Experience with 1,345 Esophageal Cancer Patients Seen At a Single Mission Hospital in Western Kenya

Abstract

Objective: To evaluate demographic, endoscopic, and pathologic findings, management and outcome in a large series of esophageal cancer (EC) patients. Methods: Records for all patients presenting with EC to a single institution in western Kenya between January, 1998 and September, 2005 were reviewed. Data for patients receiving self expanding metallic stents (SEMS) were collected prospectively, as was all survival data, while the remainder was collected retrospectively. Results: 1,345 patients were seen. Squamous cell carcinoma accounted for 86% of cases. The male:female ratio was 1.7:1, and average age was 57 years (range 14-99 years), with 16% of patients ≤40 years of age. Symptomatic obstruction requiring endoscopic dilatation was found in 976 cases (95% of cases with complete records). Perforation occurred in 28 dilatations (2.9%); 25 were treated with SEMS (one death and 24 recovered) and 3 were treated surgically (all died). SEMS were placed in 452 patients and 52 patients were treated surgically, while a large number of patients declined further treatment. Complications occurred in 10% of patients receiving SEMS, with stent obstruction due to tumor accounting for 70% of complications. Median survival following SEMS placement was 9 months. The mean dysphagia score improved from 3.3 to 2.2 (p < .01) before stenting and at the time of death respectively. In the surgical group, complete R0 resection was accomplished in 41 cases with an operative mortality of 14%, and complication rate of 50%. Incomplete resection (less than R0) was carried out in 6 cases with 4 deaths (67% mortality). The majority of surgical cases were stage III and IV (71%). Overall median survival following surgery was 24 months; 27 months for stage I and II, and 12 months for stage III and IV (p = .02). Conclusions: Esophageal squamous cell cancer is common in western Kenya, and a large number of patients present at a young age. Placement of SEMS is a reasonable palliative treatment in patients who are not surgical candidates, and is also the treatment of choice for perforation during dilation. Complete R0 resection can be carried out with acceptable morbidity and mortality in advanced stage disease in a rural mission hospital setting. If R0 resection cannot be achieved, then SEMS placement should be considered rather than incomplete resection. Future work should be directed at identification of early stage disease and selection of patients who would benefit most from surgical resection.