Research Article: Gastrointestinal malignancies at five regional referral hospitals in Uganda

Date Published: December , 2017

Publisher: Makerere Medical School

Author(s): Siraji Obayo, Luswa Lukwago, Jackson Orem, Ashley L Faulx, Christopher S Probert.

http://doi.org/10.4314/ahs.v17i4.13

Abstract

There is a paucity of published data regarding the trend and distribution of gastrointestinal malignancies in Uganda.

To study the trend and distribution of gastrointestinal malignancies over a 10 year period at five regional referral hospitals in Uganda.

Patient’s charts with histologically confirmed diagnoses of gastrointestinal malignancies for the period 2002–2011 were identified. Case information, which included age at diagnosis, sex, and year of diagnosis, primary anatomic site of the tumour and hospitals attended, was retrospectively abstracted. Patient’s clinical and demographic features were compared.

Oesophageal cancer was the most common (28.8%) followed by liver (25.8%), stomach (18.4%) and colorectal (14.3%). The mean age at diagnosis for all the cancers was not significantly different in both sexes 54.1, (SD16.1) versus 53.6, (SD 14.7). The highest mean annual number of cases of oesophageal and stomach cancers was 21.8, (SD 15.5) and 16.6, (SD 13.0) respectively from Mbarara Hospital; Lacor had the highest mean annual number of liver cancer cases (21, SD 17.7) followed by Mbale (11.4, SD 8.3). The mean annual number of colorectal cancers was highest in Mbale Hospital (10.3, SD 8.1) followed by Lacor (4.9, SD 3.9). The distribution of oesophageal, liver, stomach and colorectal cancers diagnosed per year across the five referral hospitals was different, P<0.001. Oesophageal, liver, stomach and colorectal cancer remain the most common gastrointestinal malignancies and their rate is increasing in Uganda. There is a need for awareness, endoscopic and radiological assessment of symptomatic individuals and a need for screening of high index patients.

Partial Text

Accurate national representative data on the trend and distribution of gastrointestinal malignancies in Uganda is sparse, hampering efforts to develop robust public and clinical health interventions.1,2 The challenges of diagnosis of these malignancies in this resource limited settings is significant because of inadequate endoscopic, radiological facilities and lack of screening programs.3–5 Recent reports from the Kampala Cancer Registry based in Kyadondo County, which represents about 8% of the Ugandan population, suggest that the trend of gastrointestinal malignancy, specifically oesophageal, stomach, liver and colorectal cancers, is increasing.6 However, 90% of the Ugandan population lives in rural areas: they can only access regional referral and district hospitals for their assessment and diagnosis; there is no published data about gastrointestinal cancer cases in these regional referral hospitals. An earlier survey showed variation by geographic location in the distribution of gastrointestinal malignancies, especially for oesophageal and stomach cancer.7 Oesophageal cancer was most common around the NorthEast shores of Lake Victoria and rare in Northern and SouthWestern Uganda, while stomach cancer was common in SouthWestern Uganda, but rare in Northern Uganda. Liver cancer was the most frequent cancer in the NorthEast, Northern and SouthWestern Uganda.7 Later surveys also found high prevalence of stomach cancer in SouthWestern Uganda.8,9 Cancer of the large bowel had long been noted to be relatively infrequent in Uganda,9,10 Data from Kyadondo County shows an increasing trend in the incidence of colorectal cancer.11

This was a retrospective study of patients with histological diagnoses of gastrointestinal cancers seen at five referral hospitals in the ten years from January 2002 to December 2011.

We sought permission from individual hospitals prior to accessing charts for data abstraction. The data review was performed as part of cancer survey in collaboration with the Ugandan Ministry of Health with key data collected in aggregate without retaining personal identifying information.

Descriptive analyses of cancers and gender, cases across age groups by gender, cancers across the hospitals, trend and distribution of the cancers with the calendar year were performed in all subjects. The means and their standard deviation of all cancers across the hospitals were calculated. The means were compared across all the five hospitals and p values were computed using a Kruskal Wallis test of means, a p-value of < 0.05 was considered significant using Stata version 12.0 1468 cases were identified. The average age at diagnosis was 53.9 years (SD 15.6) with a range of 10–98 years and the mean age at diagnosis was not significantly different between males and females (54.1 years (SD 16.1) and 53.6 years (SD14.7) respectively, p = ns). Oesophageal cancer was the most common (28.8%) followed by liver (25.8%), stomach (18.4%) and then colorectal cancer (14.3%), all of which were more common in males (Table 1). One thousand four hundred and sixty eight cases of gastrointestinal cancer cases were reviewed, oesophageal cancer was the most common (28.8%). It was most common in Mbarara University Teaching Hospital, Western Uganda with a mean of 22 cases annually. This was similar to earlier studies in Ethiopia, Tanzania and Kenya, which found that oesophageal cancer was the most common gastrointestinal malignancy in those countries.13–16 The frequency could be due to a number of factors, including an aging population as the life expectancy in Uganda is increasing. Other risk factors are tobacco use, alcohol intake, poor dietary patterns such as consumption of a maize-based diet that is low in fruits and vegetables. Contamination of maize with fungi may lead to the production of fumonisins, which are carcinogenic.17 However these modifiable factors are yet to be established in our setting. This study has several limitations. (i) Only regional referral and teaching hospitals where involved, thus cases only seen at district hospitals may have been missed and thus case ascertainment may be incomplete. (ii) We were unable to calculate the age-specific incidence rates and incidence in this study, as there is limited population data. (iii) We cannot exclude diagnostic bias based on interest, expertise and access to diagnostic facilities. Oesophageal, liver, stomach and colorectal cancer remain the most common gastrointestinal malignancies in Uganda and appear to be increasing. Oesophageal and liver cancers predominate. There is a need for awareness, endoscopic and radiological assessment of symptomatic individuals as well as surveillance of pre-malignant lesions. Screening campaigns have greatly improved the outcomes for patients with colorectal cancer in Europe, stomach cancer in Japan. Vaccination programmes could reduce the transmission of hepatitis B and surveillance of those with cirrhosis used to find cancers.   Source: http://doi.org/10.4314/ahs.v17i4.13

 

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