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South Africa

Cancer Statistics
Population in 2012: 50.7m
People newly diagnosed with cancer (excluding NMSC) / yr: 77,400
Age-standardised rate, incidence per 100,000 people/yr: 187.1
Risk of getting cancer before age 75:19.0%
People dying from cancer /yr: 47,400
Data from IARC GlobalCan (2012)
Regional Organisations
Latest Research Publications from South Africa

Regional Organisations (19 links)

Latest Research Publications from South Africa

Kgatle MM, Setshedi M, Hairwadzi HN
Hepatoepigenetic Alterations in Viral and Nonviral-Induced Hepatocellular Carcinoma.
Biomed Res Int. 2016; 2016:3956485 [PubMed] Free Access to Full Article Related Publications
Hepatocellular carcinoma (HCC) is a major public health concern and one of the leading causes of tumour-related deaths worldwide. Extensive evidence endorses that HCC is a multifactorial disease characterised by hepatic cirrhosis mostly associated with chronic inflammation and hepatitis B/C viral infections. Interaction of viral products with the host cell machinery may lead to increased frequency of genetic and epigenetic aberrations that cause harmful alterations in gene transcription. This may provide a progressive selective advantage for neoplastic transformation of hepatocytes associated with phenotypic heterogeneity of intratumour HCC cells, thus posing even more challenges in HCC treatment development. Epigenetic aberrations involving DNA methylation, histone modifications, and noncoding miRNA dysregulation have been shown to be intimately linked with and play a critical role in tumour initiation, progression, and metastases. The current review focuses on the aberrant hepatoepigenetics events that play important roles in hepatocarcinogenesis and their utilities in the development of HCC therapy.

Stephenson KA, Fagan JJ
Transoral laser resection of glottic carcinoma: what is the significance of anterior commissure involvement?
J Laryngol Otol. 2017; 131(2):168-172 [PubMed] Related Publications
BACKGROUND: The optimal management of glottic carcinoma involving the anterior commissure is controversial.
METHOD: A retrospective analysis was conducted of 76 patients with glottic squamous cell carcinoma treated by transoral carbon dioxide laser resection by a single surgeon.
RESULTS: Sixty-three patients (with tumour stage Tis-T3) were eligible for inclusion. Thirty patients had involvement of the anterior commissure; these patients were significantly more likely to have either uncertain or positive margins (63.3 vs 30.3 per cent, p = 0.012), and were also more likely to receive adjuvant radiotherapy (40 vs 3.2 per cent, p = 0.0005). The overall laryngeal preservation rate was 96.8 per cent; there was no statistically significant difference between those with and without anterior commissure involvement (96.7 and 96.9 per cent respectively).
CONCLUSION: Transoral laser resection with the use of adjuvant radiotherapy in a minority of patients with adverse pathological findings can be recommended for the primary treatment of anterior commissure glottic cancer from an oncological perspective; excellent local control and laryngeal preservation rates can be achieved.

Mitchell MI, Engelbrecht AM
Metabolic hijacking: A survival strategy cancer cells exploit?
Crit Rev Oncol Hematol. 2017; 109:1-8 [PubMed] Related Publications
The majority of human tumours are comprised of cancerous epithelial cells that coexist with a multitude of different cell types and extracellular matrix components creating the cancer microenvironment. Cancer-associated fibroblasts (CAFs) are the most abundant mesenchymal cell types present within most human carcinomas. Recent evidence suggests that nutrient deprived epithelial cancer cells are able to survive these conditions, as a result of their ability to undergo extensive metabolic reprogramming and exploit the metabolic capacities of surrounding CAFs. Although several studies support the role of CAFs in tumour progression and metastasis, the molecular mechanisms underlying this pro-tumourigenic interaction remains to be elucidated. This review will discuss the complex metabolic interaction that exists between epithelial cancer cells and CAF's: focussing primarily on their functional role in tumour progression, metastasis and chemotherapeutic resistance. Attempts are made at delineating the molecular mechanisms underlying this pro-tumourigenic interaction, and potential CAF-based targets are suggested.

van der Merwe D, Van Dyk J, Healy B, et al.
Accuracy requirements and uncertainties in radiotherapy: a report of the International Atomic Energy Agency.
Acta Oncol. 2017; 56(1):1-6 [PubMed] Related Publications
BACKGROUND: Radiotherapy technology continues to advance and the expectation of improved outcomes requires greater accuracy in various radiotherapy steps. Different factors affect the overall accuracy of dose delivery. Institutional comprehensive quality assurance (QA) programs should ensure that uncertainties are maintained at acceptable levels. The International Atomic Energy Agency has recently developed a report summarizing the accuracy achievable and the suggested action levels, for each step in the radiotherapy process. Overview of the report: The report seeks to promote awareness and encourage quantification of uncertainties in order to promote safer and more effective patient treatments. The radiotherapy process and the radiobiological and clinical frameworks that define the need for accuracy are depicted. Factors that influence uncertainty are described for a range of techniques, technologies and systems. Methodologies for determining and combining uncertainties are presented, and strategies for reducing uncertainties through QA programs are suggested. The role of quality audits in providing international benchmarking of achievable accuracy and realistic action levels is also discussed.
RECOMMENDATIONS: The report concludes with nine general recommendations: (1) Radiotherapy should be applied as accurately as reasonably achievable, technical and biological factors being taken into account. (2) For consistency in prescribing, reporting and recording, recommendations of the International Commission on Radiation Units and Measurements should be implemented. (3) Each institution should determine uncertainties for their treatment procedures. Sample data are tabulated for typical clinical scenarios with estimates of the levels of accuracy that are practically achievable and suggested action levels. (4) Independent dosimetry audits should be performed regularly. (5) Comprehensive quality assurance programs should be in place. (6) Professional staff should be appropriately educated and adequate staffing levels should be maintained. (7) For reporting purposes, uncertainties should be presented. (8) Manufacturers should provide training on all equipment. (9) Research should aid in improving the accuracy of radiotherapy. Some example research projects are suggested.

Boukes GJ, van de Venter M
The apoptotic and autophagic properties of two natural occurring prodrugs, hyperoside and hypoxoside, against pancreatic cancer cell lines.
Biomed Pharmacother. 2016; 83:617-626 [PubMed] Related Publications
Pancreatic cancer is only the 12th most common cancer, but the fourth leading cause of cancer-related deaths in the world. This is due to late prognosis, poor response to chemotherapy and early metastases. Natural prodrugs may play an important role in the treatment of pancreatic cancer. The main aim of this study was to determine the cytotoxicity of five natural prodrugs, namely harpagoside, hyperoside, hypoxoside, oleuropein and polydatin, by investigating apoptosis and autophagy as possible mechanism/s of action. Hypoxoside and hyperoside have shown selective cytotoxicity at IC50 values of ∼25 and 50μM against INS-1 and MIA PaCa-2 pancreatic cancer cells, respectively. Hypoxoside and hyperoside induced G2/M phase arrest and caspase-3 activation in INS-1 and MIA PaCa-2 cells, respectively. Hoechst/phalloidin staining confirmed morphological changes, including condensed chromatin multinucleation, membrane blebbing and loss of cytoskeletal arrangement in INS-1 and MIA PaCa-2 cells. Acridine orange staining was absent in INS-1 (hypoxoside) and MIA PaCa-2 (hyperoside) treated cells, whereas LC3B expression was not significantly increased. INS-1 and MIA PaCa-2 treated cells favour the cell death pathway, apoptosis, over the cell survival pathway, autophagy.

Phakathi BP, Basson G, Karusseit VO, et al.
The effect of HIV infection on the surgical, chemo- and radiotherapy management of breast cancer. A prospective cohort study.
Int J Surg. 2016; 34:109-115 [PubMed] Related Publications
INTRODUCTION: Breast cancer is the most common cancer of women in the world. Twenty-five percent of people living with the human immunodeficiency virus (HIV) reside in South Africa. The coincidence of breast cancer and HIV infection is therefore common in South Africa. There is a perception that systemic and local surgical complications are more common in HIV-infected patients, and that these patients tolerate chemo- and radiotherapy poorly.
AIM: The aim of the study was to determine the effect of HIV infection on the management of breast cancer by comparing HIV-infected to -noninfected patients. The outcomes of surgery and adjuvant/neoadjuvant therapy were examined in these groups.
METHOD: The study was performed at the Steve Biko Academic Hospital, Pretoria, South Africa, during 2009-2014. Patients scheduled for surgery for breast cancer were recruited prospectively and their HIV status was determined. All patients were managed according to standard guidelines for breast cancer. Patients were followed up for 30 days and local and systemic surgical complications documented. Completion or non-completion of courses of chemo- and radiotherapy, and reasons for non-completion were documented. HIV-infected and -noninfected patients respectively were grouped, and compared statistically.
RESULTS: One hundred and sixty patients (31 HIV-infected) were included. The frequency of surgical complications did not differ significantly between HIV-noninfected and infected patients (p = 0.08), more occurring in the HIV-noninfected patients. The risk ratio of HIV infection for surgical complications was 0.20 and the odds ratio 0.23. The completion of courses of chemo- and radiotherapy did not differ between the HIV-infected and -noninfected patients. Twenty-five of 27 HIV-infected patients (93%) and 100 of 113 HIV-noninfected patients (94%) completed their courses of chemotherapy (p = 0.68). Twelve of 14 HIV-infected patients (86%) and 40 of 41 HIV-noninfected patients (98%) completed their courses of radiotherapy (p = 0.16).
CONCLUSION: These results suggest that HIV-infected patients with breast cancer do not experience more treatment-related complications and can be treated according to standard guidelines.

Rice TW, Apperson-Hansen C, DiPaola LM, et al.
Worldwide Esophageal Cancer Collaboration: clinical staging data.
Dis Esophagus. 2016; 29(7):707-714 [PubMed] Related Publications
To address uncertainty of whether clinical stage groupings (cTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for clinically staged patients from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 22,123 clinically staged patients, 8,156 had squamous cell carcinoma, 13,814 adenocarcinoma, 116 adenosquamous carcinoma, and 37 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (18.5-25 mg/kg(2) , 47%), little weight loss (2.4 ± 7.8 kg), 0-1 ECOG performance status (67%), and history of smoking (67%). Cancers were cT1 (12%), cT2 (22%), cT3 (56%), cN0 (44%), cM0 (95%), and cG2-G3 (89%); most involved the distal esophagus (73%). Non-risk-adjusted survival for squamous cell carcinoma was not distinctive for early cT or cN; for adenocarcinoma, it was distinctive for early versus advanced cT and for cN0 versus cN+. Patients with early cancers had worse survival and those with advanced cancers better survival than expected from equivalent pathologic categories based on prior WECC pathologic data. Thus, clinical and pathologic categories do not share prognostic implications. This makes clinically based treatment decisions difficult and pre-treatment prognostication inaccurate. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient characteristics, cancer categories, and treatment characteristics and should direct 9th edition data collection.

Rice TW, Lerut TE, Orringer MB, et al.
Worldwide Esophageal Cancer Collaboration: neoadjuvant pathologic staging data.
Dis Esophagus. 2016; 29(7):715-723 [PubMed] Related Publications
To address uncertainty of whether pathologic stage groupings after neoadjuvant therapy (ypTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for pathologically staged cancers after neoadjuvant therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 7,773 pathologically staged neoadjuvant patients, 2,045 had squamous cell carcinoma, 5,686 adenocarcinoma, 31 adenosquamous carcinoma, and 11 undifferentiated carcinoma. Patients were older (61 years) men (83%) with normal (40%) or overweight (35%) body mass index, 0-1 Eastern Cooperative Oncology Group performance status (96%), and a history of smoking (69%). Cancers were ypT0 (20%), ypT1 (13%), ypT2 (18%), ypT3 (44%), ypN0 (55%), ypM0 (94%), and G2-G3 (72%); most involved the distal esophagus (80%). Non-risk-adjusted survival for yp categories was unequally depressed, more for earlier categories than later, compared with equivalent categories from prior WECC data for esophagectomy-alone patients. Thus, survival of patients with ypT0-2N0M0 cancers was intermediate and similar regardless of ypT; survival for ypN+ cancers was poor. Because prognoses for ypTNM and pTNM categories are dissimilar, prognostication should be based on separate ypTNM categories and groupings. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics and should direct 9th edition data collection.

Rice TW, Chen LQ, Hofstetter WL, et al.
Worldwide Esophageal Cancer Collaboration: pathologic staging data.
Dis Esophagus. 2016; 29(7):724-733 [PubMed] Related Publications
We report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for patients with pathologically staged cancer of the esophagus and esophagogastric junction after resection or ablation with no preoperative therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted de-identified data using standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 13,300 patients, 5,631 had squamous cell carcinoma, 7,558 adenocarcinoma, 85 adenosquamous carcinoma, and 26 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (51%), little weight loss (1.8 kg), 0-2 ECOG performance status (83%), and a history of smoking (70%). Cancers were pT1 (24%), pT2 (15%), pT3 (50%), pN0 (52%), pM0 (93%), and pG2-G3 (78%); most involved distal esophagus (71%). Non-risk-adjusted survival for both squamous cell carcinoma and adenocarcinoma was monotonic and distinctive across pTNM. Survival was more distinctive for adenocarcinoma than squamous cell carcinoma when pT was ordered by pN. Survival for pTis-1 adenocarcinoma was better than for squamous cell carcinoma, although monotonic and distinctive for both. WECC pathologic staging data is improved over that of the 7th edition, with more patients studied and patient and cancer variables collected. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics, and should direct 9th edition data collection. However, the role of pure pathologic staging as the principal point of reference for esophageal cancer staging is waning.

Magangane P, Sookhayi R, Govender D, Naidoo R
Determining protein biomarkers for DLBCL using FFPE tissues from HIV negative and HIV positive patients.
J Mol Histol. 2016; 47(6):565-577 [PubMed] Related Publications
DLBCL is the most common lymphoma subtype occurring in older populations as well as in younger HIV infected patients. The current treatment options for DLBCL are effective for most patients yet the relapse rate is high. While many biomarkers for DLBCL exist, they are not in clinical use due to low sensitivity and specificity. In addition, these biomarkers have not been studied in the HIV context. Therefore, the identification of new biomarkers for HIV negative and HIV positive DLBCL, may lead to a better understanding of the disease pathology and better therapeutic design. Protein biomarkers for DLBCL were determined using MALDI imaging mass spectrometry (IMS) and characterised using LC-MS. The expression of one of the biomarkers, heat shock protein (Hsp) 70, was confirmed on a separate cohort of samples using immunohistochemistry. The biomarkers identified in the study consisted of four protein clusters including glycolytic enzymes, ribosomal proteins, histones and collagen. These proteins could differentiate between control and tumour tissue, and the DLBCL immunohistochemical subtypes in both cohorts. The majority (41/52) of samples in the confirmation cohort were negative for Hsp70 expression. The HIV positive DLBCL cases had a higher percentage of cases expressing Hsp70 than their HIV negative counterparts. The non-GC subtype also frequently overexpressed Hsp70, confirming MALDI IMS data. The expression of Hsp70 did not correlate with survival in both the HIV negative and HIV positive cohort. This study identified potential biomarkers for HIV negative and HIV positive DLBCL from FFPE tissue sections. These may be used as diagnostic and prognostic markers complementary to current clinical management programmes for DLBCL.

Lukhele ST, Motadi LR
Cannabidiol rather than Cannabis sativa extracts inhibit cell growth and induce apoptosis in cervical cancer cells.
BMC Complement Altern Med. 2016; 16(1):335 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Cervical cancer remains a global health related issue among females of Sub-Saharan Africa, with over half a million new cases reported each year. Different therapeutic regimens have been suggested in various regions of Africa, however, over a quarter of a million women die of cervical cancer, annually. This makes it the most lethal cancer amongst black women and calls for urgent therapeutic strategies. In this study we compare the anti-proliferative effects of crude extract of Cannabis sativa and its main compound cannabidiol on different cervical cancer cell lines.
METHODS: To achieve our aim, phytochemical screening, MTT assay, cell growth analysis, flow cytometry, morphology analysis, Western blot, caspase 3/7 assay, and ATP measurement assay were conducted.
RESULTS: Results obtained indicate that both cannabidiol and Cannabis sativa extracts were able to halt cell proliferation in all cell lines at varying concentrations. They further revealed that apoptosis was induced by cannabidiol as shown by increased subG0/G1 and apoptosis through annexin V. Apoptosis was confirmed by overexpression of p53, caspase 3 and bax. Apoptosis induction was further confirmed by morphological changes, an increase in Caspase 3/7 and a decrease in the ATP levels.
CONCLUSIONS: In conclusion, these data suggest that cannabidiol rather than Cannabis sativa crude extracts prevent cell growth and induce cell death in cervical cancer cell lines.

Shires K, Wienand K
Cancer testis antigen MAGE C1 can be used to monitor levels of circulating malignant stem cells in the peripheral blood of multiple myeloma patients.
J Cancer Res Clin Oncol. 2016; 142(11):2383-96 [PubMed] Related Publications
PURPOSE: Monitoring the levels of malignant disease-causing cells in multiple myeloma, as opposed to the clinical symptoms alone, is an important move forward in the management of this disease. While current methods including multiparametric flow cytometry and PCR analysis of the clonal plasma cells can be used in a patient-specific manner, their use is limited and the fundamental malignant progenitor cell is not being monitored. The expression of cancer testis antigen MAGE C1 has been linked to the malignant stem cell in this disease, and thus, we investigated the use of both flow cytometric and qRTPCR approaches to monitor its expression as an alternative monitoring methodology in this pilot study.
METHODS: We compared the levels of MAGE C1 in the peripheral blood to serum M protein and serum beta 2 microglobulin levels at 3-monthly intervals over a 2-year period, for 12 patients on chemotherapy regimens and 4 patients undergoing stem cell transplantation.
RESULTS AND CONCLUSIONS: The analysis indicated that the novel flow cytometric analysis of MAGE C1 expression in the peripheral blood was extremely relevant as a potential minimal residual disease-monitoring tool. Expression of this cancer testis antigen was detectable in all patients throughout treatment, with comparable increases and decreases to serum M protein and/or serum beta 2 microglobulin, but with the advantage of being able to detect disease at a more sensitive level. Furthermore, due to the increased sensitivity, the ability to pre-empt disease relapse before clinical changes were evident, was preliminarily indicated. The qRTPCR approach showed potential as a monitoring tool in the chemotherapy patient cohort, with the mRNA MAGE C1 levels following a similar pattern of expression observed in the flow cytometry analysis.

Magodoro IM, Esterhuizen TM, Chivese T
A cross-sectional, facility based study of comorbid non-communicable diseases among adults living with HIV infection in Zimbabwe.
BMC Res Notes. 2016; 9:379 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Increased antiretroviral therapy uptake in sub-Saharan Africa has resulted in improved survival of the infected. Opportunistic infections are declining as leading causes of morbidity and mortality. Though comprehensive data are lacking, concern has been raised about the rapid emergence of non-communicable diseases (NCDs) in the African HIV care setting. We therefore set out to characterise the NCD/HIV burden among adults living and ageing with HIV infection in Zimbabwe.
METHODS: We conducted a cross-sectional study among patients receiving care in a public sector facility. We reviewed patient records and determined the prevalence of comorbid and multi-morbid NCDs. Associations with patient characteristics were evaluated using univariate and multi-variate logistic regression modelling. Significance testing was done using 2-sided p values and 95 % confidence intervals calculated.
RESULTS: We recruited 1033 participants. 31 % were men. Significant gender differences included: older median age, more advanced disease at baseline, and greater use of stavudine and protease inhibitor containing regimens in men compared to women. The prevalence of comorbidity and multi-morbidity were, respectively, 15.3 % (95 % CI 13.3-17.7 %) and 4.5 % (95 % CI 3.4-6.0 %). Women had higher rates than men of both co-morbidity and multi-morbid ity: 21.8 vs. 14.9 %; p = 0.010 and 5.3 vs. 2.9 %; p = 0.025 respectively. The commonly observed individual NCDs were hypertension [10.2 %; (95 % CI 8.4-12.2 %)], asthma [4.3 % (95 % CI 3.1-5.8 %)], type 2 diabetes mellitus [2.1 % (95 % CI 1.3-3.2 %)], cancer [1.8 % (95 % CI 1.1-2.8 %)], and congestive cardiac failure [1.5 % (95 % CI 0.9-2.5 %)]. After adjusting for confounding, only age categories 45-≤55 years (AOR 2.25; 95 % CI 1.37-3.69) and >55 years (AOR 5.42; 95 % CI 3.17-9.26), and female gender (AOR 2.12; 95 % CI 1.45-3.11) remained significantly and strongly associated with comorbidity risk.
CONCLUSIONS: We found a substantial burden of comorbid non-communicable diseases among HIV infected patients in a high HIV and low-income setting. Integrating non-communicable diseases care, including active screening, with HIV care is recommended.

Wu JT, Zhou J, Naidoo N, et al.
Determining the cost-effectiveness of endoscopic surveillance for gastric cancer in patients with precancerous lesions.
Asia Pac J Clin Oncol. 2016; 12(4):359-368 [PubMed] Related Publications
AIM: To identify the optimal strategy for gastric cancer (GC) prevention by evaluating the cost-effectiveness of esophagogastroduodenoscopy (EGD)-based preventive strategies.
METHODS: We conducted a model-based cost-effectiveness analysis. Adopting a healthcare payer's perspective, Markov models simulated the clinical experience of the target population (Singaporean Chinese 50-69 years old) undergoing endoscopic screening, endoscopic surveillance and usual care of do-nothing. The screening strategy examined the cohort every alternate year whereas the surveillance strategy provided annual EGD only to people with precancerous lesions. For each strategy, discounted lifetime costs ($) and quality adjusted life years (QALY) were estimated and compared to generate incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analysis was conducted to identify influential parameters and quantify the impact of model uncertainties.
RESULTS: Annual EGD surveillance with an ICER of $34 200/QALY was deemed cost-effective for GC prevention within the Singapore healthcare system. To inform implementation, the models identified six influential factors and their respective thresholds, namely discount rate (<4.20%), age of starting surveillance (>51.6 years), proportion of program cost in delivering endoscopy (<65%), cost of follow-up EGD (<$484), utility of stage 1 GC patients (>0.72) and odds ratio of GC for high-risk subjects (>3.93). The likelihood that surveillance is the most cost-effective strategy is 69.5% accounting for model uncertainties.
CONCLUSION: Endoscopic surveillance of gastric premalignancies can be a cost-effective strategy for GC prevention. Its implementation requires careful assessment on factors influencing the actual cost-effectiveness.

Ruff P, Al-Sukhun S, Blanchard C, Shulman LN
Access to Cancer Therapeutics in Low- and Middle-Income Countries.
Am Soc Clin Oncol Educ Book. 2016; 35:58-65 [PubMed] Related Publications
Cancer is rapidly becoming a major health care problem, especially in developing countries, where 60% of the world's total new cases are diagnosed. The success of new antineoplastic medicines and modern radiation devices to cure a good proportion of patients with cancer and to alleviate the suffering of many more has been achieved at a dramatic cost. Therefore, it has become mandatory for health care authorities and pharmaceutical companies to cooperate to use and develop resources in an efficient manner to improve health care delivery to patients with cancer worldwide. Regulatory harmonization is an important key to overcome delays in the approval process, whether for antineoplastic and pain control medicines or for essential medical devices. More emphasis on the significant role of opiates in pain control among patients with cancer is needed to overcome the ingrained belief in their potential for addiction. The World Health Organization (WHO) serves an important role in guiding priorities for health care and efficiently allocating resources by providing essential medicine lists (EMLs) and device lists. However, the financial challenge for access to health care is multi-tiered and requires collaboration between key stakeholders including pharmaceutical industry, local national health authorities, WHO, and other nonprofit, patient-oriented organizations.

Mk H, Prince S, Mohan AM, et al.
Association of Notch4 with metastasis in human oral squamous cell carcinoma.
Life Sci. 2016; 156:38-46 [PubMed] Related Publications
AIMS: Despite the development of several therapeutic strategies in the past decades, clinicians have failed to improve the survival rate of oral squamous cell carcinoma patients due to the highly metastatic nature of the disease and its high recurrence rate. However, there is accumulating evidence that aberrant Notch4 expression has a critical role in tumorigenesis but its prognostic value and function in OSCC remains uncertain. This study therefore investigates (1) the expression of Notch4 and its downstream target, myelin associated glycoprotein (MAG) in tissue samples representative of different stages of OSCC with varied clinicopathological features and (2) the possible involvement of Notch4 in the proliferation and migration of OSCC cells.
MAIN METHODS: Sixty patients reported positive for OSCC were obtained along with the clinicopathological parameters and we performed immunohistochemistry, western blotting and RT-PCR for Notch4 and MAG expression. Further, the metastatic role of Notch4 was analyzed in the HSC-3 cell line by cell proliferation and migration assays.
KEY FINDINGS: Our findings reveal that Notch4 and MAG expression are significantly upregulated in specifically late stages of OSCC tumor sections and perineural invasion (PNI) positive cases. In addition, depletion of Notch4 by siRNA inhibited the proliferative and migratory ability of the highly metastatic HSC-3 OSCC cells.
SIGNIFICANCE: Our study indicates that the aberrant activation of Notch4 promotes OSCC metastasis through perineural spread and ascertains its value as a significant prognostic marker and potential therapeutic target to treat this highly aggressive malignancy.

George BP, Abrahamse H, Hemmaragala NM
Caspase dependent apoptotic inhibition of melanoma and lung cancer cells by tropical Rubus extracts.
Biomed Pharmacother. 2016; 80:193-9 [PubMed] Related Publications
Rubus fairholmianus Gard. inhibits human melanoma (A375) and lung cancer (A549) cell growth by the caspase dependent apoptotic pathway. Herbal products have a long history of clinical use and acceptance. They are freely available natural compounds that can be safely used to prevent various ailments. The plants and plant derived products became the basis of traditional medicine system throughout the world for thousands of years. The effects of R. fairholmianus root acetone extract (RFRA) on the proliferation of A375 and A549 cells was examined in this study. RFRA led to a decrease in cell viability, proliferation and an increase in cytotoxicity in a dose dependent manner when compared with control and normal skin fibroblast cells (WS1). The morphology of treated cells supported apoptotic cell death. Annexin V/propidium iodide staining indicated that RFRA induced apoptosis in A375 and A549 cells and the percentages of early and late apoptotic populations significantly increased. Moreover, the apoptotic inducing ability of RFRA when analysing effector caspase 3/7 activity, indicated a marked increase in treated cells. In summary, we have shown the anticancer effects of RFRA in A375 and A549 cancer cells via induction of caspase dependent apoptosis in vitro. The extract is more effective against melanoma; which may suggest the usefulness of RFRA-based anticancer therapies.

Kim SH, Kaschula CH, Priedigkeit N, et al.
Forkhead Box Q1 Is a Novel Target of Breast Cancer Stem Cell Inhibition by Diallyl Trisulfide.
J Biol Chem. 2016; 291(26):13495-508 [PubMed] Article available free on PMC after 24/06/2017 Related Publications
Diallyl trisulfide (DATS), a metabolic byproduct of garlic, is known to inhibit the growth of breast cancer cells in vitro and in vivo This study demonstrates that DATS targets breast cancer stem cells (bCSC). Exposure of MCF-7 and SUM159 human breast cancer cells to pharmacological concentrations of DATS (2.5 and 5 μm) resulted in dose-dependent inhibition of bCSC, as evidenced by a mammosphere assay and flow cytometric analysis of aldehyde dehydrogenase 1 (ALDH1) activity and the CD44(high)/CD24(low)/epithelial specific antigen-positive fraction. DATS-mediated inhibition of bCSC was associated with a decrease in the protein level of FoxQ1. Overexpression of FoxQ1 in MCF-7 and SUM159 cells increased ALDH1 activity and the CD49f(+)/CD24(-) fraction. Inhibition of ALDH1 activity and/or mammosphere formation upon DATS treatment was significantly attenuated by overexpression of FoxQ1. In agreement with these results, stable knockdown of FoxQ1 using small hairpin RNA augmented bCSC inhibition by DATS. Expression profiling for cancer stem cell-related genes suggested that FoxQ1 may negatively regulate the expression of Dachshund homolog 1 (DACH1), whose expression is lost in invasive breast cancer. Chromatin immunoprecipitation confirmed recruitment of FoxQ1 at the DACH1 promoter. Moreover, inducible expression of DACH1 augmented DATS-mediated inhibition of bCSC. Expression of FoxQ1 protein was significantly higher in triple-negative breast cancer cases compared with normal mammary tissues. Moreover, an inverse association was observed between FoxQ1 and DACH1 gene expression in breast cancer cell lines and tumors. DATS administration inhibited ALDH1 activity in vivo in SUM159 xenografts. These results indicate that FoxQ1 is a novel target of bCSC inhibition by DATS.

Franzen D, Diacon AH, Freitag L, et al.
Ultrathin bronchoscopy for solitary pulmonary lesions in a region endemic for tuberculosis: a randomised pilot trial.
BMC Pulm Med. 2016; 16(1):62 [PubMed] Article available free on PMC after 24/06/2017 Related Publications
BACKGROUND: The evaluation of solitary pulmonary lesions (SPL) requires a balance between procedure-related morbidity and diagnostic yield, particularly in areas where tuberculosis (TB) is endemic. Data on ultrathin bronchoscopy (UB) for this purpose is limited. To evaluate feasibility and safety of UB compared to SB for diagnosis of SPL in a TB endemic region.
METHODS: In this prospective randomised trial we compared diagnostic yield and adverse events of UB with standard-size bronchoscopy (SB), both combined with fluoroscopy, in a cohort of patients with SPL located beyond the visible range of SB.
RESULTS: We included 40 patients (mean age 55.2 years, 45 % male) with malignant SPL (n = 16; 40 %), tuberculous SPL (n = 11; 27.5 %) and other benign SPL (n = 13; 32.5 %). Mean procedure time in UB and SB was 30.6 and 26.0 min, respectively (p = 0.15). By trend, adverse events were recorded more often with UB than with SB (30.0 vs. 5.0 %, p = 0.091), including extensive coughing (n = 2), blocked working channel (n = 2), and arterial hypertension requiring therapeutic intervention (n = 1), all with UB. The overall diagnostic yield of UB compared to SB was 55.0 % vs. 80.0 %, respectively (p = 0.18). Sensitivity for the diagnosis of malignancy of UB and SB was 50.0 % and 62.5 %, respectively (p = 0.95).
CONCLUSION: UB is not superior to SB for the evaluation of SPL in a region endemic with tuberculosis, when combined with fluoroscopic guidance only.
TRIAL REGISTRATION: ClinicalTrials.gov (Identifier: NCT02490059 ).

Pohl H, Kotze MJ, Grant KA, et al.
Impact of MammaPrint on Clinical Decision-Making in South African Patients with Early-Stage Breast Cancer.
Breast J. 2016; 22(4):442-6 [PubMed] Related Publications
The aim of the study was to evaluate the impact of MammaPrint on treatment decision-making in patients with breast cancer. Clinicopathologic information of all breast cancer patients referred for MammaPrint testing in South Africa was collected from 2007 until 2014. A total of 107 patients (109 tumors) with estrogen receptor/progesterone receptor positive and human epidermal growth factor receptor-2 negative tumors were selected with tumors ≥10 mm, or when 1-3 nodes were involved without extra-nodal extension. None of the clinical indicators correlated significantly with the MammaPrint risk classification, which changed the decision for adjuvant chemotherapy in 52% of patients. Of 60 patients who were clinically high risk, 62% had a low-risk MammaPrint result and of the 47 clinically low -risk patients 40% had a high-risk MammaPrint result. This study indicates that MammaPrint could reduce the need for adjuvant chemotherapy by 17% using the selection criteria stipulated. The significant impact on treatment decisions confirmed the clinical utility of MammaPrint independent of standard clinicopathologic risk factors as supported by long-term clinical outcome studies.

Awada A, Colomer R, Inoue K, et al.
Neratinib Plus Paclitaxel vs Trastuzumab Plus Paclitaxel in Previously Untreated Metastatic ERBB2-Positive Breast Cancer: The NEfERT-T Randomized Clinical Trial.
JAMA Oncol. 2016; 2(12):1557-1564 [PubMed] Related Publications
Importance: Efficacious ERBB2 (formerly HER2 or HER2/neu)-directed treatments, in addition to trastuzumab and lapatinib, are needed.
Objective: To determine whether neratinib, an irreversible pan-ERBB tyrosine kinase inhibitor, plus paclitaxel improves progression-free survival compared with trastuzumab plus paclitaxel in the first-line treatment of recurrent and/or metastatic ERBB2-positive breast cancer.
Design, Setting, and Participants: In the randomized, controlled, open-label NEfERT-T trial conducted from August 2009 to December 2014 at 188 centers in 34 countries in Europe, Asia, Africa, and North America, 479 women with previously untreated recurrent and/or metastatic ERBB2-positive breast cancer were randomized to 1 of 2 treatment arms (neratinib-paclitaxel [n = 242] or trastuzumab-paclitaxel [n = 237]). Women with asymptomatic central nervous system metastases were eligible, and randomization was stratified by prior trastuzumab and lapatinib exposure, hormone-receptor status, and region.
Interventions: Women received neratinib (240 mg/d orally) or trastuzumab (4 mg/kg then 2 mg/kg weekly), each combined with paclitaxel (80 mg/m2 on days 1, 8, and 15 every 28 days). Primary prophylaxis for diarrhea was not mandatory.
Main Outcome and Measures: The primary outcome was progression-free survival. Secondary end points were response rate, clinical benefit rate, duration of response, frequency, and time to symptomatic and/or progressive central nervous system lesions, and safety.
Results: The intent-to-treat population comprised 479 women 18 years or older (neratinib-paclitaxel, n = 242; trastuzumab-paclitaxel, n = 237) randomized and stratified in their respective treatment arms by prior trastuzumab and lapatinib exposure, hormone-receptor status, and region. Median progression-free survival was 12.9 months (95% CI, 11.1-14.9) with neratinib-paclitaxel and 12.9 months (95% CI, 11.1-14.8) with trastuzumab-paclitaxel (hazard ratio [HR], 1.02; 95% CI, 0.81-1.27; P =.89). With neratinib-paclitaxel, the incidence of central nervous system recurrences was lower (relative risk, 0.48; 95% CI, 0.29-0.79; P = .002) and time to central nervous system metastases delayed (HR, 0.45; 95% CI, 0.26-0.78; P = .004). Common grade 3 to 4 adverse events were diarrhea (73 of 240 patients [30.4%] with neratinib-paclitaxel and 9 of 234 patients [3.8%] with trastuzumab-paclitaxel), neutropenia (31 patients [12.9%] vs 34 patients [14.5%]) and leukopenia (19 patients [7.9%] vs 25 patients [10.7%]); no grade 4 diarrhea was observed.
Conclusions and Relevance: In first-line ERBB2-positive metastatic breast cancer, neratinib-paclitaxel was not superior to trastuzumab-paclitaxel in terms of progression-free survival. In spite of similar overall efficacy, neratinib-paclitaxel may delay the onset and reduce the frequency of central nervous system progression, a finding that requires a larger study to confirm.
Trial Registration: clinicaltrials.gov Identifier: NCT00915018.

Tiloke C, Phulukdaree A, Chuturgoon AA
The Antiproliferative Effect of Moringa oleifera Crude Aqueous Leaf Extract on Human Esophageal Cancer Cells.
J Med Food. 2016; 19(4):398-403 [PubMed] Related Publications
Esophageal cancer (EC) is commonly diagnosed in South Africa (SA), with high incidences occurring in SA's black population. Moringa oleifera (MO), a multipurpose tree, is used traditionally for its nutritional and medicinal properties. It has been used for the treatment of a variety of ailments, including cancer. We investigated the antiproliferative effect of MO crude aqueous leaf extract (MOE) on a cancerous esophageal cell line (SNO). SNO cells were exposed to a range of MOE dilutions to evaluate cytotoxicity (MTT assay). Oxidative stress was determined using the TBARS assay. The comet assay was used to assess DNA damage. We then determined cell death mechanisms by measuring phosphatidylserine (PS) externalization (flow cytometry), caspase-3/7 and caspase-9 activities, and adenosine triphosphate (ATP) levels (luminometry). Protein expression of Smac/DIABLO and PARP-1 was determined by western blotting. SNO cells were treated with a range of MOE dilutions to obtain an IC50 value of 389.2 μg/mL MOE (24 h), which was used in all subsequent assays. MOE significantly increased lipid peroxidation (P < .05) and DNA fragmentation (P < .0001) in SNO cells. The induction of apoptosis was confirmed by the increase in PS externalization (P < .0001), caspase-9 (P < .05) and caspase-3/7 (P = .22) activities, and decreased ATP levels (P < .0001). MOE significantly increased both the expression of Smac/DIABLO protein and cleavage of PARP-1, resulting in an increase in the 24-kDa fragment (P < .001). MOE possesses antiproliferative effects on SNO EC cells by increasing lipid peroxidation, DNA fragmentation, and induction of apoptosis.

Wasl H, McGuire J, Lubbe D
Avoiding allogenic blood transfusions in endoscopic angiofibroma surgery.
J Otolaryngol Head Neck Surg. 2016; 45:25 [PubMed] Article available free on PMC after 24/06/2017 Related Publications
BACKGROUND: Surgical approaches for many tumours are often limited by blood loss, exposure and risk to vital anatomical structures. Therefore, the standard of care for certain skull base tumours has become endoscopic transnasal resection. Other surgical disciplines often use cell salvage techniques, but review of the otolaryngology literature revealed very few case reports. This study investigated the value and safety of salvage-type autologous blood transfusion during the endoscopic resection of juvenile nasopharyngeal angiofibromas (JNA).
METHODS: JNA is a rare vascular nasal tumour and the study extended over a 3-year period to obtain adequate patient numbers. All patients undergoing endoscopic resection during this period were included in the population sample. Ten patients with JNA were identified and underwent embolization prior to the endoscopic resection. In all cases the intraoperative blood salvage apparatus was used. Close post-operative monitoring was performed.
RESULTS: Homologous blood transfusion could be avoided in all cases. Postoperative monitoring revealed transient bacteraemia in two cases where the leukocyte filter was not used, but no evidence of septicaemia.
CONCLUSIONS: Perioperative cell saver and autologous blood transfusion in endonasal JNA surgery is safe. Homologous blood transfusion can be avoided by using this technique. The use of cell salvage allows for single stage surgery without the need to abandon surgery due to excessive blood loss and its future use is promising.

Smith M, Hunter R, Stellenboom N, et al.
The cytotoxicity of garlic-related disulphides and thiosulfonates in WHCO1 oesophageal cancer cells is dependent on S-thiolation and not production of ROS.
Biochim Biophys Acta. 2016; 1860(7):1439-49 [PubMed] Related Publications
BACKGROUND: Garlic has been used for centuries in folk medicine for its health promoting and cancer preventative properties. The bioactive principles in crushed garlic are allyl sulphur compounds which are proposed to chemically react through (i) protein S-thiolation and (ii) production of ROS.
METHODS: A collection of R-propyl disulphide and R-thiosulfonate compounds were synthesised to probe the importance of thiolysis and ROS generation in the cytotoxicity of garlic-related compounds in WHCO1 oesophageal cancer cells.
RESULTS: A significant correlation (R(2)=0.78, Fcrit (7,1) α=0.005) was found between the cytotoxicity IC(50) and the leaving group pK(a) of the R-propyl disulphides and thiosulfonates, supporting a mechanism that relies on the thermodynamics of a mixed disulphide exchange reaction. Disulphide (1) and thiosulfonate (11) were further evaluated mechanistically and found to induce G(2)/M cell-cycle arrest and apoptosis, inhibit cell proliferation, and generate ROS. When the ROS produced by 1 and 11 were quenched with Trolox, ascorbic acid or N-acetyl cysteine (NAC), only NAC was found to counter the cytotoxicity of both compounds. However, NAC was found to chemically react with 11 through mixed disulphide formation, providing an explanation for this apparent inhibitory result.
CONCLUSION: Cellular S-thiolation by garlic related disulphides appears to be the cause of cytotoxicity in WHCO1 cells. Generation of ROS appears to only play a secondary role.
GENERAL SIGNIFICANCE: Our findings do not support ROS production causing the cytotoxicity of garlic-related disulphides in WHCO1 cells. Importantly, it was found that the popular ROS inhibitor NAC interferes with the assay.

Gordon LG, Elliott TM, Wright CY, et al.
Modelling the healthcare costs of skin cancer in South Africa.
BMC Health Serv Res. 2016; 16:113 [PubMed] Article available free on PMC after 24/06/2017 Related Publications
BACKGROUND: Skin cancer is a growing public health problem in South Africa due to its high ambient ultraviolet radiation environment. The purpose of this study was to estimate the annual health system costs of cutaneous melanoma, squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) in South Africa, incorporating both the public and private sectors.
METHODS: A cost-of-illness study was used to measure the economic burden of skin cancer and a 'bottom-up' micro-costing approach. Clinicians provided data on the patterns of care and treatments while national costing reports and clinician fees provided cost estimates. The mean costs per melanoma and per SCC/BCC were extrapolated to estimate national costs using published incidence data and official population statistics. One-way and probabilistic sensitivity analyses were undertaken to address the uncertainty of the parameters used in the model.
RESULTS: The estimated total annual cost of treating skin cancers in South Africa were ZAR 92.4 million (2015) (or US$15.7 million). Sensitivity analyses showed that the total costs could vary between ZAR 89.7 to 94.6 million (US$15.2 to $16.1 million) when melanoma-related variables were changed and between ZAR 78.4 to 113.5 million ($13.3 to $19.3 million) when non-melanoma-related variables were changed. The primary drivers of overall costs were the cost of excisions, follow-up care, radical lymph node dissection, cryotherapy and radiation therapy.
CONCLUSION: The cost of managing skin cancer in South Africa is sizable. Since skin cancer is largely preventable through improvements to sun-protection awareness and skin cancer prevention programs, this study highlights these healthcare resources could be used for other pressing public health problems in South Africa.

Stelma T, Chi A, van der Watt PJ, et al.
Targeting nuclear transporters in cancer: Diagnostic, prognostic and therapeutic potential.
IUBMB Life. 2016; 68(4):268-80 [PubMed] Related Publications
The Karyopherin superfamily is a major class of soluble transport receptors consisting of both import and export proteins. The trafficking of proteins involved in transcription, cell signalling and cell cycle regulation among other functions across the nuclear membrane is essential for normal cellular functioning. However, in cancer cells, the altered expression or localization of nuclear transporters as well as the disruption of endogenous nuclear transport inhibitors are some ways in which the Karyopherin proteins are dysregulated. The value of nuclear transporters in the diagnosis, prognosis and treatment of cancer is currently being elucidated with recent studies highlighting their potential as biomarkers and therapeutic targets.

Oskrochi G, Lesaffre E, Oskrochi Y, Shamley D
An Application of the Multivariate Linear Mixed Model to the Analysis of Shoulder Complexity in Breast Cancer Patients.
Int J Environ Res Public Health. 2016; 13(3) [PubMed] Article available free on PMC after 24/06/2017 Related Publications
In this study, four major muscles acting on the scapula were investigated in patients who had been treated in the last six years for unilateral carcinoma of the breast. Muscle activity was assessed by electromyography during abduction and adduction of the affected and unaffected arms. The main principal aim of the study was to compare shoulder muscle activity in the affected and unaffected shoulder during elevation of the arm. A multivariate linear mixed model was introduced and applied to address the principal aims. The result of fitting this model to the data shows a huge improvement as compared to the alternatives.

Dunning AM, Michailidou K, Kuchenbaecker KB, et al.
Breast cancer risk variants at 6q25 display different phenotype associations and regulate ESR1, RMND1 and CCDC170.
Nat Genet. 2016; 48(4):374-86 [PubMed] Article available free on PMC after 24/06/2017 Related Publications
We analyzed 3,872 common genetic variants across the ESR1 locus (encoding estrogen receptor α) in 118,816 subjects from three international consortia. We found evidence for at least five independent causal variants, each associated with different phenotype sets, including estrogen receptor (ER(+) or ER(-)) and human ERBB2 (HER2(+) or HER2(-)) tumor subtypes, mammographic density and tumor grade. The best candidate causal variants for ER(-) tumors lie in four separate enhancer elements, and their risk alleles reduce expression of ESR1, RMND1 and CCDC170, whereas the risk alleles of the strongest candidates for the remaining independent causal variant disrupt a silencer element and putatively increase ESR1 and RMND1 expression.

Dlamini Z, Rupnarain C, Naicker S, et al.
Expression analysis and association of RBBP6 with apoptosis in colon cancers.
J Mol Histol. 2016; 47(2):169-82 [PubMed] Related Publications
Apoptosis is normally kept under strict control by a range of regulators and inhibitors, and loss of this regulation strongly directs tumour progression. The novel RBBP6 gene has been implicated in apoptosis due to its ability to bind both p53 and Rb, as well as its structural and functional affiliation to ubiquitin and E3 ligases. RBBP6 has already been implicated as an important marker for cancer diagnosis and many studies have investigated its suitability as a potential genetic target for cancer treatment. This study endeavoured to assess the transcription and expression patterns and levels of the three isoforms of RBBP6 in colon cancer and to evaluate its potential role in apoptosis. Colorimetric and fluorescent in situ hybridisation was used to localise the mRNA and the different RBBP6 mRNA transcripts in normal and cancerous colon tissue. Immunohistochemistry was used to localise different RBBP6 isoforms in normal and cancerous tissues. All the RBBP6 transcripts were found to be up-regulated in cancerous tissues, and the expression levels of the RBBP6-1 and RBBP6-3 (DWNN) proteins were also found to be increased in cancerous structures. Higher levels of apoptosis were detected in the same regions as those that showed increased expression of RBBP6-3 transcript and protein, whereas Bcl-2 was down-regulated in these areas. In contrast we observed an increase in Bcl-2 levels in areas where RBBP6-3 was down-regulated. These results suggest that the RBBP6-3 isoform may be involved in promoting apoptosis in cancerous cells.

Sewram V, Sitas F, O'Connell D, Myers J
Tobacco and alcohol as risk factors for oesophageal cancer in a high incidence area in South Africa.
Cancer Epidemiol. 2016; 41:113-21 [PubMed] Related Publications
BACKGROUND: The Eastern Cape Province of South Africa, which includes the former Transkei has high rates of squamous cell oesophageal cancer (OC), thought to be caused mainly by nutritional deficiencies and fungal contamination of staple maize. A hospital-based case-control study was conducted at three of the major referral hospitals in this region to measure, among other suspected risk factors, the relative importance of tobacco smoking and alcohol consumption for the disease in this population.
METHODS: Incident cases (n=670) of OC and controls (n=1188) were interviewed using a structured questionnaire which included questions on tobacco and alcohol-related consumption. Odds ratios (ORs) with 95% confidence intervals for each of the risk factors were calculated using unconditional multiple logistic regression models.
RESULTS: A monotonic dose-response was observed across the categories of each tobacco-related variable in both sexes. Males and females currently smoking a total of >14g of tobacco per day were observed to have over 4-times the odds of developing OC (males OR=4.36, 95% CI 2.24-8.48; females OR=4.56, 95% CI 1.46-14.30), with pipe smoking showing the strongest effect. Similar trends were observed for the alcohol-related variables. The quantity of ethanol consumed was the most important factor in OC development rather than any individual type of alcoholic beverage, especially in smokers. Males and females consuming >53g of ethanol per day had approximately 5-times greater odds in comparison to non-drinkers (males OR=4.72, 95% CI 2.64-8.41; females OR=5.24, 95% CI 3.34-8.23) and 8.5 greater odds in those who smoked >14g tobacco daily. The attributable fractions for smoking and alcohol consumption were 58% and 48% respectively, 64% for both factors combined.
CONCLUSION: Tobacco and alcohol use are major risk factors for OC development in this region.
IMPACT: This study provides evidence for further reinforcement of cessation of smoking and alcohol consumption to curb OC development.

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