Topic Highlight
Copyright ©2014 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastroenterol. Apr 14, 2014; 20(14): 3875-3879
Published online Apr 14, 2014. doi: 10.3748/wjg.v20.i14.3875
Gastric cancer in Africa: Current management and outcomes
Akwi W Asombang, Rubayat Rahman, Jamal A Ibdah
Akwi W Asombang, Rubayat Rahman, Jamal A Ibdah, Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO 65212, United States
Author contributions: Asombang AW wrote the manuscript; Rahman R was involved in reviewing the literature; Ibdah JA provided the overall conceptual design and edited the manuscript.
Correspondence to: Jamal A Ibdah, MD, PhD, Professor, Director, Division of Gastroenterology and Hepatology, University of Missouri-Columbia, 5 Hospital Drive, Columbia, MO 65212, United States. ibdahj@health.missouri.edu
Telephone: +1-573-8827349 Fax: +1-573-8844595
Received: October 27, 2013
Revised: January 10, 2014
Accepted: February 17, 2014
Published online: April 14, 2014

Abstract

Gastric cancer is the fourth most common cancer and second most common cause of cancer death worldwide. Globally, gastric cancer poses a significant public health burden - both economically and socially. In 2008, the economic burden from premature cancer deaths and disability was $895 billion and gastric cancer was the second highest cancer responsible for healthy life lost. With the expected increase in cancer deaths and non-communicable diseases, these costs are expected to rise and impact patient care. World Health Organization, estimates a 15% increase in non-communicable disease worldwide, with more than 20% increase occurring in Africa between 2010 and 2020. Mali, West Africa, is ranked 15th highest incidence of gastric cancer worldwide at a rate of 20.3/100000, yet very scarce published data evaluating etiology, prevention or management exist. It is understood that risk factors of gastric cancer are multifactorial and include infectious agents (Helicobacter pylori, Epstein-Barr virus), genetic, dietary, and environmental factors (alcohol, smoking). Interestingly, African patients with gastric cancer are younger, in their 3rd-4th decade, and present at a late stage of the disease. There is sparse data regarding gastric cancer in Africa due to lack of data collection and under-reporting, which impacts incidence and mortality rates. Currently, GLOBOCAN, an International Agency for Research on Cancer resource, is the most comprehensive available resource allowing comparison between nations. In resource limited settings, with already restricted healthcare funding, data is needed to establish programs in Africa that increase gastric cancer awareness, curtail the economic burden, and improve patient management and survival outcomes.

Key Words: Gastric cancer, Africa, Cancer outcomes, Cancer survival, Cancer management, Non-communicable diseases

Core tip: There is a paucity of published data regarding gastric cancer in Africa and a need for more research to elucidate etiology and management. There is a growing opportunity for partnerships between African nations and more developed nations to advance the understanding and management of gastric cancer and thus improve overall patient outcomes. Such partnerships would provide a bilateral learning opportunity and help set a platform for training opportunity amongst healthcare providers.



INTRODUCTION

Gastric cancer is the fourth most common cancer worldwide, and second most common cause of cancer death[1]. In 2008, the economic burden from premature cancer deaths and disability was $895 billion and gastric cancer was the second highest cancer responsible for healthy life lost[2]. With the expected increase in cancer deaths and non-communicable diseases, these costs are expected to rise and impact patient care. World Health Organization (WHO), estimates a 15% increase in non-communicable disease worldwide, with more than 20% increase occurring in Africa between 2010 and 2020[3].

In Africa, gastric cancer is ranked twelfth most common cancer[1]. The estimated incidence and mortality rates of gastric cancer in Africa is 4/100000 and 3.8/100000 respectively[1]. The incidence is higher in men (4.7/100000) than in women (3.3/100000), as is mortality rate at 4.5/100000 and 3.2/100000 respectively[1]. There is a great deal of variation in reported incidence and mortality within the individual African countries. For instance, in Mali, West Africa, gastric cancer is the most common cancer in men with an incidence rate 21.6/100000 and mortality rate 21.1/100000[1]. These rates are markedly higher than developed nations such as United States/United Kingdom, yet very scarce published data evaluating etiology, prevention or management exist[4]. The lack of published reports may have to do with the focus on communicable diseases and less attention to non-communicable disease (NCDs). The variation in reported incidence and mortality within the individual African countries is most likely related to etiology. Recognized carcinogens include diet, infectious agents, inflammatory process or genetic variability[5]. Low incidence and mortality rates reported for some regions may be due to the limited diagnostic capability and inadequate data recording. Interestingly, gastric cancer in African patients are younger, in their 3rd-4th decade[6], and present at a late stage of the disease[7].

It has been recognized that there is an upward trend in NCDs, including cancers within developing nations[8]. WHO estimates an increase in cancer deaths of 45% between the years 2007 to 2030[9]. Cancer kills more people than AIDS, tuberculosis and Malaria combined[10], yet it has received less focus. Understanding risks, etiology and management of gastric cancer impacts the survival outcome. With the increasing westernization of diet, obesity, lifestyle (alcohol and smoking), there is increased risk of gastric carcinogenesis. It is prudent to increase research related to cancer in Africa, including gastric cancer.

INCIDENCE AND MORTALITY RATES

A comprehensive and comparable resource for incidence and mortality rates is the GLOBOCAN database. The Globocan database is part of the International Agency of Research on Cancer-World Health Organization (IARC-WHO)[1]. Globocan database is one of the world’s largest, most reliable and organized incidence and mortality data resources for gastric cancer in Africa, however, it has its limitations[1]. Globocan recognizes the limitations in data collection. First, the development of the database relies on the cancer registries with the individual countries, which may not capture the realities or may be an under-representation of the incidence and mortality rates[1]. Second, some countries do not have a cancer registry thus reliance on data from individual hospitals[1].

There is significant variation from country to country in Africa with estimated incidence rates as high as 20.3/100000 in Mali to as low as 0.3/100000 in Botswana[1]. Table 1 details the incidence and mortality rates in Northern, Eastern, Central, Southern and Western Africa. The geographic demarcation is that from the Globocan database recognizing 53 African countries, with the highest incidence and mortality from Eastern Africa 4.7/100000 and 4.6/100000 respectively[1]. Other countries with high incidence and mortality rates are La Reunion (12.6/100000, 9.3/100000), Western Sahara (11.9/100000, 11.9/100000), Burundi (9.8/100000, 8.4/100000), Uganda (9/100000, 8.7/100000), Rwanda (8.3/100000, 8/100000), Kenya (7.6/100000, 7.3/100000) and Democratic Republic of Congo (7.3/100000, 7.2/100000)[1]. These rates are higher than Western nations such as United States (4.1/100000, 2/100000) and United Kingdom (5.5/100000, 2/100000), but lower than Eastern nations such as Japan (31.1/100000, 13.5/100000), South Korea (62.2/100000, 22.5/100000) and China (29.9/100000, 22.3/100000). Some African countries with lower incidence and mortality rates are Botswana (0.3/100000, 0.3/100000), Namibia (1.1/100000, 1.1/100000), Lesotho (1.3/100000, 1.3/100000), Equatorial Guinea (1.6/100000, 1.6/100000), Sudan (1.6/100000, 1.8/10000) Malawi (1.7/100000, 1.6/100000), Central Republic of Africa (1.9/100000, 1.8/100000) Swaziland (1.9/100000, 1.9/100000) and The Gambia (1.9/100000, 1.9/100000)[1].

Table 1 Gastric cancer incidence and mortality rates.
Incidence1
Mortality1
MalesFemalesBothMalesFemalesBoth
Africa24.73.34.04.43.23.8
Northern3.92.43.23.72.33.0
Eastern5.64.04.75.43.84.6
Central5.34.74.05.24.64.8
Southern4.12.23.03.91.82.8
Western4.53.33.84.33.13.7
Asia25.911.718.518.38.913.4
North America5.82.84.22.81.82.1
South America17.38.412.414.26.910.2
Europe14.57.010.311.35.37.9
Australia7.43.45.34.32.13.1

This variation in reporting may be related to the late patient presentation and lack of cancer reporting systems. It is also unclear if these are autopsy reports or live cases. Some of the differences in the rates can be attributed to the degree of advances in medicine within the country and available expertise. McFarlane et al[11] conducted a retrospective survey in the Eastern part of Kenya with a population of approximately 1.2 million. The researchers reviewed medical records between 1991-1993, and compared to data from the same area obtained in the 1970s. There was a 10 fold increase in the incidence rate between 1965-1970 and 1991-1993. The authors note that endoscopy services were established in the Eastern part of Kenya in 1980s, which could have impacted diagnostic capabilities. Similar finding of increased gastric cancer incidence over decades in Uganda has been documented but attributed to an increased access to healthcare and endoscopy availability[11]. In Uganda, East Africa, most recent data shows a seven fold increase incidence of gastric cancer from 0.8/100000 in the 1960s to 5.6/100000[12]. This has led to development and implementation of guidelines regarding management of patients presenting with dyspepsia[12].

MANAGEMENT AND OUTCOMES

Initial diagnosis of gastric cancer is typically via an upper endoscopy with biopsy of an abnormal appearing lesion confirmed by histopathology. Staging options include endoscopic (endoscopic ultrasound, EUS) and radiographic [computed tomography (CT), magnetic resonance imaging, positron emission tomography and abdominal ultrasound], with CT being the most common[13]. EUS is not an option in most African countries due to the absence of technology and trained personnel, thus radiology is the mainstay of staging. There are also limitations to staging related to patient financial constraints, which impacts overall patient care. Screening modalities (barium study, gastroscopy and serum pepsinogen) have been implemented in high risk Asian countries such as Japan, South Korea, and Taiwan[14], however these are not part of the management of patients at risk for gastric cancer in Africa. Late presentation plays a significant role in the poor outcome in most African countries; hence increased awareness amongst the general population and more training of healthcare providers have an important role.

After the initial diagnosis of gastric cancer, staging should be performed to determine next step in management. The staging system evaluates nodal and other organ involvement. Staging extends from 0 to 4, with 0 being localized (also known as carcinoma in situ) and stage IV representing metastatic disease to distant organs in the body. This staging has implications on the overall prognosis and treatment plan. With surgical intervention, the 5 year survival outcomes for patients with localized disease are estimated to be 75%, and for those with lymph node involvement the prognosis is poorer, 10%-30%[13]. Factors impacting outcome can be broadly defined as tumor specific or patient specific. The tumour related risk factors are: stage, grade, size, gastric location of primary tumour, lymph node or vascular involvement[13]. The patient specific factors are age, gender, co-morbidities and performance status[13]. Delayed presentation, limited radiotherapy and surgical capability also impact management[7].

Surgery plays a role in diagnosis, palliative therapy or curative therapy[12]. The role of surgery as curative modality seems to be limited to patients who present in the early stage[12,13]. Mabula et al[15] conducted a retrospective analysis of gastric cancer patients in Kenya, East Africa, evaluating the clinicopathology and outcome over a 4 year period. They enrolled 232 patients, median age was 52, 92% presented in late stage of the disease, 223 (96%) underwent surgery (commonly gastrojejunostomy) as primary treatment, 56 (24%) chemotherapy and 12 (5.1%) radiotherapy[15]. The post-operative complication and mortality was 37.1% and 18.1% respectively[15]. The 5 year survival was 32.8%[14]. Ahmed et al[16] conducted a retrospective study in Nigeria, West Africa, evaluating clinical pattern, management and outcome of 179 patients. The mean age was 51 ± 6 years, 155 (86%) underwent surgical intervention, (mainly gastrectomies), the overall median survival was 13.6 mo[16]. For patients who underwent gastrectomy, the one and five year survival were 70.1% and 21.8% respectively[16]. The post-operative complication and mortality were 43 (27.7%) and 25 (16.1%) respectively[16]. These studies also highlight significant post-operative complications and mortality, which seem related to the late patient presentation. Table 2 summarizes the treatment, post surgical complications and outcomes of gastric cancer in some African countries.

Table 2 Treatment and survival outcome.
CountryYear of publication and study designAuthorSample sizeOverall survivalTreatmentPost-operative complicationPost-operative mortalityIncidence and Mortality rate per Globocan
Tanzania2012, retrospective reviewMabula et al[15]2325 yr survival: 32.8%Surgery: 223/232 (96.1%)37.1%18.1%2/100000
Chemotherapy: 56 (24%)2/100000
Radiotherapy: 12 (5.1%)
Mali (Abstract, French article)2012Dembeleet al[17]4251 yr survival: 15.5%200 (65%): surgery--20.3/100000
105 (34.3%) : no surgery19.7/100000
4 (1.3%): chemotherapy
Nigeria2011, retrospective reviewAhmed et al[16]17913.6 moSurgery: 155 (86.6%)43 (27.7%)25 (16.1%)2.2/100000
1 yr post gastrectomy: 70.1%2.1/100000
5 yr post gastrectomy: 21.8%
Zimbabwe2011Chokunonga et al[18]-5 yr survival: 20%---5.3/100000
5/100000
Nigeria2010, retrospectiveOsime et al[19]-mortality rate 39.1; 66% died within one year of diagnosis30.4% presented within in year2.2/100000
2.1/100000
Tunisia (Abstract, French article)2006, retrospectiveArfaouiet al[24]14026.5 mo, 13 mo and 5 mo after curative resection, palliative resection and without resectionCurative and palliative resection
Tunisia (Abstract, French article)2004Ayite et al[23]633 mo: 21%4.2/10000000
1 yr survival: 7%3.9/100000
Senegal (Abstract, French article)2003Fall et al[20]60Total overall survival : 20%---6.1/100000 5.9/100000
Uganda2001, prospective, descriptiveIbingira[21]351 yr survival after partial gastrectomy: 39.1% -94.5% presented with advanced cancer, and no curative surgery possible9/100000
8.7/100000
Ethiopia2000, prospectiveJohnson et al[22]9690% presented in advanced stage;-18.6%3.5/100000
40% had resectable lesions3.4/100000
CONCLUSION

Published data regarding gastric cancer management and outcome within most African countries is scarce. It is plausible that overall incidence and mortality in some nations is lower due to the underreporting and lack of an organized, adequate database. What’s clear is the consistency of poor prognosis and lower overall survival rates which are related to advanced stage at diagnosis, lack of disease awareness and limited health access. The increase post-operative mortality could be related to the late/advanced stage at presentation, poor performance status of the patient, and other co-morbidities such as non-communicable disease. The healthcare focus has predominantly been in communicable diseases, however recent data show an increasing trend of non-communicable diseases such as obesity, hypertension and cardiovascular diseases which impact both the risk and management of gastric cancer in Africa. More research into gastric cancer management and outcomes in Africa, along with training of healthcare providers to improve patient survival is needed.

Footnotes

P- Reviewers: Carneiro F, Lee SH S- Editor: Zhai HH L- Editor: A E- Editor: Ma S

References
1.  Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM.  GLOBOCAN 2008 v2.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer, 2010. Accessed on August 1 2013;  Available from: http://globocan.iarc.fr.  [PubMed]  [DOI]
2.  American Cancer Society The global economic cost of cancer. Accessed October 20, 2013.  Available from: http://www.cancer.org/acs/groups/content/@internationalaffairs/documents/document/acspc-026203.pdf.  [PubMed]  [DOI]
3.  WHO Global Status Report on Non-communicable Diseases 2010. 2013; Available from: http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf.  [PubMed]  [DOI]
4.   Available from: http://www.wcrf.org/cancer_statistics/data_specific_cancers/stomach_cancer_statistics.php.  [PubMed]  [DOI]
5.  Asombang AW, Kelly P. Gastric cancer in Africa: what do we know about incidence and risk factors. Trans R Soc Trop Med Hyg. 2012;106:69-74.  [PubMed]  [DOI]
6.  Kelly P, Katema M, Amadi B, Zimba L, Aparicio S, Mudenda V, Baboo KS, Zulu I. Gastrointestinal pathology in the University Teaching Hospital, Lusaka, Zambia: review of endoscopic and pathology records. Trans R Soc Trop Med Hyg. 2008;102:194-199.  [PubMed]  [DOI]
7.  Kendig CE, Samuel JC, Tyson AF, Khoury AL, Boschini LP, Mabedi C, Cairns BA, Varela C, Shores CG, Charles AG. Cancer Treatment in Malawi: A Disease of Palliation. World J Oncol. 2013;4:142-146.  [PubMed]  [DOI]
8.  Dalal S, Beunza JJ, Volmink J, Adebamowo C, Bajunirwe F, Njelekela M, Mozaffarian D, Fawzi W, Willett W, Adami HO. Non-communicable diseases in sub-Saharan Africa: what we know now. Int J Epidemiol. 2011;40:885-901.  [PubMed]  [DOI]
9.  Gupta1 KK. CNN gene: The deregulated expression leads to myriad number of cancers.  Available from: http://www.who.int/features/qa/15/en.  [PubMed]  [DOI]
10.  Sylla BS, Wild CP. A million africans a year dying from cancer by 2030: what can cancer research and control offer to the continent. Int J Cancer. 2012;130:245-250.  [PubMed]  [DOI]
11.  McFarlane G, Forman D, Sitas F, Lachlan G. A minimum estimate for the incidence of gastric cancer in Eastern Kenya. Br J Cancer. 2001;85:1322-1325.  [PubMed]  [DOI]
12.  Galukande M, Luwaga A, Jombwe J, Fualal J, Kigula-Mugamba J, Kanyike A, Gakwaya A. Gastric Cancer Diagnosis and Treatment guidelines 2008: Uganda Cancer Working Group. East Central African J Surg. 2008;13:142-149.  [PubMed]  [DOI]
13.  Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM. Gastric adenocarcinoma: review and considerations for future directions. Ann Surg. 2005;241:27-39.  [PubMed]  [DOI]
14.  Tan V, Wong B. Management of gastric cancer in the Asia-Pacific region - necessity drives differences. AGA perspectives. 2012;8:16-17.  [PubMed]  [DOI]
15.  Mabula JB, McHembe MD, Koy M, Chalya PL, Massaga F, Rambau PF, Masalu N, Jaka H. Gastric cancer at a university teaching hospital in northwestern Tanzania: a retrospective review of 232 cases. World J Surg Oncol. 2012;10:257.  [PubMed]  [DOI]
16.  Ahmed A, Ukwenya AY, Makama JG, Mohammad I. Management and outcome of gastric carcinoma in Zaria, Nigeria. Afr Health Sci. 2011;11:353-361.  [PubMed]  [DOI]
17.  Dembélé BT, Togo A, Kanté L, Traoré A, Diakité I, Tounkara Y, Samaké B, Keita M, Diallo G. [Non-resecable gastric cancers at the department of general surgery at CHU Gabriel TOURE Bamako]. Mali Med. 2012;27:14-18.  [PubMed]  [DOI]
18.  Chokunonga E, Borok MZ, Chirenje ZM, Nyabakau AM, Parkin DM. Cancer survival in Harare, Zimbabwe, 1993-1997. IARC Sci Publ. 2011;249-255.  [PubMed]  [DOI]
19.  Osime OC, Momoh MI, Irowa OO, Obumse A. Gastric carcinoma--a big challenge in a poor economy. J Gastrointest Cancer. 2010;41:101-106.  [PubMed]  [DOI]
20.  Fall B, Dieng M, Mbengue M, Dangou JM. [Care management of lower gastric tumors at Dakar. Preliminary study of 60 cases]. Dakar Med. 2003;48:50-53.  [PubMed]  [DOI]
21.  Ibingira CB. Management of cancer of the stomach in Mulago Hospital Kampala, Uganda. East Afr Med J. 2001;78:233-237.  [PubMed]  [DOI]
22.  Johnson O, Ersumo T, Ali A. Gastric carcinoma at Tikur Anbessa Hospital, Addis Ababa. East Afr Med J. 2000;77:27-30.  [PubMed]  [DOI]
23.  Ayite AE, Adodo K, Dosseh E, Abita T, Ocloo A. [Management of primary gastric cancer at university hospitals in Lome. Report of 63 cases]. Tunis Med. 2004;82:747-752.  [PubMed]  [DOI]
24.  Arfaoui D, Elloumi H, Hamila F, Gouma M, Ben Abdellaziz A, Sfar S, Jmaa A, Gannem H, Bel Hadj HR, Ajmi S. [Epidemiologic profile of gastric carcinoma: study of 140 cases]. Tunis Med. 2006;84:301-304.  [PubMed]  [DOI]