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Tumours in a Tropical Country: A Survey of Uganda 1964–1968 PDF

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Recent Results in Cancer Research Fortschritte der Krebsforschung Progres dans les recherches sur Ie cancer 41 Edited by V. G. Allfrey, New York' M. Allgower, Basel· K. H. Bauer, Heidelberg I. Berenblum, Rehovoth . F. Bergel, jersey . J. Bernard, Paris W. Bernhard, Villejuif • N. N. Blokhin, Moskva' H. E. Bock, Tiibingen P. Bucalossi, Milano' A. V. Chaklin, Moskva M. Chorazy, Gliwice . G. j. Cunningham, Richmond· M. Dargent, Lyon G. Della Porta, Milano' P. Denoix, Villejuif . R. Dulbecco, La jolla H. Eagle, New York· E. Eker, Oslo' R. A. Good, New York P. Grabar, Paris' H. Hamperl, Bonn' R. J. C. Harris, Salisbury E. Hecker, Heidelberg· R. Herbeuval, Nancy' j. Higginson, Lyon W. C. Hueper, Fort Myers' H. Isliker, Lausanne J. Kieler, Kobenhavn . G. Klein, Stockholm' H. Koprowski, Philadelphia L. G. Koss, New York· G. Martz, Zurich· G. Mathe, Villejuif O. Miihlbock, Amsterdam' W. Nakahara, Tokyo' L. J. Old, New York V. R. Potter, Madison' A. B. Sabin, Rehovoth . L. Sachs, Rehovoth E. A. Sax en, Helsinki· C. G. Schmidt, Essen' S. Spiegelman, New York W. Szybalski, Madison' H. Tagnon, Bruxelles . R. M. Taylor, Toronto A. Tissieres, Geneve . E. Uehlinger, Zurich· R. W. Wissler, Chicago T. Yoshida, Tokyo Editor in chief P. Rentchnick, Geneve Sponsored by the Swiss League against Cancer Tumours in a Tropical Country A Survey of Uganda 1964 - 1968 Edited by A. C. Templeton With 131 Figures 1973 William Heinemann Medical Books Ltd. London Springer-Verlag Berlin. Heidelberg. New York A. C. TEMPLETON, M.R.C. Path. (U.K.), M.R.C.P. (Edin.), Professor of Pathology, University of Minnesota, Minneapolis, Minnesota, U.S.A. Formerly Senior Lecturer in Pathology, Makerere University, Kampala, Uganda Supported by a grant from the Cancer Research Campaign, London ISBN-13 :978-3-642-80727-5 e-ISBN-13 :978-3-642-80725-1 001: 10.1007/978-3-642-80725-1 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is coneerned, specifically those of translation, reprinting, re-us. of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Under S 54 of the German Copyright Law where copies are made for other than private use, a fee is payable to the publisher, the amount of the fee to be determined by agreement with the publisher. @) by Springer-Verlag Berlin· Heidelberg 1973. Library of Congre •• Catalog Card Number 72-96042. Sohcover reprint of the hardcover I st edition 1973 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that sum names are exempt from the relevant protective laws and relations and therefore free for general use. Foreword The geography of medicine is a classical subject that can be studied wherever medicine is practised and the population counted. It has already contributed a great deal to knowledge of the causes of disease and it might be thought that the subject had little more to teach. This, however, is unlikely. First, there are many parts of the world that have only recently been provided with the full range of diagnostic services. Secondly, it is now realised that the ob- servation that a disease occurs only very rarely under some conditions can be just as important as the observation that it occurs very often under others. Thirdly, the spread of industrializa- tion has not yet eliminated the wide variety of conditions of life that has been produced by different cultures and different standards of living. We have still an opportunity to determine their effect on the incidence of disease, but not perhaps for long. That an interest in the geography of cancer can pay dividends is shown by many examples ranging from the relationships between cancer of the buccal cavity and chewing habits and between cancer of the lung and smoking, to the current enquiries relating Burkitt's lymphoma to malaria, cancer of the oesophagus to the comsumption of maize beer, cancer of the liver to food contaminated with aflatoxin, and cancer of the large bowel to the dietary content of fibre and fat. Many of these observations have been made in Africa and particularly in Uganda, where Sir ALBERT COOK began to record clinical impressions of the incidence of cancer before the end of the last century. Now, in this book, Templeton and his colleagues add a mass of new data that will serve as a source of new ideas for many years to come. The data refer to nearly 11,000 tumours registered in the Kampala Cancer Registry over the period 1964-68. With the exception of a few patients in whom cancer was diagnosed by clinical and radiological means in the immediate vicinity of Kampala, patients were registered only when specimens were received for pathological examination. It is obvious, therefore, that incidence rates must be grossly underestimated, particularly for those parts of Uganda that are remote from the capital. The value of the work lies, therefore, not so much in the provi- sion of detailed incidence rates, but in the picture it provides of the distribution of cancer, subdivided by organ, site within an organ, and histological type and in the relationships that have been observed between these characteristics and the sex, age, tribe, and place of residence of the affected patients. With such data, bias due to incomplete registration may be unimportant and useful information can be obtained by comparing the relative proportions of different types of cancer recorded for different cultural groups in different parts of the country. It is, for example, unlikely that any sort of selective bias could have brought about the observation that cancers of the lower end of the oesophagus were reported relatively more often from the Eastern part of the country than cancers of the upper end of the oesophagus, while the reverse was true for cancers of the pyloric part of the stomach in comparison wit\1 cancers of the cardia. Similarly, it is difficult to see how bias could have brought about speci"' fic correlations between the tribal incidence of cancers of the penis and the vulva and, to a less extent, between cancers of the penis and the cervix uteri. Nor is there any reason to sup- pose that bias could have accounted for a high incidence of Hodgkin's disease of the mixed cellular type in childhood without any evidence of a peak incidence at older ages. When, twenty five years ago, Sir AUSTIN BRADFORD HILL and I began to study the smok- ing histories of patients with and without lung cancer, we were immediately struck by the rarity with which patients with lung cancer were recorded as having been life-long non- smokers. For some time we had difficulty in persuading ourselves that the difference between the two groups of patients was not an artefact due, for example, to a difference in the inten- sity of questioning to which they had been subjected, or to exaggeration of their smoking VI Foreword habits by patients with respiratory symptoms. Gradually, however, as we reviewed the criteria on which the diagnoses were made, we became aware that the diagnosis of bronchial carcinoma had to be abandoned in a much higher proportion of the 'lung cancer' patients who had never smoked than of those who had. As one non-smoker after another was found to have had a fibrosarcoma of the chest wall, a hamartoma, or an alveolar cell carcinoma, the conviction grew that the difference we had observed was real; for the histological classifications had been made independently by many different pathologists and could not have been biassed by knowledge of our interest or of the patient's smoking history. Later, Court Brown and I had a similar experience when we were investigating the relationship between the use of radio- therapy for ankylosis spondylitis and the development of leukaemia. The more that radio- therapists wrote to report the occurence of leukaemia in an unirradiated patient, the fainter our doubts became; for the leukaemia that occurred in patients who had not been irradiated was most often chronic lymphatic in type, while that which occurred after irradiation was usually myeloid. These are two personal examples of the way in which statistics can be given life and meaning when symbiotic with pathology; the records of the Kampala Cancer Registry provide many more. Oxford, April 1973 RICHARD DOLL Preface This monograph is based on material derived from the Kampala Cancer Registry of the Department of Pathology, Makerere University. The registry was founded by Prof. J. N. P. DAVIES and directed by him until 1962, and during the period of this survey was directed by Prof. M. S. R. HUTT. The collection analysed between 1964-1968 constitutes 10,945 tumours and at least eleven facts are known about each case. This whole activity has been generously financed by the British Empire Cancer Campaign (now the Cancer Research Campaign) but for which the Kampala Cancer Registry and this study could not exist. The generation, classification and retrieval of these facts are obviously the work of many people. Details of individual cases have been submitted by doctors in all hospitals in Uganda. Many have spent a good deal of time ensuring that details of cases are accurately noted down and relayed to the Registry. Registration and coding has been the work of Mrs. BARBARA WRIGHT assisted at different times by Mrs. CLAIRE D'ABREU, Mrs. MARGARET MUSOKE, Mrs. ANNE HUCKSTEP, Mrs. ALEXIS BIANCHI, Mrs. ELIZABETH BUXTON and Mrs. CAROLE NICKSON. Computer programming and dealing with the numerous alterations caused by this study have been the work of Dr. MALCOLM PIKE and Mrs. DIANA BULL of the Department of the Regius Professor of Medicine, Oxford University. Mr. KENNETH HILL advised on matters of popula- tion determination. Mr. MATT FINDLAY took, developed, and printed many of the illustrations. Messrs. ROBERTSON, SERUMAGA and BUSULWA of the Department of Medical Illustration, Makerere University, gave help with other illustrations, maps and charts. The secretarial work entailed has been patiently borne by Mrs. JENNY WHITEHEAD. Advice on different aspects of this publication has been given by Profes- sor Sir RICHARD DOLL, Dr. ROBERT HARRIS, Mr. DENNIS BURKITT and Dr. ROBERT SCULLY. Helpful discussions on various aspects of tumours in Uganda were held with Prof. Sir IAN McADAM, Prof. S. K. KYALWAZI, Dr. ROLF SCHMAUZ, Dr. JOHN THOMAS and Dr. JOHN ZIEGLER. Prof. R. R. TRUSSEL, Dr. PET LEIGHTON and Mr. O. ZEIGLER kindly allowed access to the records of the cytology department. To all these and many others who helped in so many ways grateful thanks are given. Minneapolis, January 1973 A. C. TEMPLETON Contents Chapter 1 Introduction. Distribution of Tumours in Uganda. A. C. TEMPLETON and M. S. R. HUTT. With 6 Figures. Chapter 2 Tumours of the Alimentary Canal. A. C. TEMPLETON. With 7 Figures 23 Chapter 3 Tumours of the Liver, Biliary System and Pancreas. M. S. R. HUTT and P. P. ANTHONY. With 13 Figures 57 Chapter 4 Tumours of the Respiratory Tract. G. T. O'CONOR and A. C. TEMPLETON. With 6 Figures 79 Chapter 5 Tumours of the Breast. A. C. TEMPLETON. With 1 Figure 94 Chapter 6 Tumours of the Female Genitalia. P. D. JAMES, C. W. TAYLOR and A. C. TEMPLETON. With 9 Figures 101 Chapter 7 Tumours of the Male Genitalia. O. G. DODGE, R. OWOR and A. C. TEMPLETON. With 5 Figures 132 Chapter 8 Malignant Tumours of the Kidney, Bladder and Urethra. P. P. ANTHONY. With 14 Figures 145 Chapter 9 Melanoma. M. G. LEWIS. With 5 Figures 171 Chapter 10 Tumours of the Skin. ULLA IVERSEN and O. H. IVERSEN. With 11 Figures 180 Chapter 11 Tumours of the Brain. A. C. TEMPLETON 200 Chapter 12 Tumours of the Eye and Adnexa. A. C. TEMPLETON. With 5 Figures 203 Chapter 13 Tumours of the Endocrine Glands. A. C. TEMPLETON . 215 Chapter 14 Tumours of Bone and Jaw. O. G. DODGE 222 x Contents Chapter 15 Soft Tissue Tumours. A. C. TEMPLETON. With 13 Figures. . . . . . . . . . . 234 Chapter 16 Lymphoreticular Tumours. D. H. WRIGHT and A. SERCK-HANSSEN. With 18 Figures. . . . 270 Chapter 17 Leukaemia. A. C. TEMPLETON . . . . . . . . . . . . . 298 Chapter 18 Tumours of Unknown Origin. A. C. TEMPLETON. . . . . . . . . . . . . . 302 Chapter 19 Childhood Tumours. J. N. P. DAVIES 306 References 321 Subject Index 344 Contributors Dr. P. P. ANTHONY, M.R.C. Path., Senior Lecturer in Pathol- Liver, p. 57 ogy, Middlesex Hospital Medical School, London, W. 1./ Urinary Tract, p. 145 Great Britain. Formerly Senior Lecturer in Pathology, Makerere University, Kampala. Professor J. N. P. DAVIES, M.D. (Bristol), F.R.C. Path., Children's Tumours, Albany Medical College, Albany, N. Y./USA. Formerly p.306 Professor of Pathology, Makerere University, Kampala. Dr. O. G. DODGE, M.D., M.R.C. Path., Consultant Pathologist, Male Genitalia, p. 132 Christie Hospital, Manchester/Great Britain. Formerly Bones, p. 222 Senior Lecturer in Pathology, Makerere University, Kam- pala, and University of Sheffield, England. Professor M. S. R. HUTT, M.D., F.R.C. Path., Professor of Introduction, p. 1 Geographical Pathology, St. Thomas's Hospital Medical Liver, p. 57 School London, S.E.1/Great Britain. Formerly Professor of Pathology, Makerere University, Kampala. Professor O. H. IVERSEN, M.D., Director of Institutt for Gene- Skin, p. 180 rell og Eksperimentell Patologi, University of Oslo, Riks- hospitalet, Oslo l/Norway. Formerly Visiting Professor, Makerere University, Kampala. Dr. ULLA IVERSEN, M.D., Institutt for Generell og Eksperi- Skin, p. 180 mentell Patologi, University of Oslo. Rikshospitalet, Oslo l/Norway. Dr. P. D. JAMES, M.R.C.P. (U.K.), MRC Path. Lecturer, Bland Female Genitalia, Sutton Institute of Pathology, Middlesex Hospital Medical p. 101 School, London, W. l/Great Britain. Formerly Lecturer in Pathology, Makerere University, Kampala. Professor M. G. LEWIS, M.D. (Lond.) M.R.C. Path. Professor Melanoma, p. 171 and Chairman of Pathology, Memorial University of New- foundland, St. John, Newfoundland / Canada. Formerly Lecturer in Geographical Pathology, Makerere University, Kampala. Dr. G. T. O'CONOR, M.D. National Cancer Institute, Bethesda, Respiratory, p. 79 MD 20014/U.S.A. Formerly Senior Lecturer, Makerere University, Kampala. Professor R.OWOR, M.D. (E.A), M.R.C. Path., Professor of Testis, p. 132 Pathology, Makererc University, Kampala/Uganda. Dr. A. SERCK-HANSSEN, M.D., Consultant Cytologist, Ulleval Histiocytic Hospital Oslo/Norway. Formerly Senior Lecturer in Pa- Medullary thology, Makerere University, Kampala. Reticulosis, p. 292

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