Presentation, treatment patterns, and outcomes in patients receiving care for esophageal cancer in Southern Malawi: Cohort study at queen elizabeth central hospital and malamulo adventist hospital

Abstract

Background: Esophageal cancer (EC) is a leading cause of cancer mortality in Eastern and Southern Africa. Prospective multicenter data from Malawi are limited. This study evaluates clinical presentation, symptom-based dysphagia staging, treatment, and survival among EC patients at Queen Elizabeth Central Hospital (QECH) and Malamulo Adventist Hospital (MAH) in Southern Malawi. Methods: We conducted a prospective cohort study of 172 adults with endoscopically confirmed EC from July 2022 to July 2024, with 12 months of follow-up. Clinical dysphagia severity served as a surrogate for TNM stage. Survival was assessed using Kaplan–Meier and Cox proportional-hazards models. Results: Median age was 56 years, and 93.6% of tumors were squamous cell carcinoma. Median delay to endoscopy was 4.85 months. Only seven patients underwent esophagectomy (all at MAH) with 0% perioperative mortality; 51.2% received chemotherapy. Median overall survival was 8.52 months. In univariable analysis, alcohol, smoking, feeding-tube placement, and advanced symptom-based severity were associated with worse survival, while chemotherapy was associated with improved survival. Time-dependent effects were seen for consumption of very hot drinks, higher ECOG score, and treatment at MAH, all associated with early excess mortality. In a multivariable time-interaction model, independent predictors of mortality were feeding-tube placement, higher BMI at later time points and consumption of hot drinks. Conclusions: EC patients in Malawi present late with poor survival due to delayed diagnosis and limited curative options. Chemotherapy is associated with improved survival, feeding-tube dependence reflects disease severity, and esophagectomy was safe but rare. Early diagnosis and curative therapies are much needed.