Evidence-based medicine (EBM) is critical to effectively address the “running train” of cancer in Africa. Focused on the use of best research evidence for patient care,¹ a primary assumption of EBM is that research evidence exists for the patient population being treated. What happens when this basic assumption is violated for the African population, whereby the research evidence is based on other populations? What happens when we do not have a clear understanding of cancer development, cancer progression and how cancer responds to treatment in Africans? This is the reality for most countries in Africa and it is not a good one.

Several research disciplines are crucial to fostering EBM in Africa, including health disparities, public health, behavioral research, implementation science, cancer biology and genomics, to name a few. A foundational research area is the study and diagnosis of cancer – Pathology. Pathology bridges basic biology and medicine, offering a critical role in discovery science.² However, the practice of pathology faces several challenges in Africa, including shortage of pathologists, lack of well-trained pathology workforce, deficiencies in standardization and quality control challenges.³ For cancer research, a fundamental challenge is access to high-quality human biospecimens from African patients, making tissue an issue.  The limited biospecimens from Africans limits the opportunity to effectively understand and address cancer in Africa.  Addressing this limitation requires systematic and purposeful approaches to foster pathology research in Africa, including quality assurance, research training and use of best practices. Three examples of some of the approaches are provided below.

Quantity and Quality Control of archived FFPE Tissue from Nigerian men. Funded by the US National Cancer Institute (NCI)/Leidos Biomedical Research Inc, the Prostate Cancer Transatlantic Consortium (CaPTC) facilitated this quality assurance project in Nigeria from 2016-2018.  The purpose of the project was to conduct a pilot study comparing the quantity and quality of DNA and RNA extracted from formalin fixed paraffin embedded (FFPE) tissues in developing countries for next generation sequencing. The primary goal was to explore if data derived from this analysis could serve as the basis for determining the utility of archival FFPE biospecimens from cohorts in Africa. CaPTC investigators in Nigeria contributed 755 prostate cancer samples biopsied between 2002 and 2017. Over sixty percent (61.5%) of the samples passed quantity control and 29.1% passed DNA quality control. The project demonstrated the utility of archival FFPE biospecimens from African patient cohorts, although there is room for improvement.

Pathology Training and Development of Uniform SOPs for West Africa. Recognizing the importance of a strong pathology research workforce in Africa, research training has been the focus of several organizations. In 2017, the CaPTC, Nigeria Breast Cancer Consortium (NBCC) and African Research Group for Oncology (ARGO) sponsored a Tri-Consortia Pathology Workshop. The training workshop focused on multiple topics, with the ultimate goal of improving and encouraging the use of a uniform standardized format of reporting and documenting the pathology of cancer cases in West Africa. Additionally, CaPTC has led several pathology-based research-training programs to improve clinical research capacity of African pathologists. Of note is a 2018 research-training program funded by the US NCI Center for Global Health, and co-directed by Prof. Clayton Yates (Tuskegee University) and Dr. Kayode Adeniji (University of Ilorin Teaching Hospital, Nigeria). The program provided: (1) a 2-day pathology workshop titled, “From SOP to Best Practices” as a pre-conference workshop for the Science of Global Prostate Cancer Disparities Conference in Nigeria; and (2) experiential training for four CaPTC and three African-Caribbean Cancer Consortium (AC3) pathologists at several US clinical pathology labs. The techniques that were learned by the African and Caribbean pathologists included Gleason Grading, Tissue Procurement, Biobanking and Tissue Microarray construction. Since 2018, CaPTC, led by Dr. Kayode Adeniji, who also serves as the Director of Pathology for CaPTC African Region, has conducted an annual pathology research-training program. The research-training programs have focused primarily on improving molecular pathology to understand the molecular alterations involved in cancer development, cancer progression and cancer treatment in Africans.

Biobanking: The availability of biorepositories is critically important for cancer research in Africa to accelerate progress towards a better understanding of cancer. Some of the challenges that have been noted for biobanking in Africa include inadequate storage of samples, the need to evacuate samples with power outage, reluctance of participants to donate samples and need to process the samples immediately at community events.⁴ The use of best practices cannot be overemphasized, which requires significant finances for infrastructure/resources as well as appropriate personnel. In general, most of the investments that have been made for pathology infrastructure/resources in Africa were by international institutions or organizations, often facilitated by cancer consortia. This has led to the development of regional Centers of Excellence for pathology resource network/biobanking across Africa.

Without a doubt “tissue is an issue” to foster cancer research in Africa, and ultimately EBM for Africans. There is a significant need for access to high-quality human biospecimens for cancer research in Africa. The emerging technologies in pathology may likely offer great opportunities for research advancements in Africa, if they are embraced and not seen as challenges. Pathologists in Africa do not have to take the exact route that pathologists in North America or Europe took. African pathologists can and should take the opportunity to leapfrog to the latest science of pathology using technological innovations.

 References

1. Sackett DL, Strauss SE, Richardson WS,et al. Evidence-based medicine: how to practice and teach EBM. London: Churchill-Livingstone, 2000.
2.  Rodriguez-Canales J, Eberle FC, Jaffe ES, and Emmert-Buck MR. Why is it crucial to reintegrate pathology into cancer research? Bioessays. 2011 July; 33(7): 490–498.
3. Ntiamoah P, Monu NR,  Abdulkareem FB, et al. Pathology Services in Nigeria: Cross-Sectional Survey Results From Three Cancer Consortia. J Glob Oncol. 2019 Sep;5:1-9.
4. Akinyemi RO,  Akinwande K,  Diala S . Biobanking in a Challenging African Environment: Unique Experience from the SIREN Project. Biopreserv Biobank. 2018 Jun 1; 16(3): 217–232.

Prostate Cancer Transatlantic Consortium (CaPTC)

This write up was generated from CaPTC pathology initiatives in Africa. Formed in 2005, the Prostate Cancer Transatlantic Consortium (CaPTC) is a US National Cancer Institute-approved cancer consortium. The primary foal of CaPTC is to address the globally disproportionate burden of prostate cancer among Black men. CaPTC is an open consortium comprising a team of prostate cancer scientists, clinicians, survivors, and advocates across the world. CaPTC is a consortium member of the African Organization for Research and Training in Cancer.