Portal de Periódicos da CAPES

Oncology: a forgotten territory in Africa

2007; Elsevier BV; Volume: 18; Issue: 12 Linguagem: Inglês

10.1093/annonc/mdm523

1569-8041

Massimo Pezzatini, Graziella Marino, Stefano Conte, V. Catracchia,

Genital Health and Disease

Most of the efforts and helps provided by the Western countries to Africa are spent to prevent and cure infectious diseases and malnutrition, leaving the patients with cancer to their poor destiny. Infact, oncology in Africa seems to be a branch of the medicine that is practiced only by the local traditional healers, procuring devastating effects on the natural history of the tumors. Generally, cancer is mystified, preventative actions are not taken and treatment engagement is deficient. As much as 95% of cancer patients in the African countries are diagnosed at late- or end-stage disease. The delayed diagnosis for these patients is due to the low level of cancer awareness between the population and the health workers, culture and constraints on access to specialized care, usually nonexistent in these countries [1.Loehrer Sr, P.J. Greger H.A. Weinberger M. et al.Knowledge and beliefs about cancer in a socioeconomically disadvantaged population.Cancer. 1991; 68: 1665-1671Crossref PubMed Scopus (94) Google Scholar].All these findings indicate that misinformation and misconceptions regarding cancer and its treatment among physicians and patients contribute to inappropriate care-seeking behaviors and is a task of Western countries scientists, governments and nongovernmental organizations to transfer the knowledge and technology needed to prevent, treat and provide palliative care to African people affected by cancer. We report in this paper the case of a women with cutaneous metastasis from a cervix cancer at end stage, admitted in a rural area hospital of Eritrea during our volunteering in Africa, as an example of the problem of late diagnosis for cancer in Africa.case reportA 58-year-old woman presented to the Ghindae Referral Hospital in Eritrea, with postmenopausal bleeding, hematuria, diffuse abdominal pain and dyspnea. She was also complaining about the development of cutaneous ulcerated masses localized in the lower abdominal quadrants. The patient was in a very bad condition and the physical examination revealed signs of severe anemia, cervical mass referable to cancer and cutaneous metastasis of the abdominal wall (Figure 1). No radiological instruments for diagnosis were available in the hospital and only the complete blood count was carried out, confirming the suspect of anemia.Because of her serious health condition, the patient was admitted in the medical ward and treated for the pain and anemia. A surgical operation was planned to reduce symptoms and bleeding but the patient died after 24 h from admission, without getting the surgical treatment.discussionAfrica is a continent disadvantaged in all aspects of human development. The main interdependent enemies of Africa are poverty, disease, ignorance, war and conflicts. Many resources were collected and invested by the developed countries to help Africa fighting against these enemies, but only a small amount of these resources were destined to cancer treatment. In Africa, cancer registration is inadequate and cancer incidence is grossly underestimated. In all, 95% of cancer patients present with an advanced-stage neoplasia and incidence: mortality is one for the most part [2.Kamangar F. Dores G.M. Anderson W.F. Patterns of cancer incidence, mortality, and prevalence across five continents: defining priorities to reduce cancer disparities in different geographic regions of the world.J Clin Oncol. 2006; 18: 2048-2049Google Scholar].The cancer incidence in Africa has been increasing dramatically, specially after the onset of AIDS pandemic. The rapid rises of neoplasms incidence in Africa may be only partially attributed to AIDS epidemic which, however, cannot account for all the observed increases, as subtypes not associated with AIDS are continuing to increase [3.Chokunonga E. Levy L.M. Bassett M.T. et al.Aids and cancer in Africa: the evolving epidemic in Zimbabwe.Int J Cancer. 2000; 85: 54-59Crossref PubMed Scopus (119) Google Scholar]. In particular in sub-Saharan Africa, the AIDS epidemic has created a new cancer problem in the form of Kaposi sarcoma. Formerly a rather rare, the Kaposi sarcoma, a relatively indolent cancer found in East and Central Africa, with the epidemic of AIDS became more common and some 57 000 new cases occur in Africa each year and, due to the poor prognosis for cases associated with AIDS, some 52 000 patients die of this disease [4.Parkin M.D. Bray F. Ferlay J. Pisani P. Global cancer statistics, 2002.CA Cancer J Clin. 2005; 55: 74-108Crossref PubMed Scopus (17225) Google Scholar]. Since the 1980s, in those areas where endemic Kaposi sarcoma had been relatively common before the epidemic of HIV/AIDS such as Uganda, Malawi, Zimbabwe and Swaziland, the incidence of Kaposi sarcoma has increased ∼20-fold, such that it is now the leading cancer in men and the second leading cancer in women [5.Parkin D.M. Ferlay J. Hamdi-Chérif M. et al.Cancer in Africa: Epidemiology and Prevention. IARC Scientific Publications No. 153. International Agency for Research on Cancer, Lyon, France2003Google Scholar]. The effect of HIV on Kaposi sarcoma development is probably through immunosuppression by allowing human herpesvirus 8 to escape control and increase viral load, e.g. The epidemiology of this virus probably explains the geography of Kaposi sarcoma pre-AIDS. The region most affected is central Africa (30 per 1 00 000), followed by eastern, southern and western Africa, in line with the background prevalence of HIV in each of these regions [4.Parkin M.D. Bray F. Ferlay J. Pisani P. Global cancer statistics, 2002.CA Cancer J Clin. 2005; 55: 74-108Crossref PubMed Scopus (17225) Google Scholar, 6.Bassett M.T. Chokunonga E. Mauchaza B. et al.Cancer in the African population of Harare, Zimbabwe, 1990–1992.Int J Cancer. 1995; 63: 763Google Scholar]. By the end of the second decade of AIDS epidemic, non-Hodgkin’s lymphoma is increasing in incidence and the natural history of Burkitt’s lymphoma is evolving in the backdrop of HIV infection as well. It has been estimated that ∼5% to 10% of HIV-infected persons will develop a lymphoma, and non-Hodgkin’s lymphoma is the AIDS-defining illness in ∼3% of HIV-infected patients [7.Remick S.C. Acquired immunodeficiency syndrome-related non-Hodgkin's lymphoma.Cancer Control. 1995; 2: 97-103PubMed Google Scholar]. Cervical cancer is the most common cancer in women in many developing countries, yet the true impact of HIV infection on the development of this neoplasm is not fully understood. Squamous cell carcinoma of the conjunctiva appears to be a unique AIDS-associated neoplasm that is encountered in sub-Saharan Africa as well. Finally, although the epidemiologic and clinicopathologic features for many AIDS-associated neoplasms are well characterized in developing regions of the world, there is a paucity of data on the therapeutic approach to these tumors in this setting [8.Orem J. Otieno M.W. Remick S.C. AIDS associated cancer in developing nations.Curr Opin Oncol. 2004; 6: 468-478Crossref Scopus (67) Google Scholar]. Many other tumor types are found in Africa but data regarding their incidence are insufficient (Figure 2). Moreover, most cancer epidemiology studies involve people living in North America and Europe, which represent only a fraction of the global population. The wide variety of dietary, lifestyle and environmental exposures, as well as the genetic variation among people in developing countries, can provide valuable new information on factors that contribute to cancer or that protect against it.Figure 2Rates for cancer in Africa.View Large Image Figure ViewerDownload Hi-res image Download (PPT)In Africa, the cancer problem is related not only to the underestimation of the tumors incidence but also to the low level of cancer knowledge and awareness in the health workers and general population that had had devastating consequences. In fact, it was estimated that 88%–95% of people with cancer in Africa are diagnosed at late- to end-stage disease [1.Loehrer Sr, P.J. Greger H.A. Weinberger M. et al.Knowledge and beliefs about cancer in a socioeconomically disadvantaged population.Cancer. 1991; 68: 1665-1671Crossref PubMed Scopus (94) Google Scholar, 9.Yomi J. Gonsu F.J. Social, economical and educational causes of late diagnosis and treatment of cancer in Cameroon.Bull Cancer. 1995; 82: 724-727PubMed Google Scholar]. For people with a cancer diagnosis, the chances of surviving are very low so that incidence and mortality are usually represented by closed data. This is due to cancer drugs unavailability, radiotherapy centers shortage and scarcity of trained surgeons in surgical oncology.The future of cancer medicine in developing countries should be on the basis of the demystification of cancer through positive information, coupled to an effective organization that allows for the optimal use of available resources, facilitates access to specialized care and promotes the flow of knowledge and technology among physicians.The global disparities in incidence of certain preventable cancers (e.g. cervical), as well as in survival from several that are treatable (e.g. lymphoma, leukemia and testicular), are a demonstration of a lack of equity in health apparently determined solely by the hazard of where one is born. Most of the efforts and helps provided by the Western countries to Africa are spent to prevent and cure infectious diseases and malnutrition, leaving the patients with cancer to their poor destiny. Infact, oncology in Africa seems to be a branch of the medicine that is practiced only by the local traditional healers, procuring devastating effects on the natural history of the tumors. Generally, cancer is mystified, preventative actions are not taken and treatment engagement is deficient. As much as 95% of cancer patients in the African countries are diagnosed at late- or end-stage disease. The delayed diagnosis for these patients is due to the low level of cancer awareness between the population and the health workers, culture and constraints on access to specialized care, usually nonexistent in these countries [1.Loehrer Sr, P.J. Greger H.A. Weinberger M. et al.Knowledge and beliefs about cancer in a socioeconomically disadvantaged population.Cancer. 1991; 68: 1665-1671Crossref PubMed Scopus (94) Google Scholar]. All these findings indicate that misinformation and misconceptions regarding cancer and its treatment among physicians and patients contribute to inappropriate care-seeking behaviors and is a task of Western countries scientists, governments and nongovernmental organizations to transfer the knowledge and technology needed to prevent, treat and provide palliative care to African people affected by cancer. We report in this paper the case of a women with cutaneous metastasis from a cervix cancer at end stage, admitted in a rural area hospital of Eritrea during our volunteering in Africa, as an example of the problem of late diagnosis for cancer in Africa. case reportA 58-year-old woman presented to the Ghindae Referral Hospital in Eritrea, with postmenopausal bleeding, hematuria, diffuse abdominal pain and dyspnea. She was also complaining about the development of cutaneous ulcerated masses localized in the lower abdominal quadrants. The patient was in a very bad condition and the physical examination revealed signs of severe anemia, cervical mass referable to cancer and cutaneous metastasis of the abdominal wall (Figure 1). No radiological instruments for diagnosis were available in the hospital and only the complete blood count was carried out, confirming the suspect of anemia.Because of her serious health condition, the patient was admitted in the medical ward and treated for the pain and anemia. A surgical operation was planned to reduce symptoms and bleeding but the patient died after 24 h from admission, without getting the surgical treatment. A 58-year-old woman presented to the Ghindae Referral Hospital in Eritrea, with postmenopausal bleeding, hematuria, diffuse abdominal pain and dyspnea. She was also complaining about the development of cutaneous ulcerated masses localized in the lower abdominal quadrants. The patient was in a very bad condition and the physical examination revealed signs of severe anemia, cervical mass referable to cancer and cutaneous metastasis of the abdominal wall (Figure 1). No radiological instruments for diagnosis were available in the hospital and only the complete blood count was carried out, confirming the suspect of anemia. Because of her serious health condition, the patient was admitted in the medical ward and treated for the pain and anemia. A surgical operation was planned to reduce symptoms and bleeding but the patient died after 24 h from admission, without getting the surgical treatment. discussionAfrica is a continent disadvantaged in all aspects of human development. The main interdependent enemies of Africa are poverty, disease, ignorance, war and conflicts. Many resources were collected and invested by the developed countries to help Africa fighting against these enemies, but only a small amount of these resources were destined to cancer treatment. In Africa, cancer registration is inadequate and cancer incidence is grossly underestimated. In all, 95% of cancer patients present with an advanced-stage neoplasia and incidence: mortality is one for the most part [2.Kamangar F. Dores G.M. Anderson W.F. Patterns of cancer incidence, mortality, and prevalence across five continents: defining priorities to reduce cancer disparities in different geographic regions of the world.J Clin Oncol. 2006; 18: 2048-2049Google Scholar].The cancer incidence in Africa has been increasing dramatically, specially after the onset of AIDS pandemic. The rapid rises of neoplasms incidence in Africa may be only partially attributed to AIDS epidemic which, however, cannot account for all the observed increases, as subtypes not associated with AIDS are continuing to increase [3.Chokunonga E. Levy L.M. Bassett M.T. et al.Aids and cancer in Africa: the evolving epidemic in Zimbabwe.Int J Cancer. 2000; 85: 54-59Crossref PubMed Scopus (119) Google Scholar]. In particular in sub-Saharan Africa, the AIDS epidemic has created a new cancer problem in the form of Kaposi sarcoma. Formerly a rather rare, the Kaposi sarcoma, a relatively indolent cancer found in East and Central Africa, with the epidemic of AIDS became more common and some 57 000 new cases occur in Africa each year and, due to the poor prognosis for cases associated with AIDS, some 52 000 patients die of this disease [4.Parkin M.D. Bray F. Ferlay J. Pisani P. Global cancer statistics, 2002.CA Cancer J Clin. 2005; 55: 74-108Crossref PubMed Scopus (17225) Google Scholar]. Since the 1980s, in those areas where endemic Kaposi sarcoma had been relatively common before the epidemic of HIV/AIDS such as Uganda, Malawi, Zimbabwe and Swaziland, the incidence of Kaposi sarcoma has increased ∼20-fold, such that it is now the leading cancer in men and the second leading cancer in women [5.Parkin D.M. Ferlay J. Hamdi-Chérif M. et al.Cancer in Africa: Epidemiology and Prevention. IARC Scientific Publications No. 153. International Agency for Research on Cancer, Lyon, France2003Google Scholar]. The effect of HIV on Kaposi sarcoma development is probably through immunosuppression by allowing human herpesvirus 8 to escape control and increase viral load, e.g. The epidemiology of this virus probably explains the geography of Kaposi sarcoma pre-AIDS. The region most affected is central Africa (30 per 1 00 000), followed by eastern, southern and western Africa, in line with the background prevalence of HIV in each of these regions [4.Parkin M.D. Bray F. Ferlay J. Pisani P. Global cancer statistics, 2002.CA Cancer J Clin. 2005; 55: 74-108Crossref PubMed Scopus (17225) Google Scholar, 6.Bassett M.T. Chokunonga E. Mauchaza B. et al.Cancer in the African population of Harare, Zimbabwe, 1990–1992.Int J Cancer. 1995; 63: 763Google Scholar]. By the end of the second decade of AIDS epidemic, non-Hodgkin’s lymphoma is increasing in incidence and the natural history of Burkitt’s lymphoma is evolving in the backdrop of HIV infection as well. It has been estimated that ∼5% to 10% of HIV-infected persons will develop a lymphoma, and non-Hodgkin’s lymphoma is the AIDS-defining illness in ∼3% of HIV-infected patients [7.Remick S.C. Acquired immunodeficiency syndrome-related non-Hodgkin's lymphoma.Cancer Control. 1995; 2: 97-103PubMed Google Scholar]. Cervical cancer is the most common cancer in women in many developing countries, yet the true impact of HIV infection on the development of this neoplasm is not fully understood. Squamous cell carcinoma of the conjunctiva appears to be a unique AIDS-associated neoplasm that is encountered in sub-Saharan Africa as well. Finally, although the epidemiologic and clinicopathologic features for many AIDS-associated neoplasms are well characterized in developing regions of the world, there is a paucity of data on the therapeutic approach to these tumors in this setting [8.Orem J. Otieno M.W. Remick S.C. AIDS associated cancer in developing nations.Curr Opin Oncol. 2004; 6: 468-478Crossref Scopus (67) Google Scholar]. Many other tumor types are found in Africa but data regarding their incidence are insufficient (Figure 2). Moreover, most cancer epidemiology studies involve people living in North America and Europe, which represent only a fraction of the global population. The wide variety of dietary, lifestyle and environmental exposures, as well as the genetic variation among people in developing countries, can provide valuable new information on factors that contribute to cancer or that protect against it.In Africa, the cancer problem is related not only to the underestimation of the tumors incidence but also to the low level of cancer knowledge and awareness in the health workers and general population that had had devastating consequences. In fact, it was estimated that 88%–95% of people with cancer in Africa are diagnosed at late- to end-stage disease [1.Loehrer Sr, P.J. Greger H.A. Weinberger M. et al.Knowledge and beliefs about cancer in a socioeconomically disadvantaged population.Cancer. 1991; 68: 1665-1671Crossref PubMed Scopus (94) Google Scholar, 9.Yomi J. Gonsu F.J. Social, economical and educational causes of late diagnosis and treatment of cancer in Cameroon.Bull Cancer. 1995; 82: 724-727PubMed Google Scholar]. For people with a cancer diagnosis, the chances of surviving are very low so that incidence and mortality are usually represented by closed data. This is due to cancer drugs unavailability, radiotherapy centers shortage and scarcity of trained surgeons in surgical oncology.The future of cancer medicine in developing countries should be on the basis of the demystification of cancer through positive information, coupled to an effective organization that allows for the optimal use of available resources, facilitates access to specialized care and promotes the flow of knowledge and technology among physicians.The global disparities in incidence of certain preventable cancers (e.g. cervical), as well as in survival from several that are treatable (e.g. lymphoma, leukemia and testicular), are a demonstration of a lack of equity in health apparently determined solely by the hazard of where one is born. Africa is a continent disadvantaged in all aspects of human development. The main interdependent enemies of Africa are poverty, disease, ignorance, war and conflicts. Many resources were collected and invested by the developed countries to help Africa fighting against these enemies, but only a small amount of these resources were destined to cancer treatment. In Africa, cancer registration is inadequate and cancer incidence is grossly underestimated. In all, 95% of cancer patients present with an advanced-stage neoplasia and incidence: mortality is one for the most part [2.Kamangar F. Dores G.M. Anderson W.F. Patterns of cancer incidence, mortality, and prevalence across five continents: defining priorities to reduce cancer disparities in different geographic regions of the world.J Clin Oncol. 2006; 18: 2048-2049Google Scholar]. The cancer incidence in Africa has been increasing dramatically, specially after the onset of AIDS pandemic. The rapid rises of neoplasms incidence in Africa may be only partially attributed to AIDS epidemic which, however, cannot account for all the observed increases, as subtypes not associated with AIDS are continuing to increase [3.Chokunonga E. Levy L.M. Bassett M.T. et al.Aids and cancer in Africa: the evolving epidemic in Zimbabwe.Int J Cancer. 2000; 85: 54-59Crossref PubMed Scopus (119) Google Scholar]. In particular in sub-Saharan Africa, the AIDS epidemic has created a new cancer problem in the form of Kaposi sarcoma. Formerly a rather rare, the Kaposi sarcoma, a relatively indolent cancer found in East and Central Africa, with the epidemic of AIDS became more common and some 57 000 new cases occur in Africa each year and, due to the poor prognosis for cases associated with AIDS, some 52 000 patients die of this disease [4.Parkin M.D. Bray F. Ferlay J. Pisani P. Global cancer statistics, 2002.CA Cancer J Clin. 2005; 55: 74-108Crossref PubMed Scopus (17225) Google Scholar]. Since the 1980s, in those areas where endemic Kaposi sarcoma had been relatively common before the epidemic of HIV/AIDS such as Uganda, Malawi, Zimbabwe and Swaziland, the incidence of Kaposi sarcoma has increased ∼20-fold, such that it is now the leading cancer in men and the second leading cancer in women [5.Parkin D.M. Ferlay J. Hamdi-Chérif M. et al.Cancer in Africa: Epidemiology and Prevention. IARC Scientific Publications No. 153. International Agency for Research on Cancer, Lyon, France2003Google Scholar]. The effect of HIV on Kaposi sarcoma development is probably through immunosuppression by allowing human herpesvirus 8 to escape control and increase viral load, e.g. The epidemiology of this virus probably explains the geography of Kaposi sarcoma pre-AIDS. The region most affected is central Africa (30 per 1 00 000), followed by eastern, southern and western Africa, in line with the background prevalence of HIV in each of these regions [4.Parkin M.D. Bray F. Ferlay J. Pisani P. Global cancer statistics, 2002.CA Cancer J Clin. 2005; 55: 74-108Crossref PubMed Scopus (17225) Google Scholar, 6.Bassett M.T. Chokunonga E. Mauchaza B. et al.Cancer in the African population of Harare, Zimbabwe, 1990–1992.Int J Cancer. 1995; 63: 763Google Scholar]. By the end of the second decade of AIDS epidemic, non-Hodgkin’s lymphoma is increasing in incidence and the natural history of Burkitt’s lymphoma is evolving in the backdrop of HIV infection as well. It has been estimated that ∼5% to 10% of HIV-infected persons will develop a lymphoma, and non-Hodgkin’s lymphoma is the AIDS-defining illness in ∼3% of HIV-infected patients [7.Remick S.C. Acquired immunodeficiency syndrome-related non-Hodgkin's lymphoma.Cancer Control. 1995; 2: 97-103PubMed Google Scholar]. Cervical cancer is the most common cancer in women in many developing countries, yet the true impact of HIV infection on the development of this neoplasm is not fully understood. Squamous cell carcinoma of the conjunctiva appears to be a unique AIDS-associated neoplasm that is encountered in sub-Saharan Africa as well. Finally, although the epidemiologic and clinicopathologic features for many AIDS-associated neoplasms are well characterized in developing regions of the world, there is a paucity of data on the therapeutic approach to these tumors in this setting [8.Orem J. Otieno M.W. Remick S.C. AIDS associated cancer in developing nations.Curr Opin Oncol. 2004; 6: 468-478Crossref Scopus (67) Google Scholar]. Many other tumor types are found in Africa but data regarding their incidence are insufficient (Figure 2). Moreover, most cancer epidemiology studies involve people living in North America and Europe, which represent only a fraction of the global population. The wide variety of dietary, lifestyle and environmental exposures, as well as the genetic variation among people in developing countries, can provide valuable new information on factors that contribute to cancer or that protect against it. In Africa, the cancer problem is related not only to the underestimation of the tumors incidence but also to the low level of cancer knowledge and awareness in the health workers and general population that had had devastating consequences. In fact, it was estimated that 88%–95% of people with cancer in Africa are diagnosed at late- to end-stage disease [1.Loehrer Sr, P.J. Greger H.A. Weinberger M. et al.Knowledge and beliefs about cancer in a socioeconomically disadvantaged population.Cancer. 1991; 68: 1665-1671Crossref PubMed Scopus (94) Google Scholar, 9.Yomi J. Gonsu F.J. Social, economical and educational causes of late diagnosis and treatment of cancer in Cameroon.Bull Cancer. 1995; 82: 724-727PubMed Google Scholar]. For people with a cancer diagnosis, the chances of surviving are very low so that incidence and mortality are usually represented by closed data. This is due to cancer drugs unavailability, radiotherapy centers shortage and scarcity of trained surgeons in surgical oncology. The future of cancer medicine in developing countries should be on the basis of the demystification of cancer through positive information, coupled to an effective organization that allows for the optimal use of available resources, facilitates access to specialized care and promotes the flow of knowledge and technology among physicians. The global disparities in incidence of certain preventable cancers (e.g. cervical), as well as in survival from several that are treatable (e.g. lymphoma, leukemia and testicular), are a demonstration of a lack of equity in health apparently determined solely by the hazard of where one is born.