Results from two recently established population‐based registries in Mozambique are reported: Beira in the central region (2014–2017) and Maputo, the capital city, in the South (2015–2017). The ...results are compared to those from Maputo (Lourenço Marques at the time) in 1956–1960 (appearing Cancer Incidence in Five Continents Vol 1), and with estimated incidence rates from other regions of Africa. The elevated prevalence of HIV infection (12.6% of adults in 2018) results in high rates for HIV‐related cancers, and the greater prevalence in central Mozambique, compared to the south, largely explains the rather higher rates of Kaposi sarcoma (males), non‐Hodgkin lymphoma, squamous cell carcinoma of conjunctiva and cervical cancer in Beira than in Maputo. Burkitt lymphoma is the commonest childhood cancer in Beira, with high rates typical of East Africa, while the low rates in Maputo are more typical of Southern Africa. Overall, 44% of cancers in Maputo and 52% in Beira are estimated to be caused by infectious agents. In the last 60 years, cancers more frequent in developed countries, such as breast and prostate, are emerging in Mozambique. The incidence of the former in Maputo has increased fivefold since 1956–1960, that of prostate cancer 2.5‐fold, and that of large bowel cancer doubled. The results reported here were used to make national estimates of incidence, mortality and prevalence in Globocan 2018. The two registries were important in providing data to establish priority actions in the National Cancer Control Plan, and are a valuable resource to monitor progress toward its goals.
What's new?
Mozambique established a national cancer registry in 2016. Two regional registries are operational: one in the capital city of Maputo, and the other in Beira. These authors report on the first analysis of data collected in these registries, between 2014 and 2017. Overall, they report, 44% of cancers in Maputo and 52% in Beira appear to result from infectious agents, particularly HIV. They also compared the current data with cancer incidence measured in 1956–60, and found that incidence of breast, prostate, and colon are on the rise. These data provide important guidance for establishing priorities within the National Cancer Control Plan.
There is an urgent need to identify tools able to provide reliable information on the cause of death in low-income regions, since current methods (verbal autopsy, clinical records, and complete ...autopsies) are either inaccurate, not feasible, or poorly accepted. We aimed to compare the performance of a standardized minimally invasive autopsy (MIA) approach with that of the gold standard, the complete diagnostic autopsy (CDA), in a series of adults who died at Maputo Central Hospital in Mozambique.
In this observational study, coupled MIAs and CDAs were performed in 112 deceased patients. The MIA analyses were done blindly, without knowledge of the clinical data or the results of the CDA. We compared the MIA diagnosis with the CDA diagnosis of cause of death. CDA diagnoses comprised infectious diseases (80; 71.4%), malignant tumors (16; 14.3%), and other diseases, including non-infectious cardiovascular, gastrointestinal, kidney, and lung diseases (16; 14.3%). A MIA diagnosis was obtained in 100/112 (89.2%) cases. The overall concordance between the MIA diagnosis and CDA diagnosis was 75.9% (85/112). The concordance was higher for infectious diseases and malignant tumors (63/80 78.8% and 13/16 81.3%, respectively) than for other diseases (9/16; 56.2%). The specific microorganisms causing death were identified in the MIA in 62/74 (83.8%) of the infectious disease deaths with a recognized cause. The main limitation of the analysis is that both the MIA and the CDA include some degree of expert subjective interpretation.
A simple MIA procedure can identify the cause of death in many adult deaths in Mozambique. This tool could have a major role in improving the understanding and surveillance of causes of death in areas where infectious diseases are a common cause of mortality.
Complete diagnostic autopsies (CDA) remain the gold standard in the determination of cause of death (CoD). However, performing CDAs in developing countries is challenging due to limited facilities ...and human resources, and poor acceptability. We aimed to develop and test a simplified minimally invasive autopsy (MIA) procedure involving organ-directed sampling with microbiology and pathology analyses implementable by trained technicians in low- income settings.
A standardized scheme for the MIA has been developed and tested in a series of 30 autopsies performed at the Maputo Central Hospital, Mozambique. The procedure involves the collection of 20 mL of blood and cerebrospinal fluid (CSF) and puncture of liver, lungs, heart, spleen, kidneys, bone marrow and brain in all cases plus uterus in women of childbearing age, using biopsy needles.
The sampling success ranged from 67% for the kidney to 100% for blood, CSF, lung, liver and brain. The amount of tissue obtained in the procedure varied from less than 10 mm2 for the lung, spleen and kidney, to over 35 mm2 for the liver and brain. A CoD was identified in the histological and/or the microbiological analysis in 83% of the MIAs.
A simplified MIA technique allows obtaining adequate material from body fluids and major organs leading to accurate diagnoses. This procedure could improve the determination of CoD in developing countries.
Background:
The US President's Emergency Plan for AIDS Relief aims to address the higher risk of cervical cancer among women living with HIV by offering high-quality screening services in the highest ...burden regions of the world.
Methods:
We analyzed the US President's Emergency Plan for AIDS Relief Monitoring, Evaluation, and Reporting data from Centers for Disease Control and Prevention–supported sites in 13 countries in sub-Saharan Africa for women living with HIV aged older than 15 years who accessed cervical cancer screening services (mostly visual inspection, with ablative or excisional treatment offered for precancerous lesions), April 2018–March 2022. We calculated the positivity by age, country, and clinical visit type (first lifetime screen or routine rescreening). We fitted negative binomial random coefficient models of log-linear trends in time to estimate the probabilities of testing positive and any temporal trends in positivity.
Results:
Among the 2.8 million completed cancer screens, 5.4% identified precancerous lesions, and 0.8% were positive for suspected invasive cervical cancers (6.1% overall). The positivity rates declined over the study period among those women screening for cervical cancer for the first time and among those women presenting to antiretroviral therapy clinics for routine rescreening.
Conclusions:
These positivity rates are lower than expectations set by the published literature. Further research is needed to determine whether these lower rates are attributable to the high level of consistent antiretroviral therapy use among these populations, and systematic program monitoring and quality assurance activities are essential to ensure women living with HIV have access to the highest possible quality prevention services.
Cryptococcosis is a major opportunistic infection and is one of the leading causes of death in adults living with HIV in sub-Saharan Africa. Recent estimates indicate that more than 130,000 people ...may die annually of cryptococcal meningitis in this region. Although complete diagnostic autopsy (CDA) is considered the gold standard for determining the cause of death, it is seldom performed in low income settings. In this study, a CDA was performed in 284 deceased patients from Mozambique (n = 223) and Brazil (n = 61). In depth histopathological and microbiological analyses were carried out in all cases dying of cryptococcosis. We determined the cryptococcal species, the molecular and sero-mating types and antifungal susceptibility. We also described the organs affected and reviewed the clinical presentation and patient management. Among the 284 cases included, 17 fatal cryptococcal infections were diagnosed. Cryptococcus was responsible for 16 deaths among the 163 HIV-positive patients (10%; 95%CI: 6-15%), including four maternal deaths. One third of the cases corresponded to C. gattii (VGI and VGIV molecular types, Bα and Cα strains) and the remaining infections typed were caused by C. neoformans var. Grubii (all VNI and Aα strains). The level of pre-mortem clinical suspicion was low (7/17, 41%), and 7/17 patients (41%) died within the first 72 hours of admission. Cryptococcosis was responsible for a significant proportion of AIDS-related mortality. The clinical diagnosis and patient management were inadequate, supporting the need for cryptococcal screening for early detection of the disease. This is the first report of the presence of C. gattii infection in Mozambique.
Colorectal cancer (CRC) is a significant global health concern, ranking as the third most common cancer and the second leading cause of cancer-related deaths. However, in Africa, CRC is the fifth ...most common invasive malignancy. Limited data hinder our understanding of the evolving burden of CRC in sub-Saharan Africa. This study explores CRC trends in Mozambique, utilising data from population-based oncological registries.
CRC data were gathered from Beira and Maputo population-based cancer registries, along with supplementary information from pathology-based and hospital-based registries. Comparative analyses were performed across different time periods, focusing on trends and epidemiological characteristics.
Incidence rates of CRC in Maputo and Beira were relatively low historically. However, data from recent years showed an increase, especially in age groups above 50. Analyses from pathology-based and hospital-based registries affirmed the rising trend. The age-standardised incidence rate in Maputo (2015-2017) was 3.17 for males and 2.55 for females. Beira exhibited increasing rates between 2009 and 2020, particularly in individuals aged 50 and above.
The study reveals an emerging burden of CRC in Mozambique, challenging the perception of low incidence. The rising trend underscores the necessity for tailored interventions, emphasizing early diagnosis, preventive strategies, and investments in healthcare infrastructure to address the increasing CRC burden in the region.
Background
Cervical cancer (CC) is the most common female cancer in many countries of sub‐Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival ...(OS).
Methods
Our observational study covered nine population‐based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44–125 patients diagnosed from 2010 to 2016 were selected in each. Cancer‐directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (U.S.) Guidelines.
Results
Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline‐adherent, 2.4% with minor deviations, and 8.2% with major deviations. CDT was not documented or was without curative potential in 22%; 15.7% were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease. Adherence was not assessed in 46.9% (no stage or follow‐up documented, 11.9%, or records not traced, 35.1%). The largest share of guideline‐adherent CDT was observed in Nairobi (49%) and the smallest in Maputo (4%). In patients with FIGO stage I–III disease (n = 190), minor and major guideline deviations were associated with impaired OS (hazard rate ratio HRR, 1.73; 95% confidence interval CI, 0.36–8.37; HRR, 1.97; CI, 0.59–6.56, respectively). CDT without curative potential (HRR, 3.88; CI, 1.19–12.71) and no CDT (HRR, 9.43; CI, 3.03–29.33) showed substantially worse survival.
Conclusion
We found that only one in six patients with cervical cancer in SSA received CDT with curative potential. At least one‐fifth and possibly up to two‐thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of many patients.
Implications for Practice
Despite evidence‐based interventions including guideline‐adherent treatment for cervical cancer (CC), there is huge disparity in survival across the globe. This comprehensive multinational population‐based registry study aimed to assess the status quo of presentation, treatment guideline adherence, and survival in eight countries. Patients across sub‐Saharan Africa present in late stages, and treatment guideline adherence is remarkably low. Both factors were associated with unfavorable survival. This report warns about the inability of most women with cervical cancer in sub‐Saharan Africa to access timely and high‐quality diagnostic and treatment services, serving as guidance to institutions and policy makers. With regard to clinical practice, there might be cancer‐directed treatment options that, although not fully guideline adherent, have relevant survival benefit. Others should perhaps not be chosen even under resource‐constrained circumstances.
With a multinational collection of registry data and multimodal evaluation of degree of therapy guideline adherence, this study adds population‐based evidence on the status of cervical cancer care and outcomes in the setting of sub‐Saharan Africa.
Summary
Non‐Hodgkin lymphoma (NHL) is the sixth most common cancer in Sub‐Saharan Africa (SSA). Comprehensive diagnostics of NHL are essential for effective treatment. Our objective was to assess the ...frequency of NHL subtypes, disease stage and further diagnostic aspects. Eleven population‐based cancer registries in 10 countries participated in our observational study. A random sample of 516 patients was included. Histological confirmation of NHL was available for 76.2% and cytological confirmation for another 17.3%. NHL subclassification was determined in 42.1%. Of these, diffuse large B cell lymphoma, chronic lymphocytic leukaemia and Burkitt lymphoma were the most common subtypes identified (48.8%, 18.4% and 6.0%, respectively). We traced 293 patients, for whom recorded data were amended using clinical records. For these, information on stage, human immunodeficiency virus (HIV) status and Eastern Cooperative Oncology Group Performance Status (ECOG PS) was available for 60.8%, 52.6% and 45.1%, respectively. Stage at diagnosis was advanced for 130 of 178 (73.0%) patients, HIV status was positive for 97 of 154 (63.0%) and ECOG PS was ≥2 for 81 of 132 (61.4%). Knowledge about NHL subclassification and baseline clinical characteristics is crucial for guideline‐recommended treatment. Hence, regionally adapted investments in pathological capacity, as well as standardised clinical diagnostics, will significantly improve the therapeutic precision for NHL in SSA.
Screen-and-treat programs, where screening is achieved with human papillomavirus (HPV) testing and/or visual inspection with acetic acid (VIA), have limited impact when feasible treatment options for ...precancerous cervical lesions are not available. For women who screen positive by HPV testing and/or VIA, ablative therapy is appropriate if the squamocolumnar junction (SCJ) is entirely visible, the lesion occupies less than 75% of the cervix and can be completely treated with the ablation probe, the entire lesion can be visualized (ie, does not enter the endocervical canal), and it is not suspicious for cancer or glandular disease 4,6. HTU-110 MTA-100 C3 Cost US$1500 (includes 4 probes)* US$1550 (includes one tip)* €2326 ( ~ US$2900) (includes 2 probes and 2 sliders)* Cost of additional probes/tips US$100 each* $245 USD each* €602 each ( ~ US$725)* Power sources available Rechargeable battery Rechargeable battery Wall plug or rechargeable battery (power supply included) Number of batteries/chargers included 2 batteries, 1 charger 2 batteries, 1 charger 1 battery, 1 charger Number of cycles per battery charge ~ 30-60 ~ 100 (depends on length of treatment cycle) ~ 140 Low battery indicator Yes Yes Yes Probe treatment temperature 100°C 100°C 100°C Probe heating time 8 s 30-50 s 20-30 s Treatment time 20-60 s (beeps after 1/4, 1/2, and 3/4 of treatment time)† 20, 40, or 60 s† 60 s (beeps after 30, 45 and 60 s) Built in timer Yes Yes Yes Light source LED illumination LED illumination LED illumination Temperature display No‡ Yes No Probe options 16mm flat, 19mm flat, 19mm nipple 19mm flat, 19mm x 5mm convex, 19mm x 10mm endocervical, 25mm x 7mm endocervical, 25mm flat 17 mm flat, 20 mm flat, 20 mm nipple Removable probes Yes Only probe tip is removable, shaft is not removable Yes Heat protection Yes, via an integrated plastic ring that covers the heating element. According to the manufacturer, the probe should withstand ~ 500 use-disinfection cycles before needing to be replaced.
In sub‐Saharan Africa, colorectal cancer (CRC) has historically been considered a rare disease, although some previous studies have suggested that the incidence is increasing. We examine time trends ...in the incidence of CRC using data from 12 population‐based cancer registries in 11 countries of sub‐Saharan Africa that were able to provide time series data for periods of 12 or more years, or with earlier data with which recent rates may be compared. Age‐standardized incidence rates were highest in the higher‐income countries, and were increasing in all of the populations studied, and these increases were statistically significant in all but three. Current evidence has suggested a link between the increased adoption of western lifestyle habits with colorectal cancer, and along with increasing urbanization of African populations, there is an increase in body weight, as well as evidence of increasing consumption of meat, sugars, and alcohol.
What's new?
The highest rates of colorectal cancer are in highly developed countries, but rates are on the rise in low‐ and middle‐income countries. Here, the authors analyze trends in CRC incidence in sub‐Saharan Africa. Using data from 12 population‐based registries in 11 countries covering a period of at least 12 years, they found a steady rise in CRC across all regions, possibly due to wider adoption of a western lifestyle, including consumption of more meat, sugars, and alcohol. This highlights the need for prevention, early diagnosis, and management strategies in these regions.
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