Review of cancer control policy in Nigeria and comparison with selected African countries: implications for future policy making

Context: The public health importance of cancers in Nigeria is emerging. Robust cancer control policies are needed at all levels of government, especially the state. Objective: To review cancer control policies in Nigeria, especially regarding breast and cervical cancers, with emphasis on policy development process, scope and policy implementation. Also to compare Nigerian cancer control policy with selected African countries and suggest ways through which Nigerian states, such as Abia, can develop evidence-informed, patient-centered cancer control policy. Methods: A structured literature search was done using relevant subject headings and keywords. Boolean operators 'and'/'or' were used to refine the search. Databases searched were Pubmed/Medline, Embase, PsychInfo, Cinahl, Global Health and ERIC. The search included articles published between 2008 and 2018. Data was also collected from the International Cancer Control Plan portal as well as focused Google search. Results: Of the 194 abstracts retrieved, only 29 were included in this review. The 2018 Nigerian National Cancer Control plan (NCCP) showed significant improvement over the 2008 version, in terms of scope and policy development process. Literature search did not reveal any state-level comprehensive cancer control policy. The Nigerian policy lacked specific guidelines for breast cancer compared with the Ghanaian policy. Ghana allocated 12% of total budget to cancer research compared to 0.4% in Nigeria. The South African Breast Cancer policy was developed using more findings from local research and had the most encompassing, multiple perspectives approach. Conclusion: Review shows the content, process, pearls and pitfalls of cancer control policy from Nigeria and five other African countries. Findings will inform the strategy for developing cancer control framework states in Nigeria and other countries. As more Nigerian states work towards developing state cancer control plans, it is important to address the shortfalls identified in the current NCCP, especially regarding the use of multiple perspectives analysis

Knowledge, Attitudes and Barriers to Human Papillomavirus (HPV) Vaccine Uptake Among an Immigrant and Refugee Catch-Up Group in a Western Canadian Province.

Vaccination is a key strategy to prevent cervical cancer in developed countries. Lower uptake of human papillomavirus (HPV) vaccine among new immigrants and refugees has been documented, although exploration of underlying reasons remains an understudied area. Semi-structured interviews with eleven immigrant women (ages 18-26 years) were conducted to understand their knowledge, attitudes and barriers regarding HPV vaccination in a western Canadian province. Participants had limited knowledge about HPV and the vaccine. Most women perceived that their risk of HPV was low, however expressed willingness to receive the vaccine if it were recommended by their physician. Greater efforts are needed to increase knowledge about HPV among immigrant and refugee women and support for physicians to discuss and offer vaccination to this underserved population.

Atonic Postpartum Hemorrhage: Blood Loss, Risk Factors, and Third Stage Management.

OBJECTIVE: Atonic postpartum hemorrhage rates have increased in many industrialized countries in recent years. We examined the blood loss, risk factors, and management of the third stage of labour associated with atonic postpartum hemorrhage. METHODS: We carried out a case-control study of patients in eight tertiary care hospitals in Canada between January 2011 and December 2013. Cases were defined as women with a diagnosis of atonic postpartum hemorrhage, and controls (without postpartum hemorrhage) were matched with cases by hospital and date of delivery. Estimated blood loss, risk factors, and management of the third stage labour were compared between cases and controls. Conditional logistic regression was used to adjust for confounding. RESULTS: The study included 383 cases and 383 controls. Cases had significantly higher mean estimated blood loss than controls. However, 16.7% of cases who delivered vaginally and 34.1% of cases who delivered by Caesarean section (CS) had a blood loss of < 500 mL and < 1000 mL, respectively; 8.2% of controls who delivered vaginally and 6.7% of controls who delivered by CS had blood loss consistent with a diagnosis of postpartum hemorrhage. Factors associated with atonic postpartum hemorrhage included known protective factors (e.g., delivery by CS) and risk factors (e.g., nulliparity, vaginal birth after CS). Uterotonic use was more common in cases than in controls (97.6% vs. 92.9%, P < 0.001). Delayed cord clamping was only used among those who delivered vaginally (7.7% cases vs. 14.6% controls, P = 0.06). CONCLUSION: There is substantial misclassification in the diagnosis of atonic postpartum hemorrhage, and this could potentially explain the observed temporal increase in postpartum hemorrhage rates.

Recombinant human luteinizing hormone to trigger ovulation: randomized, controlled, dose-finding pilot study in ovulation induction.

OBJECTIVE: To evaluate recombinant human luteinizing hormone (r-hLH) versus urine-derived human chorionic gonadotropin (u-hCG) to trigger ovulation in women (aged 20-40 years) with WHO Group II anovulatory infertility undergoing ovulation induction (OI) with recombinant human follicle-stimulating hormone (r-hFSH) (150 IU/day starting dose). STUDY DESIGN: For this Phase II, open-label, dose-finding pilot study, patients were randomized to doses of 825, 2,750, 5,500, 11,000, or 22,000 IU r-hLH or u-hCG (5,000 IU). Primary endpoints were ovulation and ratio of ruptured follicles/follicle > or = 15 mm (day of r-hLH/ u-hCG administration). Secondary endpoints included monofollicular ovulation and clinical pregnancy rates. RESULTS: All 67 randomized patients completed treatment. All patients in the r-hLH 2,750 (13/13), 5,500 (12/ 12), 11,000 IU (13/13), and u-hCG 5,000 IU (12/ 12) groups ovulated; 3/5 patients in the r-hLH 825 IU and 2/12 in the r-hLH 22,000 IU group failed to ovulate (p = 0.105 between evaluable groups). The mean ratio of ruptured follicles/ follicle > or = 15 mm was 1.1 (p = 0.675 between groups). The monofollicular ovulation rate was 15/60 (25%). Two cases of ovarian hyperstimulation syndrome were reported. CONCLUSION: This open-label, pilot study (conducted in 1999-2001) suggests that the minimal effective dose of r-hLH to trigger ovulation in women with WHO Group II anovulatory infertility undergoing OI with r-hFSH (150 IU starting dose) was 2,750 IU.

Effect of exercise training combined with isoflavone supplementation on bone and lipids in postmenopausal women: a randomized clinical trial.

We determined the effects of 2 years of exercise training and soy isoflavone supplementation on bone mass and lipids in postmenopausal women provided with calcium and vitamin D. Women were randomized to four groups: exercise training (Ex); isoflavone supplementation (Iso: 165 mg/d [105 mg/d aglycone equivalent]); combined Ex and Iso (ExIso); and placebo (control). Exercise included resistance training (2 days/week) and walking (4 days/week). Our primary outcomes were lumbar spine and hip bone mineral density (BMD). Secondary outcomes included hip geometry, tibia and radius speed of sound (SOS), dynamic balance (6 m backward tandem walking), blood lipids, mammography, and endometrial thickness. A total of 351 women (Ex = 86, Iso = 90, ExIso = 87, control = 88) were randomized, with 298 analyzed at 2 years (Ex = 77, Iso = 76, ExIso = 72, control = 73). There was a significant interaction for total hip BMD (p < 0.001) such that ExIso had a greater rate of decrease (absolute change [95% confidence interval] = -0.018 [-0.024, -0.012] g/cm(2) ) than either the Ex or Iso groups alone (-0.005 [-0.01, 0.001] and -0.005 [-0.011, 0.001] g/cm(2) , respectively). There were no differences between groups for changes in lumbar spine BMD and minimal significant changes in hip geometric properties and bone SOS. Exercise groups improved dynamic balance as measured by a decrease in backward tandem walking time over 6 m (p = 0.017). Isoflavone groups decreased low density lipoproteins (Iso: -0.20 [-0.37, -0.02] mmol/L; ExIso: -0.23 [-0.40, -0.06] mmol/L; p = 0.003) compared to non-isoflavone groups (Ex: 0.01 [-0.16, 0.18] mmol/L; control: -0.09 [-0.27, 0.08] mmol/L) and had lower adverse reports of menopausal symptoms (14% versus 33%; p = 0.01) compared to non-isoflavone groups. Isoflavone supplementation did not increase endometrial thickness or abnormal mammograms. We conclude exercise training and isoflavone supplementation maintain hip BMD compared to control, but these two interventions interfere with each other when combined. Isoflavone supplementation decreased LDL and adverse events related to menopausal symptoms.

Maternal exposure to folic acid antagonists and placenta-mediated adverse pregnancy outcomes.

BACKGROUND: In previous studies, maternal exposure to folic acid antagonists was associated with increased risks of neural tube defects, cardiovascular defects, oral clefts and urinary tract defects. The objective of the current study was to assess the possible effects of using folic acid antagonists in pregnancy on placenta-mediated adverse outcomes of pregnancy. METHODS: We used data from an administrative database to retrospectively compare the occurrence of placenta-mediated adverse pregnancy outcomes between pregnant women exposed to folic acid antagonists and women without exposure to these agents. RESULTS: We included in the analysis a total of 14 982 women who had been exposed to folic acid antagonists and 59 825 women who had not been exposed. Sulfamethoxazole-trimethoprim was the most frequently prescribed dihydrofolate reductase inhibitor (a total of 12 546 exposures during the preconception period and all 3 trimesters), and phenobarbital was the most frequently prescribed among the other folic acid antagonists (a total of 1565 exposures). The risks of preeclampsia (adjusted odds ratio [OR] 1.52, 95% confidence interval [CI] 1.39-1.66), severe preeclampsia (OR 1.77, 95% CI 1.38-2.28), placental abruption (OR 1.32, 95% CI 1.12-1.57), fetal growth restriction defined as less than the 10th percentile (OR 1.07, 95% CI 1.01-1.13), fetal growth restriction defined as less than the 3rd percentile (OR 1.22, 95% CI 1.11-1.34) and fetal death (OR 1.35, 95% CI 1.07-1.70) were greater among mothers with exposure to folic acid antagonists. In general, the risks associated with exposure to other folic acid antagonists were higher than those associated with exposure to dihydrofolate reductase inhibitors. Supplementary analyses involving tight matching with propensity score, restriction of the analysis to women with exposure during the first and second trimesters and restriction of the analysis to specific categories of folic acid antagonists yielded similar results. INTERPRETATION: Maternal exposure to folic acid antagonists appears to increase the risk of placenta-mediated adverse outcomes of pregnancy.

Maternal characteristics associated with pregnancy exposure to FDA category C, D, and X drugs in a Canadian population.

PURPOSE: To estimate the frequency of exposure to prescription Food and Drug Administration (FDA) category C, D, and X drugs in pregnant women, and to analyze the maternal characteristics associated with such an exposure. METHODS: A 50% random sample of women who gave a birth in Saskatchewan between January 1, 1997 and December 31, 2000 was chosen for the study. The rate of exposure to FDA category C, D, or X drugs recorded in the pharmacist database was estimated. Associations of exposure to FDA category C, D, and X drugs with maternal characteristics were evaluated using multiple logistical regression, with adjusted odds ratios (ORs) and its 95% confidence intervals (CIs) as the association measures. RESULTS: A total of 18 575 women were included in this study. Among them, 3604 (19.4%) had exposure to one or more FDA category C, D, and X drugs during pregnancy. Category C drugs were the most frequently used drugs (15.8%), followed by D drugs (5.2%), and X drugs (3.9%). Women with chronic health conditions had fourfold at increased risk of exposure than women without. Regardless of health status, women who were <20 years of age, who had a parity > or =3, and who were on social assistance plan were at increased risk of pregnancy exposure to these drugs. CONCLUSIONS: About 19.4% pregnant women are exposed to FDA C, D or X drugs during pregnancy. Women with chronic diseases, younger age, increased parity, and under social assistance are at increased risk of exposure to FDA C, D, or X drugs.

Occurrence and determinants of trimethoprim/sulfamethoxazole use in pregnancy.

OBJECTIVE: To estimate the rate of prescription trimethoprim/sulfamethoxazole use in pregnancy, and to analyse the association between maternal characteristics and use of trimethoprim/sulfamethoxazole in pregnancy. METHODS: A population-based study was conducted based on a 50% random sample of women who gave a birth in Saskatchewan between 1 January 1997 and 31 December 2000. The rate of trimethoprim/sulfamethoxazole use during pregnancy was estimated. The exposure in each trimester was also estimated. Associations between maternal characteristics and pregnancy trimethoprim/sulfamethoxazole use were evaluated using multiple logistical regression with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) as the association measures. RESULTS: A total of 18,575 women who gave a birth in Saskatchewan during the study period were included in the analysis. Among them, 596 (3.2%) had at least 1 prescription for trimethoprim/sulfamethoxazole during pregnancy, 389 (2.1%) in the first trimester, 208 (1.1%) in the second trimester, and 195 (1.1%) in the third trimester. Women with chronic health conditions (6.2%) had a 2-fold increased risk of exposure compared to women without a chronic health condition (2.8%). Younger women (<20 years) with parity >/=3 and women on Saskatchewan assistance plan were also at increased risk. There were variations in exposure by trimester. For example, teenage women without chronic health conditions were at increased risk of use in the second and third trimester. CONCLUSIONS: Some 3.2% of women are exposed to trimethoprim/sulfamethoxazole during pregnancy. Women with chronic health problems, of younger age, and of lower socioeconomic status are at elevated risk of exposure to trimethoprim/sulfamethoxazole during pregnancy.

Effects of oral contraceptives administered at defined stages of ovarian follicular development.

OBJECTIVE: To elucidate the effects of initiating oral contraceptives (OC) at defined stages of ovarian follicle development. DESIGN: Prospective longitudinal study. SETTING: Healthy volunteers in an academic research environment. PATIENT(S): Forty-five healthy women between the ages of 18 and 35 years, randomized to initiate OC when a follicle diameter of 10, 14, or 18 mm was first detected. INTERVENTION(S): The OC administration at defined stages of dominant follicle development. MAIN OUTCOME MEASURE(S): Fates of all dominant follicles and serum concentrations of E(2)-17beta, LH, and P before and after initiating OC. RESULT(S): No ovulations (0/16) were observed when OC use was initiated at a follicle diameter of 10 mm, 4/14 (29%) follicles ovulated when OC were initiated at 14 mm, and 14/15 (93%) ovulated when OC were initiated at 18 mm. When ovulation did not occur, follicles regressed or became anovulatory cysts. Peak LH and E(2) levels were lowest in the 10-mm group, moderate in the 14-mm group, and greatest in the 18-mm group. Peak endocrine levels in all treatment groups were lower than the historic reference group. CONCLUSION(S): Follicular development, ovulation, and endocrine concentrations were not suppressed effectively when OC were initiated at late stages of dominant follicle development.

Selective serotonin reuptake inhibitors and adverse pregnancy outcomes.

OBJECTIVE: The purpose of this study was to assess the safety of the use of selective serotonin reuptake inhibitors in pregnancy. STUDY DESIGN: We carried out a retrospective cohort study of 972 pregnant women who had been given at least 1 selective serotonin reuptake inhibitor prescription in the year before delivery and 3878 pregnant women who did not receive selective serotonin reuptake inhibitors and who were matched by the year of the infant's birth, the type of institute at birth, and the mother's postal code from 1990 to 2000 in the Canadian province of Saskatchewan. RESULTS: The risks of low birth weight (adjusted odds ratio, 1.58; 95% CI, 1.19, 2.11), preterm birth (adjusted odds ratio, 1.57; 95% CI, 1.28, 1.92), fetal death (adjusted odds ratio, 2.23; 95% CI, 1.01, 4.93), and seizures (adjusted odds ratio, 3.87; 95% CI, 1.00, 14.99) were increased in infants who were born to mothers who had received selective serotonin reuptake inhibitor therapy. CONCLUSION: The use of selective serotonin reuptake inhibitors in pregnancy may increase the risks of low birth weight, preterm birth, fetal death, and seizures.

Ovarian follicular dynamics during conventional vs. continuous oral contraceptive use.

OBJECTIVES: The purpose of this study was to characterize ovarian follicular and endometrial development during conventional vs. continuous oral contraceptive (OC) dosing regimens, to explore follicular development during the hormone-free interval (HFI) and to examine follicular development following OC discontinuation. STUDY METHODS: A randomized clinical trial involving 36 clinically normal healthy women between the ages of 18 and 35 years (24.4 +/- 3.9, SEM). Transvaginal ultrasonography and blood sampling were done to ascertain ovarian function. RESULTS: Fewer follicles > 4 mm developed during continuous vs. conventional OC use (p = .006). No dominant follicles developed during continuous OC use vs. eight dominant follicles (16.1 +/- 3.3 mm) during the conventional OC regimen. Two of eight (25%) dominant follicles ovulated. All dominant follicles began development during the HFI. Following discontinuation of OC use, ovulation took approximately 5 days longer when compared to natural cycles. CONCLUSION: Continuous OC regimens more effectively prevent dominant follicle development and breakthrough ovulation. The slight delay in time to ovulation following OC discontinuation and natural cycles could be attributed to suppression of follicle wave activity.

Quality-of-life analysis in the management of endometrial cancer.

OBJECTIVE: The purpose of this study was to determine whether and how the quality of life (QL) of patients with stage I endometrial cancer was influenced by different surgical procedures with or without radiation therapy. STUDY DESIGN: We conducted a retrospective analysis of 200 women with stage I endometrial cancer at the University of Saskatchewan, Canada in 2001 through 2002. Modified QLQ-C30 Questionnaires were used in evaluating differences in the weighted QL of patients who underwent staged surgery and patients who had nonstaged surgery, the latter of which refers to total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) with or without radiation therapy. RESULTS: There was a significantly lower QL in patients who underwent staged surgery compared with nonstaged surgery. In addition, radiation therapy significantly worsened the QL of patients undergoing staged surgery, whereas it had little influence on the QL of patients who received nonstaged surgery. CONCLUSION: Our study suggests that nonstaged surgery with or without radiation therapy may be a preferred treatment for stage I endometrial cancer compared with staged surgery from the perspective of patients' QL.

Ultrasound image attributes of human ovarian dominant follicles during natural and oral contraceptive cycles.

BACKGROUND: Computer-assisted analyses were used to examine ultrasound image attributes of human dominant ovarian follicles that developed during natural and oral contraceptive (OC) cycles. We hypothesized that image attributes of natural cycle follicles would quantitatively differ from those in OC cycles and that OC cycle follicles would possess image attributes indicative of atresia. METHODS: Dominant ovarian follicles of 18 clinically normal women were compared using transvaginal ultrasonography for the 7 days before ovulation during a natural cycle (n = 9) or the 7 days before peak estradiol in women using OC (n = 11). Follicles were analyzed using region and line techniques designed to compare the image attributes numerical pixel value (NPV), pixel heterogeneity (PH) and area under the curve (AUC). RESULTS: NPV was higher in OC cycle follicles with region analysis and tended to be higher with line analysis (p = 0.005 and p = 0.06, respectively). No differences were observed in two other image attributes (AUC and PH), measured with either technique, between natural and OC cycle follicles. CONCLUSION: The increased NPV value of OC cycle follicles and lack of differences in PH and AUC values between natural cycle and OC cycle follicles did not support the hypothesis that OC cycle follicles would show ultrasonographically detectable signs of atresia. Image attributes observed in OC cycle follicles were not clearly indicative of atresia nor were they large enough to preclude preovulatory physiologic status in OC cycle follicles.

Magnetic resonance diffusion imaging of ovarian masses: a first experience with 12 cases.

OBJECTIVE: The objective of the study was to determine the feasibility of using apparent diffusion coefficient (ADC) measurement for the differential diagnosis of malignancy in ovarian masses. MATERIALS AND METHODS: Twelve cases involving ovarian masses were imaged using spin echo diffusion magnetic resonance imaging (MRI). Five cases involved malignant ovarian masses, on the basis of postoperative histologic examination, and the rest involved benign masses. The ovarian masses were imaged in vivo (10 cases) before surgery and ex vivo (8 cases) after surgical resection. Diffusion-weighted data were corrected for motion using the phase data from unweighted data in nine cases. Multifactorial analysis of variance was used to evaluate the effects of malignancy, location (in vivo versus ex vivo), and motion correction on the measurement of ADC intensity and texture. RESULTS: Motion correction caused an undesirable spatial smoothing of the ADC maps and a significant interaction (p=0.047) was found between location and motion correction. ADC value (p=0.028) and texture (p=0.001) differences were found between malignant and nonmalignant ovarian masses. CONCLUSION: Measurement of ADC intensity and texture has the potential to differentially diagnose malignancy in individual ovarian masses if the problem of image motion artifact can be eliminated through the use of faster imaging sequences.

Transvaginal sonography and fiberoptic illumination of uterine vessels for abdominal cervicoisthmic cerclage.

BACKGROUND: Transabdominal cervicoisthmic cerclage is a procedure carried out to increase the fetal salvage rates in women who are poor candidates for the more usual procedure of transvaginal cerclage or for those with previously failed vaginal procedures. Although several modifications have been applied to the original procedure in an attempt to reduce the morbidity, bleeding arising from trauma to the uterine vessels during suture placement remains problematic. CASE: Our technique involves transilluminating the uterine vessels during placement of the 5-mm-wide Mersilene (Ethicon Inc., Peterborough, Ontario, Canada) tape suture through an avascular space above the junction of the cervix and the uterine isthmus. This obviates the need to dissect or tunnel into the broad ligament. Simultaneous intraoperative transvaginal ultrasonography is used to enhance high suture placement at the isthmus and monitor the fetoplacental unit. We have used this technique in a series of five women with cervical incompetence for seven pregnancies. All but one procedure resulted in live term births. There were no major complications. CONCLUSION: Simultaneous intraoperative ultrasonography and uterine vessel transillumination simplified suture placement during abdominal cerclage, and reduced the amount of dissection and bleeding.

Incorporating sexual and reproductive health care in the medical curriculum in developing countries.

Medical educators have a responsibility to train physicians and other health professionals in the core competencies needed to improve the sexual and reproductive health of their communities. Yet sexual and reproductive health care is significantly under-represented in the basic educational curriculum for medical and other health professionals, as well as in continuing medical education and professional development programmes for practising physicians and other health professionals. The Commonwealth Medical Association Trust is developing a model curriculum on sexual and reproductive health that can be integrated into undergraduate medical education and used with appropriate amendments for continuing medical education. This paper outlines topics for inclusion in the curriculum and three strategies for incorporating core components of sexual and reproductive health in the curriculum--by developing themes that can be integrated into the general curriculum in a multi-disciplinary fashion, adding free-standing modules as electives, and delegating cross-cutting issues such as gender issues and adolescent reproductive health to courses run by other departments. It argues for the use of problem-solving and case-based learning methodologies, as well as lectures, as the best way to teach health professionals how to provide information, counselling and support for sexual and reproductive health, as well as to cover the range of prevention and treatment needs of women and men seeking these services.