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https://doi.org/10.1038/s41467-021-27106-w
OPEN
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Molecular and phenotypic profiling of colorectal
cancer patients in West Africa reveals biological
insights
Olusegun Isaac Alatise1,20, Gregory C. Knapp2,19,20, Avinash Sharma2, Walid K. Chatila3,4,5,
Olukayode A. Arowolo1, Olalekan Olasehinde1, Olusola C. Famurewa1, Adeleye D. Omisore1,
Akinwumi O. Komolafe1, Olaejinrinde O. Olaofe 1, Aba I. Katung6, David E. Ibikunle6,
Adedeji A. Egberongbe 6, Samuel A. Olatoke7, Sulaiman O. Agodirin7, Olusola A. Adesiyun7,
Ademola Adeyeye 7, Oladapo A. Kolawole8, Akinwumi O. Olakanmi9, Kanika Arora3,4, Jeremy Constable2,
Ronak Shah3,4, Azfar Basunia3,4, Brooke Sylvester4, Chao Wu 4, Martin R. Weiser10, Ken Seier11,
Mithat Gonen11, Zsofia K. Stadler12,13, Yelena Kemel 14, Efsevia Vakiani4, Michael F. Berger 4,
Timothy A. Chan 4,15, David B. Solit 4, Jinru Shia 16, Francisco Sanchez-Vega 4, Nikolaus Schultz4,
Murray Brennan 17, J. Joshua Smith 4,10 & T. Peter Kingham 18 ✉
Understanding the molecular and phenotypic profile of colorectal cancer (CRC) in West
Africa is vital to addressing the regions rising burden of disease. Tissue from unselected
Nigerian patients was analyzed with a multigene, next-generation sequencing assay. The rate
of microsatellite instability is significantly higher among Nigerian CRC patients (28.1%) than
patients from The Cancer Genome Atlas (TCGA, 14.2%) and Memorial Sloan Kettering
Cancer Center (MSKCC, 8.5%, P < 0.001). In microsatellite-stable cases, tumors from
Nigerian patients are less likely to have APC mutations (39.1% vs. 76.0% MSKCC P < 0.001)
and WNT pathway alterations (47.8% vs. 81.9% MSKCC, P < 0.001); whereas RAS pathway
alteration is more prevalent (76.1% vs. 59.6%, P = 0.03). Nigerian CRC patients are also
younger and more likely to present with rectal disease (50.8% vs. 33.7% MSKCC, P < 0.001).
The findings suggest a unique biology of CRC in Nigeria, which emphasizes the need for
regional data to guide diagnostic and treatment approaches for patients in West Africa.
A list of author affiliations appears at the end of the paper.
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C
olorectal cancer (CRC) is the third most common cancer
and the second leading cause of cancer-associated death
globally1. The number of new cases is predicted to increase
by 77% between 2012–2030, and the majority of that growth is
projected to occur in low- and -middle income countries
(LMICs)2. In sub-Saharan Africa, the incidence of CRC is
increasing, yet the disease remains poorly characterized in this
region3–5.
Retrospective series suggest that CRC in Nigeria is phenotypically characterized by a younger age of onset, a higher rate of
right colon and rectal primary tumors, and an increased prevalence of mucinous differentiation as compared to American
and European populations5–10. The molecular profile of CRC in
Nigerian patients is poorly characterized, creating an information
gap that is increasingly relevant to both prognosis and treatment
selection11,12. In two small studies at individual tertiary care
facilities in Southwest Nigeria, 43.0 and 34.5% of formalin-fixed
paraffin-embedded (FFPE) CRC specimens demonstrated
microsatellite instability (MSI), respectively9,13. A smaller analysis
from another single institution demonstrated that 23.0% of CRC
specimens exhibited deficient mismatch repair (MMR) protein
expression14. Evidence also suggests a higher incidence of wildtype BRAF (95.5%) and KRAS (79.0%) in Nigerian CRC compared to cohorts of primarily Caucasian patients from highincome countries (HICs)15. However, these previous studies rely
on FFPE specimens that can be a challenge to examine with
immunohistochemistry (IHC) in low-resource environments. As
a result, existing studies often struggle to evaluate the majority of
their patients with MSI testing. In addition, previous studies are
single institution with limited retrospective clinical data and no
long-term prospective oncologic outcomes.
In this work, we compare the molecular and clinicopathologic
profile of CRC in Nigeria to a reference population from HICs.
We provide insights into the poorly characterized molecular
changes and genomic alterations associated with CRC in West
Africa that will facilitate the adoption of evidence-based best
pratices and policies to address the rising burden of CRC in the
region.
Results
Clinical comparison. From Nigeria, 380 patients were enrolled,
and 458 patients from Memorial Sloan Kettering Cancer Center
(MSKCC) were identified for use as a comparator cohort
(Table 1). The median age of diagnosis was 55.8 years (range:
18.2–107.2) in the Nigerian cohort and 60.0 years (range:
18.1–97.4) in the MSKCC cohort (P < 0.001). There was a significant difference in the stage at presentation between the
cohorts, with a higher proportion of Nigerian patients presenting
with stage IV disease (53.8 vs. 36.2% MSKCC, P < 0.001). The
location of the primary tumor differed significantly between the
two cohorts, with more rectal primaries in Nigerian patients vs.
MSKCC patients (50.8 vs. 33.7%, P < 0.001). In addition, MSKCC
patients were more likely to present with lung (29.3 vs. 10.5%)
and/or liver metastasis (41.0 vs. 26.8%) than patients in Nigeria
(P < 0.001), whereas metastatic disease to the peritoneum was
more common in the Nigerian cohort (30.3 vs. 18.1% MSKCC,
P < 0.001).
Molecular comparison. A total of 157 Nigerian CRC tumor
specimens underwent molecular profiling with a combination of
IHC, next-generation sequencing (Memorial Sloan KetteringIntegrated Mutation Profiling of Actionable Cancer Targets
(MSK-IMPACT)), and/or methylation analysis. A total of 64
Nigerian and 1145 MSKCC specimens underwent MSK-IMPACT
analysis, including ancestry analysis for 64 of the Nigerian
2
Table 1 Sociodemographic and clinicopathologic data.
Age of diagnosis, years
Median (range)
MSKCC
(n = 458)
Nigeria
(n = 380)
P valuea
60.0
(18.1–97.4)
55.8
(18.2–107.2)
<0.001
217 (47.4)
241 (52.6)
89 (19.4)
237 (51.7)
70 (15.3)
178 (46.8)
202 (53.2)
25 (6.6)
82 (21.6)
15 (3.9)
0.89
216 (47.2)
2
41 (10.8)
0
<0.001
49 (10.7)
79 (17.2)
164 (35.8)
166 (36.2)
0
1 (0.3)
41 (12.5)
109 (33.3)
176 (53.8)
53
<0.001
52 (11.4)
69 (15.1)
25 (5.5)
33 (7.2)
124 (27.1)
154 (33.7)
1
9 (2.4)
82 (22.2)
18 (4.9)
18 (4.9)
55 (14.9)
188 (50.8)
10
<0.001
134 (29.3)
188 (41.0)
83 (18.1)
40 (10.5)
102 (26.8)
115 (30.3)
<0.001
<0.001
<0.001
Sex
Female
Male
Diabetes
Hypertension
Family history of
colorectal cancer
Smoking history
Unknown
Stageb
I
II
III
IV
Unknown
Tumor location
Cecum
Right colon
Transverse colon
Left colon
Sigmoid colon
Rectum
Unknown
Location of metastasesc
Lung
Liver
Peritoneal
<0.001
<0.001
<0.001
Data are n (%) unless noted.
MSKCC Memorial Sloan Kettering Cancer Center.
aP values by Wilcoxon rank-sum test for continuous variables and Fisher’s exact test for
categorical variables.
bFor the MSKCC cohort, tumors treated with upfront surgery were staged pathologically and
tumors treated with neoadjuvant therapy were staged clinically.
cMetastasis at presentation.
specimens and 604 of the MSKCC specimens. One hundred
percent (64/64) of the Nigerian specimens were compatible with a
genetically determined ancestry (GDA) of African origin. The
MSKCC cohort was predominately of European GDA (466/604,
77.2%), followed by African (77/604, 12.7%), East Asian (37/604,
6.8%), South East Asian (17/604, 2.8%), and Native American
GDA (7/604, 1.2%). Ninety-five percent (95.8%) of patients who
self-reported as African American had a GDA of African origin.
The ancestral analysis of the MSKCC and Nigerian cohorts is
presented in Supplementary Fig. 1.
Of the 64 Nigerian specimens that underwent MSK-IMPACT,
28.1% (18/64) were MSI-high (MSI-H), consistent with the rate of
MMR protein deficiency by IHC (20/94, 21.3%). This was
significantly higher than the rate of MSI-H in CRCs from The
Cancer Genome Atlas (TCGA; 65/459, 14.2%) and MSKCC
comparison cohorts (97/1145, 8.5%, P < 0.001, Fig. 1a). This trend
persisted when the analysis was limited to patients ≤ 45 years of
age (MSI-H 9.5% MSKCC vs. 18% Nigerian). The rate of MSI-H
in the Nigerian cohort was also higher than the rate of MSI-H in
the subset of MSKCC patients who self-identified as African
American (28.1% vs. 7.2% [7/97]). MSI-H tumors were more
common in the right colon (12/18, 66.7%) than the left colon (5/
18, 27.8%) in Nigerian patients. MSIsensor score and total
mutation burden (TMB) for Nigerian specimens stratified by MSI
status are presented in Supplementary Fig. 211. The phenotype of
CRC, stratified by cohort and MSI status, is presented in Table 2.
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Fig. 1 Molecular profile of MSI-H colorectal cancer patients. a Frequency of microsatellite instability high (MSI-H) by cohort (Nigerian, The Cancer
Genome Atlas [TCGA], Memorial Sloan Kettering Cancer Center [MSKCC]). MLH1 methylation, BRAF V600E mutation, and CpG island methylator
phenotype (CIMP) frequencies are shown for MSI-H patients. b Methylation data from Nigerian patients are presented along with CIMP classification (i.e.,
high [CIMP-H] n = 2, low [CIMP-L] n = 5, non-CIMP n = 18) and MSI status (i.e., stable [MSS] n = 18, high [MSI-H] n = 7). c Frequency of oncogenic
signaling pathway alterations in Nigerian and MSKCC MSI-H tumors (n = 18), with MSKCC patients stratified by African American and non-African
American ethnicity. d Oncoprint of BRAF V600E and mismatch repair (MMR) genomic alterations (MLH1, MSH2, MSH6, PMS1) in MSI-H Nigerian
specimens is presented with sex, location of primary, total mutational burden (TMB), methylation status, CIMP classification, and MSIsensor score.
There was no difference in the median age between the cohorts
(P = 0.57). Among rectal cancer patients, there was a significant
difference in the MSI status between the Nigerian (65.2%
microsatellite stable [MSS], 5.6% MSI-H) and MSKCC (25.1%
MSS, 8.6% MSI-H) cohorts (P = 0.034). There was also a
significant difference in the stage-at-presentation between
cohorts, with a larger proportion of MSI-H patients presenting
with stage IV disease in Nigeria vs. MSKCC (50.0 vs. 18.9%,
P = 0.032). The median overall survival (OS) was not different
between the cohorts by MSI status (P = 0.15).
Methylation analysis was used to further characterize the
molecular pathogenesis of the abnormally high incidence of MSIH specimens. Convenience sampling was used to select a subset of
the specimens examined with MSK-IMPACT (25/64). Hierarchical clustering (Euclidian distance, complete linkage clustering)
comparing the 95th percentile of variant genomic windows
revealed that 32.0% (8/25) of specimens were highly methylated.
Overall, 7/25 (28.0%) of specimens were MSI-H, and MLH1 was
highly methylated in 2/7 (28.6%) of the MSI-H cases (Fig. 1a).
Two of the 25 (8.0%) specimens that underwent methylation
analysis were CpG island methylator phenotype-high (CIMP-H)
(Fig. 1b).
We also examined the frequency of somatic oncogenic
alterations between Nigerian (n = 18) and MSKCC (n = 97)
MSI-H patients. The BRAF V600E mutation was not present in
any of MSI-H Nigerian specimens (0/18) compared to 25.8% (25/
97) in the MSKCC cohort (P = 0.01). KRAS mutations were more
common in Nigerian compared to MSKCC MSI-H patients,
although the difference was not statistically significant (61.1 vs.
41.1%, P = 0.20). In the Nigerian cohort, 58.3% (7/12) of rightsided vs. 66.7% (4/6) of left-sided tumors harbored a KRAS
mutation. In both cohorts, APC was altered at a similar frequency
(55.6 vs. 52.2%, P = 1.0). APC mutations were present in 50% (6/
12) of right-sided tumors vs. 66.7% (4/6) of left-sided tumors in
the Nigerian cohort compared to 39.3% (24/61) and 78.6% (22/
28) of non-African American (non-AA) patients at MSKCC.
TCF7L2 was more frequently altered in Nigerian patients (64.3 vs.
34.2% MSKCC, P = 0.04). There were no differences in the
frequency of alterations in ten commonly altered oncogenic
signaling pathways involved in CRC tumorigenesis between the
Nigerian and MSKCC MSI-H cohorts, including MSKCC patients
who self-identified as African American (Fig. 1c).
The high frequency of MSI-H tumors and the absence of
activating mutations in BRAF in the Nigerian CRC specimens was
suggestive of germline etiology. Anonymous germline mutation
analysis was performed on the Nigerian patients with MSI-H
tumors (n = 18) using the MSK-IMPACT data (Table 3). A highpenetrance pathogenic or likely pathogenic germline variant was
identified in 22.2% (4/18) of the patients. Three of 18 (16.7%)
patients had germline mutations in DNA MMR genes (two in
MLH1, one in MSH2), consistent with a diagnosis of Lynch
Syndrome (Fig. 1d). The fourth patient had an incidental finding
of a BRCA1 mutation. In the 46 MSS tumors, a single pathogenic
APC mutation, consistent with a diagnosis of familial
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Table 2 Clinicopathologic comparison by MSI status.
MSKCC
Median age at diagnosis, years
(range)
Sex
Female
Male
Location
Left
Rectum
Right
Unknown
Mucin
No
Yes
Unknown
Stageb
I
II
III
IV
Location of metastatic diseasec
Liver
No
Yes
Lung
No
Yes
Peritoneal
No
Yes
Other
No
Yes
Median overall survival, months
(95% CI)
P valuea
Nigeria
MSI-H (n = 106)
MSS (n = 997)
MSI-H (n = 18)
MSS (n = 46)
60.0 (20.0–85.0)
54.0 (13.0–93.0)
57.1 (31.4–84.6)
58.2 (27.7–83.3)
0.57
44 (41.5)
62 (58.5)
461 (46.2)
536 (53.8)
4 (22.2)
14 (77.8)
22 (47.8)
24 (52.2)
0.15
23 (21.9)
9 (8.6)
73 (69.5)
1
462 (47.0)
247 (25.1)
274 (27.9)
14
5 (27.8)
1 (5.6)
12 (66.7)
0
8 (17.4)
30 (65.2)
8 (17.4)
0
REF
0.03
0.30
43 (56.6)
33 (43.4)
30
619 (86.5)
97 (13.5)
281
6 (33.3)
12 (66.7)
0
32 (72.7)
12 (27.3)
2
0.90
7 (6.6)
40 (37.7)
39 (36.8)
20 (18.9)
34 (3.4)
91 (9.1)
228 (22.9)
644 (64.6)
0 (0)
3 (16.7)
6 (33.3)
9 (50.0)
0 (0)
5 (10.9)
10 (21.7)
31 (67.4)
0.03
9 (45.0)
11 (55.0)
105 (16.3)
539 (83.7)
8 (88.9)
1 (11.1)
21 (67.7)
10 (32.3)
0.93
19 (95.0)
1 (5.0)
550 (85.4)
94 (14.6)
8 (88.9)
1 (11.1)
21 (67.7)
10 (32.3)
0.92
14 (70.0)
6 (30.0)
539 (83.7)
105 (16.3)
4 (44.4)
5 (55.6)
18 (58.1)
13 (41.9)
0.79
14 (70.0)
6 (30.0)
NR (NR–NR)
496 (77.0)
148 (23.0)
69.1 (59.9–83.2)
9 (100)
0 (0)
32.1 (8.5–NR)
30 (96.8)
1 (3.2)
4.8 (2.1–10.6)
>0.95
0.15
Data are n (%) unless noted.
MSKCC Memorial Sloan Kettering Cancer Center, MSI-H microsatellite instability high, MSS microsatellite stable, CI confidence interval, NR not reported.
aThe covariates included the main effects molecular subtype and center and an interaction term of the two. A linear model was used for age, a logistic model for gender, mucin, stage, location of
metastatic disease, a multinomial model for location of primary, and a Cox model for overall survival. P values by Wilcoxon rank-sum test for continuous variables, Fisher’s exact test for categorical
variables, and log rank test for overall survival.
bThe comparison is stage I, II, III vs. IV.
cIn the subset of patients presenting with stage IV.
Table 3 Germline mutations in Nigerian patients with colorectal cancer.
MSI status
n
MLH1
MSH2
APC
BRCA1
Total germline mutations
Total MMR gene mutations
MSI-H
MSS
Total
18
46
64
2
1
3
1
0
1
0
1
1
1
0
1
4 (22.2%)
2 (4.3%)
6 (9.3%)
3 (16.7%)
1 (2.2%)
4 (6.3%)
MSI microsatellite stable, MSI-H microsatellite instability high, MSS microsatellite stable, MMR mistmatch repair.
adenomatous polyposis, as well as another pathogenic mutation
in MLH1 were identified.
In MSS specimens (Nigerian n = 46, MSKCC n = 1040), TP53
(71.7% Nigeria vs. 77.5% MSKCC, P = 0.370) and KRAS (56.5%
Nigeria vs. 44.1% MSKCC, P = 0.13) somatic mutation frequencies were not different between the cohorts. TP53 was less
frequently altered in right-sided tumors in the Nigerian cohort
(25 vs. 81.6% left-sided) compared to non-AA patients as
MSKCC (66.7 vs. 81.4% left-sided). KRAS was altered in 62.5%
(5/8) of right-sided tumors and 55.3% (21/38) of left-sided
tumors in the Nigerian cohort compared to 64% (146/228) and
38.2% (256/688), respectively, at MSKCC (non-AA). APC was
4
less likely to be altered in the Nigerian MSS cohort (36.9 vs. 76.0%
MSKCC, P < 0.01). APC was altered in 25% (2/8) of right-sided
and 42.1% (16/38) of left-sided Nigerian patients compared to
68.4% (156/228) and 78.8% (542/688), respectively, at MSKCC
(non-AA). Despite the lower frequency of APC alterations in the
Nigerian MSS cohort, CTNNB1 gene alterations were similar
between the two groups (4.4 vs. 3.7%, P = 0.68). Nigerian patients
were also more likely than MSKCC patients to have PI3K
pathway alterations, including PIK3R1 (8.7 vs. 2.2%, P = 0.02)
and PIK3CB (4.3 vs. 0.5%, P = 0.04). Mutations in the MSS
tumors were further grouped by canonical signaling pathways
(Fig. 2a). Nigerian patients had a lower frequency of WNT
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Fig. 2 Molecular profile of MSS colorectal cancer patients. a Frequency of oncogenic signaling pathway alterations in Nigerian and Memorial Sloan
Kettering Cancer Center (MSKCC) patients, with MSKCC patients stratified by African American and non-African American ethnicity. b Specific genomic
alterations and frequencies within the WNT and RAS oncogenic pathways for the Nigerian microsatellite stable (MSS) patients (n = 46). AA African
American, InDel insertion or deletion. P values by two-sided Fisher’s exact test.
pathway alterations (47.8 vs. 81.9% MSKCC, P < 0.001). The
Nigerian MSS cohort also had a higher frequency of RAS pathway
alterations as compared to MSKCC MSS patients of non-AA
ethnicity (76.1 vs. 59.6%, P = 0.03). Alterations within the WNT
and RAS pathways in the Nigerian MSS specimens are presented
in Fig. 2b.
Treatment and outcomes comparison. Given the differences in
presentation and molecular profile detected, we compared treatment modalities and outcomes between the Nigerian and
MSKCC cohorts (Supplementary Table 1). A larger number of
MSKCC patients received neoadjuvant chemotherapy (83.8%)
compared to Nigerian patients (57.5%, P < 0.001). A larger
number of MSKCC patients also underwent surgery (87.3%)
during their treatment compared to Nigerian patients (71.0%,
P < 0.001).
The median follow-up at MSKCC was 64.8 months and
16.9 months for the Nigerian cohort. The median OS for the
MSKCC cohort has not yet been reached (95% confidence
interval (CI): 71 months–NR) compared to 11.9 months (95% CI:
10.2–14.5) for the Nigerian cohort (P < 0.001). Median OS for
rectal (NR) and colon cancer (71.1 months, 95% CI:
59.4 months–NR) patients were significantly longer at MSKCC
than for both cohorts of patients in Nigeria (colon: 13.3 months,
95% CI: 9.5–17.9 months; rectal: 11.0 months, 95% CI:
9.2–14.2 months; P < 0.001) (Supplementary Fig. 3a, b). OS was
significantly longer for patients presenting with stage IV disease
at MSKCC (34.3 months, 95% CI: 28.6–41.8) compared to
Nigeria (7.3 months, 95% CI: 5.3–9.4, P < 0.001). Patients at
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MSKCC also had significantly longer recurrence-free survival
(60.4 MSKCC vs. 12.5 months Nigeria, P < 0.001, Supplementary
Fig. 3c). Notably, in the Nigerian cohort, the majority of the
events in this analysis were death (i.e., death of disease) as
opposed to recurrence.
Discussion
The burden of CRC is increasing in Nigeria12, and the Nigerian
Federal Ministry of Health’s National Cancer Control Plan
(NCCP) identifies strategies to improve the early detection and
treatment of CRC as a priority. Although literature from the US
suggests a unique profile of CRC among African Americans, there
is a glaring dearth of prospective data from sub-Saharan Africa16.
We present a comprehensive evaluation of the molecular profile
and phenotype of CRC in Nigeria as a critical step toward
addressing the NCCP recommendations. Our results suggest a
younger age of disease onset, a higher burden of rectal and stage
IV disease, and worse stage-for-stage OS in Nigerian CRC
patients as compared to CRC patients in the US5. Nigerian
patients, who were exclusively of African GDA (100%), were
more than twice as likely to have MSI-H CRC than patients from
MSKCC, who were predominately of European GDA (77.2%).
This is consistent with previous data from the region9,10,13,14.
In Nigerian patients, germline analysis revealed that only 17%
of MSI-H specimens had a pathologic MMR gene germline
mutation, similar to the rate expected in MSI-H patients in HICs
(11.0–18.5%)17,18. Typically, epigenetic methylation of the promoter region of MLH1 accounts for the majority of somatic MSIH CRC10,19. In our methylation analysis, less than a third of MSIH Nigerian CRC specimens demonstrated MLH1 methylation,
and only 8% were CIMP-H. These findings suggest that an
alternative molecular pathway, such as biallelic somatic inactivation, may play a dominant role in somatic MSI-H CRC
tumorigenesis in Nigerian patients20. This represents a departure
from the dominant pathway of MSI tumorigenesis in HICs.
The molecular profile of sporadic MSS CRC in HICs is characterized by a high frequency of inactivating APC and/or activating CTNNB1 mutations (>80%), which drive cell proliferation
through the WNT pathway21,22. Among MSS CRCs from
Nigerian patients, there were significantly fewer somatic APC
mutations vs. MSKCC patients (37 vs. 76%, P < 0.01). This difference persisted when alteration frequency was examined by
sidedness of the primary tumor. The low frequency of WNT
pathway alterations among Nigerian MSS patients suggests that
this pathway is not the dominant driver of MSS tumorigenesis in
this population.
The differences in the molecular profile of CRC raise questions
regarding disease management in Nigeria. The greater burden of
MSI-H CRC in Nigeria should be considered in recommendations for routine MSI/MMR testing and treatment guidelines for
systemic therapy23. Based on our data, it is possible that up to a
quarter of Nigerian CRC patients (i.e., those with MSI-H tumors)
would derive marginal benefit from systemic fluorouracil-based
chemotherapy. Limiting the use of chemotherapy in early-stage
disease and accelerating the use of immunotherapy for MSI-H
tumors requires examination and may improve outcomes. The
mutational profile of CRC in Nigeria also suggests that caution
should be taken before generalizing therapeutic trial results produced in the US. This insight may have implications for other
LMICs as well, as international resource-stratified screening and
treatment guidelines for CRC are being proposed and adopted24.
This study has several limitations. Staging was not concordant
between the MSKCC and Nigeria cohorts, due to a lack of
pathologic staging for many Nigerian patients who never
underwent resection. As an exploratory analysis, the number of
6
Nigerian specimens available for molecular comparison was also
small and limits the strength of our conclusions and our ability to
conduct certain analyses (e.g., somatic alteration by ancestry,
statistical comparison by sidedness of tumor). Tissue availability
for the methylation analysis was particularly limited, and the
results of this analysis should be interpreted with caution. This
limited our ability to construct a suitable internal validation
cohort and an external validation cohort does not currently exist
in the public domain. Thus, our findings are hypothesisgenerating and lay the foundation for larger studies with
broader geographic and sociodemographic coverage. The use of
the MSKCC and TCGA cohorts as comparators may also introduce an element of selection bias. MSKCC is a specialized cancer
center with a unique patient population that may not be generalizable to the US as a whole, and the TCGA cohort is predominantly of European descent.
In summary, the molecular profile and phenotype of CRC in
Nigeria may differ from that in HICs. The greater burden of MSIH CRCs in Nigeria needs to be examined in larger cohorts but
should be considered in recommendations for routine MSI/MMR
testing. Our data have implications for resource-stratified
screening and treatment guidelines for CRC and emphasize the
need for regional data to guide diagnostic and treatment
approaches for patients in LMICs.
Methods
Study design and data collection. We evaluated prospectively collected CRC data
and specimens obtained through the African Research Group for Oncology
(ARGO), a partnership between MSKCC, Obafemi Awolowo University (OAU),
and 12 tertiary care facilities across Nigeria. A prospectively maintained REDCap
(Research Electronic Data Capture, Vanderbilt University) database has been used
to collect demographic and outcome data for patients with CRC presenting at
Nigerian ARGO sites since 2013. Fresh-frozen tumor and blood specimens from
each participant are obtained for a prospectively maintained biobank. Outcome
data are collected at the time of routine follow-up.
All patients enrolled in the ARGO CRC database from April 2013 to November
2018 were included in the present analysis. Patients aged <18 years and those
without histologically confirmed colorectal adenocarcinoma were excluded. For
clinicopathological comparisons, data from MSKCC were extracted from a
prospective database and from the electronic medical record using ICD-O
histological diagnosis consistent with CRC. All new patients aged >18 years with
colorectal adenocarcinoma diagnosed from January 2013 to June 2013 were
included in the MSKCC cohort.
For both cohorts, information was collected on patient sociodemographics,
clinical presentation, histopathology, and outcomes as of the last date of follow-up.
For the MSKCC cohort, the date of diagnosis was defined as the date of pathologic
diagnosis. Clinical staging was used for patients who received neoadjuvant therapy,
and pathological staging was used for patients treated with upfront surgery, as
previously reported25. For the Nigerian cohort, the date of diagnosis was defined as
the date of clinical diagnosis, and all patients were staged clinically. Metastatic
disease at diagnosis was defined as metastases documented on initial staging or
metastases found intraoperatively. Primary tumor site was designated as rightsided for tumors from the cecum to the distal transverse colon and left-sided for
tumors from the distal transverse colon/splenic flexure to the rectum. Date of
diagnosis of metachronous metastasis was the date of first radiographic or biopsyproven evidence of metastasis.
Molecular profiling. The first half of consecutive Nigerian patients from the
ARGO database used in the clinicopathologic evaluation underwent anonymized
molecular profiling. For these patients, fresh-frozen tumor and matched venous
blood samples were sent from Nigeria to MSKCC for paired tumor and germline
genomic profiling. Targeted next-generation sequencing analysis was performed
using the MSK-IMPACT assay, as previously described26,27. Somatic alterations,
including single-nucleotide variants, small insertions/deletions, and copy number
alterations, were identified. Germline variant calling used a modified version of a
sequence analysis pipeline validated for CLIA-certified clinical use27,28. Pathogenicity of germline variants were classified based on American College of Medical
Genetics and Genomics criteria29. Somatic genomic alterations were filtered for
oncogenic variants using the OncoKB knowledgebase30. The total number of nonsynonymous mutations was quantified for each sample and divided by the number
of bases analyzed to calculate TMB. ADMIXTURE v1.3 was used to estimate the
ancestry of each patient based on the five references populations utilized in the
1000 Genomes Project: African, European, East Asian, Native American, and South
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Asian. As previously described, GDA was based on the highest proportion reference population for each patient31.
MSK-IMPACT data were also used for MSIsensor analysis, a prospectively
validated algorithm for assessing MSI/MMR status32,33. IHC was used to
supplement MSIsensor assessment due to cost and resource limitations, which
precluded next-generation sequencing of the entire cohort. Primary monoclonal
antibodies against MLH1 (clone G168-728, diluted 1:250, BD PharMingen, San
Diego, CA), MSH2 (clone FE11, diluted 1:50, Oncogene Research Products, La
Jolla, CA), MSH6 (clone 44, ready to use, Ventana Medical Systems Inc., Oro
Valley, AZ), and PMS2 (clone A16-4, diluted 1:200, BD PharMingen) were used.
Finally, a subset of the samples underwent genome-wide DNA methylation analysis
by reduced representation bisulfite sequencing using the Zymo Methyl-MiniSeq
platform (Zymo Research, Irvine, CA).
Data from the Nigerian cohort were compared to a cohort of CRC specimens
processed by the Molecular Diagnostics Service at MSKCC between April 2014 and
September 2016. Comparison was also made to data from CRC specimens included
in TCGA obtained from http://cancergenome.nih.gov/.
Immunohistochemistry. IHC was performed on 4-μm-thick sections of the freshfrozen specimens with a BenchMark XT automated immunostainer (Ventana
Medical Systems Inc., Tucson, AZ). Primary monoclonal antibodies against MLH1
(clone G168-728, diluted 1:250, BD PharMingen, San Diego, CA), MSH2 (clone
FE11, diluted 1:50, Oncogene Research Products, La Jolla, CA), MSH6 (clone 44,
ready to use, Ventana Medical Systems Inc.), and PMS2 (clone A16-4, diluted
1:200, BD PharMingen) were used. For external controls, non-neoplastic colonic
mucosa and colorectal tumors known to be deficient in MLH1, MSH2, MSH6, and
PMS2 were employed. Evidence of expression of each protein was defined by
nuclear IHC reactivity. The absence of MMR protein expression was defined by the
total absence of nuclear staining. Even very weak staining was considered
proficient.
Methylation analysis. The raw BED files were filtered to remove all reads mapped
to chromosomes other than 1–22 and converted to methylation call files formatted
for analysis using R/Bioconductor package, “methylKit” version 0.99.2. Methylation call files were filtered by coverage to exclude loci with <10 reads, as well as the
99.9th percentile of each sample’s reads to reduce PCR bias. Using loci targeted by
Infinium’s HumanMethylation450 BeadChip’s probes as a guide, we computed
percent methylation for genomic windows 51 bp long (25 bp upstream/downstream from each probe’s target) and excluded windows exhibiting methylation
>70%.
Ancestry analysis. We identified autosomal biallelic single-nucleotide polymorphisms (SNPs) with minor allele frequency >1% in the 1000 Genomes Project
and captured by MSK-IMPACT. We genotyped these sites in all consented
MSKCC and Nigerian patients using GATK v4.0 HaplotypeCaller and Genotype
GVCFs and merged with the 1000 Genomes data using PLINK v1.9. We then
performed linkage-disequilibrium pruning and filtered sites with missing call rates
of <0.1 using PLINK, which resulted in 4263 SNP markers. Samples from the 1000
Genomes Project were used to establish a reference set composed of five populations: African, European, East Asian, Native American, and South Asian. We ran
supervised analysis in ADMIXTURE v1.3 to estimate ancestral proportions for the
specimens.
Statistical analysis. Descriptive statistics, median and range, were used for continuous variables, with comparisons made using Wilcoxon rank-sum test. Count
and percentage were used for categorical variables, with comparisons made using
Fisher’s exact test. Kaplan–Meier methods and log rank test were used to assess OS
and recurrence-free survival. OS was defined as the time from diagnosis to death.
Recurrence-free survival analysis included only patients who underwent surgery
and was defined as time from surgery to recurrence or death.
To test for associations between variables of interest and molecular subtype,
various interaction models were employed. The covariates included in these
interaction models were the main effects molecular subtype and study cohort (e.g.,
MSKCC). To compare the frequency of oncogenic alterations between groups, twosided Fisher’s exact tests were performed. Pathway analysis was conducted utilizing
the pathway templates from Sanchez-Vega et al.34. The results of the genomic
analyses were considered hypothesis-generating and were not corrected for
multiple hypothesis testing due to the small sample size. SAS version 9.4 (SAS
Institute Inc., Cary, NC) was used for all analyses. All tests were two-sided, with
P < 0.05 considered significant.
Ethical approval. Ethical approval for enrolment and maintenance of the ARGO
prospective database was granted by the OAU Institutional Review Board (IRB).
All patients provided written informed consent for tissue and data collection.
Separate ethical clearance was granted to conduct anonymized molecular profiling,
including germline mutation analysis, by the OAU IRB. Approval was also
obtained from the MSKCC IRB (IRB# 15–209) for use of previously captured
patient data for the clinicopathologic and molecular profile comparisons; all
patients provided written informed consent for molecular analysis of tissue at
MSKCC via protocols approved by both the OAU and MSKCC IRBs. All tissue and
blood handling protocols and transcontinental transfer details were approved by
the OAU IRB as the IRB of record.
Reporting summary. Further information on research design is available in the Nature
Research Reporting Summary linked to this article.
Data availability
The next-generation genomic sequencing data, including somatic mutation frequency
and MSIsensor output, have been deposited in cBioPortal (www.cbioportal.org/study/
summary?id=crc_nigerian_2020). The TCGA publicly available data used in this study
are available in the GDC Data Portal under accession phs000178. The clinical data,
including patient demographics, histopathology, treatment, and outcomes, are stored on
a REDCap database at MSKCC. The clinical data are protected and are not available due
to data privacy laws. This data may be available from the corresponding author after
completion of data transfer agreements and research ethics board approval between all
relevant parties. The remaining data are available within the article, Supplementary
Information, or Source Data files. Source data are provided with this paper.
Received: 1 September 2020; Accepted: 28 October 2021;
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Acknowledgements
The authors would like to acknowledge our partners within the African Research Group
for Oncology (https://www.argo-research.org/institutional-partners/) and the research
team at Obafemi Awolowo University Teaching Hospital Complex, including Gbenga
Samson, Olalude Olawale, and Busayo. The authors would also like to recognize Agnes
Viale, PhD and S. Duygu Selcuklu, PhD at the Marie-Jose and Henry R. Kravis Center for
Molecular Oncology at Memorial Sloan Kettering Cancer Center for assistance with
specimen collection, data management/generation, and project management. Erin Patterson, PhD (Memorial Sloan Kettering Cancer Center) provided editorial assistance.
This research was funded in part by Memorial Sloan Kettering Cancer Center (MSKCC)
with support from the Thompson Family Foundation, an MSKCC Population Science
Research Grant, and the NIH/NCI Cancer Center Support Grant P30 CA008748.
Author contributions
O.I.A., G.C.K., J.J.S. and T.P.K. designed the study. O.I.A., G.C.K., A.S., W.K.C., M.R.W.,
J.J.S., M.B. and T.P.K. wrote the protocol; collected, analyzed, and interpreted the data;
and wrote the paper. W.K.C., R.S., A.B., B.S., C.W., Z.S., Y.K., M.F.B., T.A.C., D.B.S.,
J.J.S., F.S.-V. and N.S. led the tumor genomic analysis, collected and analyzed data, and
edited the paper. E.V. and J.S. reviewed pathology and edited the paper. K.S. and M.G.
provided biostatistical support and edited the paper. O.A. Arowolo, O.O., O.C.F., A.D.O.,
A.O.K., O.O.O., A.I.K., D.E.I., A.A.E., S.A.O., S.O.A., O.A. Adesiyun, A.A., O.A.K.,
A.O.O., K.A. and J.C. provided patient management/support, collected data, and edited
the paper.
Competing interests
J.J.S. has received travel support from Intuitive, Inc. for fellow education and has served
as a clinical advisor for Guardant Health, Inc. All other authors have no competing
interests to report.
Additional information
Supplementary information The online version contains supplementary material
available at https://doi.org/10.1038/s41467-021-27106-w.
Correspondence and requests for materials should be addressed to T. Peter Kingham.
Peer review information Nature Communications thanks Woong-Yang Park, Edward
Schaeffer, and the other anonymous reviewer(s) for their contribution to the peer review
of this work.
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© The Author(s) 2021
1
Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria. 2Department of Surgery, Memorial Sloan
Kettering Cancer Center, New York, NY, USA. 3Marie-Jose and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer
Center, New York, NY, USA. 4Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA. 5TriInstitutional Program in Computational Biology and Medicine, Weill Cornell Medical College, New York, NY, USA. 6Federal Medical Centre, Owo,
Ondo State, Nigeria. 7Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria. 8Department of Surgery, Ladoke Akintola
University of Technology, Ogbomoso, Oyo State, Nigeria. 9Department of Surgery, University of Medical Sciences, Ondo, Ondo State, Nigeria.
10
Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. 11Department of Epidemiology and
Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA. 12Clinical Genetics Service and the Cancer Biology and Genetics
Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA. 13Gastrointestinal Oncology Service, Department of Medicine, Memorial
Sloan Kettering Cancer Center, New York, NY, USA. 14Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center,
New York, NY, USA. 15Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA. 16Department of
Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA. 17Bobst International Center, Memorial Sloan Kettering Cancer Center,
New York, NY, USA. 18Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
19
Present address: Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada. 20These authors contributed
equally: Olusegun Isaac Alatise, Gregory C. Knapp. ✉email: kinghamt@mskcc.org
8
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