Several African countries have recently introduced or are currently introducing the HPV vaccine, either nationwide or through demonstration projects, while some countries are planning for introduction. A collaborative project was developed to strengthen country adolescent immunisation programmes and health systems in the African Region, addressing unique public health considerations of HPV vaccination: adolescents as the primary target group, delivery platforms (e.g. school-based and facility based), socio-behavioural issues, and the opportunity to deliver other health interventions alongside HPV vaccination. Following a successful "taking-stock" meeting, a training programme was drafted to assist countries to strengthen the integration of adolescent health interventions using HPV vaccination as an entry point. Two workshops were conducted in the Eastern and Southern African Regions. All countries reported on progress made during a final joint symposium. Of the 20 countries invited to participate in either of the workshops and/or final symposium, 17 countries participated: Angola, Botswana, Ethiopia, Kenya, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South Sudan, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Countries that are currently implementing HPV vaccination programmes, either nationally or through demonstration projects, reported varying degrees of integration with other adolescent health interventions. The most commonly reported adolescent health interventions alongside HPV vaccination include health education (including sexually transmitted infections), deworming and delivering of other vaccines like tetanus toxoid (TT) or tetanus diphtheria (Td). The project has successfully (a) established an African-based network that will advocate for incorporating the HPV vaccine into national immunisation programmes; (b) created a platform for experience exchange and thereby contributed to novel ideas of revitalising and strengthening school-based health programmes as delivery platform of adolescent immunisation services and other adolescent health interventions, as well as identifying ways of reaching out-of-school girls through facility and community based programmes; and (c) laid a foundation for incorporating future adolescent vaccination programmes.

OBJECTIVE: Disagreement in mammographic breast density (MBD) assessment can impact breast cancer risk stratification, choices of further breast cancer screening intervals and pathways. This study examines whether intercountry MBD expectations and assessment approaches are associated with differences in MBD assessment.
METHODS: 20 American Board of Radiology (ABR) examiners and 24 UK practitioners using the 4th edition BI-RADS
RESULTS: Strong positive correlation was observed between the study cohorts on a binary scale (1-2 vs 3-4) [ABR examiners and RANZCR radiologists (ρ = 0.950); ABR examiners and UK practitioners (ρ = 0.940); and RANZCR radiologists and UK practitioners (ρ = 0.958)]. ABR and RANZCR radiologists demonstrated slight agreement [κ
CONCLUSION: Findings demonstrate wide international and interobserver variability in MBD assessment. This level of variability underscores the need for automation and standardization of MBD assessment. Advances in knowledge: Intercountry analysis of MBD assessment shows variations, with less variation on the binary scale than on the 4-point scale. With this level of variation, automation and standardization of MBD assessment becomes more appropriate.

AIM: The reasons for pre-hospital delay of the diagnosis of cancer are multifactorial, but include a physician-related component. Urgent cancer pathways and direct-to-test approaches have been implemented, but the emergency presentation of colorectal cancer (CRC) remains little changed over recent years. We examined the variability between primary care providers in referral patterns and its effect on outcome.
METHOD: A retrospective analysis was performed of a prospectively maintained database for 2009-2014 in a UK district hospital providing bowel cancer screening and tertiary rectal cancer services.
RESULTS: Of 1145 CRC patients, 937 (81.8%) were diagnosed with a symptomatic cancer; 229/937 (24.4%) initially presented as an emergency. Between 44 primary care providers, emergency presentation varied between 8.3% and 57.1%. Patients of providers with high levels of emergency presentations (HV) had more advanced cancers than those of providers with medium (MV) or low levels (LV) [103/253 (40.7%), 154/461 (33.4%), 65/223 (29.1%); P = 0.025] and a lower 3-year overall survival (50.2%, 57.8%, 65.6%; P = 0.013), but with no difference in case-mix or deprivation levels. In adjusted analysis, this difference remained significant (advanced disease, OR 1.663, P = 0.011; 3-year hazard ratio 1.479, P = 0.010; comparing HV with LV). Conversely, elective suspected cancer referrals were less often used amongst diagnosed cancers [LV 136/223 (61.0%), MV 228/461 (49.5%), HV 114/253 (45.1%), P < 0.001] with limited evidence for a more selective approach in the use of the 2-week rule amongst all 2-week rule referrals [LV 136/2508 (5.4%); MV 228/4239 (5.4%); HV 115/1526 (7.8%); positive cancer diagnosis, P = 0.005].
CONCLUSION: Significant variability in emergency presentation of CRC requires local audit and examination of the reasons for delay in diagnosis and targeted measures to improve performance in non-emergency referral pathways.

INTRODUCTION: Sub-Saharan African (SSA) women with breast cancer (BC) have low survival rates from this potentially treatable disease. An understanding of context-specific societal, health-systems and woman-level barriers to BC early detection, diagnosis and treatment are needed.
METHODS: The African Breast Cancer-Disparities in Outcomes (ABC-DO) is a prospective hospital-based study of overall survival, impact on quality of life (QOL) and delays along the journey to diagnosis and treatment of BC in SSA. ABC-DO is currently recruiting in Namibia, Nigeria, South Africa, Uganda and Zambia. Women aged 18 years or older who present at participating secondary and tertiary hospitals with a new clinical or histocytological diagnosis of primary BC are invited to participate. For consented women, tumour characteristics, specimen and treatment data are obtained. Over a 2-year enrolment period, we aim to recruit 2000 women who, in the first instance, will be followed for between 1 and 3 years. A face-to-face baseline interview obtains information on socioeconomic, cultural and demographic factors, QOL, health and BC attitudes/knowledge, and timing of all prediagnostic contacts with caregivers in orthodox health, traditional and spiritual systems. Responses are immediately captured on mobile devices that are fed into a tailored mobile health (mHealth) study management system. This system implements the study protocol, by prompting study researchers to phone women on her mobile phone every 3 months and, failing to reach her, prompts contact with her next-of-kin. At follow-up calls, women provide updated information on QOL, care received and disease impacts on family and working life; date of death is asked of her next-of-kin when relevant.
ETHICS AND DISSEMINATION: The study was approved by ethics committees of all involved institutions. All participants provide written informed consent. The findings from the study will be published in peer-reviewed scientific journals, presented to funders and relevant local organisations and at scientific conferences.

RATIONALE AND OBJECTIVES: To investigate agreement on mammographic breast density (MD) assessment between automated volumetric software and Breast Imaging Reporting and Data System (BIRADS) categorization by expert radiologists.
MATERIALS AND METHODS: Forty cases of left craniocaudal and mediolateral oblique mammograms from 20 women were used. All images had their volumetric density classified using Volpara density grade (VDG) and average volumetric breast density percentage. The same images were then classified into BIRADS categories (I-IV) by 20 American Board of Radiology examiners.
RESULTS: The results demonstrated a moderate agreement (κ = 0.537; 95% CI = 0.234-0.699) between VDG classification and radiologists' BIRADS density assessment. Interreader agreement using BIRADS also demonstrated moderate agreement (κ = 0.565; 95% CI = 0.519-0.610) ranging from 0.328 to 0.669. Radiologists' average BIRADS was lower than average VDG scores by 0.33, with their mean being 2.13, whereas the mean VDG was 2.48 (U = -3.742; P < 0.001). VDG and BIRADS showed a very strong positive correlation (ρ = 0.91; P < 0.001) as did BIRADS and average volumetric breast density percentage (ρ = 0.94; P < 0.001).
CONCLUSIONS: Automated volumetric breast density assessment shows moderate agreement and very strong correlation with BIRADS; interreader variations still exist within BIRADS. Because of the increasing importance of MD measurement in clinical management of patients, widely accepted, reproducible, and accurate measures of MD are required.

OBJECTIVES: We examined the influence of knowledge and information, health care access and different socio-economic variables on women's decision to screen for cervical cancer using a nationally representative dataset.
METHODS: We use hierarchical binary logit regression models to explore the determinants of screening for cervical cancer among women who reported hearing about cervical cancer. This enabled us to include the effect of unobserved heterogeneity at the cluster level that may affect screening behaviors.
RESULTS: Among women who have heard about cervical cancer (N=6542), only 39% of them did undergo screening with a mean age of 33 years. The univariate results reveal that women who are educated, insured, can afford money needed for treatment and reported distance not a barrier to accessing healthcare were more likely to screen. Our multivariate results indicate that insured women (OR=1.89, p=0.001) and women who had access to information through education and contact with a health worker (OR=1.41, p=0.001) were more likely to undertake screening compared to uninsured women and those with no contact with a health personnel, after controlling for relevant variables.
CONCLUSIONS: The adoption of a universal health insurance scheme that ensures equity in access to health care and extension of public health information targeting women in rural communities especially within the Caprivi region may be needed for a large scale increase in cervical cancer screening in Namibia.

INTRODUCTION: Childhood cancer is rare and comprises only 1% of all cancers. The current incidence of childhood cancer in Namibia, as in many other African countries, is not known. The aim of this research was to assess the paediatric cancer incidence between 2003-2010 at Windhoek Central Hospital, the only pediatric oncology-referring centre in Namibia and to compare with the previous calculated incidence in the country 20 years ago.
METHODS: A retrospective, descriptive review of the paediatric oncology cases presenting to Windhoek Central Hospital between 2003 and 2010 was undertaken, and data regarding age, sex, cancer type, area of residence were extrapolated. In this study due to the appearance of the HIV epidemic, an HIV incidence was also calculated.
RESULTS: The incidence rate of all paediatric recorded cancers was 29.4 per million. Leukaemias (22.5%) and retinoblastomas (16.2%) were the most common tumours, with renal tumours, soft tissue sarcomas and lymphomas following in frequency. HIV incidence of children with malignancy was 6.8%.
CONCLUSION: The incidence rates of cancers in this study are remarkably lower compared to a similar study done in the country 20 years ago. Many cancers are still not diagnosed or reported, and others are not treated in the country. The institution of a "twinning programme" between the paediatric haematological/oncological departments in Windhoek and Tygerberg Hospital in Cape Town, South Africa, will contribute to improvement of childhood cancer cases. This twinning programme includes the formation of a cancer registry.

BACKGROUND: Receptor-defined breast cancer proportions vary across Africa. They have important implications for survival prospects and research priorities.
METHODS: We studied estrogen receptor (ER), progesterone receptor (PR), and HER2 receptor statuses in two multiracial Southern African countries with routine diagnostic immunohistochemistry. A total of 12,361 women with histologically confirmed breast cancer diagnosed at age ≥20 years during (i) 2009-2011 from South Africa's national cancer registry (public sector) and (ii) 2011-2013 from Namibia's only cancer hospital were included. Crude, age, and age + laboratory-adjusted ORs of receptor status were analyzed using logistic regression, and age-incidence curves were analyzed using Poisson regression.
RESULTS: A total of 10,047 (81%) women had known ER status. Ranking of subtypes was consistent across races: ER(+)/PR(+)HER2(-) was most common (race-specific percentage range, 54.6%-64.8%), followed by triple-negative (17.4%-21.9%), ER(+)/PR(+)HER2(+) (9.6%-13.9%), and ER(-)PR(-)HER2(+) (7.8%-10.9%). Percentages in black versus white women were 33.8% [95% confidence (CI), 32.5-35.0] versus 26.0% (24.0-27.9) ER(-); 20.9% (19.7-22.1) versus 17.5% (15.4-19.6) triple-negative; and 10.7% (9.8-11.6) versus 7.8% (6.3-9.3) ER(-)PR(-)HER2(+). Indian/Asian and mixed-ancestry women had intermediate values. Age-incidence curves had similar shapes across races: rates increased by 12.7% per year (12.2-13.1) across ER subtypes under the age of 50 years, and thereafter slowed for ER(+) (1.95%) and plateaued for ER(-) disease (-0.1%).
CONCLUSIONS: ER(+) breast cancer dominates in all Southern African races, but black women have a modest excess of aggressive subtypes.
IMPACT: On the basis of the predominant receptor-defined breast tumors in Southern Africa, improving survival for the growing breast cancer burden should be achievable through earlier diagnosis and appropriate treatment.

AIMS: To investigate patterns of practice in palliative radiotherapy in Africa.
MATERIALS AND METHODS: Fifteen centres in Africa provided detailed information about radiotherapy in both metastatic and locally advanced disease via a questionnaire. Information included general information (institution status, equipment, staff, patient number), radiotherapy and other treatment characteristics in bone metastasis, brain metastasis, metastatic spinal cord compression, lung and liver metastasis, as well as locally advanced tumours.
RESULTS: The number of patients annually seen/treated ranged from 285 to 5000. Breast, cervix, head and neck, gastrointestinal and prostate cancer were the top five cancers overall. Eight (53%) institutions were without linear accelerators, four (27%) had a single one, whereas one institution each had two, three and four linear accelerators. The number of cobalt machines ranged from 0 to 2 (median 1). Most centres still prefer to use fractionated radiotherapy regimens over single-fraction regimens in bone metastasis, although most centres are now using single-fraction radiotherapy in retreatments. Radiotherapy in brain metastasis and metastatic spinal cord compression mostly conform to worldwide standards. Lung and liver metastases are rarely irradiated, largely as a consequence of the lack of modern radiotherapy technology. Locally advanced disease in various tumour sites was mostly palliated, in agreement with current evidence-based practices.
CONCLUSIONS: African countries still lack adequate staffing and equipment to adequately address their clinical burden, being palliative in most cases. Emphasis should also be made on more rationally using existing capacities by using more of the single-fraction radiotherapy regimens, especially in bone metastasis.

Hepatocellular carcinoma is the 5(th) most common cancer in men and the 2(nd) common cause of death from cancer worldwide. The tumour commonly metastasizes to the lungs, regional lymph nodes and bone. Spinal cord compression secondary to metastatic disease as a first presentation is uncommon. We describe a patient who presented with paraplegia as a first presentation of hepatocellular carcinoma. 46 year old Namibian man presented with progressive leg weakness that was associated with a dull back ache and inability to pass urine and stool. He had no history of trauma nor did he have chronic cough, night sweats or fevers. He has been treated several times for alcohol dependence. On examination he was wasted, power 0/5 in both lower limbs and a sensory level at T12. He also had a non-tender hepatomegaly with Alpha-fetoprotein of 2000. The Chest X-ray and Chest CT showed nodular opacities indicating metastatic disease and the X-ray and CT of the thoracic spine showed osteolytic lesion with destruction of the pedicle of L1. Liver and spinal biopsy confirmed the hepatocellular carcinoma. The extra hepatic manifestations of HCC are diverse and Spinal cord metastasis is of pertinent clinical importance and should thus be greatly considered.

Developing twinning programmes in paediatric oncology between African countries is possible, encouraging and rewarding. The development of centres of excellence in Africa could serve as a means of disseminating the knowledge and channelling international support for the surrounding countries in their effort to cure children's cancer.

OBJECTIVES: The objective of the study was to describe the management of gestational trophoblastic neoplasia (GTN), with particular reference to concurrent human immunodeficiency virus (HIV) infection.
METHODS: This retrospective descriptive study comprised all cases of GTN managed at Groote Schuur Hospital over a 10-year period (1999-2008).
RESULTS: Seventy-six patients, with a median age of 30 years at presentation, were included in the study. Only 36 patients (47.4%) had known HIV status. Fourteen (18.4%) were HIV positive, and of these, 4 (28.6%) were on antiretroviral treatment (ARV). The mean CD4 count was 142 cells/μL for those on ARV and 543 cells/μL for those not on ARV (P = 0.001). Histologically, 44 patients (58%) had hydatidiform mole, and 21 (28%) had choriocarcinoma. In the remaining 10 cases, a clinical diagnosis was made. Based on the revised International Federation of Gynecology and Obstetrics (FIGO)/modified World Health Organization scoring, 43 patients (56.6%) were low risk, and 33 (43.4%) were high risk. Thirty-eight patients (50%) were staged as FIGO stage I. Of 73 patients who received chemotherapy, 56 (76.7%) achieved complete remission, 9 (12.3%) did not achieve any remission, 7 (9.6%) had a relapse, and 1 (1.4%) was lost to follow-up. Patients who never went into remission had frequent treatment delays due to poor compliance or inadequate blood counts. The overall survival at 60 months was 81.9%. Of the 13 patients (17.1%) who have died, 5 (38.5%) were HIV positive. The overall 5-year survival rates for FIGO stages I, II, III, and IV were 97.4%, 66.7%, 77.8%, and 46.2%, respectively. The overall 5-year survival for HIV-positive patients was 64.3% versus more than 85% for both the HIV-negative and HIV-unknown groups.
CONCLUSIONS: Apart from more advanced stage, HIV seropositivity and poor compliance with treatment also portend poorer outcome in GTN patients. In HIV-positive patients with poor CD4, little clarity is available whether ARV should be commenced speedily, and the administration of chemotherapy delayed until immune reconstitution occurs.

We retrospectively analysed the epidemiological features and the importance of biochemical, histological and genetic parameters in predicting survival in 14 Namibian and 34 South African children treated for neuroblastoma (NB) from 1983 to 1997. Curative treatment consisted mainly of total (13%) or partial (44%) resection after chemotherapy (cyclophosphamide and doxorubicin x6 courses or carboplatin, etoposide, epirubicin and cyclophosphamide x6 courses). Localized radiotherapy with curative intent was given to 33% of patients. The male:female ratio was 0.9. The median age was 18 months (range 1-116) and was comparable in white, black and mixed ethnic patients. Primary disease was located in the abdomen (75%), thorax (15%), pelvis (5%) or elsewhere (5%). Evans stage distribution was: stage I, 2%; stage II, 19%; stage III, 21%; stage IV, 50%; and stage IVS, 8%. Stage III/IV disease was more common in black than in white children (p = 0.0001). Urinary vanillyl mandelic acid was elevated in 63% of those tested. Survival after 5-163 months' follow-up was 90% for stages I and II combined (median 2983, range 798-4661 days), 51% for stage III (median 367, range 61-5001 days), 6% for stage IV (median 227, range 20-4379 days) and 50% for stage IVS (median 532, range 54-1543 days). All seven children with para-spinal tumours survived. Individual factors associated with significantly poorer survival were elevated serum lactate dehydrogenase (p < 0.001), Joshi histological risk categorization adapted for age (p = 0.039), n-myc amplification (p = 0.006) and diploidy or tetraploidy (p = 0.006). All seven children with serum ferritin exceeding 149 ng/ml at the time of diagnosis died and survival was 33% in children with 1p deletion and 67% in those without, but the numbers were too small to achieve significance. These findings confirm the benefit of simple biochemical tests and histology in identifying those who are likely to respond favourably to conventional chemotherapy and surgery. Supportive genetic tests on formalin-fixed paraffin-embedded tumour tissue contributed to predicting outcome in 21 patients.

OBJECTIVE: To estimate the extent of paediatric malignancy in an African country and to compare these findings with paediatric cancer rates in other countries.
DESIGN: A retrospective descriptive study which calculated incidence and frequency rates from the data obtained from a 6-year survey of childhood cancer in Namibia.
SETTING: Children from the general community who were referred by primary care physicians or clinics and diagnosed in peripheral district hospitals or a tertiary care institution.
PATIENTS: A total of 163 children less than 15 years of age diagnosed with any malignant neoplasm, intracranial tumour or histiocytosis between 1983 and 1988.
INTERVENTION: None.
MAIN OUTCOME MEASURES: The minimum overall incidence of childhood cancer recorded in Namibia was lower than the rates usually reported by economically privileged countries. The rates of certain malignancies corresponded to the rates recorded in other African countries.
RESULTS: The overall incidence of childhood cancer was 55.5 per million. Tumours of the central nervous system occurred most commonly (18%), followed by renal tumours (14%), leukaemia (12%) and lymphoma (11.5%). The 5.8 per million incidence rate of retinoblastoma was similar to the rates recorded in other African countries but higher than in the UK or the USA. The incidence rates per million children for renal tumours, malignant bone tumours and soft-tissue sarcomas were 7.4, 4.8 and 5.2, respectively, which correspond with the rates in Western Europe and the USA. The incidence rate of CNS tumours was only 9.3 per million. Both leukaemia (6.5 per million) and lymphoma (6.3 per million) had rates far lower than those recorded in central Africa or developed Western countries.
CONCLUSION: The incidence pattern of childhood cancer in Namibia demonstrates features of both the patterns described as typical for Africa and those described for industrialised countries.

The data of a survey undertaken to record all cases of childhood cancer in Namibia from 1983 to 1988 were analyzed to estimate 5-year survival rates. The projected survival rate for 150 children with cancer was 37% with no difference between boys and girls. The calculated survival rates for most of the tumor groups were poor with the exception of Wilms' tumor which had a 5-year survival rate of 76%. The zero survival rate of children with malignant bone disease may have been due to inadequate treatment. Neuroblastoma and retinoblastoma presented with advanced disease which contributed to the poor survival rates of 13% and 46%, respectively. The overall survival rate for lymphoma of 53% and 39% for all leukemias compares poorly with the rates obtained in industrialized countries. The relatively poor 25% survival rate in tumors of the central nervous system (CNS) may partly be due to the long delay between the initial diagnosis and the institution of appropriate treatment for raised intracranial pressure and for the tumor. Both cure and long-term follow-up are difficult to achieve in a developing country. Improved early diagnosis and appropriate treatment are necessary to improve survival rates.

A survey of childhood cancer was undertaken in Namibia from 1983 to 1988 to record all tumors in children less than 15 years of age. The national incidence of childhood cancer in the republic of Namibia was 55.5 per million children. The overall incidence rate was 73.3 per million in urban and densely populated areas, and 44.4 per million in the rural areas. This difference was not statistically significant. The relatively high 75 per million overall incidence of tumors amongst the white population group was probably due to the generally higher socioeconomic status and concomitant good medical care of this ethnic group during the study period. The significantly higher overall incidence of tumors (109 per million) recorded in the Rehoboth ethnic group, however, could not be accounted for by socioeconomic status or better health care facilities and remains unexplained. The cause of the increased incidence of central nervous system tumors in the Herero (26 per million) and osteosarcomas in the Kavango (11 per million) ethnic groups is also not clear and warrants further research. The apparent geographical cluster of tumors in northern and central Namibia was caused by the irregular distribution of the population.

This study records the disease profile and outcome of all 492 children with confirmed cancer below the age of 15 who were admitted to Tygerberg Hospital, South Africa, from 1983 to 1993. The black (48.3%), so-called coloured (30.3%) and caucasian (21.3%) children did not represent a confined geographical area. Leukaemia (22.8%), brain tumours (20.5%), lymphomas (15.2%), nephroblastomas (10%), neuroblastomas (8.5%) and retinoblastomas (5.7%) were the most common tumours. All children were treated with standard protocols and included in the Kaplan-Meier survival analyses. 14 patients were lost to follow-up. Projected survival in (acute lymphoblastic leukaemia) ALL was 63% in white children, but only 17% in black children. Survival was 65% in stage 1 and 2 Wilms' tumour, and exceeded 50% in medulloblastoma and astrocytoma. So-called African Burkitt's lymphoma occurred in all population groups. Overall, 5-year survival in Hodgkin's disease was 70%. Black and coloured children with neuroblastoma presented mainly with stage 3 and 4 disease. All 26 black and coloured children with retinoblastoma had a negative family history and advanced disease which needed enucleation.

The clinical features, incidence and pattern of jaw involvement, and seasonal occurrence in relation to 22 patients with Burkitt's lymphoma in the Cape province and Southwest Africa were analyzed. The mean age, male dominance, and pattern of organ involvement paralleled typical African Burkitt's lymphoma. Development of the patients' disease was more likely during the rainy season. The frequency and pattern of jaw involvement resembled typical African Burkitt's lymphoma. The frequency of jaw involvement was similar in white and nonwhite patients. Members of all racial groups had typical African Burkitt's lymphoma.

In an epidemiological study conducted in SWA/Namibia to document the prevalence of high-risk factors for cervical cancer 754 women belonging to a number of ethnic groups were examined. The prevalence of cervical intra-epithelial neoplasia and human papillomavirus infection was among the highest reported in the world. There was also an alarming incidence of other sexually transmitted diseases and disturbingly low usage of contraceptive methods. There is an urgent need for a comprehensive, well-organised cytological screening programme if an 'epidemic' of cervical cancer is to be prevented in SWA/Namibia. There was good evidence to suggest that an identical situation exists in the RSA.

The evidence linking human papillomavirus (HPV) infection with cervical intra-epithelial neoplasia (CIN), cervical cancer and similar changes in the vulval and vaginal epithelium is reviewed. Reference is made to prevalence rates for HPV and CIN in South Africa and South West Africa/Namibia and the prospect of an 'epidemic' of cervical and possibly of other squamous genital cancers is discussed. Only an effective cytological screening programme with effective follow-up arrangements will prevent this; these should be priorities for future preventive medicine strategies.