Treatment and Survival Among Patients With Colorectal Cancer in Sub-Saharan Africa: A Multicentric Population-Based Follow-Up Study

Authors:
Lucia Hämmerl Global Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle an der Saale, Germany

Search for other papers by Lucia Hämmerl in
Current site
Google Scholar
PubMed Close
 MD
,
Nikolaus C.S. Mezger Global Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle an der Saale, Germany

Search for other papers by Nikolaus C.S. Mezger in
Current site
Google Scholar
PubMed Close
 MD
,
Tobias P. Seraphin Global Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle an der Saale, Germany

Search for other papers by Tobias P. Seraphin in
Current site
Google Scholar
PubMed Close
 MD
,
Walburga Yvonne Joko-Fru African Cancer Registry Network, International Network for Cancer Treatment and Research, African Registry Programme, Oxford, United Kingdom
Clinical Trials Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom

Search for other papers by Walburga Yvonne Joko-Fru in
Current site
Google Scholar
PubMed Close
 MD
,
Mirko Griesel Global Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle an der Saale, Germany

Search for other papers by Mirko Griesel in
Current site
Google Scholar
PubMed Close
 MD
,
Jana Feuchtner Global Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle an der Saale, Germany

Search for other papers by Jana Feuchtner in
Current site
Google Scholar
PubMed Close
 MD
,
Franck Gnahatin Registre des Cancers d’Abidjan, Programme National de Lutte contre le Cancer, Abidjan, Côte d’Ivoire

Search for other papers by Franck Gnahatin in
Current site
Google Scholar
PubMed Close
 MD
,
Freddy Houéhanou Rodrigue Gnangnon Cotonou Cancer Registry, Cotonou, Benin

Search for other papers by Freddy Houéhanou Rodrigue Gnangnon in
Current site
Google Scholar
PubMed Close
 MD
,
Nathan Okerosi National Cancer Registry, Kenya Medical Research Institute, Nairobi, Kenya

Search for other papers by Nathan Okerosi in
Current site
Google Scholar
PubMed Close
 MD
,
Phoebe Mary Amulen Kampala Cancer Registry, Department of Pathology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda

Search for other papers by Phoebe Mary Amulen in
Current site
Google Scholar
PubMed Close
,
Rolf Hansen Namibia National Cancer Registry, Cancer Association of Namibia, Windhoek, Namibia

Search for other papers by Rolf Hansen in
Current site
Google Scholar
PubMed Close
,
Margaret Ziona Borok Zimbabwe National Cancer Registry, Harare, Zimbabwe

Search for other papers by Margaret Ziona Borok in
Current site
Google Scholar
PubMed Close
 MD
,
Carla Carrilho Maputo City Cancer Registry, Maputo City, Mozambique
Department of Pathology, Faculty of Medicine, Eduardo Mondlane University, Maputo Central Hospital, Maputo, Mozambique

Search for other papers by Carla Carrilho in
Current site
Google Scholar
PubMed Close
 MD
,
Brahima Mallé Registre des Cancers de Bamako, Bamako, Mali

Search for other papers by Brahima Mallé in
Current site
Google Scholar
PubMed Close
 MD
,
Clausina Ahoui Apendi Registre des Cancers de Brazzaville, Brazzaville, Republic of Congo

Search for other papers by Clausina Ahoui Apendi in
Current site
Google Scholar
PubMed Close
,
Nathan G. Buziba Eldoret Cancer Registry, Moi Teaching Hospital, Eldoret, Kenya
Moi University School of Medicine, Eldoret, Kenya

Search for other papers by Nathan G. Buziba in
Current site
Google Scholar
PubMed Close
 MD
,
Edom Seife Addis Ababa City Cancer Registry, Radiotherapy Center, Addis-Ababa-University, Addis Ababa, Ethiopia

Search for other papers by Edom Seife in
Current site
Google Scholar
PubMed Close
 MD
,
Biying Liu African Cancer Registry Network, International Network for Cancer Treatment and Research, African Registry Programme, Oxford, United Kingdom

Search for other papers by Biying Liu in
Current site
Google Scholar
PubMed Close
 MPH
,
Rafael Mikolajczyk Global Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle an der Saale, Germany

Search for other papers by Rafael Mikolajczyk in
Current site
Google Scholar
PubMed Close
 MD
,
Donald M. Parkin Clinical Trials Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
International Agency for Research on Cancer, Lyon, France

Search for other papers by Donald M. Parkin in
Current site
Google Scholar
PubMed Close
 MD
,
Eva J. Kantelhardt Global Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle an der Saale, Germany
Department of Gynaecology, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle an der Saale, Germany

Search for other papers by Eva J. Kantelhardt in
Current site
Google Scholar
PubMed Close
 MD
, and
Ahmedin Jemal Department of Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia

Search for other papers by Ahmedin Jemal in
Current site
Google Scholar
PubMed Close
 PhD
Volume/Issue:
Volume 21: Issue 9
Online Publication Date:
Sep 2023
DOI:
https://doi.org/10.6004/jnccn.2023.7041
Restricted access

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.

Submitted February 27, 2023; final revision received May 12, 2023; accepted for publication May 31, 2023.

Author contributions: Conceptualization: Hämmerl, Griesel, Feuchtner, Gnahatin, Gnangnon, Okerosi, Amulen, Hansen, Borok, Carrilho, Mallé, Clausina, Buziba, Seife, Liu, Mikolajczyk, Parkin, Kantelhardt, Jemal. Data curation: Hämmerl, Mezger, Seraphin, Joko-Fru, Griesel, Feuchtner, Gnahatin, Gnangnon, Okerosi, Amulen, Hansen, Borok, Carrilho, Mallé, Clausina, Buziba, Seife. Formal analysis: Hämmerl, Mezger, Seraphin, Joko-Fru, Griesel, Feuchtner, Liu, Mikolajczyk, Parkin, Kantelhardt, Jemal. Funding acquisition: Liu, Kantelhardt, Jemal. Investigation: Hämmerl, Mezger, Seraphin, Parkin, Kantelhardt, Jemal. Methodology: Hämmerl, Mezger, Seraphin, Joko-Fru, Griesel, Feuchtner, Mikolajczyk, Parkin, Kantelhardt, Jemal. Project administration: Liu, Parkin, Kantelhardt. Resources: Parkin, Kantelhardt, Jemal. Software: Hämmerl, Mezger, Seraphin, Joko-Fru, Griesel, Feuchtner. Supervision: Mikolajczyk, Parkin, Kantelhardt, Jemal. Validation: Hämmerl, Parkin, Kantelhardt, Jemal. Visualization: Hämmerl, Parkin, Kantelhardt, Jemal. Writing—original draft: Hämmerl, Kantelhardt. Writing—review & editing: Mezger, Seraphin, Joko-Fru, Griesel, Feuchtner, Gnahatin, Gnangnon, Okerosi, Amulen, Hansen, Borok, Carrilho, Mallé, Clausina, Buziba, Seife, Liu, Mikolajczyk, Parkin, Jemal.

Disclosures: The authors have disclosed that they have not received any financial consideration from any organization to support the preparation, analysis, results, or discussion of this article.

Funding: Research reported in this publication was supported by the American Cancer Society (43359), Stiftung Begabtenförderung Cusanuswerk (L. Hämmerl), Deutscher Akademischer Austauschdienst to Martin-Luther-University (57216764; E.J. Kantelhardt), Else Kroener-Fresenius-Foundation (2018_HA31SP; E.J. Kantelhardt), and the Volkswagen Foundation (94631, 96818). This work was also supported through the German Ministry of Research and Education (grant 01KA2220B).

Correspondence: Eva J. Kantelhardt, MD, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Magdeburgerstrasse 8, D-06097 Halle, Germany. Email: eva.kantelhardt@uk-halle.de

Supplementary Materials

    • Supplemental Materials (PDF 509 KB)
  • Collapse
  • Expand
Print ISSN:
1540-1405
Online ISSN:
1540-1413
Publisher:
National Comprehensive Cancer Network
Cover Journal of the National Comprehensive Cancer Network
  • 1.

    Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209–249.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Bingham SA, Day NE, Luben R, et al. Dietary fibre in food and protection against colorectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC): an observational study. Lancet 2003;361:1496–1501.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Friedenreich C, Norat T, Steindorf K, et al. Physical activity and risk of colon and rectal cancers: the European prospective investigation into cancer and nutrition. Cancer Epidemiol Biomarkers Prev 2006;15:2398–2407.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Pischon T, Lahmann PH, Boeing H, et al. Body size and risk of colon and rectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC). J Natl Cancer Inst 2006;98:920–931.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Robsahm TE, Aagnes B, Hjartåker A, et al. Body mass index, physical activity, and colorectal cancer by anatomical subsites: a systematic review and meta-analysis of cohort studies. Eur J Cancer Prev 2013;22:492–505.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Arnold M, Sierra MS, Laversanne M, et al. Global patterns and trends in colorectal cancer incidence and mortality. Gut 2017;66:683–691.

  • 7.

    Chokunonga E, Borok MZ, Chirenje ZM, et al. Trends in the incidence of cancer in the Black population of Harare, Zimbabwe 1991–2010. Int J Cancer 2013;133:721–729.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Dickson I. CRC trends reflect human development. Nat Rev Gastroenterol Hepatol 2016;13:122.

  • 9.

    Lorenzoni C, Vilajeliu A, Carrilho C, et al. Trends in cancer incidence in Maputo, Mozambique, 1991–2008. PloS One 2015;10:e0130469.

  • 10.

    Somdyala NI, Parkin DM, Sithole N, et al. Trends in cancer incidence in rural Eastern Cape Province; South Africa, 1998–2012. Int J Cancer 2015;136:E470–474.

  • 11.

    Zingoni C, Norris SA, Griffiths PL, et al. Studying a population undergoing nutrition transition: a practical case study of dietary assessment in urban South African adolescents. Ecol Food Nutr 2009;48:178–198.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Katsidzira L, Gangaidzo I, Thomson S, et al. The shifting epidemiology of colorectal cancer in sub-Saharan Africa. Lancet Gastroenterol Hepatol 2017;2:377–383.

  • 13.

    Agyemang-Yeboah F, Yorke J, Obirikorang C, et al. Patterns and presentations of colorectal cancer at Komfo-Anokye teaching hospital Kumasi, Ghana. Pan Afr Med J 2017;28:121.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Lambert R, Saito H, Lucas E, et al. Survival from digestive cancer in emerging countries in Asia and Africa. Eur J Gastroenterol Hepatol 2012;24:605–612.

  • 15.

    Rahman GA. Rectal cancer: pattern and outcome of management in University of Ilorin Teaching Hospital, Ilorin, Nigeria. Ann Afr Med 2010;9:164–169.

  • 16.

    Selemane C, Jamisse L, Arroz J, et al. Demographic, clinical and pathological characterization of patients with colorectal and anal cancer followed between 2013 and 2016 at Maputo Central Hospital, Mozambique. Ecancermedicalscience 2021;15:1205.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Sharma A, Alatise OI, Adisa AO, et al. Treatment of colorectal cancer in Sub-Saharan Africa: results from a prospective Nigerian hospital registry. J Surg Oncol 2020;121:342–349.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Wismayer R, Kiwanuka J, Wabinga H, et al. Prognostic factors for survival of colorectal adenocarcinoma patients in Uganda. Cancer Manag Res 2022;14:875–893.

  • 19.

    Benson AB III, Venook AP, Al-Hawary MM, et al. NCCN Harmonized Guidelines for Sub-Saharan Africa: Rectal Cancer. Version 2.2018. To view the most recent version, visit https://www.nccn.org

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Benson AB III, Venook AP, Al-Hawary MM, et al. NCCN Harmonized Guidelines for Sub-Saharan Africa: Colon Cancer. Version 2.2018. To view the most recent version, visit https://www.nccn.org

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    African Cancer Registry Network. Standard procedure manual. Accessed July 1, 2023. Available at: https://afcrn.org/index.php/resources2/53-standard-procedure-manual/131-sop

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    World Health Organization. International Classification of Diseases for Oncology (ICD-O-3). 1st rev, 3rd ed. IARC; 2014.

  • 23.

    Geneletti S, Richardson S, Best N. Adjusting for selection bias in retrospective, case-control studies. Biostatistics 2009;10:17–31.

  • 24.

    Miller DP, Gomberg-Maitland M, Humbert M. Survivor bias and risk assessment. Eur Respir J 2012;40:530–532.

  • 25.

    Piñeros M, Parkin DM, Ward K, et al. Essential TNM: a registry tool to reduce gaps in cancer staging information. Lancet Oncol 2019;20:e103–111.

  • 26.

    Brierley JD, Gospodarowicz MK, Wittekind C, eds. TNM Classification of Malignant Tumours, 8th ed. Wiley Blackwell; 2016.

  • 27.

    United Nations Development Programme. Human development report 2015: work for human development. Accessed July 1, 2023. Available at: http://hdr.undp.org/en/content/human-development-report-2015

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Chalya PL, McHembe MD, Mabula JB, et al. Clinicopathological patterns and challenges of management of colorectal cancer in a resource-limited setting: a Tanzanian experience. World J Surg Oncol 2013;11:88.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Gullickson C, Goodman M, Joko-Fru YW, et al. Colorectal cancer survival in sub-Saharan Africa by age, stage at diagnosis and Human Development Index: a population-based registry study. Int J Cancer 2021;149:1553–1563.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Jiang Y, Yuan H, Li Z, et al. Global pattern and trends of colorectal cancer survival: a systematic review of population-based registration data. Cancer Biol Med 2021;19:175–186.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Surveillance, Epidemiology, and End Results Program. SEER*Stat database: colon and rectum: recent trends in SEER relative survival rates, 2000–2020. Accessed July 1, 2023. Available at: https://seer.cancer.gov/statistics-network/explorer/application.html?site=20

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Fidler MM, Bray F. Global cancer inequalities. Front Oncol 2018;8:293.

  • 33.

    Irabor DO. Emergence of colorectal cancer in West Africa: accepting the inevitable. Niger Med J 2017;58:87–91.

  • 34.

    Chawla S, Kurani S, Wren SM, et al. Electricity and generator availability in LMIC hospitals: improving access to safe surgery. J Surg Res 2018;223:136–141.

  • 35.

    Sankaranarayanan R, Swaminathan R, Jayant K, et al. An overview of cancer survival in Africa, Asia, the Caribbean and Central America: the case for investment in cancer health services. IARC Sci Publ 2011;162:257–291.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Yawe KT, Bakari AA, Pindiga UH, et al. Clinicopathological pattern and challenges in the management of colorectal cancer in sub-Saharan Africa. J Chin Clin Med 2007;2:688–695.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health 2015;3:e316–323.

  • 38.

    Holmer H, Lantz A, Kunjumen T, et al. Global distribution of surgeons, anaesthesiologists, and obstetricians. Lancet Glob Health 2015;3:S9–11.

  • 39.

    Abdel-Wahab M, Bourque JM, Pynda Y, et al. Status of radiotherapy resources in Africa: an International Atomic Energy Agency analysis. Lancet Oncol 2013;14:e168–175.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    International Atomic Energy Agency. What is DIrectory of RAdiotherapy Centres (DIRAC)? Accessed April 28, 2023. Available at: https://dirac.iaea.org

  • 41.

    Chang GJ, Rodriguez-Bigas MA, Skibber JM, et al. Lymph node evaluation and survival after curative resection of colon cancer: systematic review. J Natl Cancer Inst 2007;99:433–441.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Le Voyer TE, Sigurdson ER, Hanlon AL, et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 2003;21:2912–2919.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43.

    Farmer P, Frenk J, Knaul FM, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010;376:1186–1193.

  • 44.

    Ralaidovy AH, Gopalappa C, Ilbawi A, et al. Cost-effective interventions for breast cancer, cervical cancer, and colorectal cancer: new results from WHO-CHOICE. Cost Eff Resource Alloc 2018;16:38.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45.

    Pervaiz R, Faisal F. Cancer incidence and mortality are associated with human development index and health setups in Africa. J Egypt Natl Cancer Inst 2017;29:123–126.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46.

    Suissa S. Immortal time bias in pharmaco-epidemiology. Am J Epidemiol 2008;167:492–499.

  • 47.

    Vanderpuye V, Hammad N, Martei Y, et al. Cancer care workforce in Africa: perspectives from a global survey. Infect Agent Cancer 2019;14:11.

Copyright:
Copyright © 2023 by the National Comprehensive Cancer Network 2023
Article Category:
Research Article
Received:
27 Feb 2023
Accepted:
31 May 2023
Print Publication Date:
01 Sep 2023
Online Publication Date:
Sep 2023
Keywords:
colorectal cancer; sub-Saharan Africa; population-based cancer registration; National Comprehensive Cancer Network (NCCN) guideline concordant treatment; survival

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 2852 1905 111
PDF Downloads 1727 1053 43
EPUB Downloads 0 0 0