Decrease in liver cancer incidence rates in Bamako, Mali over 28 years of population-based cancer registration (1987-2015)

BACKGROUND

Primary liver cancer is common in West Africa due to endemic risk factors. However, epidemiological studies of the global burden and trends of liver cancer are limited. We report changes in trends of the incidence of liver cancer over a period of 28 years using the population-based cancer registry of Bamako, Mali.

AIM

To assess the trends and patterns of liver cancer by gender and age groups by analyzing the cancer registration data accumulated over 28 years (1987-2015) of activity of the population-based registry of the Bamako district.

METHODS

Data obtained since the inception of the registry in 1987 through 2015 were stratified into three periods (1987-1996, 1997-2006, and 2007-2015). Age-standardized rates were estimated by direct standardization using the world population. Incidence rate ratios and the corresponding 95% confidence intervals (CI) were estimated using the early period as the reference (1987-1996). Joinpoint regression models were used to assess the annual percentage change and highlight trends over the entire period (from 1987 to 2015).

RESULTS

Among males, the age-standardized incidence rates significantly decreased from 19.41 (1987-1996) to 13.12 (1997-2006) to 8.15 (2007-2015) per 10⁵ person-years. The incidence rate ratio over 28 years was 0.42 (95%CI: 0.34-0.50), and the annual percentage change was -4.59 [95%CI: (-6.4)-(-2.7)]. Among females, rates dropped continuously from 7.02 (1987-1996) to 2.57 (2007-2015) per 10⁵ person-years, with an incidence rate ratio of 0.37 (95%CI: 0.28-0.45) and an annual percentage change of -5.63 [95%CI: (-8.9)-(-2.3)].

CONCLUSION

The population-based registration showed that the incidence of primary liver cancer has steadily decreased in the Bamako district over 28 years. This trend does not appear to result from biases or changes in registration practices. This is the first report of such a decrease in an area of high incidence of liver cancer in Africa. This decrease may be explained by the changes and diversity of diet that could reduce exposure to aflatoxins through dietary contamination in this population.

Relationships between gut microbiota, red meat consumption and colorectal cancer

Excessive consumption of red and processed meat has been associated with a higher risk of developing colorectal cancer. There are many attempts to explain the risk of colorectal cancer associated with the consumption of red and processed meat: The temperature cooking of meat such as grilling and smoking contribute to the formation of mutagenic compounds including heterocyclic amines and polycyclic aromatic hydrocarbons.Heme iron in red meat is involved in the formation of N-nitroso compounds and lipid peroxidation products in the digestive tract.Fatty red meat is involved in the production of secondary bile acids by the bacteria of the gut microbiota. Many of the products formed are genotoxic and can cause DNA damage and initiate carcinogenesis of colorectal cancer. Various mechanisms contributing to their genotoxic role have been established in human and animal studies. In addition, there is increasing evidence that compounds formed from red and processed meat interact with the gut microbiota in colorectal cancer pathways. Although several early studies in animals and humans suggest a direct causal role of the gut microbiota in the development of colorectal cancer, the links between diet, gut microbiota, and colonic carcinogenesis are largely associations rather than proven causal relationships. Various biological mechanisms, including inflammation and oxidative stress can lead to DNA damage, gut dysbiosis, and therefore increase the risk of colorectal cancer. Dysbiosis of the gut microbiota may increase the risk of colorectal cancer through dietary component promotion of colonic carcinogenesis. In this paper, we review and update current knowledge about the relationships between red meat consumption, gut microbiota, and colorectal cancer.

Breast Cancer Diagnostics, Therapy, and Outcomes in Sub-Saharan Africa: A Population-Based Registry Study

BACKGROUND

Breast cancer (BC) is the most common cancer in sub-Saharan Africa (SSA). However, little is known about the actual therapy received by women with BC and their survival outcome at the population level in SSA. This study aims to describe the cancer-directed therapy received by patients with BC at the population level in SSA, compare these results with the NCCN Harmonized Guidelines for SSA (NCCN Harmonized Guidelines), and evaluate the impact on survival.

METHODS

Random samples of patients with BC (≥40 patients per registry), diagnosed from 2009 through 2015, were drawn from 11 urban population-based cancer registries from 10 countries (Benin, Congo, Cote d'Ivoire, Ethiopia, Kenya, Mali, Mozambique, Namibia, Uganda, and Zimbabwe). Active methods were used to update the therapy and outcome data of diagnosed patients ("traced patients"). Excess hazards of death by therapy use were modeled in a relative survival context.

RESULTS

A total of 809 patients were included. Additional information was traced for 517 patients (63.8%), and this proportion varied by registry. One in 5 traced patients met the minimum diagnostic criteria (cancer stage and hormone receptor status known) for use of the NCCN Harmonized Guidelines. The hormone receptor status was unknown for 72.5% of patients. Of the traced patients with stage I-III BC (n=320), 50.9% received inadequate or no cancer-directed therapy. Access to therapy differed by registry area. Initiation of adequate therapy and early-stage diagnosis were the most important determinants of survival.

CONCLUSIONS

Downstaging BC and improving access to diagnostics and care are necessary steps to increase guideline adherence and improve survival for women in SSA. It will also be important to strengthen health systems and facilities for data management in SSA to facilitate patient follow-up and disease surveillance.

Rising Prostate Cancer Incidence in Sub-Saharan Africa: A Trend Analysis of Data from the African Cancer Registry Network

BACKGROUND

Prostate cancer is the leading cancer in men in sub-Saharan Africa (SSA) regarding incidence and mortality. Published data from a few registries in SSA suggest that the rates are still rising, but there is little comprehensive information on the time trends of prostate cancer incidence.

METHODS

We analyzed registry data on 13,170 incident prostate cancer cases in men aged 40 years or above, from 12 population-based cancer registries in 11 SSA countries, with at least a 10-year time span of comparable data.

RESULTS

We observed an increase in cumulative risks (CR) and age-standardized incidence rates (ASR) over time in all registries (statistically significant in all but one). The highest values of CR were found in Seychelles and Harare (Zimbabwe). The highest annual increase in the ASRs was seen in Seychelles and Eastern Cape (South Africa), whereas the lowest was seen in Mauritius. We mainly found a steady increase in incidence with age and during successive periods.

CONCLUSIONS

This analysis reveals that prostate cancer incidence rates are rising in many populations in SSA-often very rapidly-which is in contrast to recent observations worldwide. We acknowledge that the reasons are multifactorial and largely remain unclear, but believe that they are primarily associated with improvements in health care systems, for example, a broader use of prostate-specific antigen testing.

IMPACT

This study is the first to compare population-level data on time trends of prostate cancer incidence between multiple countries of SSA, presenting the different rates of increase in 11 of them.

[Health-care related infections in pediatric surgery of the teaching hospital Gabriel Toure, Bamako, Mali]

OBJECTIVES

to identify the main causative agents of infection associated with care and their susceptibility to antibiotics used and to identify risk factors for care-associated infection.

MATERIAL AND METHODS

This was a cross-sectional study with prospective data collection, conducted from 1 November 2016 to 1 April 2017 among all children admitted to the pediatric surgery department. Non-consenting parents and cases of necrosectomy were included in this study.

RESULTS

Our study involved 200 patients, 30 of whom presented a care-associated infection (15% infection rate). The average age of patients with infection was 56.33 ± 48.66 months (1 and 180 months). The main pathogens responsible for infection of the operative site were: Escherischia coli (4 cases), Acinetobacterbaumanii (3 cases), Klebsiella pneumoniae (2 cases), Staphylococcus aureus (2 cases), Enterobacter cloacae (1case), Pseudomonas aeruginosa (1 case) and Enterobacter faecalis (1 case). In the burned patients, the organisms found were: Acinetobacter baumanii (7 cases), Klebsiella pneumoniae (6 cases), Staphylococcus aureus (6 cases), Escherischia coli (4 cases), Pseudomonas aeruginosa (2 cases) and Enterobacter faecalis (2 cases). Escherichia coli was noted in urinary tract infection. Antibiotics tested were amoxicillin, amoxicillin-clavulanic acid, ceftriaxone, imipenem, gentamicin and ciprofloxacin. The mode of recruitment and the duration of hospitalization were the risk factors noted.

CONCLUSION

The infection associated with care is a frequent occurrence in our practice. These infections mainly occur at the operating sites. The germs found were: Acinetobacter, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus. They are all sensitive to imipenem and resistant to amoxicillin. The infection remains formidable in health care. It is essential to give special attention to the prevention of infectious risk, especially in the surgical setting.

Health system organisation and patient pathways: breast care patients' trajectories and medical doctors' practice in Mali

Background

Information on pathways of women seeking diagnostic services due to breast- related symptoms can help highlight challenges related to the healthcare system in improving early diagnosis of breast cancer.

Methods

We retrospectively analysed the entire patient pathway, from first symptom recognition via initial healthcare visit up to final diagnosis at the pathology service in Mali. Data from questionnaire-based structured patient interviews (n = 124) were used to calculate time to first healthcare visit (median 91 days) and consecutive time to diagnosis (median 21 days) and to extract information on type of initially visited healthcare facility (community healthcare centre, referral hospital, tertiary hospital, private clinic). Median time to first healthcare visit and time to diagnosis and type of initially-visited healthcare facility were cross-tabulated with patient characteristics. An additional survey among (n = 30) medical doctors in the community healthcare centres and referral hospitals in Bamako was conducted to understand current knowledge and referral practice with respect to female patients with breast-related symptoms.

Results

Patients who initially visited private clinics had the shortest time to first healthcare visit (median 44 days), but the longest time to diagnosis (median 170 days). Patients visiting community healthcare centres and referral hospitals took longest for a first healthcare visit (median 153 and 206 days, respectively), but the time to diagnosis was shorter (median 95 and 7 days, respectively). The majority of patients (45%) initially visited a tertiary hospital; these patients had shortest total time to diagnosis (median 56 days health seeking and 8 days diagnostic time), but did not follow the recommended pathway for patients in the pyramidal healthcare system in Mali. The doctors’ survey showed lower breast cancer knowledge in the community healthcare centres than in the referral hospitals. However, most doctors felt able to recognise suspected cases of cancer and referred patients directly to a hospital.

Conclusions

The role of different healthcare facilities in ensuring triage of patients with breast-related symptoms needs to be defined before any early detection initiatives are implemented. Especially at the entry level of the healthcare system, the access and quality of health services need to be strengthened.

[Contribution Of The Cytology In The Diagnosis And Evaluation Of The Pronostic Of Metastatic Ascites]

INTRODUCTION

Metastatsic tumoral ascites are characterised by the presence of cancerous cells in peritoneal fluid. They are frequent at an advanced stage of cancer. The goal of our work was to study cytology's contribution in the diagnosis of metastatic ascites at the teaching hospital of Point G.

MATERIAL AND METHODS

It was a 3 years retrospective and prospective study, from January 2013 to December 2015. The study included every ascitic samples containing malignant cells at the teaching hospital of Point G. We looked for clinical informations in the patient's fold to find the primary cancer site, the histological diagnosis and the folllowup.

RESULTS

We collected data from 213 patients with ascite. Among them, 61 where malignant (28.6 %). Sixty-six percent (66%) of our patients were women. The most represented range age was from 46 to 60 years with a mean of 57.7 years. Housewives were the most frequent among our patients with a rate of 50.8%. Ovarian cancer was the first site with metastatic ascite (26%). It was followed by liver and stomach with respectively 20% and 18%. Ascite was the first clinical manifestation in 36% patients with cancer. It was isolated in 78%. After 6 months, the mortality rate was 76.6%.

CONCLUSION

The cytology of ascite liquid is an imortant test for the diagnostic of metastatic ascites.

[Urethral Prolapse Of The Girl In The Service Of Pediatric Surgery Of The Teaching Hospital Gabriel Touré]

OBJECTIVES

To describe the diagnostic and therapeutic aspects of urethral prolapse in girls in pediatric surgery.

PATIENTS AND METHOD

This was a 9-year retrospective study (January 2007 to December 2015) of girls aged 0-15 years with urethral prolapse and management in the department during the study period.

RESULTS

In 9 years, 18 cases of prolapsewerediagnosed, or 2 cases / year. The averageagewas 8.9 ± 3.4 yearswithextremes of 6 years and 15 years. Of the 18 cases identified, 10 werereferred. Femalegenital mutilation wasfoundin 15 (83.3%) patients, rectal prolapsewasassociatedin 2 cases (11.1%) and a cough concept in 5 (27.8%) patients. The average consultation time was 11.6 ± 7.9 dayswithextremes of 1 and 21 days. Eleven (61.1%) patients werereceivedurgently, including 2 cases (11.1%) of strangulation. Prolapsewas in the form of a roundedswelling, centered by the urethralmeatus. The mass wasblackishin 2 cases (11.1%). Shewasbleeding and painfulin 11 (61.1%) cases. Thesesignswere absent in 5 cases (27.8%). Swellingwasassociatedwithsigns of urinarydysuria and / or urinaryblightin 10 (55.5%) girls. The diagnosiswasclinical in all patients. Treatmentconsisted of excision and suturing of the prolapsedmucosa in all patients with placement of an indwellingurinarycatheter. Immediatefollow-up was simple in 16 (88.9%) patients and 2 cases (11.1%) of surgical site infection.

Factors associated with time to first healthcare visit, diagnosis and treatment, and their impact on survival among breast cancer patients in Mali

Objective

To analyse patient and healthcare system related factors influencing the time to first healthcare visit, diagnosis and treatment of breast cancer patients in sub-Saharan Africa and the impact on survival in order to advise on early detection strategies.

Methods

A prospective hospital cohort study was conducted at the only pathology department in Mali, at the University Hospital in Bamako. All the female patients with a breast cancer diagnosis between January and April 2016 were interviewed with a structured questionnaire (N = 64) to gather information about breast symptom recognition and first healthcare visit. Information on beginning of treatment and survival were collected at 18-months follow-up. Simple Cox regression analyses were performed.

Results

The median time to first healthcare visit was 4.8 months, from first healthcare visit to diagnosis was 0.9 months and for the patients who started treatment (N = 46) the time from diagnosis to treatment was 1.3 months. Knowledge of breast-self-examination and correct symptom interpretation increased the chance of an earlier healthcare visit. Prolonged time to diagnosis was found with shorter duration to first healthcare visit, for working women compared to housewives and for those living within Bamako. Living outside Bamako and smaller tumour size (T1/T2) prolonged time to treatment. Visit of a traditional healer and larger tumour size (T3/T4) shortened survival time, whereas time to first healthcare visit and subsequent time to diagnosis had no influence on survival.

Conclusions

Down-staging strategies are only useful if the continuum of breast cancer care is warranted for the majority of patients.

Tackling Late-Stage Diagnosis of Breast Cancer Patients in Sub-Saharan Africa: A Case Study From Mali

Introduction: Breast cancer is the most frequent cancer among women in sub-Saharan Africa with high mortality rates. As 60%–100% of the patients are diagnosed at late stages, downstaging strategies have been the focus of international discussions to improve survival. The aim of this study was to analyze the entire breast cancer patient´s pathway from first symptom recognition to begin of treatment and survival in Mali to advice on such strategies. Methods: The model of pathways to treatment was used as a framework to assess important time intervals during the patient´s pathway and to match results of the mixed-methods approach. For the quantitative part, N=64 breast cancer patients were interviewed, with a structured questionnaire at the only pathology department in Mali, about breast symptom recognition and first health care visit. Information on begin of treatment and survival were collected at 18-months follow up. Simple Cox regression analyses were performed. To discover additional barriers, three focus group discussions in the communities in Bamako were conducted (2). Results: Median time to first health care visit was 4.8 months, from first health care visit to diagnosis 0.9 months, and for the patients who started treatment (N=46) time from diagnosis to treatment was 1.3 months. Knowledge of breast-self-examination, and correct symptom interpretation increased the chance to visit health care earlier. Shorter duration to first health care visit, working women compared with housewives, and living within Bamako prolonged time to diagnosis. Living outside Bamako, and smaller tumor size (T1/T2) prolonged time to treatment. Visit of a traditional healer, and larger tumor size (T3/T4) shortened survival time, while time to first health visit, and subsequent time to diagnosis had no influence on survival. In the focus groups, low level of breast cancer knowledge, mistrust in the community health care centers, and economic hardship were reported as additional barriers to first health care visit. Low quality of health care services, and lack of social support were reported as barriers to diagnosis and high costs, and lack of specialized services for treatment begin. Discussion: Patients are diagnosed with late stage diseases, due to low knowledge of breast cancer. A weak health care system and out of pocket expenses discourage patients to seek health care, to have diagnostic services, and to start treatment. Conclusion: The continuum of care has to be warranted for the majority of patients to benefit from down-staging strategies.

Treatment of retinoblastoma in Sub-Saharan Africa: Experience of the paediatric oncology unit at Gabriel Toure Teaching Hospital and the Institute of African Tropical Ophthalmology, Bamako, Mali

BACKGROUND

Retinoblastoma (Rb) is the most common intraocular primary malignancy in children. In industrialised countries, the cure rate is about 95%. We present the results of a prospective study on the management of Rb in the paediatric oncology unit of Gabriel Touré Teaching Hospital and African Institute of Tropical Ophthalmology, from November 1, 2011 to December 31, 2015.

PROCEDURE

The aims of this prospective study were to evaluate the treatment of localised Rb, ocular prosthesis after enucleation, conservative management for bilateral Rb as well as survival rates in all patients. Patients with early stage Rb at diagnosis were included. The treatment was performed according to the retinoblastoma treatment guidelines of the French-African Paediatric Oncology Group.

RESULTS

Eighty-eight patients were included in the study. Sex ratio was 1:1 (M = 44, F = 44). Median age at diagnosis was 3 years (range: 2 months-5 years). Unilateral intraocular Rb was predominant (n = 50; 56.8%). Conservative treatments were performed on nine eyes in nine patients. Overall survival and event-free survival of the entire cohort at the end of 4 years were 73% (95% CI 60.8-81.2%) and 59% (95% CI 47.9-69.5%), respectively, with a median follow-up of 3.7 years (0.1-5.6 years). In conclusion, early enucleation in early stage of Rb can improve outcomes in resource-limited countries. Delayed enucleation and refusal of adherence to treatment are still major concerns and remain a barrier to improving overall patient survival.

[Pathologies of peritoneo-vaginal canal in pediatric surgery at the teaching hospital Gabriel Touré]

The closure anomalies of the peritoneal-vaginal canal include several clinical entities, which are at the origin of various symptomatology.

OBJECTIVE

To study the anatomo-clinical and therapeutic aspects of pathologies of the peritoneal-vaginal canal.

MATERIALS AND METHOD

This was a prospective study from January 1^st to December 31^st, 2015 carried out in the pediatric surgery department of University Hospital Gabriel Touré. It covered all children aged 0-15 years old with a pathology of the peritoneal-vaginal canal operating in the department during the study period. This study did not include cases that were not operated on or not seen during the study period.

RESULTS

During the study period, 2,699 children were treated in pediatric surgery, of which 150 cases of pathology of the peritoneal-vaginal canal had a hospital frequency of 5.5%. The average age was 3.25 ± 9.63 years. The sex ratio was 14. The reason for consultation was intermittent or permanent inguinal or inguino-scrotal swelling in all children. The pathology was discovered by the parents during the pushing efforts in 46.7%. Inguino-scrotal swelling was found on physical examination in 40% of cases. The right side was reached in 60% of the cases. Hernia accounted for 80.6% of these pathologies. We recorded 31 cases of strangulation and 11 cases of craze. Immediate operative follow-up was simple in 92% of patients. This rate was 96% after 6 months.

CONCLUSION

Pathologies of the peritoneal-vaginal canal are very common in pediatric surgical practice. The first place of these pathologies is occupied by hernia. They preferentially affect male infants.

[Ileal typhoid perforations: clinical and therapeutic aspects in tropical area]

AIMS

The aim of this study was to describe the clinical and therapeutic aspects of peritonitis by typhoid ileal perforation in a tropical typhoid fever endemic area.

PATIENTS AND METHODS

A descriptive retrospective study over an 8 year period (January 2000 to December 2007) was undertaken in a visceral service of the Point G teaching hospital in Bamako, Mali. Only patients diagnosed and operated for peritonitis presenting lesions or perforations of the final ileum were included in the study.

RESULTS

The data from 120 patients meeting the inclusion criteria was collected. The average age was 22.7 years old. Triad abdominal pains (120 cases; 100%), vomiting (41; 62.3%), lack of matter and gas (22; 32.3%) constituted the main part of the functional signs. The physical examination showed a localised abdominal defence (7 cases, 10.3%), generalized defence (98 cases; 81.6%), and 2 unspecified cases (2.9%). A "wood belly" abdomen was palpated among 105 patients (87.5%), as well as umbilical hernias (106 cases; 88.3%). The Felix and Widal agglutination test was positive for 75 patients (62.5%) and negative for 27 patients (22.5%). During the operation, the quantity of aspirated pus was higher than 1500 ml in 2 cases and lower or equal to 500 ml in 57.4% of cases. The site of the perforation was ante mesenteric in 64 cases (53.3%). Excision-suture and abdominal cleansing were the most common surgical procedures (68 cases; 57%). Postoperatively 19 patients (15.83%) died of septic shock. The average duration of hospitalization was 20.6 days.

CONCLUSION

The peritonitis by typhoid ileum perforation is still the cause of a high mortality rate in our country. The prevention by the vaccination in young populations could decrease the incidence of pathology and the serious complications which result from this.

[Colon amyloidosis secondary to tuberculosis: Case report and review of the literature]

The authors report the first case of amyloidosis diagnosed by histology and documented in Mali. The patient was a young lady of 31 years old who was hospitalized in internal medicine at the University Hospital of "Point G" for edema and ascites syndrome. She had a history of diarrhea, fever, vomiting, exercise dyspnea and diffused abdominal pain. The biological assessment such as HIV serology was negative. The research of Mycobacterium tuberculosis in sputum was positive. The diagnosis hypothesis of amyloidosis has been evoked and a biopsy of the rectal mucosa has been performed. The fragments showed by histology an acellular band between the basal membrane and the periglandular area. This band was stained in red by Rouge Congo. That confirmed the diagnosis of amyloidosis.

Human papillomavirus distribution in invasive cervical carcinoma in sub-Saharan Africa: could HIV explain the differences?

OBJECTIVES

To describe human papillomavirus (HPV) distribution in invasive cervical carcinoma (ICC) from Mali and Senegal and to compare type-specific relative contribution among sub-Saharan African (SSA) countries.

METHODS

A multicentric study was conducted to collect paraffin-embedded blocks of ICC. Polymerase chain reaction, DNA enzyme immunoassay and line probe assay were performed for HPV detection and genotyping. Data from SSA (Mozambique, Nigeria and Uganda) and 35 other countries were compared.

RESULTS

One hundred and sixty-four ICC cases from Mali and Senegal were tested from which 138 were positive (adjusted prevalence = 86.8%; 95% CI = 79.7-91.7%). HPV16 and HPV18 accounted for 57.2% of infections and HPV45 for 16.7%. In SSA countries, HPV16 was less frequent than in the rest of the world (49.4%vs. 62.6%; P < 0.0001) but HPV18 and HPV45 were two times more frequent (19.3%vs. 9.4%; P < 0.0001 and 10.3%vs. 5.6%; P < 0.0001, respectively). There was an ecological correlation between HIV prevalence and the increase of HPV18 and the decrease of HPV45 in ICC in SSA (P = 0.037 for both).

CONCLUSION

HPV16/18/45 accounted for two-thirds of the HPV types found in invasive cervical cancer in Mali and Senegal. Our results suggest that HIV may play a role in the underlying HPV18 and HPV45 contribution to cervical cancer, but further studies are needed to confirm this correlation.

[Strangulation of the sigmoid colon by a giant ectopic testis]

Les causes de volvulus du colon sigmoïde sont variées et parmi elles la strangulation est des plus fréquentes dans notre contexte d’exercice. Les lésions vues tard permettent très rarement un traitement sans résection. La survenue d’un volvulus du colon sigmoïde autour d’un pédicule de testicule géant ectopique est une première que nous rapportons dans cette étude de cas.

[Laryngo-pharyngeal cancer at a health service of last resort in Mali: anatomo-clinical and therapeutic aspects]

The purpose of this study is to describe the clinical, anatomic and therapeutic aspects of laryngitis--pharyngeal cancers in Mali. It was a prospective, descriptive and cross sectional study which was help in the ORL and cervical facial department of the university hospital center Gabriel TOURE between April 2006 and March 2007. The study looked at 18 patients hospitalized for larynx or hypo pharynx cancer, diagnostic was confirmed histologically. The parameters (age, other favorable features, clinical signs, endoscopic aspect of the tumor, histological type and treatment type) have been analyzed. Men were the most affected (66.7%), with an average age of 58.17 year old. Chronic smoking has been the most evocated factor of risk (55.17) with an average consumation of 39.5 P/A. A delay in consultation was noticed (60% with a period greater than 1 year after the first symptoms appear). The burgeoning aspect (66.7%) end the carcinoma epidemic type of the tumor (94.7%) have dominated the anatomy pathologic table. Only 27.8% of patients had surgery because of late diagnosis.

[Extension of cervix cancer screening by visual methods to the community health centres in the district of Bamako]

Cervix cancer remains a public health problem in developing countries. These results are an assessment for multicentric study based on visual inspection of the cervix after application of acetiq acid (VIA) and lugol's iodine (VILI). The aim of this study is to determine the feasibility and the impact of this screening in the community health centres "CSCOM" in the district of Bamako. It was a prospective and multicentric study through 8 CSCOM, 3 Reference Centres "CSRéf", Hôpital Gabriel Touré (HGT) and National Institute of Public Health (INRSP) in Bamako. During 28 months, 5016 women aged through 25-49 years were screened. After their consent and questionnaire filling, the patient is comfortably settled for visual test. The repartition of screened patients by health level is: CSCOM (19.24% : 965/5016), CSRéf (48.64% : 2440/5016), HGT (32.12% : 1611/5016). In general, the positivity of tests was: 5.2% (VIA) and 6.8% (VILI). The positive women at the CSCOM level were oriented to the CSRéf or the HGT for the colposcopy, possible biopsy or care. At all 177 biopsies were done, and histological diagnosis were: 67 dysplasias, 3 early invasive carcinomas, 69 invasive carcinomas and 38 inflammatory metaplasic lesions or nonconclusives aspects. Patients with dysplasias or cancers were treated by cryotherapy, loop electrosurgical excision procedure (LEEP), cold-knife conization or surgery. This study showed that screening of cervical cancer by visual inspection is workable at CSCOM level. We wish a large diffusion of the method to the whole of the country.