Cancer is an emerging public health problem in Africa. About 715,000 new cancer cases and 542,000 cancer deaths occurred in 2008 on the continent, with these numbers expected to double in the next 20 years simply because of the aging and growth of the population. Furthermore, cancers such as lung, female breast, and prostate cancers are diagnosed at much higher frequencies than in the past because of changes in lifestyle factors and detection practices associated with urbanization and economic development. Breast cancer in women and prostate cancer in men have now become the most commonly diagnosed cancers in many Sub-Saharan African countries, replacing cervical and liver cancers. In most African countries, cancer control programs and the provision of early detection and treatment services are limited despite this increasing burden. This paper reviews the current patterns of cancer in Africa and the opportunities for reducing the burden through the application of resource level interventions, including implementation of vaccinations for liver and cervical cancers, tobacco control policies for smoking-related cancers, and low-tech early detection methods for cervical cancer, as well as pain relief at the palliative stage of cancer.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/cncr.27410

Cancer burden in Africa and opportunities for prevention.

Background
Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

Objectives
To assess the effectiveness and safety of alternative surgical treatments for CIN.

Search methods
We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to November 2012). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

Selection criteria
Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

Data collection and analysis
Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

Main results
Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

Authors' conclusions
The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

/pdf/surgery-for-cervical-intraepithelial-neoplasia-ouc1rfg04e.pdf

Surgery for cervical intraepithelial neoplasia

Cervical cancer: the sub-Saharan African perspective

M Bower, S Collins, C Cottrill, K Cwynarski, S Montoto, M Nelson, N Nwokolo, T Powles, J Stebbing, N Wales and A Webb, on behalf of the AIDS Malignancy Subcommittee Department of Oncology, Chelsea & Westminster Hospital, London, UK, HIV i-Base and UK-CAB, London, UK, St Bartholomew’s Hospital, London, UK, Royal Free Hospital, London, UK, Hammersmith Hospital, London, UK and Royal Sussex County Hospital, Brighton, UK

https://onlinelibrary.wiley.com/doi/pdf/10.1111/hiv.12136

British HIV Association guidelines for HIV-associated malignancies 2014

Results Overall observed cumulative rates of CIN 2/3 in the first 6 years after treatment were 14.0% (95% CI = 13.84% to 14.15%) for women originally treated for CIN 3, 9.3% (95% CI = 9.09% to 9.42%) for CIN 2, and 5.6% (95% CI = 4.91% to 5.21%) for CIN 1. Annual rates of CIN 2/3 were less than 1% after 6 years. Initial diagnosis, age, and treatment type were associated with a diagnosis of CIN 2/3 after treatment, with 6-year adjusted rates for women aged 40 – 49 years ranging from 2.6% (95% CI = 1.9% to 3.4%) for treatment of CIN 1 with the loop electrosurgical excision procedure to 34.0% (95% CI = 30.9% to 37.1%) for treatment of CIN 3 with cryotherapy. Overall incidence of invasive cancer (per 100 000 woman-years) was higher in the CIN cohort (37 invasive cancers, 95% CI = 30.6 to 42.5 cancers) than in the comparison cohort (six cancers, 95% CI = 4.3 to 7.7 cancers). Cryotherapy, compared with other treatments, was associated with the highest rate of subsequent disease (adjusted odds ratio for invasive cancer = 2.98, 95% CI = 2.09 to 4.60). Conclusion Risk of CIN 2/3 after treatment was associated with initial CIN grade, treatment type, and age. Long-term risk of invasive cancer remained higher among women treated for CIN, particularly those treated with cryotherapy. J Natl Cancer Inst 2009;101: 721 – 728

Cervical Intraepithelial Neoplasia Outcomes After Treatment: Long-term Follow-up From the British Columbia Cohort Study

The objective of the treatment of cervical intraepithelial neoplasia (CIN) is the prevention of invasive carcinoma of the cervix, which still remains the most common cancer in Zimbabwean women, as in most other low-resource countries where screening facilities are grossly inadequate. We conducted a randomised prospective study to compare CIN treatment outcome after cryotherapy and loop electrosurgical excision procedure (LEEP) in 400 women with histologically confirmed high grade squamous intra-epithelial lesions (HGSIL). Treatment outcome measures were immediate complications, persistent disease and recurrent disease evaluated at follow-up visits. Eighty-two per cent of the women (159 cryotherapy, 168 LEEP) completed their 6-month and 12-month follow-up visits. LEEP had a significantly higher overall cure rate of 96·4% (absence of persistant or recurrent disease) compared to 88·3% cryotherapy ( P =0·026). Although cryotherapy was not superior to LEEP, its cure rate (88·3%) is acceptable and therefore pro...

A randomised clinical trial of loop electrosurgical excision procedure (LEEP) versus cryotherapy in the treatment of cervical intraepithelial neoplasia.

OBJECTIVE.: To compare the treatment outcome of cervical intraepithelial neoplasia (CIN 2,3) on HIV-infected and uninfected women treated by cryotherapy or loop electrosurgical excision procedure (LEEP). METHODS.: A total of 147 women were recruited into the study between April 1997 and May 1998. Cryotherapy was performed in 75 women and LEEP in 72 women after randomization. RESULTS.: A total of 109 (74.1%) women tested positive and 38 (25.9%) tested negative for HIV-1. At 12 months follow-up visit, cryotherapy had 59.5% cure rate on HIV-positive women and 84.2% success among HIV-negative women (p = .057). LEEP had 86% cure rate on HIV-positive and 100% cure rate on HIV-negative women (p = .328). CONCLUSION.: HIV-1-infected women harboring cervical squamous intraepithelial lesions have a high failure rate (40.5%) when treated by cryotherapy.

Effect of HIV Disease in Treatment Outcome of Cervical Squamous Intraepithelial Lesions Among Zimbabwean Women.

This cross-sectional study was conducted to document the socio-demographic profile presenting symptoms disease stage and treatment modality offered to all women with a histological diagnosis of cervical cancer admitted between January 11 1998 and December 14 1998 in Parirenyatwa Hospitals and Harare Central Hospital. A total of 196 patients with a median age of 47 years (range 24-80 years) were recruited into the study. A high proportion (63.3%) of the women were from rural areas. The mean age at first pregnancy was 17.9 years (standard deviation 2.8) and 112 (63.3%) first sought treatment at the primary health care centre. Persistent vaginal discharge was the most frequent (69.4%) presenting complaint. 195 patients (99.5%) had histological confirmation of invasive cervical cancer (91.8% squamous cell carcinoma 7.7% adenocarcinoma). Clinical staging by The International Federation of Gynaecology and Obstetrics classification confirmed that the majority (80.3%) of the cancers had spread from the cervix into the parametrium and beyond (stage 2b and above) at the time of presentation. Radiation therapy was the most commonly used (77.0%) treatment modality. This study demonstrates that the burden of cervical cancer occurs around the peak age of 47 years and that the majority of women present with advanced disease. None of these women had ever been screened for cervical cancer. The planned introduction of a cervical cancer screening programme by visual inspection of the cervix with acetic acid (VIA) together with a health education campaign may result in a shift towards more women presenting early curable cervical cancer cases. (authors)

V. Akino

Papers

A randomised clinical trial of loop electrosurgical excision procedure (LEEP) versus cryotherapy in the treatment of cervical intraepithelial neoplasia.

Effect of HIV Disease in Treatment Outcome of Cervical Squamous Intraepithelial Lesions Among Zimbabwean Women.

A review of cervical cancer patients presenting in Harare and Parirenyatwa Hospitals in 1998.

A randomised trial of treatment HGSIL by cryotherapy or leep