![](3D"MustaphaNMJ64No4Page591_files/image002.png")
<=
/td>
![](3D"MustaphaNMJ64No4Page591_files/image005.png")
Dying Undiagnosed: Challenges of
Management of Ovarian Tumours
in a Resource-Poor Setting in
North-western Nigeria
=
*Ais=
ha
Mustapha1, Bashir Abubakar1, Anisah Yahya1=
, Oiza Tessy Ahmadu2, Nafisa Bello3, Ahmed Sa’ad4, Adekunle Olanrewaju Ogunt=
ayo1 .
. 1Gynaecologic oncology unit, Department =
of
Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zari=
a,
Nigeria.2Department of Radio-oncology, Ahmadu Bello University
Teaching Hospital, Zaria, Nigeria.3Department of Radiology, Ahma=
du
Bello University Teaching Hospital, Zaria, Nigeria.4Department of
Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.
![](3D"MustaphaNMJ64No4Page591_files/image007.png")
Background: Ovarian cancer is the second most prevalent but most lethal
gynaecologic malignancy in our institution. This study aimed at determining=
the
rate of non-diagnosis in suspected lesions and reviewing the management
challenges of ovarian tumours highly suspicious for malignancy in our hospi=
tal.
Methodology: A three-year retrospective review of patients’ records from the wa=
rd,
clinic, theatre, and histopathology laboratory was carried out. Cases with =
high
indices of suspicion for ovarian cancer (ovarian tumour with malignant
radiologic features with any of ascites, pleural effusion, as well as cache=
xia,
anaemia, or evidence of metastasis) were included. In-depth interviews were
carried out with a consultant from each specialty of Radiology, Radio-oncol=
ogy,
Pathology, and Gynaecologic oncology at the gynaecologic oncology
multidisciplinary team meeting.
Results: One hundred and twenty-two cases of highly suspicious ovarian
malignancies were seen with a mean age of 40.6 years. Of these, 28 (23%) had
surgery and 77% did not have any form of histological diagnosis. Of those t=
hat
had surgery, 13 (46.4%) had upfront surgery and 15 (53.6%) neoadjuvant
chemotherapy (NACT) followed by interval debulking surgery (IDS). Only two
cases had documented complete (R0) debulking. Among those that h=
ad
upfront surgery, one case (7.7%) was an ovarian fibroid and one (7.7%) was a
fibrosarcoma while two cases (15.4%) were borderline ovarian tumours.
Chemotherapy was commenced based on malignant cells on ascitic or pleural f=
luid
cytology in three cases. Of all the malignant cases, epithelial carcinomas =
were
commonest accounting for 48%. Aside from the general late presentation of
cases, insufficient funds for treatment, poor coverage of health insurance =
for
cancer care, unavailability of routine immunohistochemistry, lack of germli=
ne
and somatic testing, non-availability or prohibitive cost of some
chemotherapeutic agents, unavailability of maintenance therapies, inadequate
capacity to manage toxicities, inadequate skill across all specialties,
unavailability / erratic function of computerized tomography scans and
unavailable positron emission tomography, lack of interventional radiology
facility amongst others were all identified as challenges to management.
Conclusion: Most patients with <=
span
class=3DSpellE>tumours highly suspicious for ovarian cancers did not=
get a
histologic diagnosis and probably died undiagnosed. Management of ovarian
cancer remains a challenge despite advances in surgical and chemotherapeutic
options. Health insurance for all, infrastructure develop=
ment,
and training of all disciplines involved is recommended.
Keywords: Ovarian Tumours; Diagnosis; Undiagnosed O=
varian
Tumors; Histology; Nigeria.
= = *Correspondence: <= span lang=3DEN-GB style=3D'font-size:9.0pt;font-family:"Times New Roman",serif; mso-ansi-language:EN-GB'>Dr Aisha Mustapha Gynaecologic oncology unit, Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Email:pamustafa@yahoo.com; aisha.mustapha@npmcn.edu.ng
How to cite this article: Mustapha A, Abubakar B, Yahya A, Ahmadu OT, Bello N, Sa’ad A, Oguntayo AO. Dying Undiagnosed: Challenges of Managem=
ent of
Ovarian Tumours in a Resource-Poor Setting in North-western Nigeria. Niger =
Med
J 2023;64(4):591-603. Accepted: September 10, 2023. Published: September 21,
2023.
![](3D"MustaphaNMJ64No4Page591_files/image009.png")
Introduction
Globally, ov=
arian
cancer (OC) is a highly lethal disease. In Nigeria, it is the second most
common and most lethal gynaecologic cancer with=
72%
case fatality in 2020. [1] With 3,203 histologically confirmed cases from Ibadan,
Ekiti, Abuja, and Calabar cancer registries in the 2020 Global Cancer
Observatory (GLOBOCAN) statistics report, ovarian cancers were the fourth m=
ost
common accounting for 4.4% of all female cancers. [1] Its high fatal=
ity
could be as a result of its early stage being asymptomatic or lack of an
acceptable screening method which is responsible for the late presentation =
in
advanced stages with the consequent poor prognosis. [2] The common screening
tools considered are transvaginal ultrasound and serum CA-125 levels. Both =
have
the disadvantage of high false-positive rates leading to unnecessary
interventions. According to the randomized controlled trials on ovarian can=
cer
screening, screening did not lead to any significant reduction in mortality=
. [3]
As such, because of the negative net benefit and risk ratio, it is not
recommended to screen asymptomatic high-risk women.
For every woman that
presents with an adnexal mass in our centre, a
two-phase process is used to exclude malignancy. The first phase involves a
detailed medical history, physical examination, imaging studies, and labora=
tory
evaluation of tumour markers. The first imaging=
of
choice is the pelvic ultrasound. [2] In a large meta-analysis,
pelvic ultrasound is first-line imaging with a sensitivity and specificity =
of
up to 91% and 83%. [2] The International Ovarian Tumour Analysis (IOTA) and Ovarian-Adnexal Reporting =
and
Data System (O-RADS) may be used for the characterization and risk
stratification of adnexal masses. [4]
Second imaging like Computerized Tomogra=
phy
(CT) scan or Magnetic Resonance Imaging (MRI), though frequently requested =
in
our institution, may only be necessary if the gynaecol=
ogist
cannot determine if surgical evaluation is necessary with the pelvic scan. =
Tumour markers should be sought in all postmenopausal=
or
premenopausal women with ultrasound features suspicious of malignancy. The =
tumour markers requested in our institution depend on=
the
clinical suspicion of the type of tumour but us=
ually
include Cancer Antigen-125 (CA-125), carcinoembryonic antigen (CEA), alpha
fetoprotein (AFP), lactate dehydrogenase (LDH), Inhibin, Estradiol, and
beta-human chorionic gonadotrophin (BHCG). Malignancy is suspected based on
age, menopausal status, risk factors, elevated tumour<=
/span>
markers, and imaging findings consistent with malignancy (solid components
[most significant feature], thick septations, colour
uptake in the solid component, presence of ascites and peritoneal masses). =
[2]
If malignancy is suspected based on these (amongst other reasons), the seco=
nd
phase procedure is an abdominopelvic surgical exploration in order to stage,
and obtain a specimen for histology, et cetera. In a randomized trial of 570
women who underwent surgical evaluation for suspected ovarian cancer only 5%
was malignant. [5]
In suspected advanced
cases, however, more imaging like Computerized Tomography scans of the ches=
t,
abdomen, and pelvis (CT-CAP) is done to assess metastases. When surgery is
decided, the patient’s ability to tolerate the surgery is assessed using
various means. She is reviewed for any medical conditions, stabilized, and =
certified
fit for the surgery by different subspecialists when indicated such as the
cardiologist, anaesthetist et cetera. When a pa=
tient
is not for surgery (due to the likelihood of non-resec=
tability
of tumour, disease in the =
portahepatis
and liver or pulmonary metastasis, severe medical conditions et cetera), an
image (CT or ultrasound) - guided biopsy should be done on peritoneal
carcinomatosis or omental cake, which provides a site-specific diagnosis in=
93%
of patients [6] but this is rarely done in our centre.
Sometimes, a paracentesis/thoracocentesis is done to determine the presence=
of
malignant cells on cytology, and this is commonly done in our centre. However, only 20% of women will be diagnosed =
this
way. [7] Use of image-guided biopsy of the ovary itself even in
advanced cases is largely discouraged due to upstaging the tumour
except where the patient is not a candidate for surgery and there’s no evid=
ence
of disease elsewhere. [8] If biopsy is not feasible, asci=
tic
or pleural fluid aspiration, cystoscopy, and CA-125: CEA ratio of > 25 c=
an
be used for diagnosis. [9] Some radio-oncologists in our centre
commence neo-adjuvant chemotherapy based on highly suspicious findings on C=
T,
ascites/pleural effusion suspicious for malignancy and markedly elevated CA=
-125
levels when a biopsy is not feasible, and patient not fit for primary
debulking.
Following diagnosis =
of
ovarian (fallopian tube or peritoneal) cancer, all women should have genetic
testing for Lynch syndromes, germline, or somatic mutations for BRCA1 and 2=
if
epithelial [2] and test for DNA mismatch repair deficiency if cl=
ear
cell, mucinous, or endometrioid. [10]
Over 90% of ovarian
cancers are epithelial in origin, with over 70% of these being high-grade
serous with most presenting at stages III (51%) or IV (29%). [11]
Other subtypes are clear cell (6%), endometrioid (10%), low-grade serous (l=
ess
than 5%), and mucinous (6%). [11] High-grade serous ovarian
carcinomas (HGSOC) typically have TP53 (up to 90% of cases) [12] and
BRCA mutations (up to 20% have germline mutations). [13] They al=
so
express WT-1, estrogen receptor, and PAX-8 while low-grade serous ovarian
carcinomas (LGSOC) carry BRAF and KRAS mutations. [10]
Even though there is
increasing evidence of a common pathogenesis of HGSOC, fallopian tubal, and
peritoneal cancer, with similar management modalities, gynaecologic
oncologists still advise designating a primary site at surgical-pathologic
staging. This is however not routinely done in our cen=
tre
as immunohistochemistry is not routine.
Our setting largely
follows the above protocol to diagnosis except that image-guided biopsies f=
or
omental cake or peritoneal carcinomatosis are rarely done and hardly
successful, germline and somatic testing are not done, and immunohistochemi=
stry
is not routine. For certain reasons, most patients still do not get a
histologic diagnosis.
This study therefore
aims at determining the proportion of women who present with suspected ovar=
ian
cancer that eventually do not get a confirmatory diagnosis and go ahead to
discover the reasons for such non-diagnosis.
Materials and Methods
Study
Setting – The study was carried out at the Ahmadu Bello University Teaching
Hospital (ABUTH), Zaria, located in Giwa Local Government area of Kaduna st=
ate,
northwestern Nigeria. The hospital was designated as one of the Oncology
Our institution
therefore serves as a cancer referral centre for
other parts of northwestern Nigeria and even beyond. There is a four-year-o=
ld Gynaecologic cancer multidisciplinary team tumour board established in May 2019 consisting of
For the purpose of t=
his
study, “highly suspicious” was defined by an ovarian mass > 6cm with any=
two
of the following criteria: malignant radiologic features (solid components,
septations, colour in the solid component, pres=
ence
of ascites and peritoneal masses), pleural effusion, cachexia,
anaemia, or evidence of liver metastasis. In addition, malignant cells on
cytologic assessment of pleural fluid or ascites also fell into this catego=
ry.
Complete cytoreducti=
on/complete
debulking was defined as the removal of the uterus, cervix, both tubes, both
ovaries, omentum, and all grossly abnormal tiss=
ues in
the abdomen and pelvis at surgery.
An
in-depth interview to discuss the challenges each specialty had in the
management of ovarian tumours was<=
span
lang=3DEN-US style=3D'font-size:12.0pt;font-family:"Times New Roman",serif'=
> also done
at the gynaecologic oncology multidisciplinary team meeting held on 5t=
h
August 2019
Data
Analysis
– Data was analyzed using Microsoft Excel
Results=
A total of 122 highly
suspicious cases of ovarian cancer were seen in 3 years. Their mean age was
40.6 years.
![](3D"MustaphaNMJ64No4Page591_files/image011.png")
Figure 1: Trends of suspected ovarian cancer cases in ABUTH<=
span
lang=3DEN-US style=3D'font-size:12.0pt;font-family:"Times New Roman",serif;
background:white'>
Table 1: Socio-demographic characteristics of women with ovarian <=
span
class=3DSpellE>tumours in ABUTH n=3D122<=
/span>
|
Variable |
Category |
Frequency <=
span
lang=3DEN-US style=3D'font-size:12.0pt;font-family:"Times New Roman",seri=
f;
background:white'> |
Percent |
|
Age |
10-25 |
5 |
4.1 |
|
|
26-40 41-55 56-70 71-85 |
48 36 13 20 |
39.3 29.5 10.7 16.4 |
|
Parity |
<2 2-4 >/- 5 |
33 45 44 |
27.0 36.9 36.1 |
|
Level of education=
|
No formal Primary Secondary Tertiary Not stated<=
span
lang=3DEN-US style=3D'font-size:12.0pt;font-family:"Times New Roman",seri=
f;
background:white'> |
31 19 36 18 18 |
25.4 15.6 29.5 14.8 14.8 |
The majority (68.8%)=
of
suspected ovarian tumours were seen in women be=
tween
the ages of 26-55 years.
![](3D"MustaphaNMJ64No4Page591_files/image013.png")
Figure 2: Bar chart of cases by age of ovarian tumours
in ABUTH
Solid components wit=
h colour flow on the doppler were seen in 62%. Ascites
(either clinical or radiologic) were the most common feature present in 88%=
of
cases, while anaemia and cachexia were seen in =
23%
each. Other features such as pleural effusion was seen in 5.2%, while 4.9% =
had
liver metastasis on ultrasound and/or liver function test derangement. The
majority (63%) were multiparous.
![](3D"MustaphaNMJ64No4Page591_files/image015.png")
Figure 3: Findings
suspicious of ovarian tumours in ABUTH
Twenty-three
percent of suspected ovarian cancer cases (28/122) had surgery. Of these,
![](3D"MustaphaNMJ64No4Page591_files/image017.png")
Figure 4: Ovarian
cancer cases by treatment method
The
majority i.e., 94/122 (77.1%) had no surgery or biopsy and hence had no
histological diagnosis. There were documented attempts at image (ultrasound)
guided biopsy in 3 patients, but they were not successful. As high as 37.2 =
% of
patients who didn’t have surgery (35/94) were lost to follow up before a
definitive plan could be carried out.
Only
two cases out of the 28 that had surgery had documented complete (R0)
debulking/cytoreduction (7.1%) which is the removal of visible disease from=
the
abdomen. Other patients had no documentation of the extent of resection in
their operation notes or case folders.
Among
those that had upfront surgery, one case (7.7%) was an ovarian fibroid and =
two
(15.4%) were borderline tumours. The remaining 10 cases were malignant (76.=
9%).
All patients that had secondary cytoreductive surgery/interval debulking
surgery (IDS) following 3-4 cycles of chemotherapy had malignant histology.=
Hence
25/28 (89.3%) of patients who had surgery for highly suspicious ovarian tum=
ours
had ovarian cancer confirmed. The distribution of the 25 ovarian cancers is
shown in Figure 5.
Table 2: Histotypes
of Ovarian Cancer as seen at ABUTH.
|
Variable |
Category |
Frequency |
|
Epithelial |
HGSOC LGSOC Mucinous |
8 1 3 |
|
Sex Cord |
Granulosa cell Fibrosarcoma |
7 1 |
|
Germ cell |
Dysgerminoma |
2 |
|
Metastatic |
Metastatic |
3 |
![](3D"MustaphaNMJ64No4Page591_files/image019.png")
Figure 5: Histotypes
of ovarian cancer cases as seen at ABUTH.
Management challenge=
s as
summarized from the in-depth interview include:
=
General (mentioned by every
specialty) – Late presentation of cases hence may be unfit for surgery or
chemotherapy, insufficient funds for treatment with poor
coverage of health insurance for cancer care.
Gynaecologic oncology - Inadequate skills=
of
some health care providers. No formal gynae-oncology training in Nigeria. L=
ack
of enabling environment to practice acquired skills. Poor record keeping as
much difficulty was experienced retrieving records from torn and damaged bo=
oks.
=
Radiation/clinical
oncology
– no formal medical oncology training program in Nigeria. Poly Adenosine
diphosphate Ribose Polymerase (PARP) inhibitors are not available. Bevacizu=
mab,
a vascular endothelial growth factor inhibitor that acts as a targeted ther=
apy
for most ovarian cancers, is generally not affordable. Non-avai=
lability
or prohibitive cost of some chemotherapeutic agents. Few drugs are currently availa=
ble
on the CAP, Inadequate
capacity to manage toxicity.
=
Radiologic - Non-functional
computerized tomography scans. The two-slice CT was broken down at the time=
of
this interview and patients had to get their CT scans from the Kaduna
metropolis (about 80km distance) at a higher rate. Unavailability of positr=
on
emission tomography (PET), lack of interventional radiology facility amongst
others
=
Pathology=
- Unavailability
of routine immunohistochemistry. No Germline and somatic testing. Inadequate
cytopathologists, lack of frozen section
According
to the National Cancer Institute’s Surveillance, Epidemiology, and End Resu=
lts
program data, the incidence of ovarian cancer is declining globally, accoun=
ting
for 2.5% of all new global cancer cases in 2018.[16] This trend =
was
however, not demonstrated in our institution where Zayyan et al previously
demonstrated that the number of cases of ovarian cancer increased over a
ten-year period [17] and the current study corroborated this. A
similar study in another part of Nigeria has also shown a rising frequency.=
[18]
The reason for this rise may be related to the increase in awareness =
and
health-seeking attitude of the women in this region, as well as subtle adva=
nces
in the management of ovarian cancer in the region. Other proposed factors
include population growth, increased cancer risk factors, decreased pregnan=
cy,
and lactation length as well a decrease in tubal ligations. [19]=
Ovarian
cancer is generally a disease of older women. About half of the women diagn=
osed
are 63 years or older. [20] The incidence rises steeply after the
fifth decade to reach a peak in the 80- to 84-year-old age group. [21]=
In this study, however, the mean age of cases was 40.6 years. This is in
keeping with a previous study in this institution by Zayyan et al where gre=
ater
than 50% of patients were young women less than 40 years. [11]
Studies in other parts of Nigeria and the African region and black women in=
the
diaspora agree with this finding. [22] In comparison to White wo=
men
in the United States, women of African ancestry have a lower incidence of
ovarian cancer. [17] However, Black women have higher morbidity =
and
mortality rates, higher unstaged and unclassifi=
ed
tumors, and are thus undertreated or untreated with subsequent compromise in
progression-free survival. [23] Data also suggest there are heal=
th
disparities across the entire cancer continuum from prevention to treatment,
but few studies exist to directly address these disparities.
In this
study, the majority (63%) were multiparous. This was also demonstrated in t=
he
previous study in our institution. [17]
No matter how high t=
he
index of clinical suspicion, the diagnosis of cancer is not conclusively
established nor safely assumed in the absence of a tissue diagnosis. [=
18] An
accurate, specific, and sufficiently comprehensive diagnosis is required to
enable the clinician to develop an optimal plan of treatment and invariably
estimate prognosis. [24] The majority (77%) of the 122 c=
ases
reviewed had no histological diagnosis. Reasons for this include the known
difficulty with obtaining tissue diagnosis in ovarian cancers (as ovaries a=
re
deeply situated in the abdomen), non-availability of interventional radiolo=
gy
for image-guided biopsy, the reluctance of the gynaeco=
logists
to take patients for upfront surgery due to poor performance status or
uncertainty of disease extent, the inability of radiologists to tell with
certainty the extent of disease on imaging or more frustratingly, the inabi=
lity
of the patients to pay for surgery. This means that the statistic for ovari=
an
cancer is probably under-reported as compared with other cancers such as
cervical cancer; where the histological diagnosis is much easier and cheape=
r as
it doesn’t involve surgery in my centre, with
cervical biopsies done in the clinic, ward, or emergency unit at first
presentation. In addition, the GLOBOCAN statistics were extrapolated from
registries outside the 19 northern states of Nigeria. The Abuja registry,
located in the cosmopolitan Federal Capital Territory Abuja, might not be t=
ruly
representative of the north.
There
is a high percentage (52%) of non-epithelial tumors from this study. This
contrasts with studies among the Caucasian population but in keeping with f=
indings
from other African studies [17,22,25,26]
Some
challenges identified by the MDT include poverty and poor coverage of health
insurance for cancer care making patients unable to pay for investigations.
According to the World Poverty Clock, Nigeria has the most extremely poor
people in the world, with almost half the population living on less than $2=
per
day. [27] The majority of our patients cannot afford investigati=
ons
to confirm diagnosis making surgery and chemotherapy a mirage. It was not u=
ntil
October 2019, that the Federal Ministry of Health, in partnership with the
Clinton Health Access Initiative (CHAI), the American Cancer Society (ACS),
Pfizer, Worldwide Health Care, and EMGE Resources, launched a pioneer Chemo=
therapy
Access treatment program called chemotherapy access Partnership (CAP), to c=
ater
for 50% of treatment cost in people with cancer. [28] This will
enable patients to access high-quality chemotherapy agents (same as those u=
sed
in the United States) at seven teaching hospital pharmacies in Nigeria
including our centre, ABUT=
H.
All these problems might result in the remaining 77% of patients dying with=
out
a histologic diagnosis.
Loss to follow up before a definitive diagnosis, which may be finance-induced or as= a result of inadequate counseling with denial or cultural and religious belie= fs that cancers are not treatable in the hospital, was common in this study (3= 7%). In addition, the general belief that cancer is a terminal disease probably red= uces individual and philanthropic funding for cancer patients. It is also= a known fact that there is inadequate manpower in the health facilities to efficiently cater to the needs of patients generally and cancer patients specifically due to the massive brain drain in Nigeria. [29] The results of the ongoing Every Woman Study: Low- and Middle-Income Countries edition [30] will provide more insights into these challenges. <= o:p>
In
addition to these, adequate facilities and technology for cancer management=
are
lacking. There are only a few functional cancer centers in the country (non=
e in
the 19 northern states as of January 2023) to cater to the needs of the 233=
,911
cancer patients in the country. [1] Only 20-25% of ovarian cance=
rs
are diagnosed early in stage I/II, [11] because of late presenta=
tion
due to aforementioned reasons. This also plays a part in the late diagnosis.
Staging of ovarian tumours is surgical-patholog=
ic and
as such a patient cannot be fully staged if she doesn’t have some surgical
intervention.
Some
patients die from complications of the late disease such as severe anaemia, respiratory failure, thromboembolic events et
cetera with which they present. Aside from these probable explanations, an
in-depth study will need to be carried out to determine the root cause of
failure to make a histological diagnosis in patients with suspicion of ovar=
ian
cancer.
Findings from this s=
tudy
indicate that the likelihood that ovarian cancers are being underestimated =
is
high due to difficulty in getting a histologic diagnosis which involves
surgical intervention or interventional radiology. The late presentation of
patients and poor performance status may make them unfit for surgery while
interventional radiology is unavailable.
In
addition, the role of prevention in ovarian cancer cannot be over-emphasize=
d.
It is pertinent, particularly in this region recording a rise in ovarian ca=
ncer
cases, to research, implement and familiarize gynaecol=
ogists
with recent advances in screening for early ovarian cancer. This is importa=
nt
in women with established risk factors for the condition such as a family
history of ovarian cancer, and Lynch syndrome. Risk scoring using the Risk =
of
Malignancy Index (RMI), Risk of Ovarian Cancer Algorithm (ROCA) as well as
other risk algorithms can be applied to estimate the risk of malignancy the=
reby
triaging patients before definitive staging or histological diagnosis. The
ideal screening test for ovarian cancer has remained elusive. The most
investigated biomarker for ovarian cancer is serum CA-125 and although stud=
ies
remain inconclusive, it has been recommended for screening of high-risk wom=
en
alone or in combination with other parameters such as transvaginal sonograp=
hy,
pelvic examination, et cetera. [31,32] Furthermore, elective or prophylactic =
(risk-reducing)
bilateral salpingo-oophorectomy has been proven=
to
reduce the risk of ovarian cancer in women, particularly those of average a=
nd
high genetic risk. [33] Opportunistic bilateral salpingectomy wi=
th
ovarian retention (BSOR) has also been postulated to decrease both the
incidence of and mortality from ovarian cancer while retaining normal ovari=
an
function and thus, quality of life. [31] This is currently being
performed in our centre. Tubal ligation is also
thought to decrease the risk of ovarian cancer; the mechanism via which it =
does
this is not well understood. It has however been consistently found to prov=
ide
a 50% reduction in epithelial ovarian cancer risk. [33]
In view
of the minimal attention paid historically to cancer in Africa, the number =
of
cancer specialists as a proportion of all healthcare workers is probably lo=
w. [34]
Additionally, inadequate resources for pathology lead to an inadequate
workforce, poor facilities and equipment, and low availability of
immunohistochemistry. [35]
Conclusion
Most patients with
features highly suspicious of ovarian cancers didn’t have a tissue diagnosi=
s,
hence probably dying undiagnosed. Management of ovarian cancer in our setti=
ng
remains a challenge despite advances in surgical and chemotherapeutic optio=
ns.
Infrastructural development, prompt tissue diagnosis using interventional
radiology or laparoscopy for biopsy, and training of all disciplines involv=
ed
is recommended.
=
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