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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 33  |  Issue : 3  |  Page : 288-291

Ovarian cancer: Pattern of care in a tertiary health centre in sub-saharan Africa


Department of Obstetrics and Gynaecology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication8-Feb-2017

Correspondence Address:
U A Umar
Snr. Lecturer/Consultant, Department of Obstetrics and Gynaecology, Bayero University/Aminu Kano Teaching Hospital, PMB 3452, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJOG.TJOG_51_16

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  Abstract 

Objective: The aim of this study was to study the pattern of care offered to patients with ovarian cancer, as well as to evaluate patients' compliance to chemotherapy in our centre.
Materials and Methods: Theatre records and case files of patients who underwent surgery for ovarian cancer from January 2011 to December 2014 at our hospital were retrieved and analyzed.
Results: During the study period, 68 patients were admitted with malignant ovarian tumors. Sixty-five percent of the patients presented with advanced stages (either stage III or IV). Complete surgical staging was done in 48 (66%) patients. Only 18 (25.5%) had optimal cytoreduction during surgery. Compliance to chemotherapy was poor, as out of the 58 patients that were recommended to have chemotherapy, only 28 had it; giving a compliance rate of 48.3%.
Conclusion: Management of malignant ovarian tumor is still not optimal at our centre due to late presentation and poor compliance to chemotherapy. Training of gynaecologic oncologist and creation of Gynaecologic Oncology centres in our hospitals as well as provision of subsidized chemotherapy drugs will improve management and survival.

Keywords: Chemotherapy; ovarian cancer; pattern of care.


How to cite this article:
Umar U A, Yakasai I A, Adamou N. Ovarian cancer: Pattern of care in a tertiary health centre in sub-saharan Africa. Trop J Obstet Gynaecol 2016;33:288-91

How to cite this URL:
Umar U A, Yakasai I A, Adamou N. Ovarian cancer: Pattern of care in a tertiary health centre in sub-saharan Africa. Trop J Obstet Gynaecol [serial online] 2016 [cited 2020 Oct 1];33:288-91. Available from: http://www.tjogonline.com/text.asp?2016/33/3/288/199817


  Introduction Top


Ovarian cancer is the second most common gynecological cancer in developing countries.[1] It accounts for 18.8% of all gynecological cancers in developing countries and 28.7% in developed countries.[1] Recent studies in 2012 gave a worldwide incidence of 238,719 and a mortality of 151,913.[1] It has a case-fatality rate of approximately 59.2% because it usually manifests only in its advanced stages.[2] With an overall 5-year survival rate of approximately 45%, ovarian cancer has the worst prognosis among all gynecological malignancies.[3],[4] Previous studies showed that ovarian cancer in Nigeria constituted 7–22% of all gynecological malignancies.[5],[6],[7] Symptoms are ambiguous and often misdiagnosed, and therefore, most patients present with advanced stage disease.[8] The lack of specific symptoms and signs of early ovarian cancer precludes the possibility of early detection by clinical suspicion.

Large number of patients in developing countries such as Nigeria reside in rural areas and have poor access to specialized health care.[9] More than 61% of the Nigerian population live below the poverty line, i.e., proportion receiving less than $1 per day in income.[9] The cost of chemotherapy is usually unaffordable, and this is a major obstacle for many patients to continue with the treatment.[10]

Justification for the study

Nigeria has a huge burden of the disease with no comprehensive cancer centre that can offer appropriate multidisciplinary care.[11] Trained gynaecologic oncologist are few in Nigeria, and hence, most ovarian cancers are initially operated either by general surgeons or gynecologist. As a result, many patients may have received suboptimal care and management due to logistics and socioeconomic constraints.

Therefore, the aim of this study was to review the pattern of care offered to patients with ovarian cancer in our centre and to evaluate patients' compliance to chemotherapy.


  Patients and Methods Top


Theatre records and case files of patients who had surgery for ovarian cancer from January 2011 to December 2014 in our hospital were retrospectively analyzed. A total of 83 ovarian cancer patients were operated during the study period at our hospital. Sixty-eight cases were retrieved and analyzed using Epi INFO7 developed by the US centre for disease control (Centres for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, USA).

Information extracted from the records included clinicopathological variables, tumor type, surgical staging and outcome, chemotherapy regimen, and number of cycles received. Patients with no histological confirmation and those with incomplete records regarding their disease status were excluded from the study.

Patients were evaluated by history and physical examination, imaging studies, assessment of tumor markers (CA-125), and staging laparotomy. The goals of the initial surgery were to obtain a pathologic diagnosis, accurately determine the extent of the disease, and when feasible, optimally cytoreduce the ovarian cancer. The staging procedure was performed via a vertical incision, and a thorough exploration was performed to assess the extent of the disease. All peritoneal surfaces and organs were palpated including the diaphragm, liver, spleen, intestines, and mesentery. The extent of surgery included removal of all macroscopic visible disease, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and intestinal resection. Optimal cytoreduction was defined as residual tumor less than 2 cm. All patients with advanced diseases were offered six courses of platinum and taxane-based chemotherapy.

Descriptive method was used to summarize patient characteristics, type and extent of the tumor, and treatment data. Quantitative variables were analyzed by mean and standard deviation, whereas qualitative data were analyzed by percentage and frequency.


  Results Top


A total of 83 ovarian cancer patients were operated during the study period in our hospital, and 68 cases were retrieved and analyzed, giving a retrieval rate of 82%.

[Table 1] summarizes the age distribution of the patients. The mean age was 50.5 ± 13.5 years. Sixty-five percent of the patients presented with advanced stages (either stage III or IV). Four patients (5.9%) had stage II disease, while no patient presented with stage I tumor. Fifteen patients (22%) had incomplete staging due to either inadequate information or inappropriately done surgical staging. Serous adenocarcinoma was the most common histological type constituting approximately 56%. The least common was yolk sac tumor (2.9%). This is shown in [Table 2].
Table 1: Clinicopathological variables

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Table 2: Histological types and patients' distribution

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[Table 3] shows that optimal debulking could only be done in 18 (26.5%) patients. Residual tumors were noted in 35 (51.5%) patients. No record of size and presence of residual tumor was documented in 15 (22%) patients. All surgeries were done by general gynecologist with special interest in gynecologic oncology. Surgeries requiring intestinal resection were performed together with general surgeons.
Table 3: Residual tumor after surgery

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All patients were recommended to have adjuvant chemotherapy, except six patients died within 1 month of surgery and four patients had stage IV disease with poor performance score. Of the 58 patients who were recommended to have chemotherapy, only 28 had it. This gave a compliance rate of 48.3%, as shown in [Table 4].
Table 4: Chemotherapy regimen

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The various chemotherapy regimen that were administered to the patients are shown in [Table 5]. Cisplatin was given alone in 10 (35.7%) or with paclitaxel in 8 (28.6%) patients. Two patients had carboplatin and paclitaxel doublet. The BEP (bleomycin, etoposide, paclitaxel) regimen was given to 8 (28.6%) patients with malignant germ cell tumors and granulosa cell tumors. An average of four courses of chemotherapy were given to the patients, though only 12 (43%) patients completed the recommended six courses.
Table 5: Compliance to chemotherapy after surgery

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  Discussion Top


Ovarian cancer has been known as a disease of the sixth and seventh decades of life.[12] However, the age distribution of the patients with ovarian cancer in our unit showed that 39 patients (49.5%) presented at 40–59 years of age. This is shown in [Table 1]. This low age at presentation was also reported in a study conducted in Eastern Nigeria.[13] Another study that was conducted more than a decade ago in Ghana also reported a similar pattern for epithelial ovarian cancers.[14] This might not be unconnected to the fact that the average life expectancy of a Nigerian at birth is 53 years,[13],[15] which is shorter than that of the developed countries. In addition, poor birth record in our society may lead to a discrepancy between patients' estimated age at presentation and actual biological age. [Table 1] also shows that 44 patients (65%) had advanced stage disease at presentation. This is typical of ovarian cancer because symptoms are nonspecific.[8] Most patients waste time either by taking traditional medication or just staying at home until symptoms become prominent. Time is also wasted with the general practitioner treating those nonspecific symptoms. All this may have contributed to the large number of women presenting late with advanced disease. Studies done in Nigeria and other developing countries reported similar phenomenon.[13],[16] The operation records showed that 15 (22%) of the patients were not appropriately staged, which may have affected further treatment plan of these patients. Epithelial ovarian cancers were the most common and constituted approximately 85% of the histological types seen in our center. This is shown in [Table 2]. Similar findings have been reported from most studies across Nigeria.[5],[6],[7] All the surgeries were done by a general gynecologist. Involvement of gynecologic oncologist in care of patients with advanced ovarian cancer has been shown to provide significant survival advantage.[17] We have few trained gynecologic oncologist in Nigeria. Therefore, general gynecologists need to be trained and oriented. In addition, creation of gynaecologic oncology units in our tertiary health centre may improve outcome.

Complete cytoreduction is the main aim of surgical intervention. Reducing tumor bulk has been shown to increase the efficacy of adjuvant chemotherapy.[18] Success of surgery for ovarian cancer depends on numerous factors including patient selection, the location of the tumor, and surgeon's expertise. To achieve a survival benefit, the surgery should result in no residual tumors individually measuring more than 2 cm.[18] In our study, only 18 (26.5%) patients had residual tumor less than 2 cm after surgery [Table 3]. However, the gynecology oncology group (GOG) has defined “optimal: Debulking as residual implants up to 1 cm.[19] Such measurements are subjectively determined at the completion of surgery. Optimal debulking has been shown to be possible in only 25% and 8% of stage III and IV patients, respectively.[20],[21] In this series, we were able to achieve “optimal” debulking in 26% of the patients probably because 50% of the patients who had surgery were in stage III. Moreover, our figure of 26% may have been an overestimation because we used 2 cm as our cut-up point. Moreover, because of tissue indurations or inadequate exploration, assessment of residual tumor size is often not entirely done. Residual tumor after primary surgery was directly related to poor survival rate in a study conducted in India by Basu et al.[22]

We found that neoadjuvant chemotherapy was not administered to any of our patients with large tumors. This would have improved the resectability of the tumor. Interval debulking after few courses of chemotherapy was shown to improve survival in patients who had suboptimal debulking surgery.[22] Our patients with recurrent tumors did not receive any chemotherapy before surgery. After surgery, chemotherapy is recommended to all patients with FIGO stage II–IV disease.[23] The standard of care is paclitaxel/carboplatin, administered every 3 weeks. Paclitaxel/Cisplatin is equally effective but more toxic and less convenient to administer.[23] Six cycles are usually recommended. However, in our institution because of overwhelming financial constrain and nonavailability, most patients could not afford the preferred regimen, as shown in [Table 4]. Compliance to chemotherapy was poor as only 28 (48.3%) patients recommended to have chemotherapy had it [Table 5]. Some of these patients did not complete the prescribed number of courses because of high cost of drugs, hospital charges, and occasional chemotherapy side effects. This trend of abandonment of chemotherapy was also reported in Eastern Nigeria and other similar studies.[13],[22]


  Conclusion Top


Management of malignant ovarian cancer is still not optimal in our centre because of late presentation and poor compliance to chemotherapy. Epithelial ovarian cancers were the most common and constituted approximately 85% of the histological types seen in our center. Complete cytoreduction is the main aim of surgical intervention.

We recommend training of gynaecologic oncologist and creation of gynecologic oncology centres in our hospitals and provision of subsidized chemotherapy drugs to improve management and survival.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.1, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2014. Available from: http://globocan.iarc.fr. [Last accessed on 16/01/2015].  Back to cited text no. 1
    
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Sankaranarayanan R, Ferlay J. Worldwide burden of gynaecological cancer: The size of the problem. Best Pract Res Clin Obstet Gynaecol 2006;20:207-25.  Back to cited text no. 2
    
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Gubbels JA, Claussen N, Kapur AK, Connor JP, Patankar MS. The detection, treatment, and biology of epithelial ovarian cancer. J Ovarian Res 2010;3:8-11.  Back to cited text no. 3
    
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Jemal A, Siegel R, Ward E, Murray T, Xu J, Smigal C, et al. Cancer statistics, 2006. CA Cancer J Clin 2006;56:106-30.  Back to cited text no. 4
    
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Mohammed A, Ahmed SA, Oluwole OP, Avidime S. Malignant tumours of the female genital tract in Zaria, Nigeria: Analysis of 513 cases. Ann Afr Med 2006;5:93-6.  Back to cited text no. 5
    
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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. 7
    
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Katumba J, Obore S, Kaye DK. Health-related quality of life among patients with ovarian cancer at Mulago Hospital, Uganda. Int J Gynaecol Obstet 2013;122:115-7.  Back to cited text no. 8
    
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Nigerian Poverty Profile 2010. National Bureau of Statistics. Available from: http://nigerianstat.gov.ng. [Last accessed on 11/12/16].  Back to cited text no. 9
    
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Adekunle OO, Marliya Z, Mattew A, Abimbola DK, Sunday AA. The Burden of Gynaecological Cancer in Northern Nigeria. Open J Obstet Gynecol 2013;3:634-8.  Back to cited text no. 10
    
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Bast RC, Jr, Hennessy B, Mills GB. The biology of ovarian cancer: New opportunities for translation. Nat Rev Cancer 2009;9:415-28.  Back to cited text no. 12
    
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Iyoke C, Ugwu G, Ezugwu E, Onah N, Ugwu O, Okafor O. Incidence, Pattern and Management of Ovarian Cancer at a Tertiary Medical Center in Enugu, South East Nigeria. Ann Med Health Sci Res 2013;3:417-21.  Back to cited text no. 13
[PUBMED]  Medknow Journal  
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Nkyekyer K. Pattern of gynaecological cancers in Ghana. East Afr Med J 2000;77:534-8.  Back to cited text no. 14
    
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Abuja, Nigeria: National Population Commission and ICF Macro; 2009. National Population Commission (NPC) [Nigeria] and ICF Macro. Nigeria Demographic and Health Survey 2008.  Back to cited text no. 15
    
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International Federation of Gynaecology and Obstetrics (FIGO). 26th Annual report on the results of treatment in gynaecological cancer. Int J Gynaecol Obstet 2006;95(Suppl 1):S161-91.  Back to cited text no. 16
    
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Carney ME, Lancaster JM, Ford C, Tsodikov A, Wiggins C. A population-based study of patterns of care for ovarian cancer: Who is seen by a gynecologic oncologist and who is not? Gynecol Oncol 2002;84:36-42.  Back to cited text no. 17
    
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Hoskins WJ, McGuire WP, Brady MF. The effect of diameter of largest residual disease on survival after primary cytoreductive surgery in patients with suboptimal residual epithelial ovarian carcinoma. Am J Obstet Gynecol 1994;170:974-80.  Back to cited text no. 18
    
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Hoskins WJ, Bundy BN, Thigpen JT, Omura GA. The influence of cytoreductive surgery on recurrence-free interval and survival in small-volume stage III epithelial ovarian cancer: A Gynecologic Oncology Group study. Gynecol Oncol 1992;47:159-66.  Back to cited text no. 19
    
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Winter WE 3rd, Maxwell GL, Tian C. Gynecologic Oncology Group Study. Tumor residual after surgical cytoreduction in prediction of clinical outcome in stage IV epithelial ovarian cancer: A Gynecologic Oncology Group Study. J Clin Oncol 2008;26:83-9.  Back to cited text no. 21
    
22.
Basu P, De P, Mandal S, Ray K, Biswas J. Study of 'patterns of care' of ovarian cancer patients in a specialized cancer institute in Kolkata, eastern India. Indian J Cancer 2009;46.  Back to cited text no. 22
    
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International Collaborative Ovarian Neoplasm (ICON) Group. Paclitaxel plus carboplatin versus standard chemotherapy with either single agent carboplatin or cyclophosphamide, doxorubicin and cisplatin in women with ovarian cancer: The ICON 3 randomized trial. Lancet 2002;360:505-15.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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