Impact of delayed care on surgical management of patients with gastric cancer in a low‐resource setting

Abstract

Background: Gastric cancer is the fifth most common cancer in Eastern Africa. Diagnostic delays in low-resource countries result in advanced disease presentation. We describe perioperative management of gastric cancer in Rwanda. Methods: Retrospective review of records at three hospitals was performed to identify gastric adenocarcinoma cases from January 2012 – June 2016. Multiple perioperative and tumor-related variables were collected. Descriptive and bi-variate analyses were performed. Results: Final analysis included 229 patients with gastric cancer. Median age was 58 years (IQR 49–65) and 49.6% were female (n=114). Patients reported symptoms (i.e., weight loss, epigastric pain) for median time of 12 months (IQR 7.5–24). On presentation, 18.8% (n=43) had gastric outlet obstruction; 13.5% (n=31) had a palpable mass. Fifty-one percent (n=117) underwent an operation; of these, 74% (n=86) received gastrojejunostomy or were inoperable; 29% (n=34) underwent curative resection. Palliative care referrals were made for 9% (n=20). Pathology reports were available for 190 patients (83.0%). Only 11.3% (n=26) had H. pylori testing, and 65.4% tested positive (n=17). Conclusions: A majority of patients presented with advanced disease. Very few patients had a curative resection. Significant advances in diagnosis and treatment are needed to improve care of gastric cancer in Rwanda.

Outcomes of Conversion Surgery for Metastatic Gastric Cancer Compared with In-Front Surgery Plus Palliative Chemotherapy or In-Front Surgery Alone

“…In-front surgery usually prevents mGC-related complications, such as bleeding, obstruction, or perforation [10,12,28]. Studies have shown that in-front palliative resection can prolong survival in select patients [10,12,29]. However, chemotherapy may be interfered with, or postponed due to, surgical morbidities or surgery-related worsening of the patient's general condition.…”

Global cancer surgery in low‐resource settings: A strengths, weaknesses, opportunities, and threats analysis

“…28 Palliative cancer surgeries may be particularly important in low resource settings due to a higher burden of advanced and therefore more symptomatic disease. 43 A study in India demonstrated feasibility and effectiveness of palliative operations for a variety of cancer patients, with the vast majority of patients endorsing subsequent symptomatic relief. 18 However, postoperative morbidity is an important consideration for any procedure, especially for patients with limited financial resources, health literacy, or access; weighing these risks and benefits necessitates a case-by-case determination and discussion with the patient and family.…”

“…Other proposed barriers to improved cancer surgery access, facilitation, and outcomes in low-resource settings include, but are not limited to: delayed presentation due to geographic isolation and transportation challenges 52 and sociocultural and sociopolitical factors, which ultimately increases care cost and complexity 53 ; unaffordable out-of-pocket costs, 54 which may disproportionately affect individuals in low-resource settings 55 ; and poor national cancer and cancer surgery registries, which may hinder accurate estimations of cancer surgery gaps and needs. 7,16,43 Broader health system gaps Indirect approaches, which emphasize external systems or policies that influence surgical cancer care, have also been a source of interest to researchers. For example, a study in Morocco sought to improve early cancer detection rates by providing point-of-care fecal immunochemical testing at primary health centers and offering colonoscopies for those who tested positive 56 ; however, only 62.6% of those who tested positive successfully underwent a subsequent colonoscopy, with many patients citing logistical and financial barriers to attending the follow-up procedure and appointments.…”