Table Of ContentRecent 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
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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
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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
