Oesophageal cancer in Africa: Nutrition is a significant risk factor

9 min read
Topic(s): General Nutrition Oncology Nutrition & Disease Management
Fight Cancer

 
The Global Cancer Observatory (the World Health Organisation’s international agency for research on cancer) states that oesophageal cancer is “the 9th most common cancer in the world, with over 300 000 new cases annually of which 80% occur in developing countries”.[1] In Africa, where the incidence of oesophageal cancer is higher than the global average, researchers refer to the ‘African Oesophageal Cancer Corridor’ – an east African corridor “extending from Ethiopia to South Africa” [2], where both adenocarcinoma and squamous cell oesophageal cancer have a high prevalence. [3] In South Africa, for example, oesophageal cancer is responsible for the second highest number of cancer-related deaths [4]. (See Table 1, below, for a list of incidence rates of oesophageal cancer in selected African countries).

Aside from a genetic predisposition that is hypothesised to play a role 3, there are a number of diet- and lifestyle-related factors that have been associated with the high incidence of oesophageal cancer in Africa.

Risk factors demonstrate that healthy nutrition & lifestyle are critical

  • Picking cornA predominantly refined maize-based diet, with high use of refined maize meal as an affordable staple: Researchers have found a link between the incidence of oesophageal cancer and the easy availability of maize milling to subsistence farmers. [5] Similarly, there is a higher prevalence of cancer in low-income populations, which rely on maize-meal as a staple. It is believed that diets heavy in refined maize meal are deficient in healthy nutrients that reduce the risk of cancer. 5
  • Nutritional deficiency: A deficiency of vitamins A, E, and B12, as well as folate and selenium is associated with oesophageal cancer. [6] &[7]
  • Heavy use of tobacco: Studies have shown that heavy smokers (or those that have smoked for prolonged periods, from a young age) are at greater risk of oesophageal cancer. [8]
  • Obesity: This is a risk factor associated with the development of oesophageal cancer in both men and
    women. 3
  • High cholesterol: A high cholesterol diet has been found to “significantly increase the risk of developing oesophageal cancer”. [9] It is regarded as a risk factor for both men and women. 3
  • Alcohol use: Researchers believe that alcohol is a major contributor to the risk of oesophageal cancer in Africa (especially among men). [10]
  • Pre-existing conditions: These may increase the risk of oesophageal cancer. These conditions include GORD (gastroesophageal reflux disorder) and Barrett’s Oesophagus (which causes long-term reflux of stomach acid into the oesophagus), as well as other types of cancer. [11]

 

Interventions to remedy the problem

A number of research-based interventions are proposed to address these risk factors, and in so doing, reduce the high incidence of oesophageal cancer.

  • The formulation of national policy to address cancer, and a strategic plan to support the policy. 12
  • The implementation of interventions to monitor and address obesity and metabolic syndrome (a significant risk factor for oesophageal cancer as well as cardiovascular disease). 3
  • Improving access to healthcare, and in particular, to early detection screening. This would promote early diagnosis and improve the prognosis.3 The integration of these interventions into existing community healthcare services is key. 12
  • Interventions that control alcohol consumption (especially harmful alcohol), by targeting drinking habits and educating individuals about the risks of unmoderated alcohol consumption. 3, 5 & 10
  • Supporting cancer research. 12
  • Interventions that educate populations about the risks associated with smoking tobacco, including education programmes for school children. [12]
  • Fortification of staple foods (such as maize meal) with vitamins and minerals. 5

 

The role that HCPs can play in the prevention and management of oesophageal cancer in Africa

PatientsOesophageal cancer has a higher prevalence in men, with the World Cancer Research Fund (WCRF) finding that oesophageal cancer is the “7th most commonly occurring cancer in men and the 13th in women.” [13] Usually, oesophageal cancer begins in the cells lining the interior of the oesophagus but does not cause signs or symptoms during the early stages. [14] It is an aggressive form of cancer, and even when diagnosed (often only when it has advanced considerably), treatment options are limited. [15] As a result, this cancer has one of the highest mortality rates, and is responsible for more than 500 000 deaths annually. 3

Pertinently, the key risk factors are all manageable, via dietary and lifestyle interventions. This HCPs are well-positioned to provide reliable advice to patients, for the prevention of cancer. The recommendations include 9:

  • Maintaining a healthy weight through diet and exercise
  • Eating a diet rich in a variety of vitamins as well as macro- and micro-nutrients
  • Avoiding unhealthy cholesterols
  • Quitting smoking and avoiding chewing tobacco
  • Consuming alcohol in moderation

 
Patients should be educated about the risk factors and informed of the symptoms of oesophageal cancer (see below). High-risk patients should be encouraged to go for screening, regularly.

Symptoms of oesophageal cancer [14] & [16]

  • Difficulty swallowing (dysphagia)
  • Weight loss without trying
  • Chest pain, pressure or burning
  • Worsening indigestion or heartburn
  • Coughing or hoarseness
  • Coughing up blood
  • Dark or bloody stool

 

Table 1: Age-standardized incidence rates of oesophageal cancer in selected African countries. [17]

 

 

Age-standardized incidence rate (cases/year/100000 pop)

Country (period covered)

Males

Females

Algeria, Setif (2008-2011)

0.6

0.7

Algeria, Batna (2008-2012)

0.5

0.5

Benin, Cotonou (2013-2015)

6.9

3.6

Botswana (2005-2008)

11.4

3.9

Congo, Brazzaville (2009-2013)

0.5

0.1

Côte d´Ivoire, Abidjan (2012-2013)

0.2

0.3

Ethiopia, Addis Ababa (2012-2013)

2.2

3.8

The Gambia (2007-2011)

1.0

0.5

Guinea, Conakry (2001-2010)

0.8

0.1

Kenya, Eldoret (2008-2011)

28.7

17.1

Kenya, Nairobi (2007-2011)

14.1

14.0

Malawi, Blantyre (2009-2010)

30.3

19.4

Mali, Bamako (2010-2014)

2.6

2.7

Mauritius (2010-2012)

3.2

1.0

Mozambique, Beira (2009-2013)

5.5

3.3

Niger, Niamey (2006-2009)

1.2

0.2

Nigeria, Abuja (2013)

0.7

0.0

Nigeria, Calabar (2009-2013)

0.0

0.0

Nigeria, Ibadan (2006-2009)

1.0

0.4

Namibia (2009)

2.4

0.1

Seychelles (2009-2012)

7.5

1.9

South Africa, Eastern Cape (2008-2012)

23.8

14.6

South Africa: National Cancer Registry of South Africa (2007)

6.2

3.1

Uganda, Kampala (2008-2012)

22.9

12.1

Zimbabwe, Bulawayo: Black population (2011-2013)

23.8

10.3

Zimbabwe, Harare: Black population (2010-2012)

16.4

13.1

 

 

[1] Jin, Y., Yang, T., Li, D. and Ding, W., 2019. Effect of dietary cholesterol intake on the risk of esophageal cancer: a meta-analysis. Journal of International Medical Research, [online] 47(9), pp.4059-4068. Available at: https://www.ncbi.nlm.nih.gov [Accessed 26 January 2022].

[2] National Cancer Institute. n.d. African Esophageal Cancer Consortium (AfrECC). [online] Available at: https://dceg.cancer.gov. [Accessed 26 January 2022].

[3]Huang, J., Koulaouzidis, A., Marlicz, W., Lok, V., Chu, C., Ngai, C., Zhang, L., Chen, P., Wang, S., Yuan, J., Lao, X., Tse, S., Xu, W., Zheng, Z., Xie, S. and Wong, M., 2021. Global Burden, Risk Factors, and Trends of Esophageal Cancer: An Analysis of Cancer Registries from 48 Countries. Cancers, [online] 13(1), p.141. Available at: https://www.ncbi.nlm.nih.gov [Accessed 26 January 2022].

[4] Loots, E., Sartorius, B., Madiba, T., Mulder, C. and Clarke, D., 2016. Is Clinical Research in Oesophageal Cancer in South Africa in Crisis? A Systematic Review. World Journal of Surgery, [online] 41(3), pp.810-816. Available at: https://pubmed.ncbi.nlm.nih.gov [Accessed 28 January 2022].

[5] Sammon, A., 2021. Cancer of the Oesophagus in Africa, Population Susceptibility, and Preventive Intervention: A Literature Review. Global Journal of Health Science, [online] 13(3), p.124. Available at: https://pdfs.semanticscholar.org [Accessed 26 January 2022].

[6] Jessri, M., Rashidkhani, B., Hajizadeh, B., Jessri, M. and Gotay, C., 2011. Macronutrients, vitamins and minerals intake and risk of esophageal squamous cell carcinoma: a case-control study in Iran. Nutrition Journal, [online] 10(1). Available at: https://nutritionj.biomedcentral.com [Accessed 26 January 2022].

[7] van Helden, P., Beyers, A., Bester, A. and Jaskiewicz, K., 1987. Esophageal cancer: Vitamin and lipotrope deficiencies in an at‐risk South African population. Nutrition and Cancer, [online] 10(4), pp.247-255. Available at: https://www.tandfonline.com. [Accessed 26 January 2022].

[8] Yang, X., Chen, X., Zhuang, M., Yuan, Z., Nie, S., Lu, M., Jin, L. and Ye, W., 2017. Smoking and alcohol drinking in relation to the risk of esophageal squamous cell carcinoma: A population-based case-control study in China. Scientific Reports, [online] 7(1). Available at: https://www.nature.com. [Accessed 26 January 2022].

[9] Jin, Y., Yang, T., Li, D. and Ding, W., 2019. Effect of dietary cholesterol intake on the risk of esophageal cancer: a meta-analysis. Journal of International Medical Research, [online] 47(9), pp.4059-4068. Available at: https://www.ncbi.nlm.nih.gov [Accessed 26 January 2022].

[10] Middleton, D., Mmbaga, B., Menya, D., Dzamalala, C., Nyakunga-Maro, G., Finch, P., Mlombe, Y., Schüz, J., McCormack, V., Kigen, N., Oduor, M., Karuru Maina, S., Some, F., Kibosia, C., Mwasamwaja, A., Mremi, A., Kiwelu, I., Swai, R., Kiwelu, G., Mustapha, S., Mghase, E., Mchome, A., Shao, R., Mallya, E., Kilonzo, K., Kamkwantira, A., Kamdolozi, M., Liomba, G., Chasimpha, S., Narh, C., Bouaoun, L., Abedi-Ardekani, B., Mushi, G., Namwai, T., Suwedi, M., Solomon, T., Malamba, R. and Carreira, C., 2022. Alcohol consumption and oesophageal squamous cell cancer risk in east Africa: findings from the large multicentre ESCCAPE case-control study in Kenya, Tanzania, and Malawi. The Lancet Global Health, [online] 10(2), pp.e236-e245. Available at: https://www.thelancet.com [Accessed 26 January 2022].

[11] Memorial Sloan Kettering Cancer Center. n.d. Prevention and Risk Factors for Esophageal Cancer. [online] Available at: https://www.mskcc.org [Accessed 26 January 2022].

[12] 2012. Key Prevention And Control Interventions For Reducing Cancer Burden In The Who African Region. [ebook] World Health Organization: Regional Office for Africa. Available at: https://www.afro.who.int [Accessed 2 February 2022].

[13] WCRF International. 2018. Oesophageal cancer statistics | World Cancer Research Fund International. [online] Available at: https://www.wcrf.org [Accessed 26 January 2022].

[14] Mayo Clinic. n.d. Esophageal cancer - Symptoms and causes. [online] Available at: https://www.mayoclinic.org [Accessed 26 January 2022].

[15] Alaouna, M., Hull, R., Penny, C. and Dlamini, Z., 2019. Esophageal cancer genetics in South Africa. Clinical and Experimental Gastroenterology, [online] Volume 12, pp.157-177. Available at: https://www.dovepress.com [Accessed 26 January 2022].

[16] 2021. Fact Sheet On Oesophageal Cancer. [ebook] Cancer Association of South Africa (CANSA). Available at: https://cansa.org.za [Accessed 28 January 2022].

[17] Parkin, D., Ferlay, J., Jemal, A., Borok, M., Manraj, S., N’da, G., Ogunbiyi, J., Liu, B. and Bray, F., 2018. Cancer in Sub-Saharan Africa. [ebook] Lyon, France: The International Agency for Research on Cancer. Available at: <https://www.iccp-portal.org> [Accessed 31 January 2022].