Cancer of the oesophagus is the 6th most common cancer in Malawi. Nationwide only three hospitals are able to perform oesophagectomies, and there is no radiotherapy- or chemotherapy available. Owing to late presentation of the patients (sometimes in combination with co-morbidities such as HIV/AIDS or tuberculosis) the vast majority of patients are not suitable for surgery. Self-expanding metal stents (SEMS) of the oesophagus provide a suitable palliative option to improve the quality of life&#160; for patients. This project took a nationwide approach, raising funds for both technical equipment and training of endoscopists and nursing staff throughout Malawi

Bates, J

Fullerton, L

Kushner, AL

Thumbs, A

Vigna, L

English

PubMed

AJOL - African Journals Online

Malawi Medical Journal; 24 (1) 5-7 March 2012 Improving palliative treatment 5Improving palliative treatment of patients with non-operable cancer of the oesophagus: training doctors and nurses in the use of self-expanding metal stents (SEMS) in Malawi   AbstractCancer of the oesophagus is the 6th most common cancer in Malawi. Nationwide only three hospitals are able to perform oesophagectomies, and there is no radiotherapy- or chemotherapy available.  Owing to late presentation of the patients (sometimes in combination with co-morbidities such as HIV/AIDS or tuberculosis) the vast majority of patients are not suitable for surgery.  Self-expanding metal stents (SEMS) of the oesophagus provide  a suitable palliative option to improve the quality of life for patients. This project took a nationwide approach, raising funds for both technical equipment and training of endoscopists and nursing staff throughout Malawi. IntroductionCancer of  the oesophagus is the 9th most common cancer worldwide and the 5th most common cancer in developing countries with approximately 300 000 newly diagnosed patients every year1. In Africa there is a high incidence of  oesophageal cancer in parts of  South Africa particularly in the Transkei districts and Central and Eastern Africa, especially in the central region of  Kenya, Central Zimbabwe and - of  special interest for our project – Malawi with an estimated incidence in Malawi of  0.6 per 100 000 per year2-5. Patients often present with dysphagia, but owing to the elastic properties of  the oesophageal wall this is generally a sign of  an advanced disease. Given that the oesophagus has no serosal layer to contain the local spread of  the tumour, the cancer is locally advanced and inoperable in more than 80% of  the patients at the time of  first diagnosis6 so that the outcome is poor, with a less than 10% overall 5-year-survival rate7. The treatment of  cancer of  the oesophagus includes radical surgical resection with oesophageal reconstruction. Results vary depending on the stage of  the disease. Combined therapies, with down-staging of  the tumour with neoadjuvant radio-chemotherapy followed by surgery, seem to be more successful8. There is significant morbidity associated with oesophageal resections9,10.  Palliative treatment modalities include  chemo-radiation, argon-laser therapy, cryotherapy or self-expanding metal stents11. Most of  these are not available in developing countries because of  resource and infrastructure constraints. In any case, recent advances in more aggressive radiochemotherapy for patients with late stage presentation have not provided much benefit12. Self-expanding metal stents are an established palliative single treatment for patients with non-operable cancers of  the oesophagus13 in countries without availability of  radio-chemotherapy.  Stents provide  fast, complete and life-long improvement of  the leading symptom – dysphagia – with a reasonably low rate of  early and late complications14. So far there has been only very limited experience with SEMS in Malawi. Reasons for this include lack of  reasonably priced stents, lack of  training in their utilization and poor resources available for palliative care follow up. The aim of  this project was to build up the capacity for a nation-wide treatment programme for patients with non-operable cancer of  the oesophagus in Malawi.Map of Malawi with participating endoscopy centersMethodsTraining of doctors in placement of SEMS in Malawi:The project was funded by  generous financial support from The Lions Club of  Blantyre, Press Trust Malawi and the Society of  International Humanitarian Surgeons. Hospitals throughout Malawi performing endoscopies were invited to the training programme. Two workshops were organized – in Blantyre (at Queen Elizabeth Central Hospital and Mwaiwathu Hospital ),  and in Lilongwe (at Kamuzu Central Hospital).  Professor Dr. Russell White, an international expert on the management of  advanced cancer of  the oesophagus (who has performed more than 1000 stent procedures) from Tenwek Hospital, Kenya  was invited to train the endoscopists in Malawi. Running parallel to the surgical workshops were palliative care training seminars for nurses to support the programme in ongoing patient care. Stents, dilators, and guide wires were purchased from the project funds. The SEMS are placed without use of  an image intensifier during an endoscopy. The tumour stenosis is dilated after placing of  a guide wire, the tumour is passed to check the correct position of  the guide wire in the antrum, the size of  the tumour is measured and the SEMS is introduced with an A. Thumbs1, L.Vigna2, J. Bates3, L. Fullerton3 and A. L. Kushner4 1. Department of  Surgery, Mwaiwathu Private Hospital, Blantyre, Malawi2. Tiyanjane Clinic for Palliative Care, Queen Elizabeth Central Hospital, Blantyre, Malawi3. Surgeons OverSeas, New York, USA and Columbia University, Dept. of  Surgery, New York, USAMalawi Medical Journal; 24 (1) 5-7 March 2012 Improving palliative treatment 6applicator with a proximal and distal overlap of  about 2cm. After replacement of  the applicator the SEMS expands to a size of  approximately 18 mm.Nurse training included modules on breaking bad news, counselling the patients about dietary advice after stent placement, and pain management. Table 1: Participating Endoscopy Units throughout MalawiResultsDuring the workshop 18 doctors and 46 nurses from 11 hospitals were trained. Professor Dr. White gave the audience an overview about cancer of  the oesophagus with special focus on south-eastern Africa. In a video-demonstration he familiarised the participants with the basic procedure of  stenting. Possible early complications such as bleeding, pain and perforation and their management were discussed. Severe pain could be treated effectively with oral pain medication (e.g. liquid morphine) or diclofenac suppositories for mild-moderate pain. Bleeding after the dilatation normally subsides spontaneously. In case of  a possible perforation (revealed by surgical emphysema or by clinical and radiological signs of  a pneumothorax) the first step is to place the stent despite the complication – the covered part of  the stent will seal the perforation, and if  necessary a chest drain may be inserted. A patient with an oesophageal perforation should be kept ‘nil by mouth’ for two days, and a broad spectrum intravenous antibiotic such as ceftriaxone could be given. Professor White has successfully treated 95% of   perforations in this way, without the need for  operation. Prof. R. White demonstrating the technique of stenting to participants at Queen Elizabeth Central Hosptial/Blantyre.Following the theoretical introduction,  participants performed the placement of  a SEMS, supervised by Professor White.  Both real patients (who had fully consented) and a training model  were used for the stent placements. At Mwaiwathu Hospital in Blantyre stents were inserted with the assistance of  an image intensifier. This is not available at the other institutions. Table 2: Trained doctors and treated patients during workshops.The workshop at Blantyre was performed at Queen Elizabeth Central Hospital (QUECH) and at Mwaiwathu Private Hospital for doctors and nurses of  the southern region of  Malawi. At QECH the theoretical background was taught. Afterwards placement of  stents took place at both hospitals. The participants were able to see how safe stent insertion was possible despite differences between the resources of  the two hospitals.  Nine patients were treated with ten stents (in one patient the tumour had to be treated with two stents owing to tumour size) without any complications. The second workshop took place at Kamuzu Central Hospital at Lilongwe for doctors and nurses from the central and northern regions of  Malawi. Again nine patients were treated, this time one of  the possible complications occurred – a perforation during dilatation, with a right pneumothorax which was treated adequately with a chest drain. In this way participants were able to learn about the assessment and management of  possible complications of  stent insertion. DiscussionIn Malawi more than 90% of  the oesophageal cancers found are squamous cell tumours15 (personal data). Beside the known risk factors – alcohol (especially spirits or local brewed beer) and smoking16,17 – there is some evidence that the consumption of  maize is increasing the risk of  squamous cell cancer of  the oesophagus through contamination by aflatoxins (secreted from fungi that grow on stored grain) or even through a direct influence of  maize on the mucosal layer of  the oesophagus18.  Co-infections with HIV, Human Papilloma Virus, schistosomiasis, EBV and CMV may also play a role and are subject to further investigations19-23. Given the high frequency of  oesophageal cancer, it is vital to improve the diagnosis and treatment of  this disease.The majority of  patients presenting with cancer of  the oesophagus in Malawi have inoperable disease at presentation. SEMS placement is a simple, effective  method that can improve quality of  life in this condition in resource limited settings. Adopting a nationwide approach required dedicated funds and logistical support but has enabled all endoscopy sites in Malawi to gain skills both in stent insertion and in adopting a palliative care approach to these patients and their families. Since the training,  more than 120 patients have been successfully treated with SEMS with very good results in terms of  improvement of  dysphagia, and with a  low rate of  complications. These data will be published at the end of  the planned follow-up of  200 patients after 12 months.Complications are rare – early complications include bleeding, chest pain and perforation, while late complications include stent dislocation, tumour overgrowth or oesophagitis – the latter especially with a stent crossing the gastro-oesophageal junction. During the workshop one perforation happened and was treated adequately with a stent insertion, chest drain and iv-antibiotics. In a study in Kenya more than 1000 Malawi Medical Journal; 24 (1) 5-7 March 2012 Improving palliative treatment 7stents were inserted with an overall rate of  perforations of  approximately 3%24. Tumour overgrowth could occur in up to 20% of  patients24: in our ongoing study, four patients out of  more than 120 have had to be re-stented, but without any problem due to a blockage of  the stent.This project is unique because for the first time this technique will be used throughout Malawi in different endoscopy centres. With a lot of  effort a nationwide approach was made possible to supply a whole country with a new technique. Early results have shown that the procedure is easy to learn for endoscopists and that it  is safe even in resource limited countries. The success of  this programme can be used also in other developing countries to improve the palliative care for patients with cancer of  the oesophagus.ContributionsAT and LV were responsible for the conception of  the project and the organization of  the training workshops for doctors. JB and LF were responsible for the conception and organization of  the nurses’ training programme. LV, AK and PK were responsible for fund raising and organization of  the workshop. All authors contributed to the writing of  the manuscript with AT as  corresponding author mainly responsible for the literature research and writing of  the article and for the tables and pictures.Conflict of interestsThe authors declared no conflict of  interests.AcknowledgmentsWe gratefully acknowledge Press Trust Malawi, Lions Club Blantyre and the Society of  International Humanitarian Surgeon/Surgeons OverSeas which funded this project.References:1.Parkin D, Pisani P, Ferlay J. 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Surgery alone versus chemoradiotherapy followed by surgery for resectable cancer of the esophagus: a randomised controlled phase III trial. Lancet Oncology 2005; 6:659-689. Ajani J, D’Amico T., Hayman J et al. Esophageal Cancer: Clinical Practice Guidelines in Oncology. J. Natl. Compr. Canc. Netw. 2003; 1:14-2710. Bailey S, Bull D, Harpole D et al. Outcomes after esophagectomy: a ten-years prospective cohort. Ann. Thorac. Surg. 2003; 75:217-22211. Blazeby D. Palliative treatments of carcinoma of the stomach and oesophagus. Upper GI gastrointestinal Surgery 2nd ed. Edinburth 200112. Ilson D. Esophageal Cancer Chemotherapy: Recent Advances; Gastrointest. Cancer Res. 2:85-92, 200813. De Palma G, Galloro G, Sivero L et al. Self-expanding metal stents for palliation of inoperable carcinoma of the esophagus and gastroesophageal junction. Am. J. Gastroenterol. 1995; 90:2140-4214. White R, Parker R, Fitzwater J, Kasepoi Z, Tapazian M. Stents as sole therapy for esophageal cancer: a prospective analysis of outcomes after placement. Lancet Oncoloy 2009; 10:240-24615. Pickens A, Orringer M. Geographical distribution and racial disparity in esophageal cancer. Ann. Thoracic Surg 2003; 76:1367-6916. Wu A, Wan P, Bernstein L. A multiethnic population-based study of smoking, alcohol and body siye and risk of carcinoma of the stomach and esophagus. Cancer Causes Control 2001; 12:721-72317. Fan Y, Yuan J, Wang R, Gao Y, Yu M. Alcohol, Tobacco and Diet in relation to esophageal cancer. The Shanghai cohort study. Nutr. Cancer 2008; 60(3): 354-36318. Sammon A. Squamous cancer of the esophagus in Africa, published at scoafrica.org March 200919. Chang F, Syrjänen S, Shen Q et al. Detection of HPV DNA in oesophageal squamous cell carcinoma from the high-incidence area of Linxian, China. Scand J Gastroenterol 2000;35:123–30.20. Astori G, Merluzzi S, Arzese A et al. Detection of human papillomavirus DNA and p53 gene mutations in esophageal cancer samples and adjacent normal mucosa. Digestion 2001;64:9–14.21. Cintorino M, Tripodi SA, Santopietro R et al. Cytokeratin expression in oesophageal squamous cell carcinoma: a study of 354 cases from the high-incidence area of Linxian, China. Anticancer Res 2001;21:4195–201.22. Trottier A, Coutlee F, Leduc R et al. Human immunodeficiency virus infection is a major risk factor for detection of human papillomavirus DNA in esophageal brushings. Clin Infect Dis 1997;24:565–9.23. Pillai M, Nair M. Development of a condemned mucosa syndrome and pathogenesis of human papillomavirus-associated upper aerodigestive tract and uterine cervical tumors. Exp Mol Pathol 2000;69:233–41.24. White R, Parker R, Fitzwater J, Kasepoi Z, Tapazian M. Stents as sole therapy for esophageal cancer: a prospective analysis of outcomes after placement. Lancet Oncolgy 2009; 10:240-46

Improving palliative treatment of patients with non-operable cancer of the oesophagus: training doctors and nurses in the use of self-expanding metal stents (SEMS) in Malawi

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Improving palliative treatment of patients with non-operable cancer of the oesophagus: training doctors and nurses in the use of self-expanding metal stents (SEMS) in Malawi

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