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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 11-15

Age distribution, site of origin and HIV status of cases of gynaecological malignancies seen at a radiotherapy facility in Northern Nigeria


1 Department of Radiotherapy and Oncology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
4 PEPFAR/Nasara HIV Clinic, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication13-Mar-2015

Correspondence Address:
S A Adewuyi
Department of Radiotherapy and Oncology, Ahmadu Bello University Teaching Hospital, P. M. B. 06, Shika-Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.153147

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  Abstract 

Background: Gynecological malignancies are very common in Northern Nigeria. Although cervical cancer has been classified as HIV-related malignancy, little information is available on the pattern of presentation of gynecological malignancies in HIV patients. The objective of this study was to analyze the age distribution, site of origin, stage, and HIV status of cases of gynecological malignancies seen at a radiotherapy facility in Northern Nigeria.
Patients and Methods: Between January 2006 and December 2011, consecutive patients with histologically confirmed gynecological malignancies were studied retrospectively and evaluated with respect to age, site of tumor, histological type, stage of disease, and retroviral status. Patients' folders were reviewed using a standardized structured proforma. Results were analyzed using Epi Info software 3.4.1, 2007 edition.
Results: A total of 350 gynecological malignant cases were reviewed. The age range was 21-86 years, with a mean age of 49 years, a modal age group of 41-50 years, and a median age of 50 years. The commonest gynecological malignancy observed was cervical cancer (81.7%), followed by ovarian epithelial cancer (6%), endometrial cancer (4%), ovarian germ cell tumor (3.14%), vaginal cancer (2.3%), vulvar cancer (2.3%), and myometrial sarcoma (0.6%). In all, 85.1% patients had locally advanced disease, 9.4% had metastatic disease, and 5.4% had early stage disease at presentation. HIV seropositivity was 10.3%; however, 94.4% of those with HIV had cancer of the cervix.
Conclusion: In this review, the peak modal age group for gynecological malignancies is the fifth decade of life. Cervical cancer is the commonest gynecological malignancy seen with preponderance of late stages of the disease at presentation. HIV seropositivity is highest among women with cervical cancer than among women with other cancers, as seen in the facility.

Keywords: Advanced cancer, cervical cancers, gynecological malignancies


How to cite this article:
Adewuyi S A, Oguntayo A O, Kolawole A O, Samaila M, Adewuyi K R. Age distribution, site of origin and HIV status of cases of gynaecological malignancies seen at a radiotherapy facility in Northern Nigeria. Arch Int Surg 2015;5:11-5

How to cite this URL:
Adewuyi S A, Oguntayo A O, Kolawole A O, Samaila M, Adewuyi K R. Age distribution, site of origin and HIV status of cases of gynaecological malignancies seen at a radiotherapy facility in Northern Nigeria. Arch Int Surg [serial online] 2015 [cited 2024 Mar 1];5:11-5. Available from: https://www.archintsurg.org/text.asp?2015/5/1/11/153147


  Introduction Top


Gynecological malignancies refer to malignancies arising from the female reproductive organs, including vulva, vagina, cervix, endometrium, myometrium,  Fallopian tube More Detailss, and ovary. Gynecological cancer research has become relevant because of the aging population and the large proportion of females with malignancies, as well as because of the role of sexual activity, parity, sexually transmitted infections, fertility issues, and contraception. [1],[2] The global cancer statistics by the International Agency for Research on Cancer (IARC) revealed that gynecological malignancies account for 19% new cancer patients. [1],[3] This is worrisome and requires concerted effort to stop the tide. It is a common finding that late presentation, apathy for orthodox medicine, poor health-seeking behavior, and poverty account for poor prognostic factors for gynecological cancers in the developing world to which the study environment belongs. [4],[5]

Various factors like age, sexually transmitted infections, multiple sexual partners, promiscuity, smoking, age at menarche, and age at menopause are associated with the pattern of gynecological malignancies. Other factors include immunosuppression, obesity, few cancer screening programs, low socioeconomic status, and poverty. Despite the declining rate of incidence and mortality in developed countries, cervical cancer remains the leading cause of cancer deaths for women in developing and underdeveloped countries. [1],[6]

There is evidence in the study center that the number of cancer cases seen is increasing annually, and this is also supported by international publications of a global rise in cancer incidence. [1],[6] This increase in cancer cases may be due to an actual increase in cancer cases, improvement in diagnostic facilities, and increased awareness. The low incidence of cancer of the cervix in developed countries is related to the uptake of screening program and efficient health system for managing human papillomavirus (HPV), which is the culprit in the etiology of cancer of the cervix. [2] In the developing countries, a confounding factor for the high incidence of cancer of the cervix is the early age at first coitus, high rate of divorce and remarriages, and poverty. [5] In countries with high prevalence of HIV and AIDS, the pattern tilts to show high incidence of cancer of the vulva and vagina in addition to cancer of the cervix. [7],[8]

The poorly functioning cancer registry in the country and the reliance on hospital-based data made it difficult to ascertain the prevalence of gynecological cancers in the country and in the geopolitical zone. The number of patients seen in this study includes patients with gynecological cancer referred to the unit from within and outside the hospital for further therapy. This number does not represent the total patients with gynecological malignancies seen in Ahmadu Bello University Teaching Hospital (ABUTH), Zaria.

Currently, there are no published local data on the pattern of gynecological malignancies seen in radiotherapy facilities. In view of this, we report an audit of the cases of gynecological malignancies seen in the Radiotherapy and Oncology Department of ABUTH,a referral tertiary health institution in Northern Nigeria, and use the results as a basis for further research and planning of future oncological services.


  Patients and Methods Top


This study was conducted retrospectively at the Radiotherapy and Oncology Department, ABUTH. The study involved all adult female patients aged 18 years or more with gynecological malignancies referred to the unit between January 2006 and December 2011 for further management. Data extracted from the case files include the age at presentation, site of tumor, stage of disease and retroviral status, comorbidity, and histological type. For the purpose of this study, stage of disease was considered early stage if there was no extension into adjacent structures or regional lymph node involvement; locally advanced if there was involvement of adjacent structures, regional lymph node involvement, inoperable, or bilateral; and metastatic stage if there was evidence of distant metastasis. The patients in this study included those referred from other clinical departments within the hospital (ABUTH) and those referred from other teaching and specialist hospitals within and outside the geopolitical zone.Pediatric patients and patients with borderline histology or premalignant conditions were excluded from the study. Data were collected from the patients' folders using a structured proforma designed for the study. Results were analyzed using Epi Info software 3.4.1, 2007 edition.


  Results Top


A total of 1130 new patients were seen, of which 350 patients had gynecological malignancies during the study period. The age range was 21-86 years, with a mean age of 49 years, modal age group of 41-50 years, and median age of 50 years. [Table 1] shows the gynecological malignancies with age distribution. The commonest gynecological malignancy was cervical cancer diagnosed in 286 (81.7%), followed by ovarian cancer 9.14% {epithelial cancer 21 (6%), germ cell tumors in 11 (3.14%)}, endometrial cancer in 14 (4%), vaginal cancer in 8 (2.3%), vulvar cancer in 8 (2.3%), and myometrial sarcoma in 2 (0.6%) patients. Most patients, 298 of 350 (85.1%), had locally advanced disease, 33 (9.4%) had metastatic disease, and 19 (5.4%) had early stage disease at presentation [Table 2]. Thirty-six (10.3%) patients were HIV seropositive, of whom34 (94.4%) had cervical cancer and 1 patient each had ovarian germ cell tumor and vaginal cancer [Table 3].
Table 1: Types of gynecological malignancies with age distribution


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Table 2: Gynecological malignancies with stage of disease at presentation


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Table 3: Genital tract cancers and HIV status


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  Discussion Top


The results of this study revealed that gynecological malignancies accounted for 1 in every 3 cancer patients presenting in the radiotherapy department. This revealed the burden of the disease and the pressure on the existing facility. The mean age at presentation is in variance to the pattern in the developed countries, where 80% of the patients are aged more than 60 years. [1],[6],[9],[10] The predominance of younger women may be related to the low life expectancy in Nigeria, poor date of birth registration, illiteracy, and the prevailing poverty. The mean age of the common gynecological malignancies seen in the study is lower than that in the developed countries by about 10 years, particularly for cervical and ovarian cancers. [3],[6]

Cervical cancer is the commonest cancer and accounted for more than 80% of the patients [Table 1]. This result is similar to the findings in other developing and underdeveloped countries, but at variance to the findings in strict religious countries and countries with high compliance to screening program for cervical cancer. [6],[9],[10] Confounding factors for high incidence of cervical cancer in the population include promiscuity, multiple sexual partners, high rate of divorce and remarriages, poverty, and early age of coitus. [5] Epithelial malignancies (squamous cell carcinoma in cervical cancer and adenocarcinoma in ovary and endometrium cancers) are the commonest types of malignancies seen in the study. Soft tissue sarcoma is very uncommon, as leiomyosarcoma of the myometrium is seen in only two patients, less than 1% of all cases. Germ cell tumor of the ovary is not often referred to the radiotherapy department because most cases are seen and efficiently managed by the gynecologists. Worldwide, cervical cancer is the second commonest cancer and the second leading cause of cancer death in women. [1],[6] In the United States, cervical cancer is the third commonest cancer of the female reproductive tract. [6] In the developed countries, the introduction of Papanicolaou (Pap) smear screening has reduced the incidence and mortality of invasive cervical cancer by almost 75% over the last 50 years. [11] Cervical cancer is the leading cause of cancer mortality in women in developing and underdeveloped countries. [10],[11] Cervical cancer has good prognosis if detected early and managed effectively, but this is different in the study environment because late presentation and advanced and metastatic disease are the norms. [12] There is need for a reinvigorated campaign to encourage uptake of screening program and early presentation in view of high mortality and poor quality of life associated with advanced disease.

Ovarian cancer has been described as a disease affecting older women. The ovarian cancer patients in this environment are younger compared with the pattern in the Western world, and this was confirmed in another study in Ibadan, Nigeria. [4] The mean age for epithelial ovarian cancer in this study is 53.6 years. Ovarian cancer is the third commonest gynecological malignancy but the fourth commonest cancer of the female population in Nigeria. [4],[13] In this study, ovarian cancer is the second commonest gynecological cancer. Referral to radiotherapy department was due to inoperability, late presentation with advanced disease, and need for palliation. Epithelial ovarian cancer typically occurs in postmenopausal women, whereas most germ cell tumors present in younger women, and sex cord stromal tumors may occur at any age. Endometrial carcinoma is the commonestgynecological cancer in the United States, fourth commonest malignancy in women after breast, lung, and colorectal cancers. [14],[15] In this study, endometrial carcinoma is the third commonest gynecological cancer accounting for 4% of all gynecological malignancies seen. This may be due to non-referral of patients for postoperative radiotherapy and actual low incidence in African women. Endometrial carcinoma is predominantly a disease of perimenopausal women. Primary carcinoma of the vagina, a rare malignancy found primarily in older women, constitutes 1-2% of all gynecological malignancies. Vaginal cancer is rare even in developed countries, with 80% occurring in women aged more than 60 years. [14],[16],[17] The reverse is the case in the study environment ,with more than 80% occurring in women agedless than 60 years. In this study, vaginal cancer accounts for 2.3% of all gynecological malignancies. Radiation therapy has been found to play a significant role in management, and this may have contributed to the relatively high number observed.

Vulvar carcinoma accounted for 2.3% of gynecological malignancies seen. Most vulvar carcinomas occur in older women, with more than 50% of the patients aged 60-79 years. [18] Invasive vulvar carcinomas are being seen with increasing frequency in younger patients; however, with 15% of vulvar cancers are being seen in women aged less than 40 years. [18],[19] This increased frequency in younger patients is attributed to an increase in the number of sexual partners, resulting in venereal viral infections within the population including HIV epidemic. The result from this study correlates with the literature findings. The commonest site for sarcoma in the female pelvis is the uterus, but uterine sarcomas represent only 4-9% of uterine cancers, with an annual incidence rate of less than 20 per million females. [14] Only 2 (0.57%) patients were seen with leiomyosarcoma of the uterus in this study, which is very low.

Most patients (94.5%) had locally advanced and metastatic disease at presentation [Table 2]. Late presentation is a common denominator in the study environment and not peculiar to female patients. Previous study implicated apathy for orthodox treatment, poverty, illiteracy, ignorance, female neglect by husband and parents, and low socioeconomic status as main causes. [5],[13] Similarly, there is poor uptake of screening program for cervical cancer. Other confounding factors are the role played by herbalists and spiritualists, as most patients admitted to seeking their assistance for their ailments prior to attending hospital. The pattern of presentation in gynecological malignancy is same as seen in other patients with non-gynecological malignancies with locally advanced and metastatic disease seen at presentation. This pattern cuts across all gynecological malignancies. This pattern was also seen in the study from other developing countries. [3],[20],[21] Another reason adducible to this very high proportion of advanced stage disease seen in radiotherapy department is the palliative care services being rendered in the department.

Carcinoma of the cervix has been included as AIDS defining cancer by the Center for Disease Control and Prevention since 1993. [7],[8] The findings of 34 out of 36 patients with HIV infection having carcinoma of the cervix confirms this inclusion [Table 3]. The main culprit in carcinoma of the cervix is HPV, which is sexually transmitted and provides a fertile environment for HIV infection. The finding of one patient with germ cell tumor of the ovary with HIV may be an incidental finding. In population where there is high prevalence of HIV, there is high incidence of vulvar cancer, but this is not so in this study. All the seropositive patients were positive for HIV type 1, and none of the patients was positive for type 2. Studies in the environmenthave suggested that cervical cancer is a more aggressive disease in HIV positive patients. [22]


  Conclusion Top


The peak modal age group for gynecological malignancies is lower in the fifth decade of life. Cervical cancer is the commonest gynecological malignancy seen at the radiotherapy facility. Locally advanced and metastatic diseases are at the predominant stages at presentation. Cervical cancer is also the predominant malignancy seen in HIV positive patients with gynecological malignancies.

There is need for concerted efforts by both the government and non-government agencies to improve campaign on gynecological malignancies by addressing the various lifestyles associated with its etiology, with particular emphasis on cervical cancer. Vaccination against HPV among young females should be included in the National Immunization Program, and screening program using Papanicolaou (PAP) smear and visual inspection with acetic acid should be encouraged.

 
  References Top

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Bosch FX, de Sanjose S. Human papillomavirus and cervical cancer: Burden and assessment of causality. J Natl Cancer Inst Monogr 2003:3.  Back to cited text no. 2
    
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Parkin DM, Muir CS, Whelan SL, Gao YT, Ferlay J, Powell J. (eds), Cancer incidence in five continents. 6 th ed. IARC Scientific Publication. No 120, Lyon: IARC; 1992.  Back to cited text no. 3
    
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Odukogbe AA, Adebamowo CA, Ola B, Olayemi O, Oladokun A, Adewole IF, et al. Ovarian cancer in Ibadan: Characteristics and management. J Obstet Gynaecol 2004;24:294-7.  Back to cited text no. 4
    
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Adewuyi SA, Shittu SO, Rafindadi AH. Sociodemographic and clinicopathologic characterization of cervical cancer in northern Nigeria. Eur J Gynaecol Oncol 2008;29:61-4.  Back to cited text no. 5
    
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American Cancer Society. Cancer Facts and Figures 2005. Atlanta: American Cancer Society; 2005.  Back to cited text no. 6
    
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Buehler JW, Ward JW. A new definition for AIDS surveillance. Ann Intern Med 1993;118:390-2.  Back to cited text no. 7
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Chirenje ZM. HIV and cancer of the cervix. Best Pract Res Clin Obstet Gynaecol 2005;19:269-76.  Back to cited text no. 8
    
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Oguntayo OA, Zayyan M, Kolawole AO, Akpar M, Adewuyi SA. The burden of gynaecological cancer management in Northern Nigeria. J Obstet Gynaecol 2013;3:634-8.  Back to cited text no. 12
    
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Oguntayo OA, Zayyan M, Kolawole AO, Adewuyi SA, Samaila MO. Epidemiology of Gynaecologic cancers in Zaria, Northern Nigeria. Ital J Gynaecol Obstet 2012;24:168-73.  Back to cited text no. 13
    
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Beller U, Benedet JL, Creasman WT, Ngan HY, Quinn MA, Maisonneuve P, et al. Carcinoma of the vagina. Int J Gynaecol Obstet 2006;95 Suppl 1:S29-42.  Back to cited text no. 16
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Iversen T, Tretli S. Intraepithelial and invasive squamous cell neoplasia of the vulva: Trends in incidence, recurrence, and survival rate in Norway. Obstet Gynecol 1998;91:969-72.  Back to cited text no. 19
    
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