SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 7 REVIEW lived and repeat dilatations are usually required. 25 Patients can in addition undergo palliative chemotherapy with or without radiotherapy to achieve more sustained relief 26 . These oncological treatments are costly and dependent on availability and currently confined to a few centers in Africa. However as more oncology resources become available, and these modalities are used it will be important to assess their benefit on quality of life. 11 Surgical placed stents typified by the Celestin tube are available across the African continent. However, this modality involves the costs and access to a surgical theatre and anesthesia as placement under local anaesthesia though feasible is not well tolerated. Surgical placed stents are now rarely used as the majority of the patients present with late-stage disease are frail and may not withstand the use of general anesthesia and have a high post procedure complication rate. 10 Endoscopic techniques offer a solution that is minimally invasive and performed under conscious sedation on an outpatient basis and for these reasons in many African countries Self Expanding Metal Stents (SEMS) have become the preferred and safe method of promptly alleviating dysphagia. This is well illustrated by the report from a Kenyan institution, 1000 stents placed without fluoroscopy with complication rate of 1.9%, perforation and migration rate of 0.03% rates. 6 SEMS are usually inserted after endoscopic placement of a guide wire through the stricture into the stomach with or without fluoroscopy and then the delivery without pre- dilatation of the stent over the wire to accurately bridge the full extent of the stricture. 6,26 They can even be used successfully for very proximal tumors that are within 1-2cm of the upper oesophageal sphincter. 27 The costs compared to surgery are much lower but are still significant. The cost of stents has been shown to vary across the continent due to variability in supply sources. In several settings brachytherapy has shown better long-term outcomes but stenting has more immediate relief of dysphagia. 26 This has prompted research on radiation impregnated stents to get the best of both modalities but their Figure 3. African Oesophagael Cancer Consortium current participant sites use in African countries is still out of reach due to cost. Research and improving access to care Incidence and prevalence data is largely derived from hospital- based patients’ studies, and high quality epidemiological and clinical data from African countries is lacking. 4 This is to the detriment of health care policy planning. In South Africa, reports have shown that clinical research on OC has been mainly retrospective review and opinions with few good quality research projects. 8 There are currently ongoing efforts to help bridge this gap in research. 2 One of these initiatives is the African Esophageal Cancer Consortium (AfrECC). The consortium was formed in 2017 by OSCC researchers and institutions to facilitate research collaborations, improve early detection, clinical management, treatment and palliation of OC. 2 Participating sites are shown in Figure 3. AfrECC also has a goal of capacity building for OC research in sub- Saharan Africa. The consortium run by a six-member steering committee that is elected every two years has regular meetings. It has established several sub committees that are focused on the three key areas of research, clinical care, training and advocacy. AfrECC is keen to synergize research and training efforts on the continent. This has already been initiated by the use of harmonized research questionnaires and other data collection tools. Utilization of app-based data collection tools and also pooling of research specimens and creating an African bio- repository for a combined genomic wide analysis are other collaborative efforts. The app is available to consortium members and has primarily been used for the epidemiological data collection in the ongoing case-control studies. The consortium has been working with local professional societies in each of the countries to leverage these goals. Recruitment to the consortium has mainly been through the regional and national oncology meetings. The consortium has been actively involved in efforts to improve access to SEMS stents in high-risk areas in the continent focusing on providing access to SEMS and endoscopic training in stent deployment. The consortium efforts have led to partnership with a stent supplier as well as increase in the number of endoscopists who have expertise in stent placement. The model is geared towards self- sustainability with selection and training of in-country trainers who can then continue the training efforts in each country. Another consortium project was an endoscopy capacity survey in member countries that has helped to tailor training and inform health policy makers. The consortium membership is open to any researchers or clinicians involved in any aspect of esophageal cancer care. The stent access program is still growing and is seeking to help provide stents to areas which have high disease burden but have challenges with access. AfrECC continues to champion new partnerships in research and clinical care of oesophageal cancer. The success of the consortium has been due to the strengths of individual and institutional members. More details on the consortium and contact information is available at https://dceg.cancer.gov/ research/cancer-types/esophagus/afrecc. OSCC is a common clinical condition which in sub-Saharan Africa, presents as dysphagia It is usually at an advanced stage and has a short life expectancy. Surgical resection offers chance to get surgical cure in combination with chemotherapy and radiotherapy depending on the stage at presentation. Oesophageal SEMS placement is the best current option for alleviating dysphagia and provides immediate relief. It should be considered the starting point for palliation and the modality against which other oncological methods and technical innovations should be compared as health care resources and the ability to assess their effect