Oesophageal Cancer: Practicalities of Palliation in Sub‑Saharan Africa
Vol. 26, Issue 2 (September 2021)
Michael M. Mwachiro, MBChB, MPH, FCS(ECSA)
Department of Surgery, Tenwek Hospital
Bomet, Kenya
Mark D. Topazian, MD
Professor of Medicine, Mayo Clinic
Rochester, Minnesota, USA
Treasurer, WGO
Sandie R. Thomson, ChM, FRCS (Ed & Eng), FRCP (Ed), MWGO
Emeritus Professor, Division of Medical Gastroenterology, Department of Medicine, University of Cape Town
Cape Town, South Africa
Oesophageal cancer is the 8th most common cancer globally with 604,100 new cases and 544,076 new deaths recorded in 2020.1 The most common variants are oesophageal adenocarcinoma (OAC) and squamous cell carcinoma (OSCC).2 The latter is the main variant in Africa and the Far East, particularly China and Japan. Trends in higher income countries (HIC’s) show a decline in the incidence of OSCC and an increase in OAC.3 There is regional variation in the incidence of OSCC: gender distribution is similar in northern African countries but countries in the western, middle, eastern and southern Africa have a male predominance.4, 5 Risk factors for OSCC include smoking, alcohol, smoke exposure from wood or charcoal, poor oral health, consuming red meat, low socio-economic status and nutritional deficiencies like selenium. Risk factors that are specific for OAC include gastroesophageal reflux disease, obesity and Barrett’s oesophagus. 5-7
The highest age adjusted rates for OSCC in the world are also found in Africa and, in comparison to HICs, survival data from the continent is very poor with the number of new cases and deaths being almost the same.1, 4 The factors that contribute to poor outcomes are interlinked and relate to disease stage at presentation and infrastructural challenges due to socio-economic inequalities. Progressive dysphagia is the commonest symptom and contributes to poor nutritional status that has been associated with poor outcomes and increased mortality rate.6, 9 Poor access to and resource availability at health care facilities, are due to, referral pathways, transportation networks and scarce endoscopy, radiology, radiotherapy and surgery services. Endoscopy services are sparse, especially in rural areas, leading to delays in diagnosis and treatment.6, 10 Access to radiotherapy, which has a potential curative as well as palliative role in management, is an extreme challenge across the continent.11
In Africa, the vast majority of OSCC patients are beyond curative therapy or the hope of achieving long term survival as they present with late stage disease and comorbidities. This results in an average survival that is measured in months, not years. The main concern of these patients with end stage disease is their quality of life and the best way to improve this is palliative care focussing on prompt relief of dysphagia and providing psychosocial support.10 Nutritional support is a key component of care and is best achieved by restoring oesophageal patency. Although gastrostomy and jejunal feeding tubes can be placed surgically or endoscopically, they do not relieve dysphagia or address the risk of aspiration and their value in very advanced stage disease should be considered in terms of the overall palliative care plan.
There are multiple therapies available to alleviate dysphagia, including oesophageal dilation, argon plasma coagulation, laser therapy, oesophageal stent placement, external beam radiotherapy (EBRT), brachytherapy (intraluminal radiotherapy) and photodynamic therapy.12 Dilation should be reserved for very proximal esophageal tumors that are not stentable as dysphagia relief is short-lived and multiple sessions are usually required.13 In addition, patients can undergo palliative chemotherapy with or without radiotherapy to achieve more sustained relief.14 These oncological treatments are costly and dependent on availability and currently confined to a few centers in Africa. However, as more oncology resources become available and these modalities are used, it will be important to assess their benefit on quality of life.11 Surgically placed stents typified by the Celestin tube are available across the African continent. However, this modality involves the costs and access to a surgical theatre and general anesthesia, as placement under local anaesthesia/moderate sedation, though feasible, is not well tolerated. Surgically placed stents are now rarely used, as the majority of the patients present with late-stage disease are frail and may not withstand the use of general anesthesia. In addition, these stents have a high post procedure complication rate.10 Endoscopic techniques offer a solution that is minimally invasive and can be performed under moderate sedation on an outpatient basis. For these reasons, in many African countries, self-expanding metal stents (SEMS) have become the preferred and safe method of promptly alleviating malignant dysphagia. This is well illustrated by the report from a Kenyan institution of 1,000 stents placed without fluoroscopy with very low perforation and migration rates of 1.9% rate of 0.03%, respectively.6
SEMS are usually inserted after endoscopic placement of a guide wire through the stricture into the stomach with or without fluoroscopy, over which the stent is then delivered without predilation to accurately bridge the full extent of the stricture.6, 14 SEMS can be used successfully even for very proximal tumors that are within 1-2 cm of the upper oesophageal sphincter.15 The costs compared to surgery are much lower but are still significant. The cost of stents has been shown to vary across the continent due to variability in supply sources. In several settings, brachytherapy has shown better long-term outcomes, but stenting has more immediate relief of dysphagia.14 This has prompted research on radiation impregnated stents to get the best of both modalities, but their use in African countries is is still prohibitive due to cost.
Incidence and prevalence data for OC is largely derived from hospital-based patients studies, and high-quality epidemiological and clinical data from African countries is lacking.4 This is to the detriment of health care policy planning. In South Africa, reports have shown that published reports on OC have been mainly retrospective reviews and opinions with few good quality research projects.8 There are currently ongoing efforts to help bridge this gap in research.2 One of these iniatives is the African Esophageal Cancer Consortium (AfrECC). The consortium was formed in 2017 by OSCC researchers and institutions to facilitate research collaborations, improve early detection, clinical management, treatment and palliation of OC.2 AfrECC also has a goal of capacity building for OC research in sub-Saharan Africa. The consortium is run by a six member steering committee that is elected every two years and meets regularly. It has established several sub commitees that are focused on the key areas of research, clinical care, training and advocacy. AfrECC is keen to synergize research and training efforts on the continent. This has already been initiated by the use of harmonized research questionnaires and other data collection tools. Utilization of app-based data collection tools and also pooling of research specimens and creating an African bio- repository for a combined genomic wide analysis are other collaborative efforts. The app is available to consortium members and has primarily been used for the epidemiological data collection in the ongoing case-control studies. The consortium has been working with local professional societies in each of the countries to leverage these goals. Recruitment to the consortium has mainly been through regional and national oncology meetings.
The consortium has been actively involved in efforts to improve access to SEMS in high-risk areas in the continent focusing on providing access to SEMS and endoscopic training in stent deployment. The consortium efforts have led to partnership with a stent supplier as well as increase in the number of endoscopists who have expertise in stent placement. The model is geared towards self-sustainability with selection and training of in-country trainers who can then continue the training efforts in each country. Another consortium project was an endoscopy capacity survey in member countries that has helped to tailor training and inform health policy makers. The consortium membership is open to any researchers or clinicians involved in any aspect of esophageal cancer care. The stent access program is still growing and is seeking to help provide stents to areas which have high disease burden but have challenges with access. AfrECC continues to champion new partnerships in research and clinical care of oesophageal cancer. The success of the consortium has been due to the strengths of individual and institutional members. More details on the consortium and contact information are available at https://dceg.cancer.gov/research/cancer-types/esophagus/afrecc.
OSCC is a common clinical condition in sub-Saharan Africa. Patients typically present with dysphagia at an advanced stage of malignancy and have a short life expectancy. Oesophageal SEMS placement is a the best current option for alleviating dysphagia and provides immediate relief. It should be considered as the starting point for palliation and the modality against which other oncological methods and technical innovations should be compared as health care resources and the ability to assess their impact on this disease improve on the continent.
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