Despite the disease being potentially curable, most people with colorectal cancer in sub-Saharan Africa receive no treatment, or only inadequate treatment, and yet, the life expectancy of many of them could be significantly improved through simple measures, suggest scientists.
In research conducted by University Medicine Halle and the American Cancer Society, with various international institutes, a team analysed the data of 653 people diagnosed with colorectal cancer.
In light of the rising number of cases and low survival rates in the region, in their report published in Journal of the National Comprehensive Cancer Network, the authors emphasise the need to improve diagnosis and treatment options.
“Our study aimed to establish the amount of basic care received by colorectal cancer patients in the region, and how impactful that is in terms of survival rates,” said Lucia Hämmerl, lead author and research associate in the Global Health working group at University Medicine Halle.
Guidelines are used to make appropriate treatment decisions and options depend on the availability of personnel and the infrastructure, and vary widely around the world.
“Our focus was on harmonised colorectal cancer guidelines that take into account the circumstances in sub-Saharan Africa,” she added.
The study looked at 653 people diagnosed with colorectal cancer, using data from 11 population-based cancer registries. Additional medical information was available in 356 cases (55%).
Of these, non-metastatic colorectal cancer (stage I-III) was documented in 262 people and metastatic colorectal cancer (stage IV) in 94 people.
Only eight people (3%) with non-metastatic and potentially curable disease received guideline-compliant treatment; more than half received treatment with deviations and more than a third received no treatment at all.
This resulted in a mortality rate that was up to 3.5-times higher in the regions studied.
“Most of the patients with incomplete medical records presumably did not receive adequate treatment, which was why no clinical data was collected,” said Hämmerl.
“In the remaining patients, the survival rate was significantly higher when the treatment was guideline-concordant or slightly deviated from the guideline. However, this occurred in less than one in 20 cases, even though adequate basic care can be provided without high-tech or costly solutions.”
Inequalities were also found when the data were compared globally.
This was done using the Human Development Index (HDI), which takes life expectancy, education and income into account. The mortality rate of colorectal cancer patients in countries with low HDI scores, like Ethiopia, Mali and the Congo, is two-thirds higher than in countries with medium HDI scores, like Namibia and Kenya.
“We saw an alarming gap between the recommendations of the harmonised guidelines and the treatment that was actually being provided, especially in patients with potentially curable disease. In light of the ageing population in sub-Saharan Africa and the rising incidence of colorectal cancer, a great deal of suffering could be avoided through simple measures.
“The necessary strategies are available,” said Professor Eva Kantelhardt, co-author and head of the Global Health working group at University Medicine Halle.
“It is crucial that surgeons, in particular, are trained to perform radical cancer surgery. German hospitals can contribute by working in partnership to train specialists from African countries. In the case of gynaecological oncology, where a similar problem exists, many colleagues from Ethiopia have already received further surgical training at University Medicine Halle.”
As part of the BMBF-funded NORA research network, the study will be repeated and compared with the previous data.
Study details
Treatment and Survival Among Patients With Colorectal Cancer in Sub-Saharan Africa: A Multicentric Population-Based Follow-Up Study.
L Hämmerl, Nikolaus Mezger, Eva Kantelhardt, et al.
Published in Journal of the National Comprehensive Cancer Network in September 2023
Background
The burden of colorectal cancer (CRC) is increasing in Sub-Saharan Africa (SSA). However, little is known about CRC treatment and survival in the region.
Methods
A random sample of 653 patients with CRC diagnosed from 2011 to 2015 was obtained from 11 population-based cancer registries in SSA. Information on clinical characteristics, treatment, and/or vital status was obtained from medical records in treating hospitals for 356 (54%) of the patients (“traced cohort”). Concordance of CRC treatment with NCCN Harmonized Guidelines for SSA was assessed. A Cox proportional hazards model was used to examine the association between survival and human development index (HDI).
Results
Of the 356 traced patients with CRC, 51.7% were male, 52.8% were from countries with a low HDI, 55.1% had colon cancer, and 73.6% were diagnosed with nonmetastatic (M0) disease. Among the patients with M0 disease, however, only 3.1% received guideline-concordant treatment, 20.6% received treatment with minor deviations, 31.7% received treatment with major deviations, and 35.1% received no treatment. The risk of death in patients who received no cancer-directed therapy was 3.49 (95% CI, 1.83–6.66) times higher than in patients who received standard treatment or treatment with minor deviations. Similarly, the risk of death in patients from countries with a low HDI was 1.67 (95% CI, 1.07–2.62) times higher than in those from countries with a medium HDI. Overall survival at 1 and 3 years was 70.9% (95% CI, 65.5%–76.3%) and 45.3% (95% CI, 38.9%–51.7%), respectively.
Conclusions
Fewer than 1 in 20 patients diagnosed with potentially curable CRC received standard of care in SSA, reinforcing the need to improve healthcare infrastructure, including the oncology and surgical workforce.
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