South Africa's HIV epidemic has evolved over time in terms of numbers of people living with HIV, access to antiretroviral treatment (ART) and age. These changes have profoundly influenced local ...cancer patterns. The Johannesburg Cancer Study has, over a period of 22 years (1995‐2016), recruited over 20 000 incident black cancer patients who consented to provide answers to a questionnaire and blood samples (serum, DNA). This has presented a unique opportunity to examine the evolving association of HIV with cancer in Africa. We used logistic regression models to explore case‐control associations between specific cancers and HIV, using participants with non‐infection related cancers as controls. Using data of 20 835 cancer patients with confirmed HIV status, we found the following cancers to be associated with HIV: Kaposi's sarcoma (ORadj; 95%CI): (99.1;72.6‐135.1), non‐Hodgkin lymphoma (11.3;9.3‐13.6), cervical cancer (2.7;2.4‐3.0), Hodgkin lymphoma (3.1;2.4‐4.2), cancer of the eye/conjunctiva (18.7;10.1‐34.7), anogenital cancers (anus 2.1;1.4‐3.2, penis 5.4;2.7‐10.5, vulva 4.8;3.5‐6.4, vagina 5.5;3.0‐10.2), oropharyngeal cancer (1.6;1.3‐1.9), squamous cell carcinoma of the skin (3.5;2.4‐4.9), melanoma (2.0;1.2‐3.5) and cancer of the larynx (1.7;1.3‐2.4). Kaposi's sarcoma odds ratios increased from the pre‐ART (1995‐2004) to the early ART (2005‐2009) period but declined in the late ART (2010‐2016) period. Odds ratios for cancers of the eye/conjunctiva, cervix, penis and vulva continued to increase in recent ART periods. Our study confirms the spectrum of HIV‐associated cancers found in other African settings. The odds ratios of conjunctival and HPV‐related cancers continue to rise in the ART era as the HIV positive population ages.
What's new?
In South Africa, the changing shape of the HIV epidemic has also shifted patterns of cancer. Here, the authors studied the association between HIV infection and cancer incidence over a 22‐year period. More than 20,000 black cancer patients participated, contributing information about HIV infection status, lifestyle and behavior, and other risk factors. The researchers found that 13 cancers were associated with HIV infection. As antiretroviral treatments become more available and the population living with HIV ages, odds ratios of HPV‐related cancers and conjunctival cancer have risen, suggesting a need for education and surveillance among people living with HIV.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Cervical cancer is the leading cause of cancer death in African women. We sought to estimate population‐based survival and evaluate excess hazards for mortality in African women with cervical cancer, ...examining the effects of country‐level Human Development Index (HDI), age and stage at diagnosis. We selected a random sample of 2760 incident cervical cancer cases, diagnosed in 2005 to 2015 from 13 population‐based cancer registries in 11 countries (Benin, Cote d'Ivoire, Ethiopia, Kenya, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Uganda and Zimbabwe) through the African Cancer Registry Network. Of these, 2735 were included for survival analyses. The 1‐, 3‐ and 5‐year observed and relative survival were estimated by registry, stage and country‐level HDI. We used flexible Poisson regression models to estimate the excess hazards for death adjusting for age, stage and HDI. Among patients with known stage, 65.8% were diagnosed with Stage III‐IV disease. The 5‐year relative survival for Stage I‐II cervical cancer in high HDI registry areas was 67.5% (42.1‐83.6) while it was much lower (42.2% 30.6‐53.2) for low HDI registry areas. Independent predictors of mortality were Stage III‐IV disease, medium to low country‐level HDI and age >65 years at cervical cancer diagnosis. The average relative survival from cervix cancer in the 11 countries was 69.8%, 44.5% and 33.1% at 1, 3 and 5 years, respectively. Factors contributing to the HDI (such as education and a country's financial resources) are critical for cervical cancer control in SSA and there is need to strengthen health systems with timely and appropriate prevention and treatment programmes.
What's new?
Cervical cancer is the leading cause of cancer deaths among women in Africa. Some parts of Africa are more highly developed than others, where “development” is measured by life expectancy, per capita income, and education levels. Here, the authors compare cervical cancer survival rates across 13 population‐based cancer registries in 11 African countries, taking development into account. Overall, 3 year survival rates were 44.5%, compared to 73.7% in the United States. In countries with a medium or low development index, patients were 4 times more likely to die than those in countries with a high development index.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
HIV substantially worsens human papillomavirus (HPV) carcinogenicity and contributes to an important population excess of cervical cancer, particularly in sub‐Saharan Africa (SSA). We estimated HIV‐ ...and age‐stratified cervical cancer burden at a country, regional and global level in 2020. Proportions of cervical cancer (a) diagnosed in women living with HIV (WLHIV), and (b) attributable to HIV, were calculated using age‐specific estimates of HIV prevalence (UNAIDS) and relative risk. These proportions were validated against empirical data and applied to age‐specific cervical cancer incidence (GLOBOCAN 2020). HIV was most important in SSA, where 24.9% of cervical cancers were diagnosed in WLHIV, and 20.4% were attributable to HIV (vs 1.3% and 1.1%, respectively, in the rest of the world). In all world regions, contribution of HIV to cervical cancer was far higher in younger women (as seen also in empirical series). For example, in Southern Africa, where more than half of cervical cancers were diagnosed in WLHIV, the HIV‐attributable fraction decreased from 86% in women ≤34 years to only 12% in women ≥55 years. The absolute burden of HIV‐attributable cervical cancer (approximately 28 000 cases globally) also shifted toward younger women: in Southern Africa, 63% of 5341 HIV‐attributable cervical cancer occurred in women <45 years old, compared to only 17% of 6901 non‐HIV‐attributable cervical cancer. Improved quantification of cervical cancer burden by age and HIV status can inform cervical cancer prevention efforts in SSA, including prediction of the impact of WLHIV‐targeted vs general population approaches to cervical screening, and impact of HIV prevention.
What's new?
The cancer‐causing potential of human papillomavirus (HPV) is amplified in patients infected with HIV. This is a particular consideration in sub‐Saharan Africa. Here, the authors developed an age‐specific method to determine the global burden of cervical cancer cases attributable to HIV. They found that around 20% of cervical cancer cases in sub‐Saharan Africa were attributable to HIV. Most of these occurred in women under age 45. These data can inform design of cervical cancer prevention programs, particularly in settings hit by a double burden of HPV and HIV.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Data on invasive cervical cancer (ICC) incidence in HIV‐positive women and the effect of cervical cancer screening in sub‐Saharan Africa are scarce. We estimated i) ICC incidence rates in women (≥18 ...years) who initiated antiretroviral therapy (ART) at the Themba Lethu Clinic (TLC) in Johannesburg, South Africa, between 2004 and 2011 and ii) the effect of a Pap‐based screening program. We included 10,640 women; median age at ART initiation: 35 years interquartile range (IQR) 30–42, median CD4 count at ART initiation: 113 cells/µL (IQR 46–184). During 27,257 person‐years (pys), 138 women were diagnosed with ICC; overall incidence rate: 506/100,000 pys 95% confidence interval (CI) 428–598. The ICC incidence rate was highest (615/100,000 pys) in women who initiated ART before cervical cancer screening became available in 04/2005 and was lowest (260/100,000 pys) in women who initiated ART from 01/2009 onward when the cervical cancer screening program and access to treatment of cervical lesions was expanded adjusted hazard ratio (aHR) 0.42, 95% CI 0.20–0.87. Advanced HIV/AIDS stage (4 versus 1, aHR 1.95, 95% CI 1.17–3.24) and middle age at ART initiation (36–45 versus 18–25 years, aHR 2.51, 95% CI 1.07–5.88) were risk factors for ICC. The ICC incidence rate substantially decreased with the implementation of a Pap‐based screening program and improved access to treatment of cervical lesions. However, the risk of developing ICC after ART initiation remained high. To inform and improve ICC prevention and care for HIV‐positive women in sub‐Saharan Africa, implementation and monitoring of cervical cancer screening programs are essential.
What's new?
Data on invasive cervical cancer (ICC) incidence in HIV‐positive women and the effect of cervical cancer screening in sub‐Saharan Africa are scarce. This South African cohort analysis found that ICC incidence substantially decreased after the implementation of a Pap‐based screening program and improved access to treatment of cervical lesions. However, ICC risk remained high in women who initiated ART at low CD4 cell counts. Patient‐level monitoring of screening programs is essential to improve ICC prevention.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Disparities in invasive cervical cancer (ICC) incidence exist globally, particularly in HIV positive women who are at elevated risk compared to HIV negative women. We aimed to determine the spatial, ...temporal, and spatiotemporal incidence of ICC and the potential risk factors among HIV positive women in South Africa.
We included ICC cases in women diagnosed with HIV from the South African HIV cancer match study during 2004-2014. We used the Thembisa model, a mathematical model of the South African HIV epidemic to estimate women diagnosed with HIV per municipality, age group and calendar year. We fitted Bayesian hierarchical models, using a reparameterization of the Besag-York-Mollié to capture spatial autocorrelation, to estimate the spatiotemporal distribution of ICC incidence among women diagnosed with HIV. We also examined the association of deprivation, access to health (using the number of health facilities per municipality) and urbanicity with ICC incidence. We corrected our estimates to account for ICC case underascertainment, missing data and data errors.
We included 17,821 ICC cases and demonstrated a decreasing trend in ICC incidence, from 306 to 312 in 2004 and from 160 to 191 in 2014 per 100,000 person-years across all municipalities and corrections. The spatial relative rate (RR) ranged from 0.27 to 4.43 in the model without any covariates. In the model adjusting for covariates, the most affluent municipalities had a RR of 3.18 (95% Credible Interval 1.82, 5.57) compared to the least affluent ones, and municipalities with better access to health care had a RR of 1.52 (1.03, 2.27) compared to municipalities with worse access to health.
The results show an increased incidence of cervical cancer in affluent municipalities and in those with more health facilities. This is likely driven by better access to health care in more affluent areas. More efforts should be made to ensure equitable access to health services, including mitigating physical barriers, such as transportation to health centres and strengthening of screening programmes.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The impact of South Africa's high human immunodeficiency virus (HIV) burden on cancer risk is not fully understood, particularly in the context of antiretroviral treatment (ART) availability. We ...examined national cancer trends and excess cancer risk in people living with HIV (PLHIV) compared to those who are HIV-negative.
We used probabilistic record linkage to match cancer records provided by the National Cancer Registry to HIV data provided by the National Health Laboratory Service (NHLS). We also used text search of specific HIV terms from the clinical section of pathology reports to determine HIV status of cancer patients. We used logistic and Joinpoint regression models to evaluate the risk and trends in cancers in PLHIV compared to HIV-negative patients from 2004 to 2014. In sensitivity analysis, we used inverse probability weighting (IPW) to correct for possible selection bias.
A total of 329,208 cancer cases from public sector laboratories were reported to the NCR from 2004 to 2014 with the HIV status known for 95,279 (28.9%) cancer cases. About 50% of all the female cancer cases (
= 30,486) with a known status were HIV-positive. PLHIV were at higher risk of AIDS-defining cancers (Kaposi sarcoma adjusted OR:134, 95% CI:111-162, non-Hodgkin lymphoma adjusted OR:2.73, 95% CI:2.56-2.91 and, cervix adjusted OR:1.70, 95% CI:1.63-1.77, conjunctival cancer adjusted OR:21.5, 95% CI:16.3-28.4 and human papilloma virus (HPV) related cancers (including; penis adjusted OR:2.35, 95% CI:1.85-2.99, and vulva adjusted OR:1.94, 95% CI:1.67-2.25) compared to HIV-negative patients. Analysis using the IPW population yielded comparable results.
There is need for improved awareness and screening of conjunctival cancer and HPV-associated cancers at HIV care centres. Further research and discussion is warranted on inclusive HPV vaccination in PLHIV.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
In South Africa (SA), liver cancer (LC) is a public health problem and information is limited.
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.
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.
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.
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.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The objective of this study was to map place of cancer diagnosis in relation to Human Immunodeficiency Virus (HIV) care centre among people living with HIV (PLHIV) within South Africa (SA) using ...national laboratory database. We linked HIV and cancer laboratory data from 2004-2014 using supervised machine-learning algorithms. We performed a cross-sectional analysis comparing province where individuals accessed their HIV care versus where they had their cancer diagnosis. We used laboratory test records related to HIV diagnostics and care, such as CD4 cell counts and percentages, rapid tests, qualitative Polymerase Chain Reaction (PCR), antibody and antigen tests for HIV data that was documented as HIV positive and laboratory diagnosed cancer records from SA. The study population was 68,284 individuals with cancer and documented HIV related laboratory test. The median age at cancer diagnosis was 40 IQR, 33-48 years for the study population with most cancers in PLHIV diagnosed in females 70.9% n = 46,313. Of all the PLHIV and cancer, 25% (n = 16,364 p < 0.001) sought treatment outside their province of residence with 60.7% (n = 10,235) travelling to Gauteng. KZN had 46.6% (n = 4,107) of its PLHIV getting cancer diagnosis in Gauteng. Western Cape had 95% (n = 6,200) of PLHIV getting cancer diagnosis within the province. Our results showed health systems inequalities across provinces in SA with respect to cancer diagnosis. KZN for example had nearly half of the PLHIV getting cancer diagnosis outside the province while Western Cape is able to offer cancer diagnostic services to most of the PLHIV in the province. Gauteng is getting over burdened with referral for cancer diagnosis from other provinces. More effort is required to ensure equitable access to cancer diagnostic services within the country.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background
The Black population has lower skin cancer incidence compared to White, Indian/Asian, and Mixed‐race populations in South Africa; however, skin cancer still exists in the Black population. ...The aim of this study is to identify risk factors associated with skin cancer among Black South Africans.
Materials and Methods
A case‐control study was conducted. Cases were patients with keratinocyte cancers (KCs) and/or melanoma skin cancers (MSCs) and controls were cardiovascular patients. Sociodemographic exposures, environmental health variables, smoking, and HIV status were assessed. Stepwise logistic regression was used to identify risk factors associated with KCs and MSCs.
Results
The KCs histological subtypes showed that there were more squamous cell carcinomas (SCCs) (78/160 in females, and 72/160 in males) than basal cell carcinomas (BCCs). The SCC lesions were mostly found on the skin of the head and neck in males (51%, 38/72) and on the trunk in females (46%, 36/78). MSC was shown to affect the skin of the lower limbs in both males (68%, 27/40) and females (59%, 36/61). Using females as a reference group, when age, current place of residency, type of cooking fuel used, smoking, and HIV status were adjusted for, males had an odds ratio (OR) of 2.04 for developing KCs (confidence interval CI: 1.08–3.84, p = .028). Similarly, when age, current place of residency, and place of cooking (indoors or outdoors) were adjusted for, males had an OR of 2.26 for developing MSC (CI: 1.19–4.29, p = .012).
Conclusions
Differences in the anatomical distribution of KCs by sex suggest different risk factors between sexes. There is a positive association between being male, smoking, rural dwelling, and a positive HIV status with KCs and being male and rural dwelling with MSC. The rural dwelling was a newly found association with skin cancer and warrants further investigation.
Differences in the anatomical distribution of skin cancer by sex suggest different risk factors between sexes. The rural dwelling was a newly found association with skin cancer and warrants further investigation.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Summary Cancer is projected to become a leading cause of morbidity and mortality in low-income and middle-income countries in the future. However, cancer incidence in South Africa is largely ...under-reported because of a lack of nationwide cancer surveillance networks. We describe present cancer surveillance activities in South Africa, and use the International Agency for Research on Cancer framework to propose the development of four population-based cancer registries in South Africa. These registries will represent the ethnic and geographical diversity of the country. We also provide an update on a cancer surveillance pilot programme in the Ekurhuleni Metropolitan District, and the successes and challenges in the implementation of the IARC framework in a local context. We examine the development of a comprehensive cancer surveillance system in a middle-income country, which might serve to assist other countries in establishing population-based cancer registries in a resource-constrained environment.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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