection criteria. Heterogeneity across studies was high (I
CONCLUSIONS: The present study suggests a growing incidence of bladder cancer in Africa in recent years, particularly among men and in North Africa. This study also highlights the lack of quality data sources and collection of essential clinical and epidemiological data in several African countries, and this hinders public health planning.

BACKGROUND: Cervical cancer incidence is significant in countries, such as South Africa, with high burdens of both HIV and human papillomavirus (HPV). Cervical cancer is largely preventable if dysplasia is diagnosed and treated early, but there is debate regarding the best approaches for screening and treatment, especially for low-resource settings. Currently South Africa provides Pap smears followed by colposcopic biopsy and LEEP if needed in its public health facilities. We estimated the costs and cost-effectiveness of two approaches for treating cervical intraepithelial neoplasia grade 2 or higher (CIN2+) among HIV-infected women, most of whom were taking antiretroviral treatment, at a public HIV treatment facility in Johannesburg, South Africa.
METHODS: Method effectiveness was derived from an intention-to-treat analysis of data gathered in a clinical trial completed previously at the study facility. In the trial, women who were diagnosed with CIN2+ and eligible for cryotherapy were randomized to cryotherapy or LEEP. If women were CIN2+ at six months as determined via Pap smear and colposcopic biopsy, all women-regardless of their original treatment assignment-received LEEP. "Cure" was then defined as the absence of disease at 12 months based on Pap smear and colposcopic biopsy. Health service costs were estimated using micro-costing between June 2013 and April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered, and results from an as-treated analysis were considered in sensitivity analysis.
RESULTS: In total, 166 women with CIN2+ were enrolled (86 had LEEP; 80 had cryotherapy). At 12 months, cumulative loss to follow-up was 12.8% (11/86) for the LEEP group and 13.8% (11/80) for cryotherapy. Based on the unadjusted intention-to-treat analysis conducted for this economic evaluation, there was no significant difference in efficacy. At 12 months, 83.8% (95% CI 73.8-91.1) of women with CIN2+ at baseline and randomized to cryotherapy were free of CIN2+ disease. In contrast, 76.7% (95% CI 66.4-85.2) of women assigned to LEEP were free from disease. On average, women initially treated with cryotherapy were less costly per patient randomized at US$ 118.00 (113.91-122.10), and per case "cured" at US$ 140.90 (136.01-145.79). Women in the LEEP group cost US$ 162.56 (157.90-167.22) per patient randomized and US$ 205.59 (199.70-211.49) per case cured. In the as-treated analysis, which was based on trial data, LEEP was more efficacious than cryotherapy; however, the difference was not significant. Cryotherapy remained more cost-effective than LEEP in all sensitivity and scenario analyses.
CONCLUSIONS: For this cost-effectiveness analysis, using an intention-to-treat approach and taking into consideration uncertainty in the clinical and cost outcomes, a strategy involving cryotherapy plus LEEP if needed at six months was dominant to LEEP plus LEEP again at six months if needed for retreatment. However, compared to other studies comparing LEEP and cryotherapy, the efficacy results were low in both treatment groups-possibly due to the HIV-positivity of the participants. Further research is needed, but at present choosing the "right" treatment option may be less important than ensuring access to treatment and providing careful monitoring of treatment outcomes.

Delleman syndrome is a rare congenital disorder. We report an 8-month old female with a history of a fleshy mass covering the left eye since birth. Examination revealed poor vision in the left eye, an upper lid coloboma and an epibulbar dermoid with a large area of alopecia and scalp hypoplasia involving the left frontoparietal region. Transfontanelle ultrasound scan did not reveal any intracranial cyst. Cranial computerised tomography subsequently revealed characteristic cerebral malformations of Delleman syndrome. This report demonstrates clinical and computed tomographic features of a case of Delleman syndrome with emphasis on the usefulness of transfontanelle ultrasonography in assessing for life-threatening intracerebral cysts or hydrocephalus, particularly in resource-limited settings, where neuroimaging is not readily available or affordable.

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

Background: Cancer of the bladder is the ninth leading cause of cancer in developed countries. It is the second most common urological malignancy. Transitional cell carcinoma (TCC) is the most common histological subtype in developed countries. In most of Africa, the most common type is squamous cell carcinoma (SCC). Cancer of bladder guidelines produced by the European Urological Association and the American Urological Association, including the tumor, node, and metastasis staging is focused on TCC of the bladder.
Objectives: The purpose of the study is to review the pathogenesis, pathology, presentation, and management of cancer of the bladder in Africa and to use this information to propose a practical staging system for SCC.
Methods: The study used the meta-analysis guideline provided by PRISMA using bladder cancer in Africa as the key search word. The study collected articles available on PubMed as of July 2017, Africa Online and Africa Index Medicus. PRISMA guidelines were used to screen for full-length hospital-based articles on cancer of the bladder in Africa. These articles were analyzed under four subcategories which were pathogenesis, pathology, clinical presentation, and management. The information extracted was pooled and used to propose a practical staging system for use in African settings.
Results: The result of evaluation of 821 articles yielded 23 full-length papers on hospital-based studies of cancer of the bladder in Africa. Cancer of the bladder in most of Africa is still predominantly SCC (53%-69%). There has been a notable increase in TCC in Africa (9%-41%). The pathogenesis is mostly schistosoma-related SCC presents late with painful hematuria and necroturia (20%). SCC responds poorly to chemotherapy or radiotherapy. The main management of SCC is open surgery. This review allowed for a practical organ-based stage of SCC of the bladder that can be used in Africa.
Conclusion: Bladder cancer in Africa presents differently from that in developed countries. Guidelines on cancer of the bladder may need to take account of this to improve bladder cancer management in Africa.

Michael Kew's academic career spans five decades, representing the most proliferative and pioneering years of the expanded knowledge on all aspects of hepatocellular cancer (HCC). The preceding articles in this Festschrift bear testimony to his legacy, engagement, enthusiasm, dedication and ability to inspire others. His enormous contribution, mostly originating from research in sub-Saharan Africa (SSA), contributed immensely to the knowledge and evidence on which current understanding of the disease is based.

Hepatocellular carcinoma (HCC) originates from hepatocytes usually secondary to chronic inflammation and cirrhosis. It is an important disease of global significance with a high incidence and mortality. It is the fifth and eighth most common cancer in males and females, respectively. HCC is also extremely lethal; in 2015 it was the second and sixth most common cause of death from cancer in males and females, respectively. Chronic viral hepatitis B and C are the most frequent risk factors for the development of HCC, and the global distribution of HCC largely mirrors that of chronic viral hepatitis. More recently, there has been a notable increase in the incidence of HCC as a result of obesity-related fatty liver disease. Here, we review the epidemiology of HCC, examine recent advances in our understanding of the pathogenesis of HCC, discuss the implications for identification of potential therapeutic targets, and provide the most updated recommendations on surveillance for HCC, with particular attention to the unique challenges and potential opportunities to reduce the burden of illness and death from HCC in sub-Saharan Africa.

Human herpes virus type 8 (HHV-8) is the causative agent of Kaposi's sarcoma (KS). We systematically reviewed literature published between 1998 and 2017, according to the PRISMA guidelines, to understand the distribution of HHV-8 infection in Africa. More than two-thirds (64%) of studies reported on seroprevalence and 29.3% on genotypes; 9.5% were on both seroprevalence and genotypes. About 45% of African countries had data on HHV-8 seroprevalence exclusively, and more than half (53%) had data on either seroprevalence or genotypes. Almost half (47%) of the countries had no data on HHV-8 infection. There was high heterogeneity in the types of tests and interpretation algorithms used in determining HHV-8 seropositivity across the different studies. Generally, seroprevalence ranged from 2.0% in a group of young children in Eritrea to 100% in a small group of individuals with KS in Central African Republic, and in a larger group of individuals with KS in Morocco. Approximately 16% of studies reported on children. Difference in seroprevalence across the African regions was not significant (95% CI, χ² = 0.86;

Female genital mutilation or cutting (FGM/C) is a traditional practice that affects a significant portion of women in sub-Saharan Africa, Egypt, areas of the Middle East and some countries in Asia. While clinical and epidemiological studies have established a close association between inflammation and carcinogenesis, particularly in epithelial cancers, the relationship between FGM/C and cervical cancer is not well known. We performed a secondary analysis using combined data from six research studies conducted in and around Dakar, Senegal from 1994 to 2012. Study subjects included both asymptomatic women who presented to outpatient clinics but were screened for cervical cancer, and women with cancer symptoms who were referred for cervical cancer treatment. We used unconditional logistic regression to estimate adjusted pooled odds ratios (ORs) and 95% confidence intervals (CI) for associations between FGM/C and (1) Invasive cervical cancer (ICC) and (2) noninvasive cervical abnormalities. After adjusting for confounding, women with ICC were 2.50 times more likely to have undergone FGM/C than women without cervical abnormalities (95% CI, 1.28-4.91). Restricting to HPV-positive women increased the strength of the association (OR = 4.23; 95% CI 1.73-10.32). No significant associations between FGM/C and noninvasive cervical abnormalities were observed, except in commercial sex workers with FGM/C (OR = 2.01; 95% CI 1.19-3.40). The potential increased risk for ICC suggested by our study warrants further examination. Study results may impact cancer prevention efforts in populations where FGM/C is practiced and draw awareness to the additional health risks associated with FGM/C.

The primary objective of the Ghana Polycystic Ovary Syndrome Epidemiology and Phenotype (Ghana-PEP) study will be to assess the relevance and phenotypic distribution of polycystic ovarian syndrome (PCOS) in a medically unbiased population of reproductive-aged women. In addition, the study will also attempt to identify sociodemographic, environmental, and psychological factors that may play a role in the development of PCOS phenotype. The study aims to recruit 990 randomly selected women aged 18-45 years living in Nsawam, the district capital of the Nsawam-Adoagyiri Municipality, in the Eastern region of Ghana. Participants will complete a questionnaire with the aid of trained personnel, undergo a physical examination, and undergo ultrasonography and biochemical evaluations relevant to PCOS. It is anticipated that the study will provide the population prevalence and phenotypes, and distribution of PCOS.

BACKGROUND: In South Africa (SA), liver cancer (LC) is a public health problem and information is limited.
METHODS: Joinpoint regression analysis was computed for the most recent LC mortality data from Statistics South Africa (StatsSA), by age group, sex and population group. The mortality-to-incidence ratios (MIRs) were calculated as the age-adjusted mortality rate divided by the age-adjusted incidence rate.
RESULTS: From 1999 to 2015, the overall LC mortality significantly decreased in men (- 4.9%) and women (- 2.7%). Overall a significant decrease was noted in black African men aged 20-29 and 40-49 years, and white women older than 60 years but mortality rates increased among 50-59 and 60-69 year old black African men (from 2010/2009-2015) and women (from 2004/2009-2015). The mortality rates increased with age, and were higher among blacks Africans compared to whites in all age groups - with a peak black African-to-white mortality rate ratio of six in men and three in women at ages 30-39 years. The average MIR for black African men and women was 4 and 3.3 respectively, and 2.2 and 1.8 in their white counterparts. Moreover, decreasing LC mortality rates among younger and the increase in rates in older black Africans suggest that the nadir of the disease may be near or may have passed.
CONCLUSIONS: Findings of population-age subgroup variations in LC mortality and the number of underdiagnosed cases can inform surveillance efforts, while more extensive investigations of the aetiological risk factors are needed.
IMPACT: There was a large race, sex and age differences in trends of LC mortality in SA. These findings should inform more extensive evaluation of the aetiology and risk factors of LC in the country in order to guide control efforts.

To protect women against cervical cancer, the World Health Organization recommends that women aged 30 to 49 years be screened with tests that detect human papillomavirus (HPV). If the countries that have the greatest burden of this disease-especially those in sub-Saharan Africa-are not to be left behind, we must understand the challenges they face and identify measures that can help them take full advantage now of innovations that are transforming screening services in wealthier countries. We reviewed policy documents and published literature related to Kenya, Tanzania, and Uganda, and met with key personnel from government and nongovernmental organizations. National policy makers understand the value of HPV testing in terms of its superior sensitivity and the programmatic advantages that could result from using self-collected samples. However, while these countries have national cervical cancer prevention strategies, and some have national departments or units for cervical cancer prevention, screening is rare, funding scarce, and quality low. Age guidelines are not strictly followed, with scarce resources being used to screen many women younger than the recommended ages. Published evidence of the benefits of HPV testing-including performance, safety, and cost-effectiveness-must be provided to ministry of health leaders, along with information on anticipated costs for training personnel, purchasing supplies, providing facility space, and maintaining test kits. Despite the obstacles, a joint effort on the part of global and national stakeholders to introduce molecular screening methods can bring better protection to the women who need it most.

Access to radiation facilities in low- and middle-income countries (LMIC) is far from optimal. Latin America and Africa represent 55% of LMIC, and radiation therapy facilities are available in only 70% and 46% of the countries, respectively. Only 3 countries in both regions meet the International Atomic Energy Agency's recommendation of 250,000 population per megavoltage machine (MVM). In Africa, the mean population served by 1 MVM is 3.56 million, compared with 0.65 million in Latin America. The distribution of radiation facilities in both regions varies according to income group. In Latin America, lower-middle-income countries have a distribution of 1.64 million inhabitants per MVM, as opposed to 0.64 and 0.49 million inhabitants per MVM in upper-middle- and high-income countries, respectively. In Africa, a distribution of 39.8, 2.47, and 0.8 million people per MVM is present in low-, lower-middle-, and upper-middle-income countries, respectively. Significant correlations were clearly demonstrated between population per MVM and gross domestic product (GDP) per capita (r = -0.3, P = .014), percentage of current health expenditure from GDP (r = -0.4, P = .014), life expectancy (r = -0.5, P = .0007), and cancer mortality incidence ratio (r = 0.4, P = .003). Stepwise multivariate regression showed that life expectancy was the only statistically significant factor (P = .001). These findings may indicate the detrimental impact of low radiation therapy coverage on life expectancy and cancer mortality incidence ratio in LMIC. It is noteworthy that in Latin America, a significant negative correlation was noted between population per MVM and GDP per capita (r = -0.6, P = .0004), as opposed to Africa (r = -0.4, P = .075). This indicates that African countries face challenges other than income level in addressing radiation therapy needs. More international efforts are urgently required to address the crisis of unmet radiation therapy needs in LMIC.

OBJECTIVE: This study evaluates the occurrence of the various morphological subtypes of hepatocellular carcinoma (HCC) and their connections with some risk factors in Cameroonian patients. The database of the 360 liver biopsies received and associated medical records were reviewed for histological and demographic analysis. Archival formalin-fixed and paraffin embedded liver biopsy specimens or slide were re-evaluated in malignancies patients. HCC classification was determined according to the World Health Organization criteria.
RESULTS: Malignancies were confirmed in 24.7% (89/360) of liver biopsies. Primary liver tumors consisted in 80 cases of HCC and one case of hepatoblastoma. The distribution of the morphological variants of HCC was trabecular pattern (n = 45/80, 56.25%), acinar/pseudoglandular (32.5%) or scirrhous (11.2%). Remarkably, liver steatosis was present in 60.0% (48/80) of patients with HCC, most of them infected with hepatitis C virus (75.8%). Well-differentiated trabecular tumors were significantly associated with important fibrotic and necro-inflammatory activities in livers (P = 0.008) whereas acinar pattern was more frequent on fatty livers (P = 0.02). Our finding indicates that in Middle Africa the morphology of HCC subtypes correlates with changes affecting non-tumor liver tissue. Trabecular subtype is installed by strong liver injury whereas acinar pattern is more often associated with lipid metabolism defects.

Cancers occurring in children in Africa are often underdiagnosed, or at best diagnosed late. As a result, survival is poor, even for cancers considered 'curable'. With limited population-level data, understanding the actual burden and survival from childhood cancers in Africa is difficult. In this study, we aimed at providing survival estimates for the most common types of cancers affecting children aged 0-14 years, in three population-based Eastern African registries; Harare, Zimbabwe (Kaposi sarcoma, Wilms tumour (WT), non-Hodgkin lymphoma (NHL), retinoblastoma, and acute lymphocytic leukaemia (ALL)), Kampala, Uganda (Burkitt lymphoma, Kaposi sarcoma, WT, and retinoblastoma), and Nairobi, Kenya (ALL, retinoblastoma, WT, Burkitt lymphoma, and Hodgkin lymphoma). We included cases diagnosed within the years 1998-2009 and followed up till the end of 2011. We estimated the observed and relative survival at 1, 3, and 5 years after diagnosis. We studied 627 individual patient records. Median follow-up ranged from 2.2 months for children with Kaposi sarcoma in Harare to 30.2 months for children with ALL in Nairobi. The proportion of children lost to follow-up was highest in the first year after diagnosis. In Harare and Kampala, the 5-year relative survival was <46% for all cancer types. The 5-year relative survival was best for children in Nairobi, though with wider confidence intervals. Survival from childhood cancers in Africa is still poor, even for cancers with good prognosis and potential for cure. Supporting cancer detection, treatment, and registration activities could help improve survival chances for children with cancers in Africa.

BACKGROUND: Women in sub-Saharan Africa have high dual burden of HPV and HIV infections, which can interact to increase cervical cancer (CC) risk. The 9-valent HPV (9vHPV) vaccine has high demonstrated effectiveness against HPV types causing 90% of CC. Additionally, one dose of the 9vHPV vaccine has the potential to achieve greater coverage at lower costs than a two-dose schedule. However, the potential impact of single-dose 9vHPV vaccine accounting for HPV-HIV interactions has not been estimated.
METHODS: We adapted a dynamic HIV transmission model to include HPV acquisition and CC pathogenesis and projected the impact of a single dose 9vHPV preadolescent vaccination in KwaZulu-Natal, South Africa. We report health impacts of HPV vaccination separately for HIV-positive women stratified by HIV treatment and CD4 count and HIV-negative women.
RESULTS: At 90% coverage of females age 9 years with 80% lifelong vaccine efficacy, single dose HPV vaccination was projected to reduce CC incidence by 74% and mortality by 71% in the general female population at 70 years after the start of the vaccination program. Age-standardized CC incidence and mortality reductions were comparable among HIV-negative women, HIV-positive women, and HIV-positive women on ART. Health benefits were reduced when assuming waning protection at 10, 15 and 20 years after vaccination.
DISCUSSION: Single dose 9vHPV vaccination is projected to avert substantial CC burden in South Africa and similar high HIV prevalence settings. Health benefits were comparable across all female subpopulations stratified by HIV status, CD4 count, and ART status.

HIV-related Kaposi sarcoma (KS) is common in sub-Saharan Africa, but optimal treatment strategies in resource-limited settings remain unclear. We did a retrospective cohort study of adults diagnosed with KS before initiating antiretroviral therapy (ART) at three ART programs in South Africa, Malawi and Zambia. We extracted data from medical charts at HIV clinics and oncological referral centers and used electronic data from the International epidemiology Databases to Evaluate AIDS Southern Africa. We used descriptive statistics to assess tumor (T) and systemic illness (S) stage and treatment of AIDS-KS patients. Kaplan-Meier analyses were used to assess survival after KS diagnosis. We analyzed data from 57 patients in total (20 from South Africa, 20 from Zambia, 17 from Malawi). Median age at KS diagnosis was 35 years and similar across sites. The percentage of patients with poor risk AIDS-KS (T1S1) was similar in South Africa (25%) and Malawi (24%) and higher in Zambia (45%). All AIDS-KS patients initiated ART at the HIV clinic. For KS care, in South Africa 18 patients (90%) were referred to an oncology department; in Malawi and Zambia most patients were managed by the HIV clinics. In Malawi and South Africa, most AIDS-KS patients received systemic chemotherapy, in Zambia one patient received chemotherapy at the HIV clinic. A year after KS diagnosis, 15 patients (75%) in South Africa, 10 patients (50%) in Zambia, and 8 patients (47%) in Malawi were still alive; another 3 patients (15%) in South Africa, 8 patients (40%) in Zambia and 4 patients (24%) in Malawi were lost to follow-up. Management of AIDS-KS patients varied considerably across sites in Malawi, South Africa and Zambia. We need more reliable survival data for AIDS-KS patients in sub-Saharan Africa before we can assess which treatments and clinical pathways should be adopted in a specific setting.

BACKGROUND: Burkitt lymphoma (BL) is the most common childhood cancer in Ghana, where the endemic variant is the predominant subtype and historically presents as a highly chemo-sensitive jaw tumor. This study aimed to update the current epidemiological characteristics of childhood BL in our institution.
PROCEDURE: Patient data for all children diagnosed with BL and seen at Korle Bu Teaching Hospital between January 2007 and December 2012 were retrospectively analyzed.
RESULTS: BL was diagnosed in 173 children (<13 years) during the study period, with the abdomen as the most common tumor site (46%) followed by the jaw (31%). Abdominal tumors were associated with advanced/disseminated disease (P = 0.002), and were more likely to occur in females irrespective of tumor stage (relative risk = 1.56 [95% CI; 1.1-12.3]). Twenty-five percent (43/173) of the study cohort died and mortality was influenced by increasing age (P = 0.02) and advanced disease (P = 0.03). Treatment delay was experienced by nine in ten patients primarily due to familial financial constraint (75%). Treatment abandonment was observed as a first event in 94% of patients and two thirds of children in the study were eventually lost to follow-up.
CONCLUSION: The predominance of primary abdominal tumors in our study cohort may indicate a changing epidemiological pattern of BL in Ghana. High rates of treatment delay and abandonment were evident and are likely to be contributing factors to the poor childhood cancer survival outcomes seen in resource-limited countries in Africa.

Fanconi anaemia (FA) is an inherited genetic disorder characterised by somatic anomalies, bone marrow failure and an increased predisposition to solid tumours and haematological malignancies. South African (SA) black and Afrikaner individuals are at higher than average risk for this condition owing to genetic founder mutations in certain Fanconi-associated genes. This review explores the epidemiology, clinical presentation, diagnostic modalities and recommended care of affected patients, focusing on the founder population groups in SA. The early diagnosis of FA is important and provides improved opportunities for early intervention, but remains challenging.

BACKGROUND: Ultraviolet (UV) radiation is the most important environmental risk factor for the development of nonmelanoma skin cancer (NMSC). UV radiation is, however, also vital in the formation of vitamin D in humans. Strict sun protection advised to skin cancer patients may lead to vitamin D deficiency, yet vitamin D may have a protective effect against cancer formation.
OBJECTIVES: The primary aim was to determine whether patients with nonmelanoma skin cancer at our institution were vitamin D deficient.
METHODS: 25-Hydroxyvitamin D (25[OH]D) levels were determined in 109 patients with a diagnosis of basal cell carcinoma (BCC) and/or squamous cell carcinoma (SCC) during the summer and winter of 2015 at the Tygerberg Academic Hospital in Cape Town, South Africa. Associations between clinical and epidemiological data and the 25(OH)D level results were investigated. Vitamin D deficiency was defined as total 25(OH)D levels <20 ng/mL (<50 nmol/L).
RESULTS: It was found that 49.5% of NMSC patients were vitamin D deficient, and 41.3% had insufficient vitamin D levels. Females were more likely than males to be vitamin D deficient (P = 0.047). Winter was significantly associated with vitamin D deficiency, compared to summer (OR = 4.81, 95%CI = 2.09-11.09, P <0.001). Having a previous SCC appeared associated with not being vitamin D deficient (OR = 0.46, 95%CI = 0.20-1.11, P = 0.084).
CONCLUSIONS: The findings highlight the need for the development of recommendations and guidelines on sun protection in patients with NMSC, while still ensuring an adequate vitamin D status. High risk factors included winter and female gender.

Cervical cancer (CC) is the leading cause of cancer death among female South Africans (SA). Improved access to reproductive health services following multi-ethnic democracy in 1994, HIV epidemic, and the initiation of CC population-based screening in early 2000s have influenced the epidemiology of CC in SA. We therefore evaluated the trends in CC age-standardised incidence (ASIR) (1994-2009) and mortality rates (ASMR) (2004-2012) using data from the South African National Cancer Registry and the Statistics South Africa, respectively. Five-year relative survival rates and average per cent change (AAPC) stratified by ethnicity and age-groups was determined. The average annual CC cases and mortalities were 4,694 (75,099 cases/16 years) and 2,789 (25,101 deaths/9 years), respectively. The ASIR was 22.1/100,000 in 1994 and 23.3/100,000 in 2009, with an average annual decline in incidence of 0.9% per annum (AAPC = -0.9%, p-value < 0.001). The ASMR decreased slightly by 0.6% per annum from 13.9/100,000 in 2004 to 13.1/100,000 in 2012 (AAPC = -0.6%, p-value < 0.001). In 2012, ASMR was 5.8-fold higher in Blacks than in Whites. The 5-year survival rates were higher in Whites and Indians/Asians (60-80%) than in Blacks and Coloureds (40-50%). The incidence rate increased (AAPC range: 1.1-3.1%, p-value < 0.001) among young women (25-34 years) from 2000 to 2009. Despite interventions, there were minimal changes in overall epidemiology of CC in SA but there were increased CC rates among young women and ethnic disparities in CC burden. A review of the CC national policy and directed CC prevention and treatment are required to positively impact the burden of CC in SA.